Thursday, November 07, 2013

What Some Kansans are Saying about Health Care

I haven't written a post about health care in America, and more particularly the Affordable Care Act, in a long time. I've mentioned it, sure, but usually in connection with the Supreme Court, or the Obama administration, or some other related topic--I really haven't tried to dig deep into the wonky details or the theoretical arguments over what kind of health insurance the American people need or deserve since 2010. And in that, I suppose I'm like most Americans: exhausted by all the policy arguments once the Affordable Care Act became law. Now, I keep up with the travails of the ACA in political campaigns and legislative scrimmages, and I'm aware of how President Obama has gotten himself locked into a lie of his own making with his claim (in retrospect, an obviously ridiculous one, at least to anyone who knows anything about how profit-minded insurance companies operate and respond to changes in the law, as Obama himself has now admitted) that "people can keep their current insurance coverage if they like it"--and of course, with Kansas's own former governor, HHS Secretary Kathleen Sebelius, in the congressional hot-seat as representatives from both parties score points in the wake of the horrendous roll-out of the online state insurance marketplaces which the law requires, the jokes and complaints and attacks on her and the ACA are pretty common in these parts. But substantive discussions about what's going wrong and what's going right, and how get the current state of health insurance to where we want it to be? That's hard! Much easier to just call the person you disagree with stupid and let it go, right?

Well, recently I was invited to participate in a local symposium on health care, framed around the question of what the "just" or "merciful" distribution of insurance coverage would be. It was put together by some people associated with Northfield School of the Liberal Arts, a private academy which provides, from my observation, an education which is a wonderful mix of the deeply traditional and the experimentally radical. It brought together pastors, scholars, surgeons, health care professionals, and businesspeople from around Wichita, all of whom had the opportunity to make their case and interrogate one another. Of course, it was thoroughly Kansas crowd; most of those there were quite hostile to what they always called "Obamacare;" I think I may have been its only defender, and even that was expressed by way of a defense of its legitimacy, not its wisdom, about which I've never had high opinions. (It may be worth noting that the two actual doctors present were somewhat unique in both thinking that the ACA will ultimately be of little real consequence in terms of the availability of insurance or the long-term problem of rising medical costs--they think the whole national debate is rather hysterical and silly, in fact.) Overall though, it was a great evening of discussion and argument, one that left me both educated on some points and wanting to talk more about others. (The organizers of the symposium were very strict on keeping time!) So consider this my own attempt to get in one last response:

1) While I greatly respect the pious efforts of many of my fellow Kansans to employ scriptural and theological arguments in order to advance their particular perspectives on what justice and mercy actually mean, I find their positions both simply confused. There is a tendency--and perhaps this is emblematic of a certain kind of conservative white evangelical Protestant Tea Party thinking--among some of my fellow citizens to identify "justice" with the operations of the capitalist marketplace and the minimal rules (like property rights) which such markets require; in their minds, therefore, the original, limited government, 10th-amendment respecting Constitution was a more perfect instrument of justice than what we have today, with the government attempting to involve itself in the distribution of "mercy," which needs to remain the province of God. But the idea that attempting to impose rules over the distribution of access to health insurances is intruding upon either God or one's fellow man's opportunity or jurisdiction to act mercifully is, I think, an indefensible stretch, both logically and scripturally. Of the many holes which can be punched in this claim--that it presumes a kind of zero-sum approach to being merciful; that it makes unsupportively broad assumptions about the actual historical relationship between the Constitution, capitalism, and Christianity; and so forth--the most obvious is simply that, by that definition, free market distributions of goods also interfere with the provision and/or the experience of mercy. How? By doctors charging distortive fees for their services; by insurance company policies discouraging businesses from hiring people with pre-existing conditions; by hospitals giving incentives to medical personnel to specialize in ways which empty out the pool of providers of certain kind of basic services; etc., etc. If anyone has been building an idolatrous Tower of Babel when it comes to the matter of health care, it's not--or at least it's not just--the Obama administration with the Affordable Care Act; the shareholders and CEOs of Blue Cross Blue Shield and Aetna and Community Health Systems all got their first.

2) Related to the above point, there is the position that, while the involvement of the government in laying down rules regarding the provision of affordable health care services--or sometimes (Medicare, Medicare, VA hospitals, etc.) actually providing those services themselves--may not be idolatrous in some specific theological sense, it still depletes communities of the kind of affective, charitable responsibility which local Christian churches historically took responsibility for, and by rights ought to be able to continue to do so. This is an argument which I respect much more than the previous one, and which I think, unlike the straightforward religious claim, has an important principle behind it. Patrick Deneen elaborates on this point (while expanding it to include education as well as health care) here, and he's only one voice among many. I still find the argument unpersuasive though, and only in partly for the obvious reason that, by many (though perhaps not all) measurements, the "outsourcing" of charity to the state has enabled the concentration and develop of great medical resources to the blessing of many: "one result of the increasing separation of the Church from these practices has been a bounty of benefits deriving from an increasingly scientistic and utilitarian pursuit of each." But even more important than that qualification is the fact (long forgotten by many, but thoroughly explored by scholars like Lew Daly, whose wonderful book God's Economy I reviewed here) that throughout the 19th and early 20th centuries, Christian churches and other charities were themselves among the primary agents for organizing the democratic demand for government to formalize these responsibilities through the establishment of welfare policies. Why did they do this? Primarily because, as societies across Europe and North America urbanized and secularized and became more mobile and individualized, local and rural churches and charities found themselves simply overwhelmed by the problems of alcoholism, child abandonment, unemployment, inadequate nutrition, physical and mental handicaps, old-age poverty, and more. Obviously, what I'm talking about here is the progressive movement and the Social Gospel: whatever other intellectual developments inspired it, the breakdown of the agrarian order of local charitable provision and the Christian demand that large-scale coordinated efforts be created to assist with such was a major part of that transformation as well. And as I've long said, progressivism is a deeply problematic ideology...and yet, if such state-based, redistributive solutions are the only viable ones available, they shouldn't be dismissed simply because they don't conform to some localist/socialist/populist/Christian ideal. (After making this point about how churches themselves pushed for greater state involvement, one fellow--who is actually a very open-minded local pastor--asked me, with a knowing gleam in his eye, "And how is that working out for everyone?" I should have promptly responded, "Well, it's not without a large number of its own problems and perverse incentives...but then again, if you're a Social Security or Medicare recipient, or have spent any amount of time in VA hospitals, the evidence seems to be: relative to how old people and veterans were doing in the 1920s and 30s, it's working quite well!")

3) Finally, there were some at the symposium who eschewed deeper talk about the proper role of government or the meaning of mercy or the eclipse of localism, and instead focused on some comparative nuts and bolts regarding the system of distributing health care coverage under the Affordable Care Act. The symposium took place in the midst of the disastrous roll-out of the state insurance exchanges and, and so predictably there was a great deal of conversation--and mockery, and "told-you-so"s--regarding the impossibility of constructing a website that could handle all these customers, require from them all this information, and then present them with all the various options for satisfying the laws requirement to have insurance. As my family and I have coverage through Friends University, and as there's no indication that the ACA will require any changes in the policies which my employer provides, I'm not one of the 10 million or so people who aren't on Medicare or Medicaid, who purchase their insurance plans individually, and thus are now obliged--because of the cancellation numerous previously rock-bottom cheap plans, now forbidden under the ACA--to buy a plan through But, just for the sake of the experience, I went to the website, and went through the application process. It took me 40 minutes before I could start to look at plans, and even then the process wasn't complete, as the website told me it couldn't verify my income, and thus determine what sort of subsidies we'd be available for when it came to choosing plans. So, a headache, to be sure.

But do such headaches themselves constitute an argument against something? They may or may not, I suppose, depending on what you arguably get out of those headaches. (Everyone agrees that the Department of Motor Vehicles is a headache, and yet I don't see that translating into a widespread resistance to the idea that drivers ought to be required to register their vehicle and pass a driver's test.) There were individuals at this symposium who presented the changes which are going to be forced upon individuals, businesses, and organizations because of this law, and--comparing us negatively to the United Kingdom or other countries with much more fully socialized health care systems--argued that these were changes which Americans ought not have to put up with. My response to that was simple: the Affordable Care Act was a political redirection of the health care market, and as in any marketplace, there will be those who are advantaged and those who aren't. The political campaign at the heart of the passage of health care reform was the insistence upon coming up with a way to provide affordable health coverage to those who previously could not get it (which is happening)--and if, as a result, the costs and availability of such for those who previously were able to get it comparatively cheaply changes, well, that was a political trade-off. You can oppose that trade-off, and obviously millions do--but such trade-offs are not some kind of illegitimate crime against the "natural laws" of the marketplace, or some un-American scandal. They are the consequences of democratic choice.

Does that mean that people like me who accept that sometimes progressive solutions are the most egalitarian we can get simply have to defend Obamacare, lock stock and barrel? Not in the least. If anything, the complicated mess which the difficult road that the ACA has traveled--and has yet to travel--needs to be taken to heart by all of those of us who view health care as a good which demands more equal distribution. We have to continually point out that the particular trade-offs which we have today are the result of America's "kludgeocracy," of our willingness to generate ever more neoliberal and technocratic bureaucracies so as to administer, as Ross Douthat put it, "notionally decentralized means [of achieving]...essentially centralized ends." The failure here was a political one, one that was unable to make a more straightforward case for either leaving something entirely local, or to recognize the statist costs of progressive solutions and being honest about them. At least then we could legislate less disingenuously! Mike Konczal makes this argument, and Timothy Burke does too; as the latter put it: "Why struggle so hard to craft the ACA and protect it from political backlash, why make legislation which could so easily be painted as a labyrinthine mess of contradictions and confusion because it is a labyrinthine mess of contradictions and confusion, when there was ample evidence that a solid majority of American voters would support a simple strong regime of mandatory cost controls and something rather like a single-payer system?"

There's a thousand good reasons why such determined expression still won't make any political difference. Yet, we have to keep trying--and you never know: sometimes, they may work. After the symposium had ended, and we'd made our final comments, I was talking with the same pastor I mentioned in #2 above, and he confessed to me that the most merciful, most Christian health care regime he'd ever experienced was when he and his family lived for a time in Australia...which has a single-payer system. Private insurance was available, but they never needed it, as their version of Medicare was more than adequate to their needs. Some conservatives will have their various religious or Constitutional arguments against such schemes--and other, smarter--but still, I think, incorrect--ones, will claim that the downside in striving for both affordability and equal availability of health care is the loss of capitalist innovation in matters of health. That, however, is--again--a political decision about distinct policy aims. And sometimes, when you get together a patiently talk and listen to what others are saying, democratic discussions can actually move our understanding of one another forward. It happened that night at Northfield, for me at least; hopefully, it happened for others as well.


Withywindle said...

Adam Smith, commutative justice, critique of distributive justice. Perhaps a bit more of a genuflection in that direction?

Withywindle said...

Was "mercy" their word, or yours? It seems inappropriate, but I won't belabor the point, unless (ahem) you chose it.

Russell Arben Fox said...


Adam Smith, commutative justice, critique of distributive justice. Perhaps a bit more of a genuflection in that direction?

Frankly, I think we genuflect in the direction of Adam Smith far too much already.

Was "mercy" their word, or yours?

Theirs. The organizers' framing of the whole matter of health care was an obvious nod towards Micah 6:8; something along the lines of, "In the matter of providing health care to our fellow man, how may we as American citizens both act justly and show mercy to those in need?" For what it's worth, I actually came to the event ready to argue that the justice-mercy dyad is a poor one to make use of when talking about--as Americans have been intensely over the past five years--making health care more affordable (and thus available) and/or extending health insurance coverage. To my mind, that topic just doesn't map onto those kind of philosophical or theological ruminations; it is, I think, instead a question of citizenship, and what common goods we should (or shouldn't) feel obligated to address publicly. But then, as I mentioned in 1) above, those who spoke before me got onto the idea of equating the free market as "justice" and government regulation as an infringement upon the divine gift of "mercy," and the question of public goods was lost for the night. Still a good conversation, though.

Withywindle said...

I think you might like Smith more than Smithians. I do encourage a return to the recent literature on him. But let me rephrase slightly: some of what you present as unthinking strikes me as a latter-day variation of Scottish Enlightenment thought, and that you might approach your interlocutors more sympathetically with that framework in mind.

When next you walk the wild prairie, try out the Smithian word "benevolence" on Parties With Tea and the other braves.