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Freedom From Fear

The best appeal for universal health care isn't cost; it's fear

Governor Arnold Schwarzenegger of California is promoting compulsory health insurance by saying it will reduce the cost of paying for the uninsured: "The people who have insurance pay for them. ... Those that are fortunate enough to have coverage--we are paying a hidden tax." This is hardly a new argument; proponents of health reform have appealed to Americans' sense of thrift for roughly 100 years on the assumption that we simply don't care about anything else. As the reformer and social scientist Charles Beard wrote during the first American campaign for universal health coverage in 1912, the daily tragedy of our worse-off fellows does not move us: "A mere high mortality rate ... will not seriously disturb a nation that complacently slaughters more people on its railways and in its factories and mines than any other country in the world." As hard as our hearts have grown, Beard concluded, only an appeal to avarice can pierce their armor: "[M]athematically minded reformers are trying to reach the heart of the public through its purse by pointing out there is a great economic loss in the death of persons of working age."

Yet, though time honors the appeal to costs, little else does: One hundred years of campaigning for universal health coverage has brought no success. That's because advocates have the strategy all wrong. If the argument from utility moves some people, it moves fewer than the prospect of freedom from fear. To be truly effective, proponents of compulsory insurance should argue that implementing universal health coverage will decrease the sum total of anxiety in our society. The battle for American health care is part of the real war on terror.

The major features of America's health insurance problem have not changed in 100 years. Then as now, the cost of modern medical treatments rose ahead of many Americans' ability to pay. Disease contributed to chronic unemployment and to poverty. Private insurance plans covered a great many Americans, but by no means all. And poor Americans suffered disproportionately from disease as poverty led to sickness, and worse poverty and worse sickness. "As modern civilization has substituted expensive medicines for the vis curans naturae, the heaviest expense coincides with a sudden cessation of income," the analyst I. M. Rubinow wrote in 1904. And so on down in a spiral to death, and debt for survivors.

Objections to compulsory health insurance sounded a century ago much as they do now, too: Opponents claimed that public coverage would increase cost, bureaucracy, and the price of American goods so they could no longer compete on the world market. And rebuttals to these objections also sound familiar. The cost of private insurance was high then and has kept rising since, accompanying an extraordinary growth in litigation and private bureaucracy. Now the U.S. has an enormous private health care bureaucracy that exists chiefly to deny people coverage, and we spend more on it than other countries spend on public bureaucracies that exist chiefly to extend coverage. And what Rubinow wrote in 1904 holds true today: Somehow, universal coverage has altogether failed to scuttle other countries' manufacturing concerns--the cost of "social insurance has not stopped the goods 'made in Germany' from permeating the world-market."

This stalemate in the American debate endures partly for obvious structural reasons--the people who would immediately benefit from universal health care have less money and less political clout than its principal opponents--but also because the real issue is different from the apparent subject. And, while the apparent subject leaves too many of us unmoved, the real issue might dislodge us from our complacence.

The disagreement over health care isn't really about cost or bureaucracy or national competitiveness, nor is it even about overall quality of care, studies of which support a "positive effect of public financing on health outcomes." If Americans were really considering those factors, we would long ago have adopted universal coverage laws. What's holding us up is the question of whether all Americans should have the same economic security as the very richest among us.

The high cost of medical care scares us. We rightly pause when we consider quitting or switching jobs. Suppose we would like to leave a dull, but safe, paper-shuffling position for a stint at a startup--such entrepreneurial leaps fuel American productivity, don't they? Perhaps we dare not, though, lest we lose our health coverage. Suppose we would do better for ourselves and the American economy working part-time--we dare not, lest we lose our health coverage. Suppose we really ought to retire; suppose we're actually, in fact, sick--time and again we stay in work against our better judgment, against the welfare of the whole community, because to get sick without coverage means to lose not only well-being but everything we might leave our heirs.

Study upon study supports this common-sense supposition: People with COBRA or other portable kinds of insurance, or people with spousal medical coverage--lucky people who don't have to worry about where their health care coverage comes from--leave their jobs more readily and retire when and as gradually as they please, in almost every conceivable circumstance.

What if all Americans felt so similarly free? One hundred years ago, Americans knew what might happen: As one critic of compulsory coverage complained of the German case, it "has not filled the working class with gratitude toward the government ... nor has it made the workingmen friendly and conciliatory toward the employers." Exactly--it made employees uppity. Once they felt a little less feudally dependent on their employers, they demanded wage increases--maybe even through unions.

When the Supreme Court affirmed the constitutionality of unemployment, disability, and old-age insurance under the Social Security Act, Justice Benjamin Cardozo wrote, "Rescue becomes necessary irrespective of the cause. The hope behind this statute is to save men and women from the rigors of the poor house as well as from the haunting fear that such a lot awaits them when journey's end is near." The drafters of that law wanted to include health coverage but the intensity of opposition put them off. But the goal of health coverage is the same as Cardozo's--not whether we might pay an agreeably lower price for a better managed society, but whether, as Rubinow wrote, the ordinary American deserves "a sufficient economic and medical provision to preserve not only his bodily health but his civic self-respect as well."

By Eric Rauchway