What's dragging the Democrats down in the health-care debate isn't confusion about details. On this the president and his supporters have proven themselves the ablest of technocrats, easily identifying each plan's particulars and its shortcomings, laying everything out on nice flow charts.
It is the big questions that are tripping them up. Concerns about the size and role of government are what seem to leave reformers stammering and speechless in town-hall meetings. The right wants to have a debate over fundamental principles; elected Democrats seem incapable of giving it to them.
And in the silence, some lousy ideas have flourished. If universal health insurance goes down to defeat again this year, Democrats will have to live with the shame not only of having failed to enact their No. 1 priority, but also of having been beaten by arguments that a novice debater would have no trouble putting down.
Consider the assertion, repeated often in different forms, that health insurance is a form of property, a matter of pure personal responsibility. Those who have insurance, the argument goes, have it because they've played by the rules. Sure, insurance is expensive, but being prudent people, they recognized that they needed it, and so they worked hard, chose good employers, and got insurance privately, the way you're supposed to.
Those who don't have what they need, on the other hand, should have thought of that before they chose a toxic life of fast food and fast morals. Healthiness is, in this sense, how the market tests your compliance with its rules, and the idea of having to bail out those who failed the test--why, the suggestion itself is offensive. We have all heard some version of the concluding line, usually delivered in the key of fury: By what right do you ask me to pay for someone else's health care?
This image of sturdy loners carving their way through a tough world is an attractive one. But there is no aspect of life where it makes less sense than health care.
To begin with, we already pay for other people's health care; that's how insurance works, with customers guarding collectively against risks that none of them can afford to face individually. Our health-care dollars are well mingled already, with some of us paying in more than we consume while others use our money to secure medical services for themselves alone.
The only truly individualistic health-care choice--where you receive care that is unpolluted by anyone else's funds--is to forgo insurance altogether, paying out-of-pocket for health services as you need them. Of course, such a system would eventually become the opposite of the moral test imagined by our Calvinist friends, with the market slowly weeding its true believers out of the population.
The idea that merit determines healthiness is almost as risible. To be sure, we should all eat right, brush our teeth, and cut down on sweets, but that will hardly help us if we're born with a condition that requires expensive treatment. Or if we eat cookie dough that's tainted with E. coli. Or if our industry dies and our employer shuts down. Or if our insurance company, looking out for its own health, finds some pretext to rescind our policy.
The righteous individualists among us might also consider that our current health-insurance system, which delivers them the medicine they think they've earned, is in fact massively subsidized by government, with Uncle Sam using the tax code to encourage employers to buy health insurance. And were it not for government programs like Medicare and Medicaid taking over the most expensive populations, the political scientist Jacob Hacker pointed out to me recently, the system of private insurance would probably have destroyed itself long ago. That image we cherish of our ruggedly self-reliant selves, in other words, is only possible thanks to Lyndon Johnson and the statist views of our New Dealer ancestors.
One reason government got involved is that our ancestors understood something that escapes those who brag so loudly about their prudence at today's town-hall meetings: That health care is not an individual commodity to be bought and enjoyed like other products. That the health of each of us depends on the health of the rest of us, as epidemics from the Middle Ages to this year's flu have demonstrated. Health care is "a public good," says the Chicago labor lawyer Tom Geoghegan. "You can't capture health care just for yourself. You have to share it with others in order to protect your own health."
Yes, Democrats can prove that America pays more for health care than other countries; yes, they have won the dispute that private health insurance is needlessly expensive. But what they've lost is the argument that we are a society.