As Republicans continue their attempts to pass the American Health Care Act (AHCA), remember this: we are in this together.
In this staunchly individualistic culture it may seem natural to question our interdependence, as Republican Congressman John Shimkus did when he doubted why a man should pay for maternity care. Conservatives often revere the primacy of the individual to control one’s destiny, and argue that government should not interfere. The current administration has significant control over the degree of federal involvement in health care, and while American individualism has underpinned some of the country’s greatest achievements, Republicans would have us believe that it is also the solution for health care. They are wrong.
Tension between individualism and collectivism in health is time-worn. Civilizations have long limited personal freedom for the greater good, particularly to prevent the spread of infections. But chronic diseases like diabetes or mental illness impose the greatest burden on Americans, raising the question of who should bear their cost.
Unlike infections, most chronic diseases don’t obviously spread and have only a few modifiable risk factors: limited physical activity, poor diet, substance use. Individualists argue that patients have control and so bear the responsibility. Their solution? Make better choices. Yet an astounding body of evidence demonstrates that social and commercial determinants of health undermine our ability to freely make healthful choices.
The conservative ideology that vilifies the public sphere is an overplay of individualism veiled as virtuous protection of freedom.
Take for example a young man from southeast San Francisco who we call Alex. Born into a poor family in a poor neighborhood, he couldn’t control the stress, building mold, and polluted air that he was exposed to as a child. After a recent cold, his lungs began their signature wheeze, landing him in the hospital instead of work. Guess who pays his health care bill? We all do. He pays some for sure, but society pays the bulk through higher insurance costs, stagnant wages, tax dollars, and lost productivity.
And we can’t just blame Alex or bad luck: we’re all accountable. Society—not Alex—created many of the conditions that led to his hospitalization. Worse, there isn’t just one society that we all share. That social networks are neatly siloed by socioeconomic status means that what Alex calls society is a world apart from that of the well-to-do. This has real consequences: there is a 15-year gap in life expectancy between the richest and poorest 1 percent of Americans, and it is widening. Self-determinism doesn’t explain it, but social contagion does: we are largely a function of our networks and environments.
Steadfast conservative belief in individualism falsely dichotomizes individual and public health. Your health — your individual health — is inherently communal. Health policy that treats individual as island is a recipe for failure. No one, rich or poor, lives in a vacuum insulated from disease. And when we do get sick we turn to health care, a shared resource that we only use when needed because it is both inconvenient and costly.
Insurance is the communal system designed for these shared realities. Insurance distributes our risk through society, making us better off because we are all in it together. The young and healthy should pay for the old and sick, because one day they, too, will be old and sick. Men should pay for women’s care, because when we are in it together it deepens the funds from which both can draw. And most controversial despite the evidence: the rich should pay for the poor, because the same society and chances that helped the rich failed to bring the rest along.
Yet Republicans still focus health reform efforts on individual responsibility. Health savings accounts or high deductibles are really just smoke and mirrors. When social ills like poverty and inequity force difficult decisions like buying medications or food (or an iPhone), the best they offer is underinsurance, a euphemism for no insurance.
In other words, these policy-makers’ rally for individualism is a rally against the very idea of insurance itself.
The conservative ideology that vilifies the public sphere is an overplay of individualism veiled as virtuous protection of freedom. When our policy-makers oppose collectivism in health care, they not only neglect Alex, they misunderstand our interdependence. Like it or not, individualism and collectivism in health are two sides to the same coin. Individualism may underlay much of American achievement, but our health and health care are still in the commons.
As we contemplate our health care future, here’s a prescription: double down on the health of all. If not for altruism, then for enlightened self-interest. Your health depends on it.