Let’s give credit where credit is due. David Brooks does say one true thing in his New York Times column, “The Values Question”, on government health care reform: “The system after reform will look as it does today, only bigger and more expensive.”
Brooks is certainly right that no “health care reform” proposal with any chance in mainstream partisan politics promises any fundamental change to the status quo. What we have had is a system where pervasive government regulation, subsidy, and mandated captive markets corral workers into an industry driven by sky-high costs, managed by bureaucratic pencil-pushing and corporate economizing (often at the expense of innocent people’s health or lives), and owned by a handful of uncompetitive, well-entrenched incumbent corporations. No mainstream “reform” proposal would have changed anything about that. The proposals mainly concerned themselves with introducing new government subsidies and new captive-market mandates to force yet more workers and money into the broken system.
But Brooks took all this as a sign that the health care debate was about fundamental “values.” I think it was a sign that conventional political debate was a superficial squabble over meaningless details. The real debate was about grammar.
Brooks sees “a debate about what kind of country we want America to be”: Although “many of us” thought “we” were in a regulatory sweet spot in which “we” could extend coverage to the uninsured but also lower costs, “we” were wrong; “we” cannot make gains without substantial costs. So “we” face a “brutal choice”—a tradeoff between economic “vitality” and “security.” “Vitality” for “America” means an “unforgiving nation” but also a more “vibrant” one; security means “a more decent society” but also one where “more of the nation’s wealth would be siphoned off from productive uses and shifted into a still wasteful health care system” (emphasis added). We are told that “we all” have to decide what “we” want—for “America.”
Remarkably, among Brooks’s 800 words, supposedly on a debate about deeply held convictions, the word “I” never shows up in the author’s own voice. (The single “I” appears in a quotation.) Lost in this thicket of plural pronouns, “nations,” and “societies” is any notion that I might settle on different preferences from you, or that you might have a right to decide for yourself which preference to pursue. There is only one path for all, and “we” are left only with the engineering decision of which output to optimize for: “vitality or security.”
Mind Your Me’s and You’s
For the individualist, half of human decency in political thinking is just learning to keep your personal pronouns straight. There is no right outcome in this debate except to reject the conventional political premise that “we all” need to decide on anything when it comes to health care. Life is full of tradeoffs. But the right question to ask is not which choice to take, but rather who should choose and who should bear the costs of the choice taken. And the answer is that each person should choose how much of her own resources she wants to devote to health care and to insuring against future disasters. These tradeoffs only become “brutal” when I am forced to take your risks or you are forced to fund my security.
Brooks might reply, “Ah, you claim to avoid the hard choice here with a free market. But really you are making a choice without admitting it. Free markets mean everyone is limited to her own resources to meet medical bills; but by definition poor people have no real resources to fall back on. So really you’re just advocating one option: a system that chooses vitality and growth over security and care for the vulnerable.” Indeed, Brooks insists that “The unregulated market wants to direct capital to the productive and the young” and confusedly suggests that this is more or less the kind of “vitality”-oriented system that America has had and will continue to have unless government forces taxpayers to chip in for more extensive government “welfare policies” in health care.
That might seem true if the corporate health care system we face emerged from “the unregulated market.” But it didn’t. Government licensure controls who practices medicine, and where and how they practice it. Government prohibitions restrict which drugs are produced and where to get them because government thinks it knows better than you what drugs you should take and because it is engaged in a deliberate effort to raise drug prices through a system of patents. Federal tax loopholes and regulatory micromanagement make most full-time workers dependent on their bosses for health insurance and force most other workers to deal with government health insurance or none at all. There is a “market” of a sort here, but it’s far from a free market: It’s a rigged market, shaped by government regulation, funded by government subsidy, and owned by government agencies and government-privileged corporations.
The Meaning of a Freed Market
Pervasive confusion of the existing government-supported anticompetitive corporate health care market with health care provided by a genuinely freed market leads to two related confusions about what a real market in medicine would mean.
First is the widespread but ultimately ridiculous notion that free markets would require individual workers to rely only on personal savings or expensive corporate health insurance to cover high medical costs. In fact in the late nineteenth and early twentieth centuries, freer medical markets actually offered many competitive, noncorporate means for working folks to get affordable, decent health care for themselves by pooling resources through free-market bargaining and free association. As the libertarian scholars David Beito and Roderick Long have discussed, “contract practice” agreements, organized by low-income workers and primarily negotiated through unions, mutual-aid societies, and fraternal lodges, provided reliable medical care for 20 to 50 percent of workers in English-speaking countries for about one day’s wages per year. These affordable arrangements were ultimately driven out, not by the ruthlessness of the free market, but rather by deliberate assaults by government and the government-privileged medical guilds.
Second, if we recognize the importance of freed markets to the prospect for a civilized solution to the health care crisis, it also quickly becomes obvious that there are many opportunities for “reform” that simply do not present the kind of tradeoff that Brooks wrings his hands over—specifically, “reforms” that get rid of the government interventions that cause costs to skyrocket in the first place.
There is a clash of fundamental values in the health care debate, but it’s not a clash within conventional electoral politics. The real debate is between
politics as a means of providing health care and a freer, more humane alternative: consensual social organization.