Can We Talk? What to do about health care, part two

Charlotte and Janie Talk about Health Care, Education and NASA

.Janie and Charlotte are best friends from college who have diverged spiritually and politically until we don’t agree about anything (almost).  But as friends, we occasionally get together to talk over some of the issues of our time.  Our first discussion was about religious liberty, beginning here.  Today we wrap up a debate about a hot topic soon to get much hotter.  The first part of this particular debate can be found here.  

 

Charlotte: I’m pleasantly surprised and grateful to see that you and I agree that there should be a basic right to health care in America. I think this is a growing belief for more and more people and probably the Affordable Care Act contributed to that expectation. We are seeing reports from town hall meetings in numerous states where Republicans as well as Democrats are loudly challenging their representatives not to disrupt their access to affordable insurance and health care. With all its problems, the ACA has helped millions of people and saved numerous lives. I agree with you that it would be political suicide for the Republican Congress to repeal Obamacare without a solid replacement. If they mess this up, Town Hall meetings will only get noisier and rowdier.

I’ve been thinking about the similarities between this current process and the process America went through to provide free public education for all our children. I think there are numerous comparisons and we might be able to learn how to do this better if we will look back at our recent history.

For many years, there was no expectation that all children should be educated. Education was a privilege not a right. Before the Civil War, some states made it illegal to even teach slaves to read and write. Countless children worked the land and toiled in factories instead of going to school. I wonder how many men proclaimed that girls should tend the home and not fill their pretty heads with too much learning.

So how did America move to the place where we are now? Where our society as a whole assumes every child should go to school? And where there are often legal consequences for parents and children when they are not in school.

One reason public schools developed is that we figured out that our society as a whole is better when we have an educated population. All of us benefit when all of us function together in this community with basic knowledge and skills. All of us benefit when each of us is allowed to grow to our potential. All of us benefit when the geniuses among us are discovered and nurtured.

So it makes perfect sense to me that all of us will benefit if we will assume that everyone among us should have access to basic health care. If we will see health care as a right and not a privilege. I believe our entire nation will be healthier and more productive if we can make that societal shift in our expectations.

 

Janie: I disagree that there was little or no expectation in the U.S. that children should be educated.  It was not something we figured out along the way–education has always been important in American public life, but it was local-community-based rather than government-based.  The Northwest Ordinance, which opened US territories up for settlement after the War for Independence, divided the land into townships, with one section of each township dedicated to the support of the school.  The New England puritans and others were extremely zealous for education.  The only ethnic group that demonstrated a more casual attitude were the Scotch-Irish who settled in the Appalachians and southern foothills.  But then, the South was a much more stratified society (big divide between the landed gentry and poor whites) in colonial days, and for a long time after.  That’s one reason slavery was able to dig such a foothold there.  And yes, it was illegal in many southern states (as slavery became more entrenched in the early 19^th centuries) to teach blacks to read.

The first big step toward public education as we know it today occurred in the second half of the 19^th century, when (mostly) northern intellectuals became enamored with the Prussian model and decided that was the way to go: strict age-level divisions, certified teachers, pre-determined curriculum.  Lots of school districts adopted the model, but it was still local control.

 

Charlotte: I really like talking with smart people! Obviously you know quite a bit about American education and I appreciate your passion. I think you and I definitely need to talk more about school choice, vouchers and Secretary DeVos. (I’m holding my nose here but I’m willing to listen.)

But for now, I want to go back to my original point in this conversation: America as a whole did not have an expectation that all children should be provided with a basic, free education until about 150 years into its national life. I believe the process by which America came to this expectation that all children should have a right to education is similar to the process in which we are currently engaged: America is slowly but surely coming to understand that all citizens should have a basic right to health care.

Notice in my first foray, I did not say people did not value education. Of course, throughout human history many people have valued education; but for many societies – as for our own – the education of all children was not the common expectation. Horace Mann moved the needle on this issue in America; his advocacy for Common Schools was controversial but his ideas finally took hold. By 1918, every one of the 48 states provided public schools and had compulsory attendance laws on their books.

So my question to you: should affordable, accessible health care be a right for all our citizens much as a free, public education is now considered to be a right for all our children? Do you accept my comparison?

And secondly, since you take issue with “Obamacare” but you agree with me that there should be a basic right to health care in America, do you have any ideas for an equitable system to replace the Affordable Care Act?

 

Janie: Okay.  I was a little confused about where you were going.  I don’t think it’s entirely an accurate comparison, because education was considered more an obligation and necessity for free citizens than a “right.”  I still disagree with your statement that “America as a whole did not have an expectation that all children should be provided with a basic, free education until about 150 years into its national life”—I think that was the expectation from the beginning (in most of the country, anyway), but the disagreement was in how to provide it and who should be responsible for it. Before the late 19^th century, communities generally took responsibility for it themselves.  As the population became more diverse over successive waves of immigration and as governments, both federal and state, grew more centralized, the idea of free public schools grew along with it.  For a lot of reasons, though, not entirely as a matter of individual rights.  Education was seen—and is still seen—as a way of molding the populace, assimilating immigrants, and preparing future citizens to participate in public life (e.g., by reading newspapers and following political debates).  I don’t mean to quibble, but I think there is a difference education as a right and education as a necessity.

That said, we can certainly agree that by this time in our history a free basic education is a right as well as a necessity.  The controversy over Betsy DeVos is mostly about how much control the federal government should have, and there’s a comparison I can get behind: how much control should the federal government likewise have over health care?  The argument over Obamacare is not about right.  Over time, as I tried to demonstrate in our earlier conversation, most Americans, including Republicans, have accepted that there is a right to some kind of health coverage.  The argument is now over control.  To what extent should the federal government step in and regulate insurance companies, hospitals, doctors, treatments, etc., etc.?

The basic idea behind Republican reform—and I sure hope they hurry up and get to it—is less top-down control and more individual choice.  This would involve several elements, including 1) individual Health Saving Accounts, or HSAs, to which the government contributes (and which go with the person, not the job); 2) shopping for insurance across state lines, which we currently can’t do, 3) high-risk pools for chronic conditions, 4) safety nets for those who are unable to make decisions for themselves, 5) incentives for healthy choices, and more.  I expect any reforms will include all of these, and I think we’ll have some concrete proposals within a couple of months.  That will give us something to talk about.

 

Charlotte: I’m remembering something you said in our first published discussion on this topic. Something about it bothered me and I couldn’t put my finger on it until now.

I wonder why Obamacare prescribes a one-size-fits-all solution by requiring all insurance to cover a wide-ranging “essential benefits package” for everyone, whether they need it or not: maternity care for retirees, for instance.  I assume the purpose of that is to spread the burden equally, but I think there are other ways to do it besides making the young and healthy shoulder some of the costs for the old and sick—especially if we bankrupt ourselves to the point where the funds won’t even be there when today’s young people need it. 

I think it’s your phrase “making the young and healthy shoulder some of the costs for the old and sick” that jumped out at me.

First, I believe that shouldering the costs of living together within a society certainly ought to be part of what it means to function as a connected community. Our federal government was tasked from its inception to “promote the general welfare.” Our public schools are expected to educate every student who walks through their doors. Our interstate highway system lies ready for any vehicle to travel with convenience and comfort. Likewise, our health care system ought to be accessible and affordable to everyone who needs care.

So who pays for all of this? We all do. Our tax dollars are our contribution to this broad, complex society we live in – not just to our own advantage, but for the common welfare. Retired Americans who don’t have children or grandchildren in the public school system still pay for the education of our young people through their tax dollars. I’ve never been to Wisconsin but I’m happy to contribute to the highways that allow the dairy farmers there to transport their wonderful cheeses. I’m also quite happy to help pay the costs for contraception for American’s women as well as pre-natal care and safe deliveries for America’s children.

Before the ACA, people who were not able to afford insurance coverage went to emergency rooms whenever they got sick. Who paid for that care? We did. Those of us whose insurance covered our hospital stays paid higher premiums in order to cover unreimbursed hospital expenses. And/Or our tax dollars went to reimburse hospitals for some of that medical care. I would much rather help pay for people to stay well or to get more efficient, affordable care when they are sick.

Insurance companies have always based their business on the concept of insurance pools. Lots of people pay into the system but only a few people have exorbitant medical expenses. Those who stay well help support those who are sick. It’s a gamble companies make, and based on the way they have been jacking up the cost of coverage in the past few years, their gambles are paying off. We regular people are paying more and insurance companies are raking in outrageous profits.

But here’s another thing, Janie. You and I both operate out of our Christian faith with Christian values. Isn’t “carrying one another’s burdens” part of our spiritual ethic? The old support the young and the young serve the old. The strong care for the weak and the weak offer whatever they are able. The privileged stand up for the oppressed and we who have a voice speak out for the silenced.

I don’t think secular governments ought to function as religious societies, but I do believe in the prayer I pray every Sunday: that God’s kingdom may come on earth as it is in heaven. The more human societies live into kingdom values of grace and compassion and equity and inclusion the better off we will be. My own journey away from fundamentalism into progressive Christianity changed not only my theology; it also shifted my politics. The answer to the question: Who is my neighbor? is much larger and wider than it ever was before.

 

Janie: You’re bringing up an important point, and a very basic disagreement between the groups we label “conservative” and “progressive.”

I remember a slogan from the 2012 Democratic convention: Government is another name for what we do together.  Hillary Clinton capitalized on that idea in one of her campaign slogans: Better together.  Look, I understand that sentiment.  But a government is not a community.  As a nation, Americans can feel a sense of community when we are attacked, as at Pearl Harbor or 9/11.  We can come together when a president is assassinated or a city experiences a natural disaster.  To ask a nation to “come together” to provide for each other’s personal needs is a stretch.  The preamble to the constitution mentions providing for the common defense and promoting the general welfare.  Those verbs are not the same and I believe they were carefully chosen.

An army “for the common defense” is something the government has to provide, first because only the government should have that kind of power and second because private armies would be too prone to run amuck.  Other big projects, such as an interstate highway system, could be considered a legitimate federal expense, since no one else could finance it.  The space program was also thought to be something only the feds could do.  (But something very interesting is happening with the space program, as I’ll get to in a minute.)

When it comes to people’s personal choices and commitments, the picture gets cloudier. The ACA was built around the individual mandate, and that’s where it has run into trouble.  Younger people don’t want to pay for something they see no immediate need for.  Of course I understand your reasoning: young people pay now for something they’ll use later, like social security, and in the meantime they’re contributing to the common good.  But they are already burdened more than we were at their age: huge college loans, high mortgages (if they even take out a mortgage), fewer jobs appropriate to their college degrees, an increasing federal debt and deficit that will mean trouble down the road.  Why aren’t we more concerned about them?

Of course taxpayers have been supporting Medicare and Medicaid for two generations, but this is different: the ACA is an obvious hand reaching into your pocketbook and pulling out money to pay for people who don’t take care of themselves, or to pay for people who are here illegally, or to pay for older folks who have 401(k)s.  I know that’s not an entirely fair judgment; but that’s the way it looks to families whose insurance premiums have doubled over the last year.  This kind of “bearing each other’s burdens” does not build community.  Instead, it drives people apart by pitting them against each other.

What builds community is freedom and personal relationship.  It’s people, organizations, families, even businesses pitching in where they see a need.  It’s doctors foregoing insurance and charging a flat rate for basic care.   It’s surgeons forming their own insurance-free surgical centers where you can get a knee replacement for $10,000.  It’s Christian cooperatives like Medi-share where each family pays a monthly premium directly to another family who needs help.  It’s urgent-care clinics and private arrangements between doctors and patients with no third party in the way.  It’s being able to purchase insurance across state lines so you can get exactly what you want or need: low-cost catastrophic coverage, for instance, instead of full-range coverage for stuff you don’t need.

I’m not saying that the federal government has no role to play: Individual HSA’s that are not tied to an employer can “promote the general welfare” while allowing families and individuals to make their own decisions about which doctor to see or what treatment to pursue.  Government-supported free clinics can help provide basic care for the truly needy.  But a top-down, one-size solution is no long-term solution at all: expensive, inefficient, and more so as time goes on.   We won’t bear the burden; our kids will, and they won’t thank us for it.

(One quick word about the space program, because I think it’s relevant.  Since NASA gave up the shuttle program—and I’m really not sure what they’re doing now—entrepreneurs are stepping into that gap.  There’s a plan in the works to go back to the moon on the backs of private companies like Space X (headed by Elon Musk) and Blue Origin (Jeff Bezos).  That’s what is still so great about America: the space to dream and opportunity to make it happen.  I used to hear this a lot about 15 years ago: “If we can send a man to the moon then surely we can . .  .” create a world-class education system, eliminate poverty, provide affordable health care for everybody, etc.  What strikes me about companies like SpaceX is that they are free to employ the best people and aim straight for a goal without politics and bureaucracy getting in the way.  If we can send a man back to the moon without NASA, maybe we could be making better use of the private sector more for health care—and I DON’T mean insurance companies.)

Charlotte: Oh my! This dialog has gotten long and complex. It’s like we’re sitting together in comfortable space with a good cup of coffee letting ourselves go wherever the conversation takes us. I like this. But let’s wrap this one up and start our third effort soon.

So here’s my wrap up: I appreciate you pointing out that we are talking about a very basic disagreement between the groups we label “conservative” and “progressive,” that is, our understanding of the character of America. You say conservatives understand that what builds community is freedom and personal relationship. While I don’t disagree with your premise, I will say progressives understand it is our shared humanity that creates community and thus our governmental policies should foster that sense of care for one another.

You say: This kind of “bearing each other’s burdens” does not build community. Instead, it drives people apart by pitting them against each other. I say it is our human brokenness that pits us one against the other and creates within us a fundamental self-centeredness. I say sometimes the government, like a strong wise parent, must intervene to ensure the weak are not oppressed, the poor are not forgotten and the silenced are able to find a voice.

I have mentioned my own journey from conservative to progressive Christianity and how that has influenced my politics. I would love to hear your understanding of how religious faith ought to intersect politics. Your own personal way of doing that and your take on how public Christians should (and should not) allow religious views to influence public policy. Can that be our next conversation?

Janie:  Sure—but I’d lay some groundwork first.  You compared government (at its best) as a “wise parent.”  How else do you understand the role and function of government, and how does your faith inform your view?  Does that seem like a good place to start?  If so, I can share my ideas first.  I’ll bring the coffee!