Thursday, December 24, 2009

Health care reform: The moral heart of the matter

This follows up my recent post titled Mutual responsibility, solidarity, democracy, and health care (explained by Matt Steinglass). I quoted from a piece on the Economist's "Democracy in America" blog that points out, correctly, that "You cannot have universal health insurance without a mandate" and then explains why this is so. I indicated that this discussion "gets to the heart of the matter" and commended "its clear statement of the basic principles at stake."

A friend e-mailed me to chide me a bit for those last formulations. The piece I cited may well get to "the heart of the matter" in terms of the specific topic it addressed--the need for a health-insurance mandate as part of the logic of universal coverage. But by comparison with the more fundamental moral issues that are really at the heart of the health care controversy, those issues are secondary and almost quasi-technical.

My friend is definitely right about that, and I didn't mean to suggest otherwise. To help clarify the larger picture, here is his very cogent overview of the matter (posted with his permission):
You surprise me. The moral heart of the matter is in your headline about mutual responsibility et al.-- a decent affluent society ensures that all its people can get adequate health care and doesn't make this a matter of individual resources or accidents.

The secondary point (the political heart of the matter, if you will) is that once you affirm the moral point there is strong pressure toward doing this in somewhat more sensible, fair, and efficient ways (in other words, try and go after the insurance companies later, once you've made universal access a foundational principle).

The piece you cited gets at the very important tertiary point (the economic/administrative heart of the matter) that adverse selection will inevitably undermine a health insurance system that permits people to choose to opt out. The side critique/analysis of left populism is also a plus.

But, in my view, Obama and the Democratic Party need to hammer on the moral vision as the heart of this and related matters and take the consequences. That may not win, but the alternatives are worse.
I agree.

--Jeff Weintraub