[In response to today’s extreme social/political polarization, I’ll be writing a series of articles over the next year that take front-page-news issues and address them from a big-picture, systemic perspective—from above the partisan fray. My intent with this series is not to get people to be kinder to each another — though that would be a nice side benefit. Rather it is to help make clear that questions of all sorts today are requiring of us greater maturity and perspective, this just if we are to ask them usefully much less arrive at effective answers. This first piece in the series addresses the health care delivery debate.]
As Republicans take on redoing health care, it is hard not to chuckle. I would were the likely results of their effort not so unfortunate. But my focus here is not whether a new plan could be of benefit, but rather the curious inability of politicians of any stripe to fully recognize the complexities that efforts to address health care delivery necessarily confront. Being that much in those complexities reflects more general challenges new to our time, we can learn a lot by reflecting on them.
In recent decades, politicians on both the Left and the Right have treated health care reform as low-hanging fruit. They’ve assumed that answers were generally straightforward and that people would be broadly grateful for their efforts. At the beginning of her husband’s administration, Hilary Clinton quickly found that neither was the case. Barack Obama succeeded in passing some limited legislation, but in the process used up a major portion of his political capital—I suspect much more than he anticipated. Today Republicans propose tearing up that legislation and again starting from scratch. As with previous efforts, they will likely discover not low-hanging fruit, but conundrums that leave them the ones hanging.
I think of three factors that make the health care delivery challenge much more complex than people assume. The first is the fact that health care is not ultimately an economic commodity. In the end it is a “moral commodity.” If some people in a society make more money than others, while that that may be unfortunate, it is part of the price we pay if we want a free market economy. But if certain people have ample health care and others the bare minimum—or none at all—that is a moral problem, and possibly a moral tragedy. And it is not just those who suffer directly who become less well as a consequence, but ultimately all of us.
The second factor is also moral, but here we confront a more specific moral quandary. I’ve written extensively about how addressing the health care delivery crisis will require a maturity in our relationship to death that we have not before been capable of. The reason is not complicated. Health care costs are spiraling uncontrollably with no obvious end in sight. It is easy to ascribe blame, but what we see is for the most part a product of modern medicine’s great success. Early innovations like penicillin and sterile technique were cheap. Each new generation of advances gets more expensive.
Both liberals and conservatives react to the word “rationing” as if it reflects some ultimate evil. But if we are to stop spiraling costs, eventually we must limit health care, and not just care that is of questionable value, but care that is of real benefit. That means in effect choosing who will live and who will die. I’ve proposed that in time the health care delivery crisis will make other death-related conundrums like abortion and assisted suicide look like child’s play (see How the Health Care Delivery Crisis Demands a New Maturity in Our Human Relationship with Death).
The third factor that makes addressing health care delivery more complex than we might think is our current, highly polarized political climate. Extreme polarization leaves us vulnerable to making dangerously short-sighted decisions. At the least, we risk basing policy more on ideology than thoughtful consideration. Worse, very often we see decisions driven by little more than the need to feel that our favorite side has won.
Liberals today tend to idealize the Affordable Care Act—ObamaCare. While I think of the ACA as a positive achievement, I also see it as a minor one, not at all some ultimate answer. It addresses access to care, but only for about half of the people who before lacked it. And in spite of its name, it does little of substance to address health care costs. Liberals should also remember that the model for much of the ACA was a Republican plan, the program Mitt Romney instituted in Massachusetts.
Now Republicans want their own plan. From what I have heard thus far, they have only the most limited appreciation for the complexities involved. Yet most want to move forward as quickly as possible. Their desire for something different is based in part on differing values. But I suspect the motivation behind these efforts is as much the need simply to have a plan with their name on it. They should be wary of what they wish for. Notice that I have not included any of the more obvious complexities that the best of political planners generally do recognize. I didn’t mention the complexly interwoven and often-conflicting needs of hospitals, insurance companies, drug makers, and health care professionals. Neither did I mention the inherently unpopular economic reality that if we are to have greater access to care we have to pay for it—either through new taxes or through mandates that force healthy people to buy insurance. And on top of these additional complexities, any significant change effort also faces the major transition costs involved in tearing down one relatively workable system and replacing it with another.
When we look at the big picture, we see that it is wholly predictable that the health care delivery crisis would prove a political minefield. We also see that the factors that have made the health care delivery question so crazy-making can only get worse. Republicans today risk taking ownership of a ticking time bomb. Likely their safest strategy if they were thinking only politically would be to leave the ACA in place. It is only a matter of time until it becomes too expensive to tolerate—not because of flaws in the program but because of circumstances that would confront any program.
I think of the health care delivery crisis as a key example of a phenomenon we see increasingly in all part of our lives: challenges that require new levels of human maturity. Successfully addressing it will demand greater moral maturity. It will also demand a mature acceptance of social and political complexities that before now would have overwhelmed us to contemplate.
The health care delivery crisis is a crisis we have no choice but to ultimately take on. Effective health care delivery is essential to a healthy and vital society. The best approach for politicians who want to provide real leadership going forward would be to reopen the health care delivery conversation in a way that includes all the complexities that I have described. Few people are yet ready for what doing so asks, so this is not likely to happen soon. But reflecting deeply on what this critical cultural challenge will ultimately demand is becoming increasingly essential.