Sunday, August 9, 2009

American Values and Health Reform (1): Responsibility

This spring the Hastings Center published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to go beyond the dizzying area of sound bites and legislation in progress to consider what we want health reform to accomplish and what values our institutions and practices should be built upon. In my view the publication (which I contributed to) can be useful to the health reform process. This post is the first of three I’ll do based on the Hastings Center project.

My assignment was to discuss how the value of “responsibility” relates to the health reform debate. As I sat down to write the piece my mind drifted to a movie I hadn’t seen for at least twenty years – “Shane.” I got a copy from the local library and brought it to my office, hoping colleagues and students wouldn’t discover me watching a cowboy film.

My association to “Shane” was on target. In the film little Joey Starrett is torn between two icons of responsibility – his father, Joe, the homesteader, and Shane, the mysterious cowboy gunslinger.

Joe and Shane embody the two poles of responsibility in U.S. moral discourse. Joe exemplifies responsibility as social solidarity – building a caring community that takes responsibility for the welfare of its members. For homesteaders like Joe, the emblem of responsibility is barn-raising, in which the community bands together to help individuals meet a basic need. Shane exemplifies responsibility as individual action. For cowboys like Shane, the emblem of responsibility is the six-gun and the knowledge of when and how to use it.

Our love affair with the myth of the heroic cowboy enhances the attractiveness of market-based health reform proposals. In place of the cowboy these proposals envision a heroically empowered “consumer,” motivated by “skin in the game” and armed with knowledge, who strides into the marketplace to make choices of high-quality, low-cost health care, in accord with their own values. The empowered consumer stands tall and takes orders from no one. This constellation of values is being used to whip up the frenzy of disruptions we’re currently seeing in town hall meetings around the country. The would-be Shanes shouting at their representatives and even threatening death represent the value of individual responsibility run amok.

Proposals that emphasize universal coverage – like the single payer plan and variants of the Massachusetts program – are enhanced by the myth of an Edenic, barn-raising frontier. The single payer plan envisions a society that pools its resources to minister to the health needs of each member of the community. The Massachusetts plan plays down the communitarian ethos of the single payer approach by (1) requiring each individual to buy insurance rather than requiring contribution via taxes and (2) gives the individual a range of insurance choices. (see here, here and here for discussions of the Massachusetts program.)

One reason the Massachusetts plan has attracted so much attention nationally is the way it addresses the deeply rooted American standoff between the proponents of individual responsibility (Shane) and societal responsibility (Joe Starett). The architects of the plan like to point out that it requires everyone to take responsibility. Individuals are required to purchase health insurance, but are free to choose among a large number of private ("nongovernmental") plans. Employers are required to contribute. The state is required to pay for those too poor to buy their own insurance. And if the state's recent recommendation goes through, providers will be required to form "accountable organizations" and work within budgets.

In his inauguration speech, President Obama invoked responsibility as a major theme - "What is required of us now is a new era of responsibility - a recognition, on the part of every American, that we have duties to ourselves, our nation and the world." It sounds as if the President wants to side with both Shane and Joe Starrett. Whatever emerges from the national health reform process will almost certainly have to find ways of integrating the virtues of Shane and Joe!


Anonymous said...

Mainstream Americans fear the single payer approach because it concentrates too much power in the hands of a single monopoly. Images of "Big Brother" come to mind, and the way congressional leadership avoids addressing these concerns gives credibility to their fears. Some of the circulating rumors are ridiculous, but there is good reason for people to think twice. When they are dismissed as "un-American" without a proper substantive response, it just feeds their anger, and the rush to pass legislation without allowing time for careful consideration raises suspicions that there is something there that the leaders do not want the public to see.

I hate to see the good parts of this plan thrown out with the bad, but the concentration of power this would produce is too tempting to those that would hold control. No one knows that better than skeptical baby boomers who grew up distrusting authority in general and government and large corporations specifically.

Furthermore, a government that takes care of everyone, makes decisions for them and shields them from the consequences of their own folly does not promote responsibility, but rather dependence.

In this respect, a law mandating universal coverage with community rating, portability and elimination of pre-existing conditions does not need a public plan to achieve reform. However, the financial problems of Massachusetts must be addressed before the nation goes down that road. Thoughtful opponents will not be satisfied until they get substantive answers to these very reasonable questions.

eric said...

Dear Anonymous: I agree with everything that you say, except for an error of fact. Democrats have been proposing some form of national health care plan since 1948, not to mention the near-miss in the Clinton era. America is not being "rushed." America has been dragging its feet for sixty years.--Eric

Anonymous said...

Very true, Eric. I did not mean to imply that much effort has not been made to inform the public of the need for change. However, there is a lot of "devil in the details" and people (including myself) are concerned that there hasn't been time to understand exactly what's being proposed. When we learn that our representatives don't know what's in the bills, it increases this concern.

No legislator can sift through every page, but that's what they have staff for. Corporate executives would never be excused for ignorance of something this important. Laypeople can't understand some of the technical details, but if what's in the bill isn't explainable in terms that a reasonably intelligent person can understand, it's probably too complex and perhaps too detailed to be stipulated in statutory law.

Public anger turns into wildly exaggerated fears. Add to that the fact that the Democrats' proposed budget numbers don't add up and you have the present stalemate.

Jim Sabin said...

Hi Anonymous and Eric -

I'm sorry for the delay in responding - I've been out of the country for the last 2 1/2 weeks. (I did some posts in advance to keep the blog "alive"!)

I'm torn by Anonymous's argument. I agree that the issues deserve more time for reflection among our leaders and genuine public education and debate. The practical politicians, however, say that more time means more sloganeering, more "death panel" lies, and not more reflection and learning. This is the basic problem of how democracies tackle complex problems.

Anonymous's comment about public fears of "concentration of power" point to an important paradox. Our fear of a powerful "Big Brother" have led to laissez faire policies which in turn have allowed emergence of a VERY powerful "Fifth Column," in which multiple economic interests have taken over our health system and rendered the public powerless.

My hope is that the tremendously messy situation we're seeing will generate the kind of reflection and learning that Anonymous wants to foster. My fear is that what we'll see is one more victory for the "Fifth Column" and another five years of out-of-control spending, tremendous waste, and poor value for our money.



Chiropractic EMR said...

We need to engage in a deeper and more productive discussion about values so that reform is built on a solid foundation. The relevant values range from justice to liberty to responsibility to stewardship. These values must be placed in historical and philosophical context before we can determine the policy implications for health care reform of taking each value seriously.
Everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them.
Thanks for sharing