The Morality of Health Care Reform, Pt. 1

During Take Back America 2008 [1], I spent part of a day running around with a camera and a microphone asking people which issue was most important to them in the upcoming election. Just when I thought I was done, the camera turned to me and I was faced with the same question.

My answer came quickly and easily: health care reform. When I explained why, the argument that came out of my mouth was based more in morality than economics.

Competing Voices

"In a country as wealthy as this one," I said, "It's criminal that a single child lacks coverage and does without health care." I was thinking of my own two kids — particularly Dylan, who was less than a year old, and had regular well-baby checkups. But I was also thinking about children like Deamonte Driver [2], whose death from complications due to lack of access to dental care and a resulting abscessed tooth made headlines a couple of years ago.

It wasn't because the cost of providing coverage and care to children was less than the cost of not doing so. (Though an $80 tooth extraction would have spared Deamonte the need for brain surgery and $250,000 worth of medical care because of the spreading infection.) It was because of a core belief that, as a country, we have moral imperative to make sure everyone has access to quality health care [3].

I don’t remember where I heard it, but it’s something a core belief of mine: Freedom and liberty are meaningless concepts without two things—knowledge of them and the ability to act on them. To my mind, the former is basically education, and the latter means health care. I’ve come to believe that a country that can’t provide those two basic things to its citizens can’t have more than a tenuous grasp on the two concepts above.

Not long ago, I wrote that on election night Americans weren't just choosing a president, but choosing the kind of country we want to be. Voting for Barack Obama, on the basis of his campaign platform after eight years of George W. Bush and a Republican Congress, signaled that we were approaching a crossroads as a country and were deciding which road to take.

If this past August is an indication, we're still at that crossroads, shouting at each other about which path to take.

With her acuity for distilling and channeling diverse American voices in her work, Anna Deveare Smith [4] in her recent New York Times piece captures voices on both sides of the health care reform debate, revealing perhaps one of the most difficult tasks that reforming health care will require of us: not only are we still deciding what kind of country we want to be, but continuing down the path of change we apparently chose in November will mean changing the story we tell ourselves about who we are and who is included in that "we."

That choice is illustrated in two of the voices Deveare Smith. One, a nurse from the Western United States, illustrates part of the problem some Americans have with health care reform, and specifically with universal health care achieved through a government-funded public heal care plan.

When you come to the West, you have a different mentality. There's an independence and an individuality here that you don't get anyplace else, because when you're in the city, you're kind of like part of the hive. You know, people that take the light rail in to work and come back and live in these big apartment buildings and have restaurants and things and they're fine with that.

Here, people are really, really proud, and they cherish their independence. And they cherish the fact that we are all individuals. And that's what we're afraid of, is that we're going to lose our individuality and we're just going to be part of the hive. If you're just part of the hive, then what are you going to do? You're going to cull out the weak links. You're going to cull out the lady that's on crutches and got diabetes, because she may be a good grandmother and she may be a good person, she lives by herself, and her house is paid for, but you know, her medicines cost a lot.

Another voice, that of a doctor from Montana, shows how much will have to change if we're going guarantee quality , affordable health care for all.

American culture simply has never been based on caring about what happened to your neighbor. It's been based on individual freedom and the spirit of, if I work hard I'll get what I need and I don't have to worry about [the] fellow that maybe can't work hard. It's a pretty cynical view of America.

But I honestly think that drives an awful lot of this debate — the notion that I've done my job, I've worked hard, I've gotten what I'm supposed to get. I have what I need and if the other people don't, then that's sort of their problem. And unfortunately the big picture — that our nation can't thrive with such a disparity between the rich and the poor, the access people and the disenfranchised — that hasn't seemed to really strike a chord with Americans.

So your average person actually has fairly good access. They're happy with their physician and they're really frightened that something's going to happen to that, on behalf of people that maybe they don't think it's their job to take care of

Obama addressed much of this in his speech to Congress [5]. Anyone who wasn't busy heckling might have heard him frame whether or not we have the will to reform health care makes as a defining a test of American character.

That large-heartedness—that concern and regard for the plight of others—is not a partisan feeling. It’s not a Republican or a Democratic feeling. It, too, is part of the American character—our ability to stand in other people’s shoes; a recognition that we are all in this together, and when fortune turns against one of us, others are there to lend a helping hand; a belief that in this country, hard work and responsibility should be rewarded by some measure of security and fair play; and an acknowledgment that sometimes government has to step in to help deliver on that promise.

With so much discussion about what health care reform will or won't cost, and the cost of not reforming health care, every suggested compromise in Congress seems designed to cost less up front while covering fewer people. James Kwak [6] turned the discussion of costs and consumer choice around to one very basic question about health care reform.

This just illustrates that a core function of any health insurance scheme is redistribution. People start out in different economic circumstances, and they suffer different fates in their lives. Without redistribution in some form, the ones who are poor and get sick will simply not be able to afford health care. Cashing out their employer health benefits and giving them "choice" won't change that — especially if they don't have employer health benefits to begin with. Yes, insurance can play a redistributive role on its own, but it only works if poor people can afford to buy insurance that will cover them against serious illness. And once they have that insurance, then the price signals so beloved of conservatives won't function anymore. The problem is really very simple: for price signals to work, you have to be willing to let consumers run out of money, since no one can predict his future health care needs. And then they die.

So what really frustrates me about this whole "consumer choice" fraud is the premise it begins with. It starts out by framing health care as a problem of consumer incentives — health care is too cheap. This is a factually accurate framing that leads you to a dead end (unless you think people who underestimate their future sickness should die). I think the right way to frame this issue is with this question: Given a poor person and a rich person who have the same potentially fatal disease, should both of them live, or only one?

Put another way, it becomes a personal question: If you and a rich person (or someone much wealthier than you) have the same potentially fatal disease, should both of you live, or only one? That our current system often determines that whoever has the most "wins," or that the person with the most money lives, makes it a moral question.

How we answer that question will not only determine if or how we will reform health care, but also what kind of country we become — because ultimately whether everyone should have access to quality, affordable health care, and whether the government should provide that access, is a moral question.

In writing about the moral case for health care reform [7] (and the absence of such an argument in our current debate about health care reform), Ezra Klein quoted T.R. Reid's The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care [8] about successful efforts to reform their health care sector into a national system — by making a moral case for reform.

Both countries decided that society has an ethical obligation — as a matter of justice, of fairness, of solidarity — to assure everybody has access to medical care when it's needed. The advocates of reform in both countries clarified and emphasized that moral issue much more than the nuts and bolts of the proposed reform plans. As a result, the national debate was waged around ideals like "equal treatment for everybody," "we're all in this together," and "fundamental rights" rather than on the commercial implications for the health care industry.

Over the next week, I plan to write about health care reform as a moral issue, in hopes of staring a discussion about why health care reform that provides quality, affordable health care to all Americans is simply the right thing to do.