Cruelty, Freedom and the Politics of Health Care Reform

On the eve of the health care vote liberal columnist Paul Krugman wrote in the Times that "our system is unique in its cruelty," as he urged passage of the imperfect but still progressive bill. In a tense, ambivalent piece published just after the bill passed, conservative David Brooks recognized in the same newspaper that the Democratic party had for decades been the party of fairness and security, but he still worried that the pursuit of fairness might result in a decline in standard of living for the country as a whole. This is one way of framing a core debate of our era: Can we reduce cruelty and unfairness in America without sacrificing economic growth and cultural vitality?

It is no longer publicly permissible to be against reducing cruelty. When we become aware that something we are doing is causing suffering, we know we should stop doing it. Even if change will be inconvenient, or if it takes us out of our typical ways of doing things, we know that it is wrong to continue to cause pain to others. Although surely sometimes one might want to say "but I'm having so much fun," or "but I don't like that person [who suffers] anyway," our moral codes have evolved (most of the time) to a point where we can't simply say "too bad, let em suffer." That's why the parts of the health care bill that deal with children with pre-existing conditions, or sick people who get dropped by insurance companies because of chronic afflictions carry so much weight with proponents of reform. To be excluded from the insurance "pool" is to be excluded from the commons of concern. You no longer count. We know that our system makes these folks suffer, and we should change that.

It's clearly untenable to say in response to this cruelty something like, "I make a lot more money this way," or "It's much easier to keep really sick people out of the pool so the rest of us don't have to pay so much." When we become aware of cruelty, we need to stop perpetuating it. Right?

Brooks, though, raises the question of how we should act if our efforts to reduce cruelty will make life worse for everyone. That's why the deficit is relevant to the cruelty question. If we wreck the entire health care system and cripple the economy in our efforts to be less cruel, then we don't protect the vulnerable. We just join them.

That's why the economic arguments about the importance of bringing healthy people into the insurance pool were so important in this debate. Arguments about how reform will eventually save money and reduce the overall deficit were also efforts to return the focus to the fact that our current system "is unique in its cruelty." If reform didn't create worse problems, than we had no excuse but to protect the vulnerable.

But the powerful emotions activated on the Right don't really have to do with the size of the deficits or with compromising economic growth. These economic concerns would be trumped by "excluding children with pre-existing conditions." The powerful emotions, the violence, activated on the Right arises instead from the Republican reframing of health care as an issue of freedom: "My freedom is as sacred as your need to protect your sick children; I may choose to help you, but don't tell me I have to."

Fear of the government is a reasonable fear, and it is an important part of our political culture. There is no doubt that giving the government more responsibility for health care will increase its general powers. How could one argue otherwise? If suspicion about governmental control is a healthy political instinct, however, it can also be fanned in to a consuming anti-political rage. By stoking the reasonable fears of government interference into paranoia about Federal control over deeply personal decisions, the Right has created passionate fury - a frenzied anxiety that Republicans will struggle mightily to keep alive until November. But passionate fury will be very difficult to sustain or contain.

Obama won this round because he reminded his base, his party and the country why we must reject a system of care that causes suffering for individuals and families while creating huge profits for insurers. He was able to do this because he asked us to believe that we could reduce cruelty while preserving our freedom. He asked us to care more about the suffering of those "dropped from the pool" than about an abstract threat to our future freedom. He asked for empathy and care for our fellow-citizens, and, thank goodness, we gave it to him.

Fear of government won't disappear and it shouldn't. But now we have to show that these reforms can really reduce suffering and vulnerability without engendering a bureaucracy that erodes our freedom.