



I HAVE been devoting this space to deliberately implausible ideas lately, and the time has come to turn to an issue that our politicians are actually debating: health care reform. Though “debating” might be a strong word, since the politicians I’m talking about are all Republicans, and it’s hard to have a serious argument when most everyone involved (including our unhappy president) really, really wishes that they could just stop and talk about tax cuts instead.

In theory there is a coherent vision underlying Republican health care policy debates. Health insurance should be, like other forms of insurance, something that protects you against serious illnesses and pays unexpected bills but doesn’t cover more everyday expenses. People need catastrophic coverage, but otherwise they should spend their own money whenever possible, because that’s the best way to bring normal market pressures to bear on health care services, driving down costs without strangling medical innovation.

This theory — along with, yes, a green-eyeshade attitude toward government expenditures on the working poor — explains why conservatives think a modest subsidy to help people buy health insurance makes more sense than Obamacare’s larger subsidies. Republican politicians may offer pandering promises of lower deductibles and co-pays, but the coherent conservative position is that cheaper plans with higher deductibles are a very good thing, because they’re much closer to what insurance ought to be — and the more they proliferate, the cheaper health care will ultimately be for everyone.

Is there an existing health insurance system that vindicates this boast? Yes, in a sense: There is Singapore, whose health care system is the marvel of the wealthy world. Singaporeans pay for much of their own care out of their own pockets, and their major insurance program is designed to cover long-term illnesses and prolonged hospitalizations, not routine care. The combination has produced genuinely extraordinary results: The island state has excellent health outcomes while spending, as of 2014, just 5 percent of G.D.P. on health care. (By comparison, a typical Western European country that year spent around 10 percent; the United States spent 17 percent.)