OPINION -- Last year I was on a committee of the Institute of Medicine. Our task was to provide the most recent data on the consequences of 47 million uninsured people in America. What could we say? We provided lots of data and agreed with the conclusion of a previous committee that " .. health insurance contributes essentially to obtaining the kind and quality of healthcare that can express the equality and dignity of every person. Unless we can ensure coverage for all, we fail as a nation to deliver the great promise of our healthcare system, as well as the values we live by as a society." Put simply, the experts said: Universal coverage for healthcare is a good thing; it's the right thing; do it now! In the midst of working with this second committee, I asked one of my distinguished colleagues two questions. First was this: Is solving the healthcare problem a matter of assembling more or different facts -- is it primarily about the data? He acknowledged that even the clearest facts and most compelling evidence wouldn't ensure a favorable policy outcome. Second was this: Are we, the United States, really stupider than every other industrialized country in the world that has solved this problem? Do they really know something that we don't know? His answer to this one was a blank stare. Thomas Pynchon wrote in "Gravity's Rainbow," "If they can get you asking the wrong questions, they don't have to worry about answers." Those looking to reform healthcare have taken on, as their central question, the issue of controlling cost: How can we bend the cost curve? For the opponents of reform, there could be no better question to occupy the do-gooders. You'd think we have so many Nobel Prize economists and truly brilliant people in this country that we'd be able to make that cost curve not just bend but jump up and dance. But here's the really crazy thing. The reformers think there's an answer to the cost-curve question that will satisfy the opponents. Not likely. But if there were, the answer would reflect a level of service so low that the proponents would be left with a "solution" that didn't solve the problem. Millions would still not be covered and even some of those who were couldn't afford to use their coverage. So the reformers are trapped in their own question. The answer won't really matter, or it won't matter enough. And yet they work hard to find it because of the reasonable and rational belief that it has to matter.
Opponents of reform are occupied with an entirely different question: Are we willing to give up our freedom? John Boehner, the House minority leader, said recently, "This bill is the greatest threat to freedom that I have seen in the 19 years I have been here in Washington. ... It's going to lead to a government takeover of our healthcare system, with tens of thousands of new bureaucrats right down the street, making these decisions [choose your doctor, buy your own health insurance] for you." This question has little to do with cost but everything to do with the role of government. Whom can we trust? Opponents like to say, "We trust the people; they trust the government." So here's the problem. The reformers are arguing about cost and efficiency, and the opponents are arguing about freedom and competence. When that's the argument, freedom wins. For the reformers, healthcare reform means helping others, fairness, advancing the common good, perhaps even a measure of social justice. And it means an active role for government. But for opponents, it means a loss of freedom, giving others something at my own expense, government ineptness, loss of quality and undermining personal responsibility, not to mention waste, fraud and abuse. So the argument is not really about cost. It's about freedom. Reformers won't gain a sufficient victory because they haven't argued effectively about freedom. And, of course, they haven't answered the cost question either. This is an argument that pits fear and resentment against hope and trust. To my great sadness, fear and resentment is an easier and more compelling appeal. As a society we're still not at the point where we can effectively make an equally compelling argument for hope and trust. Harry Truman reportedly said, "The American people cannot read the writing on the wall until their backs are up against it." Well, we're right up against the wall with healthcare, but we still lack the focus to read the headline. Woody Allen, the wise pop philosopher of my generation, once explained that the world is facing a fork in the road that's more important than at any other time in history. One path, he said, leads to alienation and despair. The other path leads to total destruction. "I pray," he added, "that we have the wisdom to make the right choice." For the reformers, not passing healthcare reform leads to alienation and despair; for the opponents, passing healthcare leads to total destruction. In the end, it's more than what we know as a country. It's about what we believe. It's about who we are. Lawrence Wallack has been Dean of the College of Urban and Public Affairs Portland State University since 2004. He is also Emeritus Professor of Public
Health, University of California, Berkeley and was a founding senior fellow and first President of the Rockridge Institute, a California-based think tank and later a senior fellow at the Longview Institute.
