Tuesday, March 09, 2010

Lessons for the Health Care Debate from the Tragedies in Haiti and Chile

One of the principle lines of argument from the Republicans in the President's health care summit a few weeks back is that universal health insurance, especially health insurance that covers what people will need from health insurance is an affront to personal freedom. We ought to have the right, they argued, to forgo health insurance or choose to have something that is called health insurance, but would not function like health insurance in the case of illness, pregnancy, or injury.

There are two arguments given for this position. First is the libertarian line, that maximal freedom is an end in itself, that it does not matter how helpful the government mandate is to the individual, that it is a mandate itself is the problem. The second grounds for opposing universal coverage is the radical capitalist view that such a mandate (especially if coupled with a government run option) interferes with the functioning of the free market and the market forces will always in every case bring about the best results for all because it is the only way to actively balance the interests of all concerned.

Both of these positions are flawed and the problems are easy to pick out when we consider a different topic, the earthquakes in Haiti and Chile. The Chilean quake was hundreds of times more massive and yet did much less damage and claimed many fewer lives. Why? There are, of course, several overlapping causes, but one of the most important was government regulation. In Chile there were strict guidelines and building codes requiring homes and offices be built to specifications that made them sturdier in the event of a natural disaster like this. In Haiti, this was not the case. The difference in results is stunning. In this case, government mandates saved lives, saved money, and improved the prospects of those dealing with the aftermath.

This, of course, would not have happened without the governmental regulations forcing it to happen. Human beings are not the purely rational self-interested agents that the Enlightenment picture used by the libertarians holds us to be. We are short term thinkers. That is just how we are wired. There is a passage in Aldo Leopold's A Sand County Almanac which recounts what happened when the government repealed its requirement for windbreaks between fields. Farmers who were staring down the banks, who were on the verge of losing their homes, their livelihoods, their family lands because of erosion of the top soil during the dust bowl quickly undermined the thing that would keep it from happening again just for a few more square feet to plant. They saw what happened to their neighbors and what almost happened to them, but the short term gain won out over the more rational long term gain. In the case of natural disasters and health care, that means that we know what people will choose by in large and it is not that which brings about the best result for them or the society at large.

Further, we see that this propensity to irrationally prefer less advantageous short term benefits will affect the workings of the marketplace. If we look to market forces to bring about the best possible distribution of goods and services at the most rational prices, then these forces will be undermined. The market will in fact create conditions which harm, rather than help those in the market and the wider society because we do not take long term or catastrophic risk seriously and we are wired to take irrationally rosy views of our prospects, confusing our wishes for likelihoods. These errors strike at the heart of the neo-classical capitalist worldview underlying the conservative claims.

Problems with our health care system and how we pay for it is now at or approaching crisis level and indeed those who ignore history are in fact doomed to repeat it. We should heed the warnings of the dust bowl and the recent earthquakes. If we all strive to maximize human well-being, then we will have to be concerned about protecting civil liberties. The underlying premise of the libertarian view is correct that human flourishing requires a great degree of personal freedom. But the problem comes when freedom itself is made abstract and turned into an idol, when it becomes an end in itself and not a means to living maximally human lives. Because we live in organized communities and because there are times when we are better off being protected from our own worst elements, there is a place for making sure that we do what we should do. Human freedom, or at least the exercise of it, requires a cultural context in which we are (a) alive, and (b) have the material means and social and physical infrastructure to make plans for growth. Both of these preconditions need protection. We have to limit our freedom in certain ways in order to make sure we have any.

If we learn nothing else from current events, it will hopefully be that these spurious arguments about freedom should not keep us from doing what we need to do to fix our health care system and insure all Americans.