There is a pernicious idea that permeates American politics. It lies at the root of far right ideology but belief in it has become so widespread that many progressives often find themselves subtly accepting it. In the realm of health care, this idea manifests itself most extremely as a conviction that the poor are undeserving of anything more than emergency care. It states that their economic misfortune justifies denying them treatments that could improve and prolong their lives because it might be “inefficient”. The idea is this: that the dictates of the market, no matter their outcome, are always moral and, correspondingly, anything that distorts the “natural state” of the market must be inherently wrong.
Paul Ryan, for example, has spoken about his belief in the philosophy of Ayn Rand, who he says has demonstrated the “morality of capitalism”. Rand is, of course, the most well known proponent of these views. In her telling, society is divided between the producers – those paragons of morality who single-handedly drive the economy – and the looters who take from them.
This belief is also evident in the way we talk about our society. The word “entitlement” – which originally meant a minimum benefit we guaranteed to one another based upon our natural rights as humans – has become an epithet, spat out with vitriol as the speaker curses big government. No longer does it signify a compact between fellow citizens to care for each other. Instead, it now connotes a handout given to those who have done nothing to earn it, who are undeserving simply because the market has found them lacking.
The reaction to the Supreme Court's recent decision on the Affordable Care Act (ACA) provides us with an interesting case study of this philosophy. The Court, while finding the vast majority of the health care law constitutional, also limited the law's Medicaid expansion, essentially saying that States would be able to opt out of the expansion without repercussions from the federal government.
In response to the ruling, a number of conservative Governors quickly declared that their States would refuse to participate in the expansion, often citing reasons of cost. This is despite the fact that the Urban Institute has estimated that the expansion, which is funded almost entirely by the federal government, would end up saving States billions of dollars because they would spend less on compensating hospitals for care provided to the uninsured. Far from safeguarding the fiscal health of their States, these Governors are instead implementing a rigid ideology which insists that programs for the poor are wrong in and of themselves.
Conservatives are not the only ones who fall prey to the idea that the market is a suitable substitute for our moral values. Progressives sometimes tacitly accept a version of this argument, albeit in a weaker form. Health care reformers often find ourselves talking about cost-benefit analyses and the efficiency of care while neglecting to mention the purpose of reform: building a more inclusive health care system that provides better care to all people. In doing so, we reinforce the notion that market efficiency is valuable in its own right, rather than as a means to a specific end.
The faults of a belief system which mistakes the market for a moral arbiter ought to be apparent. It assumes that markets are immutable and exist in a vacuum outside of the human institutions which have created them. It requires us to believe that maximizing economic output automatically increases well being even while tens of thousands of people die each year as a result of being uninsured. And it presupposes that we lack selflessness, that we would not be willing to sacrifice a percentage point of growth in our gross domestic product in exchange for providing basic health care to those who lack access to it.
Overcoming the hold that this pernicious idea has on our politics is not an easy task. For our part, we must remind ourselves that the cause of health care reform is not primarily about reducing costs or improving efficiency. It is not about the growth of the American economy or the size of our national debt. It is, first and foremost, about increasing the expansiveness of our compassion by ensuring that no one lacks access to the care which we all deserve.