Why It is Inevitable that the Debate over Healthcare Will be Partisan

Over at Healthcare Policy and Marketplace Reform, Bob Laszewski reports that “the extension and expansion of the State Children's Health Insurance Program (SCHIP) has now passed the full House and the Senate Finance Committee and is on its way to the full Senate where it will undoubtedly also pass and then be reconciled with the similar House bill.

“However,” he warns, “the way it is being done does not give me a good feeling.

“In the Senate Finance Committee the Democrats were only able to get the support of one Republican--Maine's Olympia Snowe--on the way to a 12-7 approval.

“They did not have the support of the ranking Republican, Chuck Grassley of Iowa.”

Laszewski is worried: “Senate Finance Democrats lost the support of the Republicans when they insisted on departing from last year's bipartisan agreement to leave existing policy on covering the children of legal immigrants as is. As it now stands, a legal immigrant agrees not to apply for Medicaid and SCHIP benefits for the first five years they are in the country. Under the new rules states would have the option of covering legal immigrants. The new bill also left out provisions from the earlier bipartisan comprise to limit benefits for higher income families.

“Without judging on the merits whether these two new provisions should have been in the bill, what the Democrats have done is moved away from earlier bipartisan agreements,” he points out, “ and in doing so lost moderate Republicans like Grassley who showed good faith in reaching an earlier bipartisan compromise.”

He concludes: “As I have repeatedly said on this blog, major health care reform is not possible unless it is bipartisan.”

Here I have to disagree with Laszewski.  Inevitably, healthcare reform will be partisan because it is all about social values—and our beliefs about what is fair.  Progressives tend to emphasize a collective vision of the common good. Conservatives are more likely to stress the rights of the individual.

From a progressive point of view, it seems only fair that poor legal immigrants should have access to healthcare, especially if they are children. They have done nothing wrong. And they need help. Some would say: “from each according to his ability, to each according to his need.”

Many conservatives would reject that sentiment as socialist dogma. “Why,” a right-learning business man might ask, “should I pay taxes to provide healthcare for every poor immigrant who comes to this country?  I have worked hard all my life. And if I have more ability than the next fellow, and so amassed a certain amount of wealth, why should I be penalized for that?  ‘From each according to his ability, to each according to his need,’ means that the strong are supposed to support the weak. I take care of my family, that’s my responsibility. But it’s unfair to ask me to support everyone else’s children. I didn’t bring them into this country.”

In many ways the debate about whether legal immigrants have a right to share in national healthcare is a perfect test case for the difference between the two parties. The debate is about values. Progressives and conservatives each are committed to certain beliefs about what is “right.”  When it comes to bedrock values, how do you split the difference? How do you compromise your values?

Ultimately, universal healthcare is not just about technical details. There, we can compromise. But it also is about what we, as a society, believe is ethically right. So the debate over healthcare reform should be a partisan debate.

In part two of this post, I’ll comment on Senator Daschle’s statement that, when it comes to healthcare reform, legislators should “be guided by evidence and effectiveness, not by ideology.”  Certainly, Daschle is right: medical evidence and science should guide our decisions about what to cover. But when it comes to who to cover—and whether we are going to continue to ration care according to ability to pay,  country of origin, or some other rule that divides “us”  into “me and people like me” versus “them,”—we are going to have to wrestle with “ideological questions”.

For many the word “ideology” has a negative connotation. During the Cold War we used “ideology” to refer to communism. Capitalism, by contrast, was not an ideology. But if you look at a dictionary you’ll find that the word is not as charged as the “Red Scare” made it seem.  An ideology, it turns out, is simply “A set of doctrines or beliefs that form the basis of a political, economic, or other system.”

Health care reform is about beliefs as well as science. We can try to sweep that under the rug, but I doubt we’ll get far.

Comments

[Gman]

http://opinionator.blogs.nytimes.com/2009/08/07/weekend-opinionator-a-sick-debate/

August 7, 2009, 8:13 pm
Weekend Opinionator: A Sick Debate
By Tobin Harshaw

Comments:
12. August 8, 2009 1:57 am
I have lived in Europe, the USA (NYC and FLA) and currently live in Canada. I am a reasonably well-informed financial executive. I make my living as a capitalist.

I wouldn’t know where to begin re: the health care debate but I will make a couple of observations:

1. The USA has the finest health care in the world — bar none — provided that you have a no-limit gilt-edged money is no object health plan. Or you are rich. In my experience the 2 go hand in hand.

Failing such insurance or such boundless wealth how any rational human being with an IQ over 75 and an income below, say, $250k (forget the social compassion argument) could defend the existing system is beyond comprehension.

2. The outright lies — yes lies — that critics of health care reform spew is disturbing. The intentional misrepresentation of the Canadian and European models is outrageous. The Canadian model is flawed. There needs to be greater access to ‘private-delivery’ alternatives (which currently exist in some fields.) Having said that, since I returned to the province of Ontario in the late 1990’s until now the improvement in standards and care is staggering and in most cases matches anything I witnessed or experienced in NYC. Yes, health care is rationed here (hence a need for ancillary private care) but it is rationed everywhere — including the US. The exception being as per point #1 above. Per capita Ontario spends approximately 65% of what the consumers/taxpayers of the US/NY spend. However Ontario delivers 90% — or more — of the US standard. That is one very big financial/efficiency/productivity gap. That money gap goes to the US insurance companies, doctors, malpractice lawyers and lobbyists. The common canard about Canada etc is that “faceless bureaucrats make life or death decisions” (as opposed to, say, faceless HMO clerks). The truth is that in Canada the ‘gatekeepers’ who allocate critical care are the physicians themselves — the specialists.

3. Aside from private-payment plastic surgeons it is true you will not see many doctors in Canada driving a Rolls Royce. But you will see an awful lot driving a Benz or a Jag. Doctors here work hard and are well compensated. What we lack here is the concept that a medical degree should be attributed Venture Capitalist returns.

4. Lastly, a general observation/question (again, I really am a capitalist). Why is it that in the USA (a country I genuinely love) millions of people who barely make a living or are working class and/or just holding on to the ‘middle class’ are the most vocal — hysterical wouldn’t be an exaggeration — in defending the privileges of the rich and the corporate? Against their own self-interest I might add. Anywhere else in the western world the existing US health care tyranny would have people in the streets demanding reform — not ‘debating’ it.

— jon c

[Tiviacuallona]

Great site this www.healthbeatblog.org and I am really pleased to see you have what I am actually looking for here and this this post is exactly what I am interested in. I shall be pleased to become a regular visitor :)

[Patrick Schoenfelder]

Maggie --

There is a difference between rational and irrational fear.

It is rational to fear drunk drivers, driving without a seat belt, walking down the middle lane of I-5, touching the third rail on the BMT, and having large numbers of people mixed in the population who cannot afford to get doctors' visits, antibiotics, vaccinations, and other basic health care -- again, regardless of race, religion, sex, or national origin.

It is irrational to fear women (well, most women,) African Americans,walking on cracks in the sidewalk, and foreigners.

One type of fear would be better described as "prudence," the other as "prejudice."

[Maggie Mahar]

Patrick--

It seems to me that the politics of fear always leads to hatred and prejudcie:

Fear of African-Americans; fear of Gays,
fear of immigrants; fear of Arabs (that Bush encouraged in his effort to create support for the war in Iraq), fear of withces (Salem) . .

Fear of women is, I would submit, at the bottom of misogyny in our culture.

Fear, it seems to me, is a very dangerous weapon. When people are afraid, many become mean.

You're definitely right about life-long academic careers . ..

[Patrick Schoenfelder]

Maggie --

Your response is an excellent example of what I am talking bout. You say Aristotle, I say Camus. You say Rawls, I say Illich. Lifelong academic careers are built on the fact that these arguments cannot and will not be resolved, only argued ad infinitum.

And yes, I say that public health and preventative medicine are important issues in arguing for comprehensive health care for everyone. It is an undisputable fact that people without access to health care are more likely to have untreated diseases than those who do -- regardless of national origin or immigration status. And in fact, public health policy is partly based on justifiable fear, but not on prejudice.

[Maggie Mahar]

Patrick and PM

Thanks for your comments.

Patrick-- I like the adage. But I have to disagree with your conclusions.

You write: "However, the problem with arguing ethics or morality of positions is that while we may agree on the ethics, and while our allies may agree on the ethics, ethics are of their nature a thing that cannot be assessed by scientific measurement or statistical analysis. All someone has to say is “I disagree,” and they are just as much right as you are."

First, the fact that certain ideas cannot be assessed by scientific measurement or statistitical analysis does not render them meaningless. As the sign in Einstein's office said: "There are some things that count that can’t be counted. And some things that can be counted that don’t count.“

Didn't the Jesuits ever have you read any moral philosphy --any ethics? John Rawls? Other commentators?

Simply saying "I disagree" does not make you "just as right" as Rawls, or Aristotle.

They have arguments. And they appeal to empirical evidence.

The history of what happens in societies that become increasingly decadent --and unjust-- is not pretty. Typically they are overrun by barbarians.

Perhaps the Jesuits didn't have you read secular philosphers, because they thought questions of ethics and morality are solved by faith? (But that doesn't sound like the Jesuits!)

Saying "I disagree" does not make one persons' point of view as good as another's. That type of ethical realativisim leads to nihilism. ("Definitoni "Ethical relativism" is a moral theory that holds that the moral good itself is a matter of personal preference, and therefore that everyone can have different moral rules – that is, that there is no such thing as morality at all.")

There are a great many things that civizlized communites have decided are simply wrong. Civilized societies have decided that torture is wrong.
This is why the majority of Americans are deeply troubled by what we have done to people who were simply accused of being terrorists. (See the excellent documentary film, "Taxi to the Dark Side."

Saying "I disagree"-- I think torture is okay becuause Dick Cheney says so" doesn't make you right. You need an Argument--and Evidence.
What happens to societies that allow torture? What happens to the torturers
themselves psychologically?

Many people believe that equal healthcare for all is a moral obligation that civilized societies have toward their memebers --it's a way of recognizing each other as equals--mortal and human.

One could say "But some people drive much more expensive cares than others. Why should they have equal healthcare?

Here the argument is that, unlike a car, healthcare is not a commodity. It is, a necessity. Without it, "life, liberty and pursuit of happiness" is not possible.

Moreover, to live in a society where we step over the bodies in the streets is dehumanizing for all of us.

You could say "I disagree"-

And I could point to studies of what happens to people in dehumanizing contexts . .

I think we should base our political arguments on what is right and just. Otherwise, we are reduced to arguments like:
"Do you want the people who are preparing your food and rubbing shoulders with you on the street to have communicable diseases that they cannot afford to treat?"

This is an argument that only feeds fear and prejudice. Illegial immigrants do not carry typhoid. We are not going to get sick and die by breathing the same air.

PM Yes, progresives believe that healthcar is a matter of social responsibility--society's moral obligation to its members; conservatives believe it is an individual responsiblity.

And you are right--people do not "buy" coverage; it is "sold" to them. This could be said of most healhcare: a provider (a doctor or hospital) tells you what you need.

People can begin to learn more about what they are buying, they can ask questions about risks and benefits.
I strongly believe in "Shared decisoin-making when it's appropriate.

But when healthcare consumers are making their most important decision often they are in pain, elderly and afraid.

The is why the health care provider--unlike other sellers--must put their interests first. "Caveat emptor" cannot apply here.

Moreover, even if one is middle-aged, not in too much pain and only somewhat frightened, the fact that I haven't gone to medical school means that I am going to have to rely on the provider to explain things that even he is not certain of.

The ambiguity and uncertainty of medicine is extreme; many things are not cut and dried. Much of what a doctor knows is intuitive knowledge --based on having seen, smelled or felt similar symptoms in other bodies.

Here, of course I am talking about the patient buying healthcare, not insurance coverage.

But the purchase of insurance coverage also exists in a realm of uncertainty: who knows what I will need? Will I, or someone in my family, ever need treatment for addiction? Will we exceed a $1 million limit in a given year?
And while insurance policies tend to be purposefully confusing, there are some things that they cannot be entirely clear about: often a procedure or treatment is covered under certain circumstances, but not others, depending on co-morbidities, etc. . ..
Bottom line, I think patients should be inquiring, but I also think that society needs to look out for us by setting up tight regulations for insurance, insisting that insuers only sell "comprehenisve coverage"--no holes-- and by having us pool our money so that whatever our fate, we are all protected against risk.

[Philip Micali of bWell-informed]

Healthcare coverage issues are, in fact, based on a beliefs. It is inevitably a partisan issue, given that Democrats feel at least a basic benefit coverage package is a social responsibility of government and the Republicans believe citizens should find their own coverage, if they don't qualify for an existing entitlement program (e.g. Veterans Administration, Medicaid, Medicare, Tricare - Military, etc.).

The problem is that coverage is sold to consumers and not bought by them. Whether there is universal health coverage in American, or we continue with the employer based and free market system for non-entitlement covered individuals, each citizen is responsible for understanding the coverage they buy, that is sold to them, or given to them.

At bWell-informed (www.bWell-informed.com) we find that people need it simply stated to learn the fundamentals. Once they get it, they can learn more detail, but not until that is done.

[Patrick Schoenfelder]

Maggie --

Law school adage: “If you have the law on your side, argue the law; if you have the facts on your side, argue the facts; if you have neither the law nor the facts on your sides, pound the table.”

Thanks for the detailed response.

As a victim of a Jesuit education condemned never to be able to enjoy myself when I know what other people are going through, I agree completely. I also agree that many, but not all, conservatives have forfeited the right to lay claim to the heritage of Burke and Hayek because of the policies they have maintained.

However, the problem with arguing ethics or morality of positions is that while we may agree on the ethics, and while our allies may agree on the ethics, ethics are of their nature a thing that cannot be assessed by scientific measurement or statistical analysis. All someone has to say is “I disagree,” and they are just as much right as you are. I know of people who believe firmly that any health care system that maintains anything of the profit motive and the capitalist system is wrong, and I understand that from within their own frame of reference they are right – as right as I am until I can marshal fact based arguments to support my position. I do believe that arguments about ethics are good ways to rally the faithful, and perhaps to assure the support of lower income people, people of color, immigrants, members of some religious groups, and others. However, I am afraid that in the long run there is a danger in emphasizing ethics as an argument that the argument will quickly deteriorate into the type of subjective argument that characterizes national debates over abortion and GLBT issues. Those are issues that will be resolved only when one side or the other manages to create a huge population advantage for their side.

For example, it is certainly possible to argue that legal immigrants and their children should have access to health care programs like SCHIP and Medicaid because it is morally right.

However, I believe it is more effective to argue the question from a public health and financial viewpoint. Do you want the people who are preparing your food and rubbing shoulders with you on the street to have communicable diseases that they cannot afford to treat? Do you want your children attending school beside kids who cannot afford vaccinations, antibiotics, and other basic childhood health care that protects the entire population? Do you really want to exclude people who have medical conditions that are easily treatable with inexpensive outpatient treatments from being able to afford those treatments and instead ending up in the intensive care unit with advanced problems, with the costs bourn by the public? Or are you willing to accept the notion that as you walk to your job you will have to make your way around the bodies of the dead and dying in the street, as happens in some third world countries?

We have the facts. We should argue the facts.

[Maggie Mahar]

Jack--
You know I agree that campaign contributions have corrupted the political process
Members of both parties take these contributions--and so are compromised.
But traditionally, conservatives tend vote in line with corporate America because they share the same values: a belief that "the market" should solve problems, and a distaste for regulation, taxes, or any social policies aimed at re-distributing services(like healthcare) or wealth.

I also would like to see employers out of the loop. But as I have noted before, "better paid" workers are more likely to have employer-based insurance, adn their employers typically pay between 70% and 100% of the premium.
These employees do not want to give that up.
So I don't think we can dismantle employer-based insurance all at once--but we can begin taxing at as income, at least above certain levels--and if we do that, more employers are likely to drop out of the insurance business. . .

[Maggie Mahar]

Patrick--

I agree that we are in strong agreement on the most important issues.

Some of the questions you raise turn on who conservatives are, how one defines "conservatives" and whether, as a tactical strategy, it is wise to define the debate in terms of moral issues like "equality."

First,in terms of who conservatives are and what they believe, I think you cut them too much slack when you say: "I will grant that the conservatives lost a lot of ground on the issue of ethics back in the days of the civil rights movement, ground they have not yet recovered"

It is not just that they haven't recovered the ground. I am afraid that racism is alive and well among people who call themselves conservatives. Obama did not win a majority of the white vote--in fact he won about the same share as Kerry--even though Kerry was running against a much stronger ticket and campaign.

Polls show that white, affluent, conservative voters voted against Obama?
Why? Pure racism in some cases, but also a suspicion that he might try to redistribute wealth.

As a friend of a friend living in Westchester County put it: "He's going to take our money (our tax cuts) and give it to poor people."

Secondly, I should make it clear when I speak of conservatives, I am not speaking of Burke. I am talking about those who have defined the "conservative" ideology in the U.S. since Ronald Reagan.
(With a nod back to those Southern Conservatives who insisted that Medicaid must pay doctors much lower fees than Medicare--because in the South most people over 65 were white (blacks didn't live that long) while a large number of the poor who would be on Medicaid would be black. Henry Aaron explains this in his most recent book on Medicare.

The conservative ideology of recent years is all about the right of the individual to amass and conserve wealth--without interference from government (regulations, taxes) or unions (it was a turning point when Reagan "broke" the air-controllers' union)--and without feeling obliged to share with those who are less fortunate.

"I am not my brother's keeper."

See Cato and the Heritage Foundation. And see Greg Anrig's excellent, very well-written book "The Conservatives Have No Clothes." (Full disclosure: Greg recruited me to come to the Century Foundation.)

Healthcare reform --and whether we All should have Equal rights to the best effective care available is an ethical issue because it is a class issue.

Shoud progressives make this clear in the debate on health care reform? Perhaps--if we want to rally lower-middle class blacks, whites, hispanics and others to stand together. (This could happen under Obama as the election results showed. )

But the question of how to frame the issue is a tactical issue, and depends on where conservatives take the battle.

Though I would say that we don't "lower" the tone of the conversation by talking about social values and ethics. As a society, we need to talk about these issues. The fact that conservatives have co-opted discussions of right and wrong--and turned them into shouting matches-- does not mean that they have a monopoly on the issue. We should be discussin Rawls theory of Justice. We should be teaching it in our schools.

But whether or not we publicly frame the issue in terms of equality and eglatarianism, we should keep those values firmly in mind because egalitariansim is what conservaties will be fighting as they fight to protect their wealth and privilege.

For example, I predict that conservatives will fight against community rating and aggainst a public-sector insurer (Medicare for all) competing with private insurers.

Most imporantly, I predict that they will want a "menu" of health care plans available to all Americans so that they are "free to choose" (or "forced to choose") the plan they can afford.

I predict that the lowest tier in this tiered system will not be very good. See the lowest tier of federal employee insurance--called "postman's insurance." Conservatives do not want to spend very much on healthcare for the lower-middle-class.

In the lowest tier you also are likely to find high-deductible plans than low-income people cannot afford to use.

I predict that conservatives will want the top tier to include however many MRIs the patient(or his doctor wants). Individual freedom. No one should come between the solo practioner and his patient--even if the doctor is ignoring medical evidence while doing unncessary angioplasties.

Progressives will want to use comparative effectiveness reserach to set co-pays and fees. (Higher co-papys and lower fees if we have no medical evidence that the treatment is appropriate for a patient meeting a particular profile.

Conservatives will fight cutting fees for the most lucrative services charged by the wealthiest doctors--even if we have no medical evidence that these services are effective.

Conservatives will want to hold onto employer-based insurance and many (not all) will fight taxing it.

You found this class-based strain of conservativism in the 1920s and the 1930s--these are the people who considered FDR a "traitor to his class."

Reagan loved to portray the poor as cunning connivers who were ripping off hard-working Americans. (See his fables about "welfare queens)

Many well-educated people who came of age in the 1980s (the Greed Decade) and the 1990s (so very much like the 1920s) have very little empathy or concern for the poor.

Conservatives in stress individual rights. Progressives emphasize equality and eglaitarianism.

Progressives believe that poverty is the greatest problem in America, and that the lack of economic equality is at the root of so many of our problems.

Yesterday, when Obama said that what is important is not the "size" of GDP, but the "reach" of GDP , he was standing up to the conservatives.

Below, an excerpt fromm a post I wrote some time ago where I quote Dr. Steve Schroeder, former head of the CommonWealth Fund. Schroeder recognizes that this is a class issue:

The post begins:
"Yesterday, the Census Bureau came out with a report that provides a compelling window on poverty and health in America.

It’s somewhat modestly titled “Income, Poverty and Health Insurance Coverage in the United States, 2007.” I would suggest it deserves a headline that does justice to its sweep, perhaps “Connecting the Dots: Health and Poverty, America’s Shifting Priorities, 1960-2007.

Begin with this chart:
(Sorry, can't copy and paste chart--you'll find it here http://www.healthbeatblog.org/2008/08/poverty-health.html.

At first glance, what is most striking is how well President Lyndon B. Johnson’s “War on Poverty” worked in the late 1960s. Seniors--who were then the poorest group in the U.S-- benefited most. The share of Americans over 65 scraping along somewhere below the poverty line plummeted from roughly 30 percent in 1965 to just over 15 percent in the early 1970s. Johnson made Medicare and Medicaid legislation a priority, and when it passed Congress in 1965, it made an enormous difference.

The War on Poverty also helped kids: the share of the nation’s children trapped in poor households fell from roughly 23 percent in 1965 to 15 percent during the Carter years.

By contrast, look at what has happened during the latest economic cycle. As the Economic Policy Institute’s Jared Bernstein points out, “Despite strong overall economic growth, the cycle that began in 2000 and ended late last year has turned out to be “one of the weakest on record for working families.”

Today, our children are our poorest citizens. Since President George W. Bush took office, the number of children living in poverty has climbed from 16 percent to 18 percent. In other words, a larger share of American children are poor today than in the early 1970s --when the nation was mired in a deep recession.

Later in the post, I explain how premature deaths correlate with poverty.

"As the chart above (#2)demonstrates, most other developed countries are largely middle-class. In the U.S.we accept much bigger gaps between the haves and the have-nots.

The chart below (#3) reveals that, as a result, a much larger percentage of U. S. children live below the poverty level. (Child poverty is defined as children living in households where income is less than 50% of household median income within each country.

In the U.S. median household income is $54,800; a child living in a household where joint income falls below $27,400 would be considered poor.)

This difference can be explained by the fact that in other developed countries the affluent pay a significantly higher share of their income in taxes, and those revenues are used to create a social safety net.

The blue line in the chart above illustrates the correlation between expenditures and child poverty rates for all countries. Individually, the Nordic countries —Sweden, Norway, and Finland— stand out, with child poverty rates between 2.8% and 4.2%. France, Germany, Switzerland, the Netherlands all have child poverty rates below 10%--and all spend somehwere between 8% and 14% of GDP on their social safety net.

The United States is once again, the outlier. We spend the smallest share of GDP on social programs --3%--and have the highest rate of childhood poverty — 23% of our children are living in poverty.

Delivering the 117th Shattuck Lecture before the Massachusetts Medical Society last year, Dr Steve Schroeder connected the dots: “One reason the U.S.does poorly in international health comparisons may be that we value entrepreneurialism over egalitarianism.

"Our willingness to tolerate large gaps in income, total wealth, educational quality and housing has unintended health consequences. Until we are willing to confront that reality, our performance on measures of health will suffer.”

*****“It is arguable that the status quo is an accurate expression of the national political will — a relentless search for better health among the [upper] middle and upper classes,” Schroeder added. “This pursuit is also evident in how we consistently outspend all other countries in the use of alternative medicines and cosmetic surgeries and in how frequently health ‘cures’ and ‘scares’ are featured in the popular media. The result is that only when the [upper] middle class feels threatened by external menaces (e.g., secondhand tobacco smoke, bioterrorism, and airplane exposure to multidrug-resistant tuberculosis) will it embrace public health measures. In contrast, our investment in improving population health — whether judged on the basis of support for research, insurance coverage, or government-sponsored public health activities — is anemic.

This in part because “the disadvantaged" are less well represented in the political sphere here than in most other developed countries, which often have an active labor movement and robust labor parties,” Schroeder continued. “Without a strong voice from Americans of low socioeconomic status, citizen health advocacy in the United States coalesces around particular illnesses, such as breast cancer, human immunodeficiency virus infection and the acquired immunodeficiency syndrome (HIV–AIDS), and autism.

These efforts are led by upper-middle-class advocates whose lives have been touched by the disease. There have been a few successful public advocacy campaigns on issues of population health — efforts to ban exposure to secondhand smoke or to curtail drunk driving — but such efforts are relatively uncommon.

“Little is likely to change,” Schroeder acknowledged, “unless low-income families have a political voice and use it to argue for more resources to improve health-related behaviors, reduce social disparities, increase access to health care, and reduce environmental threats.

*** Social advocacy in the United States is also fragmented by our notions of race and class. To the extent that poverty is viewed as an issue of racial injustice, it ignores the many whites who are poor, thereby reducing the ranks of potential advocates.”

**Indeed, both racism and “identity politics” has divided poor African-American and poor white Americans, blinding many to their common interests.

“The relatively limited role of government in the U.S. health care system is the second explanation,” Schroeder argued, for the lack of attention to public health in the U.S. . . .

*** “The American emphasis on the value of individual responsibility creates a reluctance to intervene in what are seen as personal behavioral choice”

“Given that the political dynamics of the United States are unlikely to change soon and that the less fortunate will continue to have weak representation, are we consigned to a low-tier status when it comes to population health?” he asked

If we paid more attention to public health, and the poor, Schroeder concluded, we could “enhance the productivity of the workforce and boost the national economy, reduce health care expenditures, and most important, improve people's lives.

“But in the absence of a strong political voice from the less fortunate themselves, it is incumbent on health care professionals, especially physicians, to become champions for the population.”

This does not mean that health care professionals can solve the problem. But they can lead the way in focusing attention on public health-- and the fact that poverty and poor health are blood relatives."

Sorry to go on at such length, but you raise important issues.

[Jack Lohman]

Maggie: "The debate is about values."

Maggie, I know that you personally agree, but let me say again that this debate is not about "social values," it is and always has been about the "value" of the campaign contributions. And the insurance industry financially supports the Republicans because they can be bought (and for the record, I'm a McCain Republican). But right is right, only when cash does not change hands.

We can only hope that Obama, whom I did not vote for, does the right thing. The nation's economy depends on our getting employers out of the health care loop, and only a single-payer system will do that. See "Medicare-for-all is best corporate bailout" at
http://moneyedpoliticians.net/2009/01/05/medicare-for-all-is-best-corporate-bailout/

[Patrick Schoenfelder]

Maggie --

We are clearly largely in agreement. In particular, I do not look for a lot of bipartisanship on health care reform, and expect that a lot of what conservatives try to sell as bipartisanship will be obstructionism. That is why I believe that health care reform will stand or fall on the ability of Obama and his allies to rally the general public on his side.

I just have a problem with portraying the fight over health care as good guys vs. bad guys (or the ethical vs. the unethical,) since I am concerned that lowers the conversation to a level similar to the worst talk radio spouting about “socialized medicine” and “the government getting between you and your doctor.” Claiming to represent the ethical high ground is a fine way to get the converted jumping out of their seats, but tends to put off a lot of people sitting on the fence – people we need in order to win this.

I will grant that the conservatives lost a lot of ground on the issue of ethics back in the days of the civil rights movement, ground they have not yet recovered. I will also grant that there is a “philosophical” or “ethical” divide on the issue of whether health care is a right or a responsibility, as was so nicely demonstrated in the presidential debates.

There is also a problem in that the Republican “big tent” strategy has created some confusion over what a conservative actually is, even for many conservatives.

However, I don’t believe that the difference is one of ethical vs. non-ethical. The philosophic founders of modern conservatism, Burke and Hayek, were very committed to the notion of ethical government and even to the good of the lower classes (including recommending some government intervention on their behalf under some conditions.)

The difference is not ethics vs. lack of ethics. It is a difference between what is seen as most ethical, as manifested by a conservative belief that many government interventions are failures, harmful or wasteful or both. They are able to cite plenty of good examples of progressive programs that had bad ethical outcomes (Barry’s mention of the large scale public housing complexes of the 50’s and 60’s being an outstanding one.)

The argument over health care does focus on the notion of a right to health care. But the question of coverage of the uninsured and underinsured that proceeds from this right, while important in the discussion of health care reform, is not the major area of contention. Many conservatives, including McCain and his associates during his campaign, are willing to admit that problem. However, they offer a counter-proposal for how to fix it. The proposal involves avoiding direct government involvement except for financing and depending on the market to solve problems of inefficiencies.

It is the second area where I and most other progressives disagree with conservatives. I believe that the market cannot handle the issue of control of medical costs because of the problem of lack of information – a viewpoint Adam Smith would agree with. Consequently I believe that the government must be involved, and that a government insurance program backed by a government Health Board to make decisions about efficacy and cost effectiveness is necessary to make the system work.

Gay rights is an ethical issue. Abortion is an ethical issue. Health care is predominantly an issue of mechanism and analysis of facts, not predomina

[Maggie Mahar]

Alex, Anthony, J.T. Russel-
David Thanks for your comments

Alex,
Yes I know that Marx popularized "From each according to his ability"

It also is a central tenet of what is known as "Christian Socialism" and can be traced back to the early Christian communism of the 1600s.

Christian communism is a form of religious communism centered around Christianity which looks back to the Bible--Acts of the Apostles.

In Acts Luke describes the organization of the first Christian congregations following the death of Jesus
"And all that believed were together, and had all things common; And sold their possessions and goods, and parted them to all men, as every man had need. (Acts 2:44-45)
...
"Neither was there any among them that lacked: for as many as were possessors of lands or houses sold them, and brought the prices of the things that were sold, and laid them down at the apostles' feet: and distribution was made unto every man according as he had need. (Acts 4:34-35)"

Finally, Catholic social teaching agrees with "From each according" aruging that everyone has the right to a basic standard of living, even if they are unable to earn it by their own efforts. Thus, for example, the able-bodied are bound to subsidise the handicapped.

By contrast, Ayn Rand (Alan Greenspan's inspiration) argued strongly that the strong did not have a responsibility to help the weak or handicapped. Greenspan shared Rand's believe that "the market" is "moral" and would reward the deserving--ignoring the degree of acccident involved in whether one is born strong or handicapped.

Anthony,
Thanks for the reference to the post on your blog.
I read your post and agree. The goal here is to pass the legislation --not to win 90% to 10% just to prove how agreeable and comromising liberals can be. I don't watch California politics closely, but by impression is that Schwarzenegger thinks that politics is a popularity contest--or perhaps a beauty contest--where your goal is to amass power by getting everyone to like you.)
I'm not sure that Scwarzenegger believes in anything.
And yes,if liberals agreed to leave legal immigrant children behind they would (and should) lose Hispanic votes.

Hispanic voters were key to giving Obama his victory. Now that they know that their votes do count,hopefull many more Hispanics will be voting in the future.

In other words, U.S. politiics is no longer a stand-off between liberals and conservatives. We are fast becoming a beautiful mosaic, and those who embrace diversity are likely to be the winners.

We also have to accept the fact that conservatives --including some "blue dogs" --just do not accept the liberal empahsis on equality and egalitarianism. We do not have to compromise with them on our core beliefs. We do not need their votes--just as Obama did not need their votes.

J.T. Russel-- You hit upon a central irony of U.S. healthcare when you note that more docs did not equal more competition and lower prices:
"They found that wherever there were new MD graduates, they would produce medical care and make a handsome income while doing it. The equation was more docs=more procedures and higher medical costs—not lower fees.
By producing more Docs, Washington had increased the supply of costly medical care providers who continued to command a great return on the investment the government had made in their education"

When LBJ agreed to let doctors set their fees under Medicare, he assumed, wrongly, that more doctors would lead to lower prices. But what we have discovered is that the normal laws of supply and demand do not operate in the healthcare market. This is becuase suppliers create demand--doctors and hospitals tell patients what they need. And when doctors and hospitals have more time in their appointment books (because their are more of them)and more beds--the doctors will see their patients more often and more of those patients will land in the hopsital, where they will undergo more tests and treatments.

In this country, excess capacity has led to overtreatment, which explains why Medicare patients receive far more aggressive, intensive treatment in parts of hte coutry where we have more doctors and more beds--though their outcomes are no better, sometimes worse.

The other reason the market's laws of supply and demand do not apply to the health care market is because the buyer is rarely looking for a bargain. Tell him that surgeon X is significantly cheaper, and you scare him.

David-
Your suggestion that everyone should buy their own healthcare, using HSAs ignores the basic fact that median joint household in this country is about $47,000--before taxes.

Imagine you and your spouse were raising just one child on that amount. After rent, food, utilities, trasnportation to work, car repair, gasoline, clothing, taxes etc.---just how much do you think you would have left to put into an HSA account? What if you were also trying to put something aside for your child's college education?
Then consider the fact that half of all households earn less than $47,000. Imagine that you and your spouse earned $39,000 . . .
HSA's are a great tax shelter for the rich--that's about it.
Finally, conservative economists are the only social scientists who believe that human beings reguarly act in their own
enlightened self-interest.
Psychologists, sociologists, anthropologists and liberal economists know better--as do health care economists.
Give a person a high deductible, a high co-pay, or an HSA that isn't large enough to meet all of his health care needs, and he is just as likely to defer needed treatment as he is to defer unnecessary treatment.

[Alex]

"Some would say: “from each according to his ability, to each according to his need.”
Many conservatives would reject that sentiment as socialist dogma."

That's because Karl Marx popularized that quote.

[Anthony Wright]

Thanks for the post. I refer to it in my discussion of how far health reformers should go to be "bi-partisan," on the Health Access WeBlog, at:
www.health-access.org/blogger.html.

[JT Russell]

There was a time when, if you wanted to become a physician, the bankrolling required more than the velleity of simply making the making the choice and the financing appears.
Then in the 1950’s and 1960’s the (then) HEW came up with what seemed a simple solution to the health care conundrum: financial aid to medical schools. They planned to flood the market with new MD’s and so cause increased competition to lower the cost factor attributable to doctors’ incomes.
In the mid 1970’s I was a dinner guest of a brilliant couple of Washington health apparatchiks. He was (among other things) guiding the nascent EPSDT program. And she (the sister of one of the Brookings Institution’s leading economists) was eventually to become the Director of the National Center for Health Statistics. In short, not only were they broadly wired into the beltway health establishment, they had their hands on the steering wheel.
Another guest that evening was the wife of a health economist who had recently been jilted by her co-researcher husband. And she was getting back at him by blabbing about the results of their latest findings, before they had been published: financial support of medical education was having the opposite effect on health costs than they had anticipated!
Although the money given to Medical Schools had worked to increase the supply of physicians, there hadn’t been the expected depressive influence on doc’s incomes. They had found that wherever there were new MD graduates, they would produce medical care and make a handsome income while doing it. The equation was more docs=more procedures and higher medical costs—not lower fees.
By producing more Docs, Washington had increased the supply of costly medical care providers who continued to command a great return on the investment the government had made in their education.
There was amused consternation around the dinner table. Medical Economics had not responded to the “Law” of supply and demand. “Well, maybe we’ll do better with this new entity, The HMO.”

[Maggie Mahar]

Patrick--

Thanks for a very interesting comment.

You write: "Conservatives tend to favor plans to reduce the total amount of spending on health care on a global basis, assuming that either patients or providers would make the appropriate choices to eliminate fat and keep the muscle. Progressives tend to reject that approach based on pretty strong evidence that patients almost always have trouble making appropriate decisions in the face of costs and that providers frequently make errors in decision making as well (after all, our current mess is based on providers making choices.)"

I agree--and would add that conservative economists are virtually the only social scientists who believe that most human being make rational decisoins, reflecting their own self-interest, most of the time.

Psychologists, anthropologists, social scientists and liberal economists know better.

This is why they do not believe that the market can correct all ills: "the market" is only as rational as we are.

You add: Obviously, this is not a discussion of ethics, but rather a discussion of mechanisms"
(the market vs. government intervention.)

Here I begin to disagree.
The world-view that says man are rational and can be counted on to make decisons that will reflect their own self-interest is really saying "they OUGHT to be rational. And if not, that's their problem, not society's problem.

It is a world-view that says "I am not my brother's keeper" --and there is only so much you can do for "Those People."

It is a world view that and ignores the fact that some of us are born smarter, stronger, and into a luckier situation than others.

Liberals believe that we have a moral obligation to reach out and make sure that people who aren't us lucky stil get a fair shake when it comes to the essentials needed to pursue "life liberty and happieness"--that means equal opportunity access to high quality health care, education, and safe, clean housing.

On Bob Laszlewski's blog, where I commented on his post, a conservative reader wrote that there's no reason that poor legal immigrants (poor by definition because we are talking about people who qualify for Medicaid and Schip) shouldn't buy health care for their kids.
"And if they don't"he wrote, "that's their choice."

Some conservatives insist on believing that very poor people--families of 3 or 4 trying to live on $20,000 a year- are simply wasting their money on cokes and potato chips. If they didn't do that, they would have plenty of money to buy healthcare, just like everone else. They are simply irresponsible. (IF you read enough conservative blogs, you'll find this is only a slight exaggeration of the point of view.)

Moving on in your post, you write: "Conservatives sometimes reject the idea that there is a problem, pointing out that ER’s are required to provide care for everyone, regardless of ability to pay. However, conservatives are somewhat contradictory on that approach, since they often are very critical of the cost shifting used by providers to finance that approach."

Yes--here I agree completely. Though I would add that, under the Bush administration, the law regarding ERs was reinterpreted to say that if the patient is ambulatoy--capable of walking out of the ER-- the ER doesn't have to provide treatment.

In my book I talk about 3 ERs who turned away a man with a badly smahsed jaw because he didn't have insurance or a credit card. He was a legal citizen, and had proof of that.

I agree that blue dogs are as much of a problem--if not more--than Republicans.

I tend to think in terms of conservatives vs. progressives rather than Dem. vs. Rep.--though these days the two parties have lined up under farily clear ideological lines.

The liberal Republicans have been drummed out of their party--people who I once admired, like Lowell Weicker, aren't around any more.

Finally, I totally agree that Obama should "use strong public support to deal with the Washington political opposition following the old political adage that if you have someone by the balls their hearts and minds will follow."

Well-put.

Let me add only that Conservativss do tend to differ on the whole issue of class--which I see as a moral issue.

They take a more Darwinian point of view.

Conservatives defend the rights of strong individuals who are lucky enough to be born in the right place and time--to amass wealth and "conserve that wealth"--consolidating it in families that then have far more power in our political system than anyone else.

There is a degree of disdain--even contempt--for people who are born weak or poor. (I remember when I moved, with my very, very young children, from Fairfield County to Manhattan in the late 1980s. Most of the (mainly conservative) suburban mothers I knew were horrified: "Do you really want your children to SEE all of those homeless people?!!"

I did. I thought it would teach them empathy-- and make them realize how simply lucky they were. (It did.)

PRogressivs tend to believe in a collective vision based on the realization that "there but for fortune . . ."
This is why "from each according to his ability, ot each according to his need" makes sense.
This is a different value set.

Thanks much for your thoughtful comment.

[Patrick Schoenfelder]

Progressives and conservatives – at least those in both camps who understand the facts of the health care system – agree on many health care issues, but tend to disagree on the way to deal with those issues.

Everyone with any sense agrees with the idea that health care costs too much and that a lot of US health care is either not useful or is downright harmful. However, progressives tend to see the solution to that to be using government to make health care conform to reasonable standards and to reduce costs for some parts of health care such as administrative overhead and drug costs. Conservatives tend to reject the idea that the government should become involved in making health care conform to reasonable standards, fearing that government controls would interfere in a malicious way with patients and providers achieving ideal results. Conservatives tend to favor plans to reduce the total amount of spending on health care on a global basis, assuming that either patients or providers would make the appropriate choices to eliminate fat and keep the muscle. Progressives tend to reject that approach based on pretty strong evidence that patients almost always have trouble making appropriate decisions in the face of costs and that providers frequently make errors in decision making as well (after all, our current mess is based on providers making choices.)

Obviously, this is not a discussion of ethics, but rather a discussion of mechanism. It is a discussion almost all developed countries have already settled with excellent results in terms of cost vs. effectiveness, coming down overwhelmingly on the side of control by government or pseudo-government entities.

Almost everyone, including most conservatives, agrees that people without health care need a means of getting health care. Conservatives and progressives disagree on the mechanism of solving that problem, with conservatives looking for marketplace solutions incorporating ideas already discussed above, and progressives leaning in the direction of direct government intervention in the problem. Conservatives sometimes reject the idea that there is a problem, pointing out that ER’s are required to provide care for everyone, regardless of ability to pay. However, conservatives are somewhat contradictory on that approach, since they often are very critical of the cost shifting used by providers to finance that approach. There is also some disagreement as to who needs help, some of it focusing on levels of income and some focusing on other characteristics, such as the current GOP focus on excluding legal immigrants and their children – an argument more based on poor understanding of public health issues and the cost of deferring care the system eventually must provide than on any real philosophical differences.

In reality, while these are focuses on values, the values tend to be more focused on mechanism than on ethics. We are talking less about the question of helping people and more about how to help people. In general, conservatives tend to reject government involvement as always leading to failure and inefficiencies, despite evidence that there are some things the government does a lot better than the private sector. They also tend to reject, on ideological grounds, the notion of taking the experience of other countries seriously, despite evidence that their systems are both cheaper and better than ours. Progressives tend to reject criticism leveled at real examples of failed government policies, and to be hesitant to include protections to stop those sorts of things from happening. For example, a lot of the discussion about a federal option for health care – excepting purely ideological objections or support – is focused on how to make sure that the government does not tilt the playing field to give additional tax dollar support to the public option beyond whatever subsidies are available to both federal and private insurers.

In the end, I think that the best we can hope for in terms of bipartisanship is that a few (low single digits) Republicans will cross the line because they believe that the programs are necessary and will succeed. Otherwise Republican talking points really mean “veto power,” not bipartisanship, since they are following the dictum expressed clear back in the early 90’s by Bill Kristol, who said that potentially successful government programs had to be derailed at all costs, since they undermine the Reagan-conservative position that the government is always wrong and ineffective.

The biggest threat to obtaining health care reform is not the issue of bipartisanship, but the issue of obtaining near unanimity among Democrats. If health care reform is derailed, the Blue Dogs and the Democrat far left – allies in destroying centrist reform – will have more effect than the Republicans. So far, that seems to be the alliance that Obama and his surrogates are spending more time on than wooing the Republicans.

Obama also seems to be planning an aggressive campaign-like grass roots effort, using strong public support to deal with the Washington political opposition following the old political adage that if you have someone by the balls their hearts and minds will follow.

[Maggie Mahar]

Robert and Barry --

Thanks for your comments.

Robert-I agree, medical ethics is becoming very interesting at this juncture. I have a couple of medical ethicists in my
Working Group, including Jim Sabin--who Barry mentions in his comment.

Here is a link to a list of what are supposedly the best 50 medical ethics blogs: ttp://www.uspharmd.com/blog/2008/top-50-medical-ethics-blogs/.

I know a few of them--worth checking out. I also
very much like Daniel Callahan's work. He has a number of books, you can also google him.

Barry--
Yes- Sabin is at Harvard and very good. Thanks for the recommendation.

[David A Westbrock, MD]

I certainly agree that health finance, not care reform is a partisan issue owing to an essential difference in point of view. Progressives and conservatives both agree that Americans should get health care, quoting Dr Edward Annis, former AMA president and conservative, when they need it and as much as they need. The difference is how to pay! i differ with your supposition that conservatives "want to keep profits high." The collective system of the HMO brought this on and the unintended consequences of a "progressive" egalitarian philosophy brought us to where we are now. And those same progressives now want to fix it by government fiat. No, conservatives just want people to think and act on behalf of their own best interests in a free market, one that has been disabled by excessive regulation, monopolies (insurance) and resultant undo profits (government designed by the HMO Act of 1973. We doctors still give discounts and free care when indicated and can still afford to keep our families. Its just the government that keeps making the problem worse. Let's compromise by offering everyone HSAs to choose for themselves (employer based or individual combined with tax credits).. this is ultimately humane, fair, ethical and fits the American Constitution based on free and open markets. But that would not be acceptable because it destroys the collective!

David A Westbrock, MD, FACP, FACE

[Barry Carol]

Robert -- Regarding healthcare and ethics, I think you might find the book, “Setting Limits Fairly” by James Sabin and Norman Daniels of interest. Daniels is actually a philosopher while Sabin is a doctor at Harvard, I think.

[robertdfeinman]

Maggie:
After debating economics on various blogs over the past few years and getting bogged down in the implicit assumptions about human nature (selfish vs altruistic) as well as the value of monetary vs fiscal policy, I've decided to take a new tack.

I'm leaving the bulk of that to the traditionalists (I just compared one ongoing debate to that between the Big Endians and the Little Endians).

My new hobby horse is ethics. Notice how Obama has surrounded himself with economists, but no ethicists, philosophers, sociologists, or anthropologists.

In fact I dare anyone to even name a prominent moral philosopher in the public eye. The last seems to have been John Rawls.

I think this important. We need to emphasize the moral aspects of not only choices, but assumptions. I think Obama might at least be open to broadening his view to take in such thoughts, as opposed to the Bush regime of the amoral and sociopathic.

This will be especially true in the area of health care where there is already some ethical debate going on as concerns treatment. This needs to be built upon and expanded out of its narrow focus to the larger issues.

I hope you may find some who are discussing these topics to use as jumping off points for future postings.

[Maggie Mahar]

Robert, Barry & Chris--

Thanks for your comments.

Robert --
Point taken on whether this really goes back to Jeffersonian landowners.

(You wrote: "We have never had a hereditary ruling (landowning) class as did Europe, yet we still seem to resent taxes,"

I thought of those landowners because now we really do have an upper class that is inheriting its wealth-- and that group is growing, not only in term of wealth, but in terms of their power.

Baby-boomers now range from younger boomers in their mid to late 40s to older boomers in their late 50s/early sixties.

Wealthier boomers have healthier parents who live longer. So they are just beginning to inherit. AS that wealth is handed down, I am concerned about what that will mean for politics and class divisions.

That said, I think you are entirely right that "Perhaps it has to do with the fact that the US was never involved in a domestic land war (Civil war excepted) and thus has never really had to sacrifice for the greater good. This allows people to continue with the fantasy that they are independent actors, self-made men and not beholding to government."

Our reaction to 9/11-- how could that possibly happen HERE?!! demonstrates what you are talking about.

I have a friend in her 70s who is Jewish and was born in the Netherlands. When she was very young, in the early 40s, her father told the family that they were going on vacation to the U.S. He had converted what he could into diamonds which he sewed into his clothes.

When he, his wife, their three duaghters and their Nanny arrived here, he explained that they would be staying here.

He became a successful businessman in the U.S. , but all of teh Jewish people that he and his wife had known in the Netherlands-- family, close friends-- were killed. No one survived.

Her parents never got over this.

And when 9/11 happaned and my friend, who has lived here since she was 3, heard the American reaction,she couldn't help but remark on how Americans live in what you call a "fantasy world."

You're right that Obama is beginning "to talk about 'sacrifice" a bit, but is still offering an economically ineffective tax break to soften the blow - and he hasn't even laid out what the sacrifice might entail."

I'm going to wait and see.
But I'm worried.

Robert, in your most recent post, you write:

"In the past 30 years the US has also taken in a unprecedented number of immigrants which has expanded the population and the working age sector. This has allowed consumption to grow while keeping pressure on wages.

"Compared to all these factors the allocation of money to social services is a secondary effect. Even if Europe has chosen to focus on these areas it is not clear that this has been significant. What is clear is that there has been a lot less misery as a result and that people are healthier and live longer too.

"Ethics, not economics should be the determinant for action."

Yes, this is all very true, and an excellent explanation of the difference between what has happend in Europe vs. the U.S.

Barry--

Let me reply to the last part of your comment first:
low-income African Americans (and some otherer minorities) do want to die in a high-tech hospital or ICU because a) they don't have a nice home where they
could die in peace with help from hospice and b) they don't trust our medical system.

They are afraid that doctors will simply let them die, without giving them the hi-tech care that we give to white Americans. This fear was fanned by the case of an AFrican American who was in a traffic accident
in South Carolina. Officers on the scene confirmed that he was dead, and shipped him to the morgue.

AT some point after he arrived at the morgue, he returned to consciousness.
He was in one of those metal drawers . . .

He did recover, but a doctor down there told me that this news story fueled the fears of many African Americans.

Going back to the top of your comment-- On Europe vs. the U.S., see Robert
Feinman's second comment (which came in after yours.)

He is right. Many factors have affected Europe's post WW II and recent economy. On the whole, the social safety net has helped Europe, not hurt it.

As for seondary education in the inner cities--it is serously underfunded. Look at how much is spent, per pupil, in this country's wealthiest suburbs, vs. how much is spent, per pupil in the inner cities.

Inner city teachers need higher pay because they are doing a much tougher job. And they need much smaller classes. We should be spending more per pupil in our poorest city neighborhoods than in affluent suburbs, not less.

Chris--

Good to hear from you. You
wrote that "the healthcare debate is necessarily partisan because it is a stalking horse, a metaphor, that serves as a stand-in for many other issues of social policy. Robert Feinman put his finger on it in the first comment in this thread -- ;you're on your own' vs. 'we're all in this together.' All social policy questions reflect the tug-of-war between these two extreme positions,"

Exacty. I do think that hearlth care reform is the first, major domestic policy issue that we are going to confront, and it will make us face the ideolgical divide between those who believe in so-called rugged American individualism ("You're on your own") vs. a collective view ("We're all in this together.")

I am hoping that after facing up to the problems in our healthcare system, we may begin to work on public education, and utlimately, the biggest problem in our society: poverty.

And, I agree, at this point, the principle that healthcare is something that everyone deserves is basically settled among all but super-conservatives. Now as you say, we are "debating the details, not the principle."

That said,

[robertdfeinman]

Barry, the measure of "economic" growth is a difficult one. Since WWII Europe has had to rebuild, weather the inefficiencies of the USSR, and then integrate many of these states into the EU. At the same time the US had almost no competition for its exports since the rest of the developed world was rebuilding.

In the past 30 years the US has also taken in a unprecedented number of immigrants which has expanded the population and the working age sector. This has allowed consumption to grow while keeping pressure on wages.

Compared to all these factors the allocation of money to social services is a secondary effect. Even if Europe has chosen to focus on these areas it is not clear that this has been significant. What is clear is that there has been a lot less misery as a result and that people are healthier and live longer too.

Ethics, not economics should be the determinant for action.

[Chris Johnson]

I think the healthcare debate is necessarily partisan because it is a stalking horse, a metaphor, that serves as a stand-in for many other issues of social policy. Robert Feinman put his finger on it in the first comment in this thread -- "you're on your own" vs. "we're all in this together." All social policy questions reflect the tug-of-war between these two extreme positions. Everyone, except perhaps for die-hard fanatics on both ends of the political spectrum, accepts the notion that there are some things best done by the collective (government) and some things best done by the individual.

The thrust of healthcare reform as I see it is simply taking health care completely from one pot and putting it in the other pot. This is not such a huge change -- among Medicare, Medicaid, and a host of other government programs, we have already effectively conceded that healthcare is a matter for the collective, not the individual. It's already most of the way into the collective pot anyway. I think it's our refusal to recognize this fact that causes much of the chaos in the way we do things now. Since that chaos also results in enormous profits to some interests, though, change will be difficult. And partisan, too.

To me the guiding principle is that now (unlike a century ago), basic healthcare is like clean air, clean water, and safe foods -- it's a service best and most fairly provided to people by the people acting as a collective. Now we're debating the details, not the principle.