Sunday, August 16, 2009

American Values and Health Reform (2): Liberty

As I noted in a post last week, The Hastings Center has published eleven short essays as a small booklet – “Connecting American Values with Health Reform.” The aim of the project was to consider what we want health reform to accomplish and what values our institutions and practices should be built upon, based on the belief that more clarity about underlying values would allow legislators and the public to handle reform more effectively. This post is the second of three I plan to do based on The Hastings Center project.

Bruce Jennings, senior consultant at The Hastings Center, wrote about "liberty." In the context of the orchestrated hooliganism that is disrupting town meetings and the stunningly confused public fear that government involvement means euthanasia, Jennings's comments are remarkably prescient:
Values so ubiquitous [like liberty] are often taken for granted and not sufficiently scrutinized. They therefore have great political power yet are vulnerable to cynical misuse and manipulation...The health reform conversation has to be reframed at the grass roots level so that a new way of seeing what liberty is and what it requires will grow out of that conversation. (emphasis added)
The reframing of liberty that Jennings wants to encourage is to see liberty as freedom to, not simply freedom from:
Health care is not simply about preserving you from the 'outside' interference of others or of disease; it is also about obtaining the active assistance of others so as to enhance the types of activities you can pursue and the kinds of relationships you can have. Thus, health care is as much about positive liberty as it is about negative liberty.
The fundamental American skepticism about claims made by government and other authorities has largely been a force for the good. But as Jennings suggested, our attachment to liberty from external control is vulnerable to "cynical misuse and manipulation." That's what we're seeing now, as in this statement by Newt Gingrich about the allegation by Sarah Palin and others that the House health reform bill promotes euthanasia:
I think people are very concerned, when you start talking about cost controls,'re asking us to trust the government. Now, I'm not talking about the Obama administration. I'm talking about the government...We know people who have said routinely, well, you're going to have to make decisions. You're going to have to decide. Communal standards historically is a very dangerous concept...You're asking us to trust turning power over to the government, when there clearly are people in America who believe in -- in establishing euthanasia, including selective standards.
The President has tried to mobilize a sense of crisis about health reform, but thus far the true danger that runaway health costs will euthanize American prosperity does not measure up to the false claim that health reform threatens the lives of our citizens. A subset of the population that appears to hold a monolithic commitment to negative liberty - freedom from -is prepared to believe the Republican lie that an administration led by a "foreigner" is covertly preparing to kill its citizens.

Words like "insane" and "paranoid" are being used too casually. While there probably are a few clinically paranoid people among the hooligan protesters, my guess is that most are folks who would (a) get a "D" in a college ethics class because (b) they are unable or unwilling to see complexity among values but who (c) unlike lazy students are (d) prepared to be mobilized into a fascist gang disrupting public meetings.

Jennings's essential argument is powerful:
One tenet of [health reform] should be that equity in access to health care, reduction in group disparities in health status, and greater attention to the social determinants of the health of populations and individuals are all policy goals through which liberty will be enhanced, not diminished...we must see that health reform involves equitable access to the social preconditions of health, as well as to health care...that when anyone lacks such access the liberty of all is compromised.
His vision, however, won't silence the hooligan disrupters, especially as their fears are stoked by cynical politicians of the Gingrich/Palin ilk. But his analysis, and others, may help legislators and members of the public understand the otherwise perplexing frenzy we are currently seeing and turn against it.


Anonymous said...

Perhaps it is not that opponents of government health care are unable to see alternatives, but rather that they see alternatives not being considered by Congress.

Discounting orchestrated disruptive protests on both sides, I see nothing monolithic about the substantial number of what appear to be ordinary citizens very worried that they will lose access to the care they currently have. Congressional leadership is ignoring other possibilities in their rush to control. The public sees this and has given Congress a failing grade.

I doubt that this group of citizens, which now represents a significant majority according to several of the more reliable national polls, has much more in common than that they dislike what Congress is proposing. If one opened up all the possible choices, I expect that they would gravitate in smaller groups toward several different solutions.

We know that prioritization will occur. The only question is how. I think many members of the public would be more comfortable knowing that, if they disagree with the methods of their insurer, they could leave and purchase coverage from a competitor.

Ann Neumann said...

There are two problems with health care reform as it is being formulated: that opposition has been allowed to mislead the public on what the bill will do; and Obama's administration has given them credence. The bill allows for plenty of choice. No one will lose their current care. No grandmas will be killed. Anonymous above says that both sides are disruptive. Only one "side" is showing up at town halls with guns, Nazi slogans, and monkey signs. There is more at work here, as the writer notes, than simple opposition to reform. You are wrong to conclude that a majority of the population opposes this reform; they are simply misinformed, misguided, and egged-on by the medical corporations and power-hungry Republicans. Once again, erroneous nostalgia and corporate monopoly are keeping this country in the dark. Liberty indeed.

onlique estefan said...

President Obama has repeatedly said that a health care overhaul "will be paid for" and that he won't sign a bill that isn't deficit-neutral. But neither the House bill nor the Senate HELP Committee bill meets that criteria. According to the nonpartisan Congressional Budget Office and Joint Committee on Taxation, the House bill as introduced would add a net $239 billion over 10 years to the deficit, while the HELP Committee bill racks up more, $597 billion over 10 years.

Obama has also said he has "identified two-thirds of those costs to be paid for by tax dollars that are already being spent right now." But "identified" is the operative word. These savings are estimates and whether around $650 billion (about two-thirds of the cost of health care over 10 years) can be saved remains to be seen. Most of the money would come from Medicare, but cuts in payments to insurers and practitioners aren't popular measures that move easily through Congress.

Ashley Bowen said...

Excellent post, and thanks for pointing me to the work at the Hastings Center. I also appreciate that you are willing to take on the health care protesters not as "anti-American" but within the context of American dissent (that greatest of our historical values).

Reasonable people can disagree on health care and reform but they must come to the debate with clear ideas and reasoned arguments.

Jim Sabin said...

Dear all -

I'm sorry for the delay in responding. I actually wrote this post before heading off to Europe for 2 1/2 weeks and just got back yesterday.

Anonymous - I agree with your hunch that many Americans favor a system of multiple insurers because the multiplicity gives a sense of security through the possibility of changing insurers. In "Exit, Voice, and Loyalty" Albert Hirschman describes the alternative strategies of trying to exert influence within an organization as opposed to bailing out. My preference for health care is maximum use of "voice," since give-and-take, whether between patient and doctor or enrollee and insurer provide a better opportunity for mutual learning and quality improvement.

Re the degree of public fear of "Obamacare," I agree with L.A. Neumann that in large degree these fears are being fomented by clever, devious strategies and misinformation. This isn't surprising given the huge amounts of money at stake in any changes from the status quo.

I share Onlique Estafan's view that looking for savings in Medicare fees is a bad idea if it is done as it has been done in the past - blunt ratcheting down across the board. Some fees should go up substantially (primary care). Some should come way down (many specialty procedures). With regard to overall cost I continue to believe that there is enough money in the system now if we spent it more wisely. I've written about that topic in a number of posts.

Ashley - great that you've now been introduced to the Hastings Center. The Center shares your commitment to civilized debate and the expectation that one come to the process with "clear ideas and reasoned arguments." Unfortunately the salvos that boil down to what L.A. Neumann called "killing grandmas" is disinformation, not argument.

Thanks for your comments!



John Eley said...

While I welcome the Hastings effort on American values in health care reform, I have serious doubts that the route from assertion of values to the identification of policy alternatives is as direct as the various authors seem to believe. If values are valuable in the policy process their value is directly related to their ability to generate principles that can provide the basis for policy. In the current debate President Obama has done a good job keeping a focus on principles such as "the reform should lower costs" "no reform should result in higher deficits" "all who want to keep their current coverage can to do so". These principles provide at least some broad guidance that is more concrete than that provided by the values in the Hastings set. Many of them could be supported by persons holding very different values. I know from your work on Setting Limits that you are attuned to the idea of principles as guide to policies and I would encourage you to develop your ideas. My own modest efforts will begin to appear on my new blog that I am beginning to develop at

Jim Sabin said...

Hi John -

I agree with you that to be relevant for making policy, practical consequences have to be derived from the values discussed in the Hastings project. But the Hastings project had a different aim - namely, to explicate values that were invoked in health reform discussion in order to show the range of implications the values have. My "assignment" was "responsibility." Often it is invoked to condemn those who are "irresponsible," and taking responsibility for ourselves is a crucial part of a sensible approach to health. But historially responsibility also referred to a responsible, caring community, which suggests that our call for responsibility has a communitarian as well as an individualistic meaning.

Great to hear about the blog you are starting. Welcome to the world of blogging! I look forward to reading your thoughts over time.