The American Health Care Act (AHCA) was passed by the US Congress by a narrow margin on May 4, 2017. It has yet to pass through the Senate. Many commentators were struck by the incongruity of billions of dollars transferred to the most wealthy in the context of a health care bill. Most read this as a disguised tax cut at odds with the interests of the President’s political base, often described as the “white working class.” To the extent that these critics impute a reason for Trump’s actions, it is that his administration’s intention is to benefit the very wealthy. But this says nothing that could not be said about every Republican policy, and almost every Democrat policy as well. It tells us nothing about this policy. The AHCA has its own rationale; one that is also evident in the proposed budget. Complaining that it serves the cause of “the billionaire class,” or that it proves many Trump supporters voted against their own interests avoids reckoning with its unique calculus of value and care.
Debates over risk-pooling and health care provision cannot be reduced to deliberations about money. Neither can disputes over budgetary priorities. These debates involve money at various points, of course, but that cannot explain the general irrelevance of cost–benefit analyses, particularly in the history and structuring of U.S. health policy. Research conducted by the Organization for Economic Cooperation and Development (OECD) before the introduction of the Affordable Care Act (ACA), which compared 13 countries’ health care systems (including that of Japan, Germany, and Australia), illustrated that spending on health care in the U.S. is remarkably high and, at the same time, that this high level of expenditure did not translate into better life expectancy outcomes or the decrease of chronic disease. But to assume that the AHCA’s objective is the health and welfare of people in the U.S. ignores the presence of a different aim—one that involves the expansion of systems of faith-based care exempted from non-discriminatory mandates.
Seen in this light, the tax cut is not simply a billionaire giveaway. It is part of an evangelical campaign for the restoration of a conditional, paternal philanthropy that runs contrary to the principle of unqualified access to health care that is represented by the ACA’s inclusion of people with “pre-existing conditions” in the insurance markets it regulated. Unqualified access means spreading the cost and risks of ill health and therefore sharing the benefits of maintaining good health. For those evangelicals who view health and disease through the lens of a moral economy, spreading the costs of health care is tantamount to facilitating moral hazard, or encouraging sinful behavior and usurping God’s judgment. More so, for evangelicals influenced by Seven Mountains’ dispensationalism—such as the New Apostolic Reformation (NAR), otherwise known as dominionists—the enormous transfer of wealth to the wealthiest is part of a “divine mandate… to do whatever is necessary, by the power of the Holy Spirit, to retake the dominion of God’s creation.”1
Dispensationalism regards history through the lens of “household administration”—oikonomia—where care is dispensed according to a covenant with God and therefore to the faithful by divine representatives. Dominionist versions have extended this into the Seven Mountains mandate (from God) to occupy seven administrations of worldly influence (education, religion, family, business, government and military, arts and entertainment, and the media) before the Second Coming. By this view, the enormous transfer of wealth to priests and “divinely-anointed kings,” allows them to fulfill their divine commission to retake the Seven Mountains of worldly power before the end of days. Simply put, that “divine commission” involves a religious mandate to transfer wealth to the anointed so that they may instead dispense care according to evangelical stricture: through private, paternal philanthropy and faith-based institutions, including that of the family, to those deemed to be deserving of care.
White evangelicals don’t look positively at cutting food and disaster relief programs because they love privatization for its own sake. They embrace privatization as a means to the reconstruction of a patriarchal, deeply racialized and religious authority over calculations of risk and worthiness, one that actively embraces selective redemption in preparation for a catastrophic end of days. Particularly at the state level, the trend toward privatization is modified by a re-routing of public taxes to faith-based contractors who, because of “religious freedom” legislation, are increasingly loosened from the sway of non-discriminatory and constitutional mandates over both employment and service provision. Institutions of care are at the center of this conflict.
In other words, policy debates in the U.S. are shot through with assumptions derived from theologies of moral hazard and original sin, and for straightforward reasons: well over a third of evangelicals around the world are concentrated in the U.S., arguably at the center of a mission to convert the political economy of care worldwide (as with the recent Executive Order, “Protecting Life in Global Health Assistance,” otherwise known as the “gag-rule”). For white evangelicals—and some Catholics on the issues of contraception and sexuality—these moral values are the stakes of debates over health care and government services. For many Trump voters, of whom white evangelicals make up the strongest bloc, those stakes are more important to a calculus of risk than delivery of affordable, accessible, relatively inexpensive and effective government care.
This tax cut, then, may as well perfectly align with the invariant interests of “the billionaire class” in paying less taxes. But it is End Time theology that has imbued this enormous transfer of wealth with a sense of apocalyptic urgency and moral certitude, linking it to a debate over health insurance and other forms of care, such as Meals on Wheels and food stamps. At the center of this is a conflict between the anti-discriminatory mandates of the U.S. Constitution and a religious mandate which white evangelicals have derived from biblical scripture through a dispensationalist reading. White evangelicals are a well-resourced, mobilized minority of both the U.S. electorate and Christians, but it is no political fringe. Hedge fund billionaire Robert Mercer—who was the largest financial backer of the overtly dominionist candidate Ted Cruz before he switched to backing Trump’s election—provided Trump’s campaign with staffers such as Steve Bannon and Kellyanne Conway, and is a key financial support for Breitbart. Conway shifted from running a Cruz super PAC on behalf of Mercer to running Trump’s campaign, and both she and Bannon were members of the dominionist Council for National Policy, which Vice President Mike Pence and Attorney General Jeff Sessions also have ties to. The National Day of Prayer Task Force, whose small membership includes Pence and the New Apostolic Reformation’s Peter Wagner, has an explicit Seven Mountains’ mission.
Without confronting the rationale and purchase of evangelical doctrine—how its understanding of moral risk and orders splices together with fascism’s call to restore the purportedly true and natural measure of things and people—there is no way of understanding Trumpism. It is not simply that white evangelicals have toyed with a prosperity doctrine, according to which wealth is viewed as a sign of God’s grace. It is that in their calculus of risk, health and ill health are similarly viewed as the outcome of an individual’s moral choices (this is what Pence means by “bringing freedom and individual responsibility back to American health care”). In this context, care is seen as an adjunct to God’s administration of a moral order through faith-based institutions, which is analogous to the father’s administration of a patriarchal household—a mandate in this case permeated with End Time imperatives.
In many evangelical accounts, the End Time will be presaged by the rise of the anti-Christ: a brutal, authoritarian leader who is instrumental to ushering in the apocalypse. It is not trivial that many white evangelicals described Trump as “an imperfect instrument,” or, as the dominionist Lance Wallnau put it, “God’s wrecking ball.” Where fascism denotes the purifying restoration of national essences and natural orders by inducing a catastrophic break in the regular measures of time and law, dispensationalism similarly embraces destructive crises as the return to oikonomic equilibrium (the restoration of a moral administration in family, government, and the other Seven Mountains). Yet, unlike the violent fascist restoration that animated Hitler’s writings and Mussolini’s speeches, it does so with a view of ushering in the irreversible violence of the end of days. White evangelicals believe this literally, as inerrant prophecy contained in scripture. They are not only unconcerned about how destructive and chaotic Trump’s presidency is, they have already celebrated it through the embrace of prophetic apocalyptic narrative.
There has been little, if any, critical response to the theology that underpins the AHCA and the corollary expansion of the Religious Freedom Restoration Act, the re-criminalization of drug use, the defunding of Planned Parenthood, and the global “gag-rule.” This has made it possible for commentators to imply that the conservatism inherent in these policies is due to Trump’s “white working class” base and not the influence of far Right dominionists in the administration. And the pursuit of “the white working class” has already accomplished the promotion of an anti-abortion Democratic candidate, Heath Mello, standing under the banner of “working families.” But while every study of exit polls and voting patterns has debunked the myth of a decisive swing by white, working class voters to Trump, the persistence of that myth nevertheless makes it seem as if overtures to religious conservatives are embracing the common folk.
The transposition between “white working class” and religious conservatives makes little sense outside the most fetishistic view of class—one which treats the economic locus of class far more like an exotic and homogeneous culture, untouched since the 1950s, irrespective of incomes and assets, and invariably white. With the exception of black churches and Pentecostals, of which around a quarter are linked to Latin American Pentecostal traditions, upwards of two-thirds of evangelical/born-again congregations are in middle- to upper-income ranges. Over 80 percent of white evangelicals voted for Trump, and around a third of the U.S. citizens refer to themselves as evangelical, which corresponds fairly closely with what commentators quantify as “Trump’s base,” reflecting a similar income distribution (over two-thirds being in the middle- to upper-income brackets). The discursive substitution of “evangelical” by “white working class” therefore makes it possible to trade on bleached, normative representations of “working families”—indeed, the kind of bourgeois fetishism for scenes of nature and industrious “ordinary people” that Adam Smith scattered throughout in The Wealth of Nations.
Versions of these theologies have been pivotal to the history of the United States, though the influence of dispensationalism across evangelical assemblies has grown significantly in recent decades. Dispensationalist hermeneutics, or ways of reading the bible, have become more influential within evangelism along with the expansion of evangelical educational institutions. Even so, theology has been integral to the history of insurance and finance, inseparable from the history and present of capitalism. Anyone who tells you that capitalism is not a moral order, or can be fixed by restoring a moral order and values, knows next to nothing about its history, cannot explain its contemporary course and is peddling down a blind alley paved with false assumptions—not least of which is that economics involves only quantification, concerned only with numbers and not qualities. This fails to explain how a system of qualified care comes about, let alone the qualified categorical terms of race, gender, and sexuality that inform notions of care and the organization of care work, which obtain in evangelical accounts of “household administration,” and have shaped evangelical understandings of faith-based care, including health care.
The classical and neoclassical tenet of self-regulating markets is grounded in theories of natural law and theological understandings of freedom as the constricted, conscious “choice” between redemption and eternal torment. This is present, for example, in the Christian parameters of “individual liberty” and in the scrupulous terms of the Religious Freedom Restoration Act, which in practice means: the freedom to discriminate against those whose conduct is deemed sinful. In the history of insurance, treatments of insurable and uninsurable risk have always been governed by an understanding of the “rational economic man” as someone who calculates the moral risks with a view to the afterlife— Lockean liberalism, for instance, hinged on a prudential idea of preparing for God’s reckoning.2 Whether by a prudential (Lockean) or punitive logic derived from apocalyptic evangelism—in either case weighing risk premiums according to a moral economy—the sinner who does not choose to embrace a moral calculus has freely chosen their misfortune.
In the evangelical perspective, spreading the costs of welfare and healthcare beyond one’s more or less symbolic but otherwise private household, facilitates moral hazard and emboldens sin. Where such a state extends care, it does so as a philanthropic benefaction that retains paternal control over moral conduct as a condition of care, which is how religious conservatives perceive the tax cut that the AHCA promises to deliver: as part of the restoration of an oikonomia, or a well-ordered household, which arranges society in qualitative categories of race, gender, and sexuality.
The passage of the AHCA is not, then, simply an inept tax giveaway. It marks an effort to restore a religious societal order in which these purportedly natural qualifications of gender and race are encoded in law as different classes of risk in the treatment of pre-existing conditions and structure of risk-pools. Handling health conditions as if they arise by nature or divine providence inscribes a theory about the etiology of those conditions into their management through the pricing of healthcare and insurance premiums as much as it prescribes courses of treatment. If, for instance, pregnancy is seen as women’s natural, God-given destiny, then interfering with pregnancy is a sin—leading to Pence’s involvement in the politics of Indiana, which resulted in some of the most restrictive policies on contraception and abortion in the U.S.
In the U.S., more than in any other capitalist state, government policy has been handled through a calculus derived from of a moral economy of health and wealth—a theology of fortune and misfortune. In a theological sense, privatization means that individuals bear the risk of decisions they make and that the morality or immorality of those decisions is reflected in the distribution of health and wealth. Rampant inequality and untreated or poorly treated diseases are features, not bugs, in this system. Opposition to the ACA’s non-discriminatory standard, and a penchant for discrete risk-pools is a stand-out feature in that system, involving a mechanism for selecting who and which conditions can qualify for relief. So too is the belief, pronounced among white evangelicals influenced by the doctrine of dispensationalism, that the intrusion of non-faith-based institutions in care usurps the role of a providential God and his worldly representatives; that is, “fathers of households,” whether those are taken literally, or denote pastors, or refer to the owners of healthcare companies, or pertain to the “closely-held corporations” of the Religious Freedom Restoration Act and the Hobby Lobby ruling.
A willingness to discard anti-discrimination principles by waving them away as “non-core” or “identity politics” should be concerning. It also plainly contravenes the tenet of unqualified access—a term that I prefer over the concept of “universal health care” because it does not presume the idealized, universal human body that also underpins eugenics in its assumption of bodily norms and the treatment of abnormalities. In any event, if health care policy does not include a non-discriminatory standard in determining access to care and relief, then it qualifies that care and people’s lives by falling back on moral judgments about the value of lives, the conducts that are extraneous to medical considerations, and most criteria of effective relief. In the case of the AHCA, it will do so irrespective of whether that care is funded through single-payer arrangements or contracts with insurance companies.
However, there is nothing inexorable about the apocalypse that white evangelicals desire, nothing inevitable about the appeal of fascism or dominionist theocracy, and nothing in the electoral numbers short of allowing massive voter suppression to go unchallenged that suggests their constituencies should be treated as allies at the expense of the lives and health of those who do not share those desires. It is, in other words, possible to envision and campaign for infrastructures of care that are not bound to dreams of fascist restoration and apocalyptic devastation, which instead embrace an expansive view of life, of the unruliness and interdependence of living things, in an unqualified way.