Why They Fear Socialized Medicine

In my last post, I made the point that those who carp against “socialized medicine” are speaking nonsense. In the modern world, many things, including education, fire protection, and food safety have already been “socialized,” and, in fact, without the “socializing” tool of insurance, our modern economy would not be possible. I made fun of the phrase “socialized medicine,” labeling it code for something else. Today I want to take that “code” seriously.

First of all, the people who oppose changes in the health care system in general and the creation of a public health insurance plan in particular aren't fighting for the right to continue paying insurance premiums to private companies. I don’t think anyone is so in love with Blue Cross or United Health Care that they’d be willing to take to the streets in defense of either company’s right to keep operating in the way it now does. I also don’t think that this is a battle about the right of individual Americans to choose between competing insurance companies. Most Americans are stuck with the insurers offered by their employers, and if we do not adopt health care reform, most Americans will have even less choice as health insurance coverage becomes too expensive for anyone but the very rich to afford.

What energizes the people at the grassroots level who are opposed to the Democrats’ health care plans are two levels of fear, one of which is rational and one of which, sadly, is irrational and the product of decades of mistrust cynically cultivated by the Republican party to advance its electoral fortunes. While the first kind of fear can be addressed with facts and logic, the second is more visceral and cannot be addressed in the same way.

The first of the fears is that the health care reform proposals, if adopted, will prevent people from getting the prompt and effective attention they have come to expect from the medical system. Let’s forget, for the moment that there is a broad swath of people who do not have adequate insurance coverage and who do not, therefore, get prompt and effective attention from the medical system. For now, let’s focus on the legitimate fears of the middle class people who are fortunate enough to have health insurance.

The President won’t tell you this, and neither will the Democratic leaders who are spearheading the reform effort, but the truth is that health care reform means that we will have to change the way in which we currently ration health care. It is a simple fact that health care in this country is already rationed; it is, however, rationed on the basis of ability to pay for it and not on the basis of need or on a generic per capita basis.

Basic arithmetic tells us that for some people to have more health care than they currently have without adding to the cost of the overall system, some people will have to have less than they have now. While comparative effectiveness research, electronic medical records, and an increased emphasis on wellness will, according to the President, free up about two thirds of the resources needed for everyone to receive coverage, the plans still have to find a way to make up the difference. Even if we assume that the political authorities are willing to raise taxes or cut other national priorities required to make this a first class system, more for some means less for others in the form of higher taxes or lost benefits. It cannot be otherwise in a communal system where limited resources must be equitably shared. The trick, of course, is to find that optimal point at which everyone receives a fair share of the limited resources.

If that optimal point cannot be found, the tragedy of the commons will rear its ugly head: in a zero sum game, nobody will be willing to reduce his or her consumption unless everyone else has to reduce consumption as well. Instead, everyone will myopically see it to be in his or her interest to consume as much of the resource as possible--until the some of all the individual consumption results in the collapse of the resource. Unfortunately, there is no way around the fact that health care reform will create, either intentionally or unintentionally, a new group of winners and losers. Obviously, nobody wants to be one of the losers.

The second fear is that of a government swollen with enormous power, able to impose life-altering choices on the people without their consent. It is a vision of a totalitarian state, a nightmare out of Orwell or Huxley, and it betrays a massive lack of faith in ourselves and in our system of government. The irony is that the great threat to our government “of the people, by the people and for the people” in the years of crisis ahead is that it will be able to do too little, and not that it will be able do too much.

Specifically, those who fear socialized medicine worry that some government bureaucrat will some day decide which doctors a person may see and what treatments a person may have, even to the extent of prescribing death to a person whose life that bureaucrat deems to be of little value. Perhaps health reform opponents would even concede that insurance company clerks already have this power; these opponents would argue, though, that in our free market system, there is at least the possibility of buying other insurance from companies whose clerks are no more accountable but potentially more lenient. Not so in a world where the government holds a monopoly over this crucial aspect of life.

What saddens me about this debate is that we are even having it on these terms. I was born in an expansive era in which we were exhorted by a vigorous young president to ask not what our country could do for us, but rather to ask what we could do for our country. It was a clarion call to community, an acknowledgement of the Biblical lesson that we are all our brothers’ keepers.

Only 20 years later, that young president’s polar opposite, Ronald Reagan, told us that the problem with our society was our communal concern for one another as manifested in our government. Government rules and regulations meant to protect the community were encumbrances on liberty, he argued. Taxes, what Oliver Wendell Holmes once described as the “dues we pay for a civil society” were not a necessary evil, but instead, just an evil. Reagan insisted that it was far better for individuals to keep their money and spend it on themselves, rather than to contribute it for the purpose of escaping from the tragic commons.

The problem is that Ronald Reagan’s selfish view of the world still resonates. It’s so much easier, after all, to provision one’s own lifeboat for a flood than to join with others to try to prevent the flood in the first place, particularly when he or she can’t be sure that everyone else will be willing to make a similar contribution or sacrifice.

Unfortunately, the key lesson to take from the tragedy of the commons is that ultimately, no one can escape the tragedy alone. To survive, it takes a community.