Posted on April 8, 2010 - by David

Health Care Reform and Impossible American Ideals

Since Barack Obama’s election in November of 2008, health care reform has been at the center of our nation’s attention. This debate has been almost inseparable from discussion of the ongoing economic crisis, both because of the question of what effect reform measures might have on the economy, and because many individuals are unemployed or making less money and cannot afford health insurance. Naturally, because the most visible players in this game are politicians, much of the discourse surrounding the health care debate has been boiled down to Democrats vs. Republicans, or, (to essentially say the same thing twice), liberals vs. conservatives. Obama and the Democrats have been demonized by their opposition as socialists instituting a totalitarian regime, and the responses of those pushing for reform have not been much kinder.

As we all know, the new legislation has been passed, and with the sounds of celebration on one side and apocalyptic lament on the other, it still seems easiest to conceive of this issue in terms of a conflict between two political parties or groups with opposed economic interests. It strikes me, though, that there is a more basic and more powerful force driving this debate, and it goes straight to the heart of what it means to be an American. This is the contradiction between our two supreme national values: liberty and equality.

The chapter on America in Liah Greenfeld’s Nationalism: Five Roads to Modernity, provides an excellent analysis of how conflicting ideals of liberty and equality have shaped the nation’s history and identity.

“It must be realized that individualistic-libertarian nationalism sets itself an impossible task. A nation, ideally, is a society composed of individuals equal in their human worth. But in fact such perfect equality cannot be achieved. The reality of an individualistic nation and its ideals are necessarily inconsistent, and this inconsistency breeds discontent and frustration.” (449-450)

Before America was truly a “nation,” (according to Greenfeld’s careful account this was not until after the Civil War), and in fact even before independence from England, liberty and equality existed here to a greater degree than in any country across the Atlantic, conferring on the individuals who experienced these values an unparalleled sense of dignity. Of course, despite rhetoric about the natural birthrights of all mankind, initially only white male land-owners could enjoy these rights. The inconsistency between social reality and the professed ideals would inevitably have to be confronted. Greenfeld writes of the decades preceding the Civil War:

“That equality in American society had advanced beyond anything imaginable elsewhere at the time cannot be disputed. But the American society was also committed to equality to an extent that was unimaginable elsewhere. Thus, while the reality in America in this regard was incomparably better than in any other society, the gap between it and its brilliant ideal was nonetheless wider.”(452)

“Inequality inherent in social reality was blatantly inconsistent with American national commitment. In a society which believed that “all men are created equal,” the denial of equality meant that one was not human, was less of a human than others.” (453)

Of course, slavery, the most blatant contradiction of the national principles, was eventually abolished, and, though it took almost another 60 years, women were given the right to vote in 1920. In many ways, the course of American history can be characterized as an attempt to close the gap between social reality and the national ideals. But there is an important distinction between equality of rights under the law and equality of conditions. Equal rights can be, to a large extent, provided by government, but they cannot guarantee that conditions will be equal. On the contrary, in a free society where individuals are not only able, but expected to achieve for themselves what they can, inequality of conditions will necessarily result. Even if we admit that “all men are created equal” does not mean that everyone is born with the same natural ability, Americans still desire equality of opportunity – the sense that we all start on a level playing field, that achievement will not be dictated by inherited wealth, geography, or social connections. But common sense and observation tell us that equality of opportunity is not achieved through equality of rights. The federal government, then, becomes a means of creating equality of conditions:

“In a society which sets great store by equality, economic inequality acquires a significance which goes beyond the effects of differences in material well-being. It is necessarily seen as unjust by the “have-nots” and is perceived as an affront to their dignity, because it belies the proposition that all men are created equal and have equal rights to life and happiness. Equality in liberty (that is, self-government) becomes less important in such situations. In fact, rather than being regarded as an absolute good, it is likely to be seen as a tool for the perpetuation and concealment of existing inequalities. Liberty is infinitely divisible; other goods are not. An increase in the liberty of another does not imply a proportional decrease in one’s own; increase in another’s share of a finite quantity of something, whether power or wealth, does. When these resources become scarce, the demand for equality of opportunity, dignity, and respect commensurate with one’s abilities gives way to the demand for equality of result. It is clear that equality of opportunity, which does not provide for the equality of result, would appeal more strongly to those who have the qualifications necessary to realize the opportunities open to them. It is also clear that in the early American society, actually characterized by equality of conditions, equality of opportunity would be generally acceptable without special provisions for the equality of result because it would appear that the latter was implied, inherent in the former. But when actual equality of conditions no longer obtains, the provisions for equality of opportunity only (the legal equality of rights) must appear unsatisfactory. The transformation in the nature of desired equality began to be evident in America in the 1830s. It initiated the transformation in the perception of the functions of the government: government as essentially a protective agency (guarding against encroachments on the people’s rights by others) no longer appeared sufficient; there was a feeling that it should act as a distributive agency. This, in turn, affected the attitudes towards centralization, making it acceptable and even necessary.” (439)

We know that equality of health care does not exist, and this bothers us. It is difficult to accept that some individuals might be held back from achieving their goals or providing for their families, that children might not grow up to enjoy life on earth to the fullest, because they could not afford a treatment that millions of others receive. At the same time, we understand that health care is not an infinite resource – many opponents of the new legislation who are more or less satisfied with their current health insurance fear there will be “rationing” of care. This idea is offensive to the American mind, because it limits the individual’s ability to obtain the level of care he has worked hard for. Those wealthier individuals who currently enjoy a high level of care also fear having to pay a greater portion than others in order to fund a system which threatens to limit their choices. Can coverage be expanded without also being limited? It seems some must give more so others can receive more. While the goals may be liberty and equality, this legislation may actually send a contradictory message. If some people experience a reduction in their level of care, does that tell them that hard work doesn’t pay off after all? Does providing coverage to the uninsured send the message that they are unable to provide for themselves?

Of course there are also serious concerns about how this health care bill will impact the national debt. If the nation’s commitment to equality results in a worsening of the economic situation, liberty and equality will be put at further risk.  But the supreme value we place on the individual life, and the belief in equal access to all forms of treatment as a fundamental right, may prove to be dangerously expensive. In a March 31^st article from the New England Journal of Medicine, Dr. Molly Cooke says it’s time to give up the old lie that doctors give 100% to each and every patient, and advises that considerations of cost must be taught in med school:

“…we must abandon the myth of the physician as single-minded advocate for any amount of benefit for every patient. We make all kinds of choices in caring for patients; some involve denying care that patients perceive as — and that might actually be — beneficial. Given that we make value-based decisions about the deployment of other finite resources, such as our time and the use of beds in the intensive care unit, why not about costly treatments? In fact, numerous studies in the United States and Europe confirm that bedside rationing of care is common practice. Problematically, it is done in an occult and unpredictable manner.”

Practical as this sounds, I think these are tough words to hear for most Americans. When it comes to health and life, the idea of dollar-value calculations is extremely distasteful to us. It is not that we are fundamentally opposed to the idea of discontinuing care or deciding against a potentially beneficial treatment. It makes perfect sense to us when a family decides it’s time to “pull the plug” on a relative whose chance of recovery is virtually non-existent. We don’t question the cancer patient who finally elects to move home and receive hospice care rather than undergo another risky and painful surgery, even though it could buy him some extra time. We accept these decisions because they are made on the basis of individual dignity and liberty. Of course, with advances in medicine and technology our options are constantly multiplying. That any of these options might be denied to us on the basis of cost almost amounts to cultural blasphemy, but this may be the reality.

A New York Times article published online yesterday also acknowledged the impending cost crisis in health care. Author David Leonhardt identifies some of the same cultural values I mentioned above as obstacles, but is hopeful that reform measures which require that patients be provided with more information may actually help to keep spending down:

“The health act requires Medicare and other agencies to help hospitals and doctors give patients more information — which is practically a no-lose proposition. In the course of receiving more control and more choice, two distinctly American values, patients will probably help hold down costs.”

Whether or not this proves to be true, it’s interesting that this potential solution still relies on the sense of individual liberty and dignity.

My intention is not to guess at whether or not health care reform will work, but to suggest that the principles driving this national debate are older than the nation itself. In an introduction to President Obama’s speech following the historic signing, Vice-President Joe Biden told us that, “For much too long, for much too long, Americans have been denied what every human being is entitled to — decent, affordable health care.” I am sure that 200 years ago, no one in the nation could have imagined health care as a basic human right, but the identification of the American value of equality with basic human rights would have made perfect historical sense. For better or worse, it seems America will keep striving to create a world that matches our impossible ideals.