Philosophy and Wonkery in the Defense of Health Care Reform

This is a guest post by Paul Kelleher, an Assistant Professor of Bioethics and Philosophy at the University of Wisconsin-Madison.  

There is some buzz this week about Theodore Marmor's contribution to the excellent set of essays in the current issue of Journal of Health Politics, Policy, and Law. Austin Frakt posted on it at TIE, and further discussion unfolded on the twitter machine (with Harold Pollack linking to an earlier but related post of his own). Marmor laments "how little attention was paid to general philosophical principles and what particular conception of social justice the reform was to serve." He notes that many nations struggled openly with such questions along their way to universal coverage, and he asks whether this lack of philosophical debate is the reason for the "mixed reform" we ended up with. Perhaps more importantly, Marmor insists that we'll have to revisit these questions postenactment in order "to rally a public in response" to Republican efforts to weaken or repeal the ACA.

As a professional philosopher, I suppose I should be delighted to have health policy folks stressing the importance of my discipline. Then again, if they really knew what I do, they might powerdown the Bat-signal. For there is no consensus among even left-leaning philosophers about the nature of social justice or the shape of entitlements to health and/or health care. And of course the philosophical commitments of the American people are even more diverse than those separating liberal political philosophers. Although I (naturally) believe in the conception of social justice that I hone at my office desk, I also believe it may be both practically and perhaps even morally necessary to seek ecumenical rationales that can achieve wide appeal.

Consider how this plays out in the context of John Rawls's theory of justice. First, an explicit appeal to Rawlsian justice would have fallen flat politically, despite the 250,000+ copies of A Theory of Justice making the rounds at Powells Books. Second, Rawls had little to say about justice in health care, and those who have sought to extend his theory face significant hurdles in doing so. Third, Rawls himself came to question the famous Rawlsian demand to make the worst-off as well off as possible. Sometimes it seems permissible to neglect the worst off for the sake of a more numerous group who are still badly off, as I would do if I failed to save one person from drowning because I instead chose to prevent 1,000 from going blind. 

Of course, Obama and the Democrats did not entirely avoid substantive moral appeals. I recall Obama repeatedly invoking Senator Kennedy's claim that health care is a right and not a privilege. I recall Obama repeatedly laying into the insurance companies in response to various "abusive practices" (e.g. unjustified "recissions"). And I recall Obama repeatedly making the case that we simply cannot outlaw preexisting condition exclusions without a mandate, and that we cannot have a mandate without subsidies for those who would struggle to purchase of legally mandated insurance. I also recall that nearly universal coverage passed, something no president had been able to do. It is therefore very hard for me to hit Obama for his neglect of philosophy, and it is very difficult for me to believe that a more philosophically charged debate would have boosted the chances of success.

What about holding onto the successes postenactment? Will that require clearer articulation of background moral convictions? I doubt it. It will require a periodic reminder of the wonkish account of why health care reform had to be the "Three Legged Stool" it ended up being. It will probably also require reminders of who actually bears the brunt of paying for universal coverage, as this is a legitimate concern for families who are struggling in an unrelentingly weak economy.

Things brings me to the surpsing conclusion (at least for a philosopher) that we may need more wonkery and less moralizing. I end with an example bearing on this point. Here is a passage from the economist Mark Pauly's 1995 analysis of why the Clinton health reforms failed politically:

I hasten to add that this is not my own personal preference; I would prefer more redistribution. But I realize that I am being out-voted by other middle-class people who do not want to play more taxes. Indeed, I strongly suspect that a major blow to bipartisan health reform was the success of the president’s budget plan, which sopped up (and then some) any surplus willingness of the upper middle class to pay more taxes. We could have had universal insurance coverage or a lower budget deficit, but not both.” (p. 12)

Pauly says it was the "upper middle class" who felt the brunt of the 1993 Clinton tax increases. This made them less willing to pay for health reform. Is this explanation plausible? Not from what I can tell.

According to economist Robert Pollin, the 1993 Clinton tax increases "increased the levy on [family] incomes over $140,000 from 30 to 36 percent, with an additional 10 percent surcharge for incomes over $250,000" (p. 26). And according to the Center on Budget and Policy Priorities, these families had incomes in the top 5% of the national income distribution.

Here is a graphic from a report by the Federal Reserve Bank of Cleveland that shows the increase in taxes for families at different income levels:

Given that the the median family income was 54,369 in 1990, and given that only families in the top 3-4% (those above $200,000) really saw an appreciable increase in taxes, it seems quite inaccurate to say that the "upper middle class" paid for these increases. One might therefore think that the (upper) middle class should have been willing, morally speaking, to pay higher taxes in order to finance universal health insurance for their fellow class-mates. But that's just one way to look at it. Another way is to note that what Pauly presents as non-ideological analysis seems actually to misrepresent the nature of the tax increases. This sort of analysis may well have led the middle class to think their taxes really had gone up significantly. This in turn may have led to the justified belief that they had already done enough for their country.

Why would someone who presents himself as sympathetic to reform provide such an analysis? I won't speculate. I simply want to highlight the tremendous political effect such analyses can have, and the supreme importance of getting the wonkery correct before moving on to philosophical claims. Philosophical claims are, in themselves, harder to vindicate than straightfoward claims empirical claims about how reform works, who it helps, and who will be burdened. Sometimes it is the latter we need most.

Comments

[Brendan Saloner]

Hi Paul,

I thought this was really interesting. I want to make two points.

First, I don't know how to evaluate your (highly qualified) statement: "Philosophical claims are, in themselves, harder to vindicate than straightfoward claims empirical claims about how reform works, who it helps, and who will be burdened." If all you mean by this is that we have lots of published estimates (like the one you showed) of the redistributive consequences of reforms, and that people don't pay enough attention to those, then I definitely agree with you. But there are plenty of empirical questions about reform that are difficult to settle, because they aren't straightforward questions -- and sometimes even the metrics that we choose to evaluate those questions are themselves irreducibly normative ("affordability" of health insurance is the example that comes to mind). For these questions, and the debates that arise, we should be prepared to engage with ethical principles and defend them in a clear and coherent manner.

Second, I think the degree to which ethical appeals will resonate with the public is grossly underestimated. We have some opinion poll evidence that the public would have been receptive to certain reforms that are framed in terms of helping others, WHEN the concept of fairness that accompanies that reform is also articulated. We've sort of reached a point of consensus that the American people care only about how much they themselves will benefit from health reforms. That doesn't cohere very well with the complex way in which average taxpayers and voters think about values in public debates.

Thanks!

[Paul]

Thanks for the comments, Brendan! On the first point, take the Lynch and Gollust aritcle you linked to yesterday on Twitter. They note evidence that there is agreement on various moral claims, but they themselves put forward the moral view that everyone is entitled to an equal opportunity to pursue a worthwhile life (I forget their exact language and the mobile device I'm using makes it hard to check right now). As you know, I have signficant philosophical doubts about an equal opportunity based argument, and I would have cringed if we had gotten into that sort of argument during HCR. Perhaps I should have just bit my tongue and agreed for strategic reasons, since the reforms we got do move the US toward justice as I see it? In a sense, I guess I'm saying that's exactly what happened, and why I'm skeptical that what we really needed was *more* appeals to philosophy and "conceptions of social justice" than we got. I took that to be Marmor's suggestion, Perhaps I misread him?

I hope we'll (you and I) will spend more time analyzing the poll evidence you cite. But it is one thing for people to agree that something is unfair, and quite another to explain *why* it is unfair. Again, I took Marmor to be saying that we should explore the Why Question. After all, he admits that Obama and the Democrats claimed that there was unfairness in the status quo.

My worries about digging deeper into the nature of fairness are also connected to my claim about philosophical versus empirical propositions. Of course there are highly contentious and uncertain empirical propositions. But we cannot help but seek the truth about them and then rely on that understanding in policymaking. The case is different for philosophical claims, however. Often--but not always--when philosophical are contentious, the truths we might discover by thinking harder about them will be so parochial that we should be reluctant to base laws on them.

My own view about social justice depends on the hope that the empirical issues that bear on it are in fact tractable, and that the moral/philosophical claims are sufficienly ecumenical that, when combined with the empirical claims, no reasonable person could disagree. There is no way to prove that this hope can be vindicated. The most I can do is keep offering rationales and hope others find them compelling.

[Beth Haynes, MD]

Paul -- as a philosopher promoting Rawlsian social justice, I am curious if you are familiar with Friedrich Hayek's critique of social justice both in The Road to Serfdom, and more in depth in Law Legislation and Liberty vol 2 The Mirage of Social Justice? If you are, I'd be very interested in your thoughts.

[Paul Kelleher]

Beth, you are mistaken. I did not defend Rawlsian justice in this post. The one paragraph on it critiqued Rawls. That said, I am not a libertarian, and do find the arguments of Hayek, Friedman, Nozick, etc. to be predicated on a flawed conception of liberty's point and value.

[Beth Haynes, MD]

Paul--Rereading the paragraph on which references Rawls, this time following through on the links, I apologize for misinterpreting your points. I also find Hayek's use of liberty flawed but I am not sure what you mean by "liberty's point and value." The point of Hayek's I do find worth consideration is how the implementation of distributive justice conflicts with equality before the law.
I will check out Buchanan's article. Did you ever finish writing the "completion" mentioned in the linked comment?

[Paul Kelleher]

Hi Beth, I expect to have opportunity to address libertarianism more full here in the future. By "liberty's point and value" I meant that, in my view, a proper understanding of liberty and why it's valuable does not demand libertarianism and laissez faire economic arrangements.

Of course it matters what conception of social justice we're working with we say that it conflicts with equality before the law. That said, I do not believe that sensible left-liberal conceptions of social justice conflict with equality before the law at all. I can see someone saying they conflict with a libertarian understanding of liberty, but that again is a point I don't agree with. (Of course a lot more needs to be spelled out before anyone should believe me!)

[Harold Pollack]

Hey cool post. We need to have a beer halfway between our universities

[Paul Kelleher]

Thanks Harold. And I'd love a beer. Maybe the Pres can moderate the discussion.---I may actually be at U of Chicago in the fall. I'll touch base on Twitter.

[Beth Haynes, MD]

Hi Paul--I look forward to reading more of what you have to say on this subject. Thanks for responding.