The concept of the common good, ancient in origin, would seem on the face of it an ideal foundation for health-care reform. We all get sick and depend on others to care for us, and many of us will need expensive treatments that are beyond the means of all but the most affluent. At the core of the idea of a common good is the Aristotelian understanding of man as a social being—as well as the understanding that, in the words of Pope John XXIII's Mater et magistra, “individual human beings are the foundation, the cause, and the end of every social institution.”
Except for Catholics and a few others, however, the common good as a moral value has little purchase in American culture and politics. The closest some come is to speak of the “public interest,” but that notion seems more political than moral, useful perhaps but not quite the same. European health-care systems are based on the idea of solidarity, which is closely related to the common good, but the term “solidarity” has even less resonance here than the term “common good” does. For Europeans, it is a matter of solidarity that everyone have access to health care because it is a necessity for human welfare; and government, they believe, is the appropriate institution to guarantee this access. For Europeans, the 46 million uninsured Americans, together with the excessively high cost of care for those Americans who have insurance, is a source of astonishment. How can an affluent, civilized country tolerate treating millions of its citizens this way? Since every other developed nation provides universal care, it is worth exploring why we are different and whether anything can be done about it.
One important difference is the absence in this country of a solid common-good tradition. In their opposition to liberal reform efforts, conservatives invoke freedom, choice, and competition as their leading values. Liberals—and the Obama administration in particular—have no agreed-upon set of countervailing values. Mid-August news stories reported that members of the administration were urging the president, in the face of declining support for his reform efforts, to invoke “morality” to help his flagging campaign. He did so, belatedly, in his September 9 address to Congress, citing a letter from the late Senator Edward Kennedy, who wrote that “what we face is above all a moral issue; at stake are...fundamental principles of social justice and the character of our country.” To those words Obama added, “We are all in this together.”
It is hard to know what impact such expressions have on the American public, partly because they have not been used consistently. Liberals have a recent history of failure to find a satisfactory way of talking about values. In 1975, a colleague and I had a chance to meet with Senator Kennedy and Senator Jacob Javits. They were trying to introduce a Senate bill for universal health care. The principle they invoked, popular at the time, was that of a “right to health care.” But Senator Kennedy said they had a serious problem: “We don't know how to set a limit to that right.” I remarked that I had not heard politicians discussing the problem of limits. “Oh,” Senator Kennedy replied, “we can't talk about that.” Senator Javits immediately agreed. Kennedy said, “Your people at the Hastings Center should take it on.” Our staff at that time was all of four people. It was both flattering and disquieting to be told that we were better able to open a national discussion than members of the U.S. Senate.
The Kennedy-Javits effort never made it out of committee, and, with its failure, talk of a right to health care seemed to fade away, returning only sporadically in subsequent years. In the early 1980s, a federal commission on bioethics deliberately avoided the language of rights and spoke instead of a government “obligation” to provide health care. By the '80s, reformers had begun to appeal to another idea: justice. Inequality in health care, they said, is simply unjust. Interest in this way of framing the issue was stimulated in great part by John Rawls's influential 1971 book A Theory of Justice. But arguments based on justice did not have much staying power. They caught on with academics and some religious groups, particularly Catholics, but not with most of the general public, nor with politicians.
By the time the Clinton administration began its reform effort in 1993, it was hard to find any clear set of animating values. References to rights or justice were sparse. Apart from his recent address to Congress, President Obama has not done much better. A case can be made that the woolliness of the Obama health-care plan stems in part from a failure to come up with compelling and coherent principles. Finding such principles among the president's more wonkish speeches on the subject is not easy. Nor have his rare references to principle been as crisp and patriotic-sounding as his opposition's language about “choice” and “competition.”
Even if the president did talk more about the common good, however, there's evidence that the American public might not listen. Opinion surveys show a long-standing bipolarity about reform. On the one hand, a majority supports reform (though this majority has lately become smaller). On the other hand, there is enormous ambivalence about having to pay higher taxes to fund reform. A recent Kaiser Family Foundation survey found that only 51 percent of Americans are willing to pay more in taxes for an improved health-care system, and that number, too, seems to be falling.
At the same time, there is considerable resistance to cutting medical benefits—especially in the Medicare program—in order to deal with unsustainable cost increases. After a nationwide tour as a consultant for a health-care documentary, Robert Lezeweski noted that he could find no doctors or hospital administrators who thought they could do with less income, and no patients who thought they could do with less care. Over the years I have heard many people say, in almost the same words, that the country should cut its spending on health care, but not if it's for “my wife, or child, or friend.”
President Obama has gone out of his way to assure the elderly that there will be no cuts in their Medicare benefits. That seems highly improbable in light of projections that show that, without serious changes, the program will be insolvent in eight years. Nothing less than a painful increase in taxes, or a great reduction in benefits, or some combination of both can save it. But even if the president denies there will be any cut in benefits, the public senses that there will be—and it is alarmed.
Advocates of reform must now cope with the growing fear among the 80 percent of Americans who have adequate health insurance that they may have to lose some benefits, or pay more for them, in order to extend coverage to the 20 percent who lack insurance. More than fear is operating here. There is also an unwillingness to make sacrifices. As one person put it at an Iowa town-hall meeting organized by Senator Charles Grassley, “People here have worked hard all their lives. They see this [the Obama plan] as having to pay to take care of someone else.”
The thought that we might have to ration health care in the name of the common good—even to ensure that others get a fair share—is objectionable to most Americans, and our politicians have not dared to talk about it. It is the medical equivalent of not-in-my-backyard. Americans understand that in a flu pandemic a shortage of vaccines might require rationing and priority-setting. In such a case, where our backs are against the wall, the good of the community self-evidently comes first. Not so with the health-care system overall. Rationing is tolerable only in an emergency. We are a rich country, even during a recession; we can afford expensive wars abroad and McMansions. So why should we have to limit health care?
Liberals mostly ignore the question. They like to say that the real problem with health-care costs is waste and inefficiency, curable with better management and better incentives. No one needs to give up anything. Conservatives say that the market by itself can do the job by leading people to make more careful health-care choices. If insurers were forced to compete, everyone would have a wide range of options, and the net result would be lower costs. Again, no one needs to give up anything. Both the Right and the Left have their fairy tales; both refuse to face reality.
The striking feature of conservative health-care thinking is its radical individualism. The idea of a common good is entirely absent. The editorial and op-ed pages of the Wall Street Journal, the National Review, and the Weekly Standard hold high the banner of untrammeled freedom. No stories of families lacking insurance, bankruptcies occasioned by medical debts, or services denied by private insurers make it into their pages. Instead, there are endlessly repeated tales of Canadians fleeing their universal-care system for life-saving operations across the border, or of Britons waiting months for hip replacements or being denied life-saving care by the National Institute for Clinical Excellence (NICE), the British agency that assesses new technologies for their efficacy and cost-effectiveness. That's what you get, the conservatives say, with “socialized medicine.” They never mention the lower costs of the British and Canadian systems, the greater life expectancies of Canadians and Brits, or the greater popularity of those systems among the people who use them, waiting lists notwithstanding.
Adam Smith is famous for his idea that, in a free market, an invisible hand shapes individual interests into common benefits. But he also believed that markets could not flourish without a strong underlying moral culture. Smith believed that such a culture is animated by empathy and fellow-feeling, by our ability to understand our common bond as human beings and to recognize the needs of others. He also acknowledged that in modern societies government will and must grow.
But no such depth and nuance appear in the analysis of those who are now arguing that health care should be entrusted entirely to the free market. For them, patients are just consumers: conscious of cost and savvy about quality, they can make their own health-care choices as long as they have access to enough good information. They don't need the assistance of faceless bureaucrats wielding the stick of comparative-effectiveness research. They don't want the nanny state telling their doctors how to treat them.
The thought that sick people may not be smart shoppers, that they may be anxious, confused, and dependent—and cared for by physicians who know that medicine is an uncertain science and art—is completely absent from this sort of analysis. So is Adam Smith's recognition of the importance of empathy. While a government safety net for the poor is grudgingly accepted—what else can you do about losers?—there is not the slightest hint of a common-good perspective. We are told that the market system that brings us prosperity, jobs, and a cornucopia of cheap consumer goods will also work its magic in health care if we let it, never mind that there is no good evidence to support that leap from commerce to health care.
For decades there has been a deep split in public opinion about the role government should play in health care. A majority of Americans now say that health reform is needed, but there is still no widespread agreement about what role the government should play in a reformed system. The fact that close to half of American health care is government—supported-mainly through Medicare, Medicaid, and the Veterans Administration—while the other half is controlled by the private sector seems to reflect this ideological split. Pope John XXIII wrote in Mater et magistra that government intervention is justifiable because “the economic prosperity of a nation is not so much its total assets in terms of wealth and property, as the equitable distribution of this wealth.” My guess is that an American vote on that proposition would be as split as public opinion on the role of government in health care. (The late William F. Buckley Jr., a staunch critic of most forms of government intervention, famously rejected that encyclical with the quip, “Mater si, Magistra no.”)
Evidence of the success of government-run health-care systems in other countries, or of Medicare in our own, seems to carry little weight with free-market conservatives. One might think they would be interested in the model of universal health care one finds in such countries as the Netherlands, France, and Switzerland, where the government mandates employer-employee private insurance. But the conservatives show little interest in that model, despite its market features. The tax-based systems of the U.K. and Canada are easier targets for government-bashing. “Socialized medicine” is a one-size-fits-all term of abuse for any system that guarantees universal coverage, no matter how it actually works.
Most remarkable is the worship of the private sector as a kind of spotless virgin in a white gown, untouched by the sins of fraud, abuse, and bureaucracy that are supposed to belong to promiscuous government. That myth is hard to sustain in light of recent events. It was, after all, the depredations of an unregulated private sector that brought about our current recession—the cupidity of the credit card vendors, the folly of the subprime mortgage industry, the decline of the American automobile industry. The best antidote to the market-intoxicated editorial pages of the Wall Street Journal are the news stories in the rest of that paper. Few governments could do quite so badly as many businesses have recently done. Nonetheless, the relentless campaign against government-managed health care, aimed at stirring up fear and loathing, has been remarkably successful. It is a campaign that tacitly rejects the idea that health care should have anything to do with the common good. W
hile the common good is not just a code word for big—or bigger—government, there is of course a correlation. In Canada and the countries of Europe where the common good is considered an important political principle, the government takes a more active role: hence their stronger welfare programs (and much lower poverty rates), as well as their universal health-care systems.
To be sure, you get higher taxes with that much government activity. Yet Europeans appear to understand a simple point: Good public services require adequate funding, and the tax revenue that pays for such services is money well spent. This simple correlation often gets overlooked in American debates about entitlement programs. Americans want a strong and solvent Medicare program, for example, but seem unwilling to pay much more in taxes to support it, though some opinion polls have indicated that they might be willing to pay a little more. In any case, Congress hasn't been willing to test the country's tolerance for higher taxes. So the program remains underfunded. Yet when Medicare, starved for resources, performs less well than it should, it is government that gets the blame, not stingy taxpayers.
I have not painted a hopeful picture about the common good in American health care. That simply does not seem possible. An abiding suspicion of government, a belief in the free market as an engine of prosperity (and thus, by an illogical leap, as an engine of good health care), and the majority's fear that they may lose the benefits they already have—all this leaves little room for an embrace of the common good. Solidarity, the value behind European health-care systems, seems to me the best basis for universal care, better than justice or rights. But the sense of solidarity required for serious health-care reform cannot be wished into existence. It was the solidarity of the British people in defense of their country during World War II that afterward helped get the National Health Service off the ground in 1946: they had all been in it together during the war, and now they needed to be together in insuring health care for all. We do not have that kind of history, and it shows.
Suffering, disease, and death are our common lot. They ought to be dealt with as our common problem. It is a shame that the kind of empathy and mutual support that Adam Smith understood to be a requirement of morality have not, in our culture, been extended to health care—extended to one another in the recognition that we all have bodies that go awry and fail. Instead we are offered a consumer model, a national Walmart of medical choice where we are all sharp-eyed purchasers getting the best possible deal for ourselves. A construal of the common good as the freedom of consumers to get what they want, indifferent to the fate of others, is a cheap substitute for the real thing.