From Office to Era (JM)

Kevin Drum of the Washington Monthly and Matthew Yglesias of the Atlantic both posted today about regulating the health insurance industry. They both bring up some fairly salient points about what free competition in the health insurance industry actually means. Matt, in particular makes the interesting arguments that efficiency and competitiveness in the insurance industry is enhanced by better assessing risk, not by providing more access to care. This argument holds some water, though I think competitiveness could also be fostered by helping to prevent risk and by offering better packages of insurance from the get go.

Either way, these arguments bypass the 20,000 pound elephant in the room whenever we discuss something like health insurance: fairness. The idea behind insurance is the aggregate risk, but at the point companies can curtail as much risk as possible the product becomes illegitimate. This is largely because insurance is better viewed as a public good, rather than a private commodity. In some very real sense any federal government is form of insurance, a way of collectively allocate risks and resources over a large population of people. It would simply be better if insurance were universalized and everyone bought in at equal cost.

This is where the problem becomes more interesting. Is it, in some sense, just to ask every individual to pay for people who are more likely to fall ill or get injured. I think it makes the most sense to actually discuss this in the margins, talking about people who presumably behave in such a way that they are more likely to get ill or injured.

Let's say we grant that behavioral factors effect one's health more than any other variable (a premise I am only willing to grant for the furtherance of this discussion). We should still consider that behavior is not solely a matter of personal choice, but is often socially ingrained in an individual or still a function of genetics. We know very little of development of taste and habits, but it is perfectly plausible that many of them are not so much a matter of free choice, as they are qualities, that while internal, have been developed by some external, difficult to control source.

I feel strongly that this is a matter that has largely been ignored in the political arena because it makes us feel uncomfortable (also the Right has succeeded in lampoon this position to death. The simple truth is that people are often not responsible for their position in life, in terms as health, as well as financially and social. The truth is that opportunity is a limited function and if it's a value we truly believe in it is critical for us to go beyond simply "leveling the playing field" to accounting for difference in players by "handicapping the playing field".

This, as it applies to something as fundamental as health insurance, is critical. People don't deserve to have less access to health care because they were unfortunately born with a proclivity to eat poorly, engage in risky activity or substance abuse than do to be put at greater risk because they were born with a congenital heart defect. The truth is these are essential the same, only the heart defect is more legible. We ought to search for inequalities rather than only helping those whose inequalities are so apparent that we cannot help but see them.

Of course, this opens us up to some terribly difficult questions. If this is true within the health care industry, surely it also true as it applies to criminal justice. If we buy that much of what we perceive as personal choice is guided by the random vagaries of life, then it seems pretty unfair to punish someone for a crime they very well may not have committed if they had been born a very different person. Obviously, this becomes a crazy debate about free will and one in which politicians are certainly not likely to engage. However, it seems clear to me that this is the key pushback against the tidal wave of libertarian/free marketism that we see. The problem lies in how to frame this debate to our rhetorical advantage. The truth is, even in terminology, this a conflict that those who believe in a supportive state have already lost. Heck, as Dennis has so very often pointed out, welfare reform came to us straight from 1990's version of Barack Obama, William Jefferson Clinton.

Much reluctance to engage in this debate can be traced back to the Cold War. The hint of socialist implications in a person was obviously enough to turn them in to a pariah. But with the demise of the Cold War and an entirely different amorphous enemy to combat, the time is ripe to begin having this fight. The Democrats are talking about the policies, but not their justification. People are discussing this as the tipping point for the liberal movement, perhaps ushering in a 30 year period of dominating the scene as we have seen the conservatives do. Maybe. To me it seems unlikely, because we are still playing and talking their game. Gun control? Unthinkable! Single-payer healthcare? Absurd! Kyoto? Unmentioned.

Neither of these are really "change" candidates. One of them says "hope" and "unity" with reference to nothing. The other says "mandates" and "peace", but her actions are often very different than her words. What is lacking in this battle is the right kind of rhetoric, paradigm changing rhetoric. We need to redefine the game, not play it better. Ronald Reagan helped bring down entitlement programs by discussing a "welfare queen" who was living a life of luxury scamming the system. While this seems like a reprehensible lie (and it is), what he was really doing is changing the rules of the game. He was saying, "It's their fault they are unfortunate, not yours. Your situation in life is solely dependent on your choices." That would be nice if it were true, but it is very much not.

If Democrats want to win this time around they have to convince the American public that their lives are completely dependent on so many different random events in society. They need to stand up for programs that recognize this reality, like affirmative action and welfare. They need not just create these policies, they need to convince the American public that they are important and that they are right. Maybe I discounted Edwards a little too early, because his "two Americas" rhetoric really touched on some of these critical ideas. But it is not too late, either of these candidates can stand before John McCain and lambaste him for wanting to cut taxes while millions of Americans have no healthcare, poor education, no access to technology and jobs that barely allow people to survive. If either candidate wants to usher in a new era they cannot just win this election, they have to win this battle. Do you see it happening? I don't.