Click here for a full text transcript of the conversation.

Host Ira Flatow said in his introduction:

“Lost in the fray [of acronyms and actuarial tables] is the whole reason to have the health care debate in the first place…we’re going to try to reel it back in to talk about our values. What role do they play in shaping health care policy?”

Flatow noted that in its recent collection of essays, Connecting American Values with Health Reform, “The Hastings Center has tried to bring values back into the discussion.”

Len Nichols, health policy director at the New America Foundation, also participated in the show. Nichols, a health economist who wrote an essay on stewardship for the Hastings Center collection, said that passage of the final health care reform legislation is contingent on leadership that promotes shared values. “It is sometimes true is that those values seem to differ among political antagonists….but when you probe deeply and get in a dialogue you find out the values are actually shared,” Nichols said. “I believe most people share them and therefore we will end up with a bill that moves our country forward.”

Many immigrants who lawfully entered the United States are working at low-wage jobs without health insurance. They struggle, as generations of immigrants to the United States did, to get by each day, to pay the rent and put food on the table. And they are often forced to go without the health care they need because they cannot pay a doctor.

Imagine what it would be like to wait five years to get a cancer screening. Think about what you might do if you had a sick child but could not afford to see a doctor. Or imagine having diabetes and waiting five years to get regular treatment. This is unacceptable.

Today in America, legal immigrants who qualify for Medicaid services are unfairly denied access to the program for five years even though they pay taxes like everyone else. If we value fairness as a society, we must provide children and adults with access to essential, preventive care that keeps people healthy.

Why? When we prevent legal residents who diligently pay taxes from accessing routine medical care, it leads to an inefficient, costly and wasteful system of treating patients who are forced to seek care in an emergency room. It’s an expensive and ineffective way to treat conditions that require ongoing management like diabetes, heart disease or even cancer.

Letting legal immigrants pay into the health care system and get access to the care they need will bring down health care costs for the entire nation. It will allow for true access to health care for everyone who needs it and save money for our health care system in the long-run. Taxpaying legal immigrants deserve timely access to essential medical care.

If our core values as a nation are the concepts of fairness and justice, we must reflect that in the reforms of our health care system. It’s time to do what’s right and end the wait for health care.

Deeana Jang, JD is the Policy Director of the Asian & Pacific Islander American Health Forum.  As head of the D.C. office, Deeana Jang leads APIAHF’s policy work which includes improving access to health coverage, improving quality of care including linguistically and culturally competent health care services, promoting a diverse health care workforce, improving data on Asian American, Native Hawaiian and Pacific Islander health, and increasing investment in community-driven health strategies.

Nothing but a pale and partial shadow of a serious form of universal health insurance and a right to health care, the public option idea in American rhetoric has been quickly branded as socialism. If anything, it is actually a bolster for liberty and consumer choice.

In addition to my scholarly work in bioethics and health policy studies, I am an elected trustee in the Village of Hastings-on-Hudson, NY, and I am a Democrat. I view the public option as only a stepping stone to more thoroughgoing reform that will be needed as a long term project after the current legislation is enacted in some form. Still, it has both potential practical and symbolic importance. Politics, as they say, is the art of the possible, and it is also the domain of appearances.

Under the leadership of the late Senator Edward Kennedy and others over many decades, the Democratic Party has made a commitment to the American people to repair a damaged health care system marred by both inefficiency and inequity. Those of us who serve in local government, close to the grassroots problems and hopes of our constituents, look to those Democrats who hold federal office as stewards of that commitment.

Without the innovation of a public option in the health insurance marketplace, health reform package now under consideration in Congress will be incomplete and will fall short of its promise. Many see it as an element to promote greater equity and social justice. I am not so sure about that, but I do think that it is an important element of health reform that will promote the value of liberty. This may seem like a paradox, because many of the Republicans and conservative Democrats who oppose the public option do so because they oppose a larger role of government in health insurance, and this they do seemingly because they believe that government diminishes individual liberty and choice.

I suggest that the opponents of the public option have the logic of liberty upside down. The public option will enhance consumer choice, not diminish it. The public option will build into market competition itself powerful incentives to provide better affordability, value, and quality health care. The entire burden of protecting consumers (when they are purchasing insurance) and patients (when they are making claims on their insurance for coverage of needed services, a moment when they are quite vulnerable) should not fall to government regulation alone. But it will without a competitive public insurance option. The public option, working in tandem with important regulatory requirements on insurance carriers, will put a new accountability into the health care marketplace. The public option is an interesting kind of policy innovation, one that offers something to both progressives and centrists. It uses market competition, not administrative sanction or other subsidies and incentives, to achieve goals that otherwise would have to be addressed by more direct, and more intrusive, regulation.

Opponents of the public option have offered a compromise approach that “triggers” a public option if the private insurance market fails to perform well. However, this is not a true compromise. It is a political strategy of misdirection. It will distract attention from an important innovation and shunt it aside until a tomorrow that will never come, a tomorrow when anything like the public insurance option can be neutralized bureaucratically and quietly. I venture the guess that the trigger will never be pulled, for the public option will be buried in a cloud of data and spurious disagreement about how well private insurance is actually performing.

According to a recent article by Elizabeth Drew, Washington insiders say that the public option has no chance of surviving the coming floor votes and reconciliation process in Congress. In this legislative end game, however, the public option is worth fighting for, both because insiders might be wrong and votes could shift and because it should be at least used as a bargaining chip by progressive Democrats to improve other parts of the bill. Beyond that, this little fight over the public option may be a symbolic moment of considerable significance for the remainder of the Obama presidency.

President Obama’s resounding election arouse a large contingent of citizens who rejected the public philosophy of the Bush years and who sought a new kind of pragmatism and healing reasonableness. I among them. Where have we all gone? It is time for progressives to show some backbone; to draw some lines of value and principle in the sand; and, in the final hours of health reform legislation 2009, to play a skillful and winning game of chicken.

Bruce Jennings is senior consultant and Fellow of The Hastings Center and director of the Center for Humans and Nature. brucejennings@humansandnature.org

Let me start with Bruce Jennings’ fascinating opening essay on liberty. Given reform opponents’ frequent appeals to personal freedom both in specific cases–fears about government intrusion into end of life care, most notably–and in broader “the government is controlling your body” terms, establishing that health care reform is part and parcel of American ideals of freedom is absolutely essential, and so arguments like Jennings’ are absolutely critical to winning the debate.

That said, I fear Jennings is pursuing the wrong tack. I fear that buying into Isaiah Berlin’s famous distinction between positive and negative liberty is ultimately harmful both on this issue, and for advocates of progressive causes more generally. First off, the dichotomy is altogether too strict. As Cass Sunstein and Stephen Holmes argued in their The Cost of Rights, the negative rights we have are enabled by government protection, just as much as positive rights are. To pick the most obvious example, the negative right to property only exists in a world with police, firemen, and civil courts to protect that rights for individuals. Positive rights require more resources, perhaps, but this is a difference of degree, not of essence.

More to the point, a focus on positive liberty is essentially a focus on the least popular element of health reform, namely taxation. After all, the difference between positive and negative liberty in Berlin’s formulation is the necessity of tax dollars for the former, so defenses of positive liberty must necessarily be defenses of taxation. There is nothing wrong with this, of course; I have no problem with using tax dollars to reform the health care system, or indeed with raising taxes for that purpose if need be. However, in a nation with a long, distinguished history of tax revolts, this will be a difficult argument to win.

I would posit that a more productive conversation would focus on the gains health care reform would bring in terms of enabling greater freedom of action. A positive liberty conversation focuses on the costs health reform would exact due to financing issues, but a freedom of action conversation would focus on how American would have a greater ability to take risks, change jobs, and generally live freely without fear of medical bankruptcy or a similar calamity befalling them. The model here would be an exceptionally clever ad launched by Ron Wyden for his Wyden-Bennett health care bill. The ad emphasizes how health care reform would enable to change jobs without fear of losing their health care.

Of course, Wyden had a better bill to promote than the current watered-down legislation emanating from Max Baucus’ negotiations, but the principle is still one worth emphasizing. This approach recasts health care reform not as government intrusion in one’s health decisions, but as an end to insurance company and employer intrusion, and in doing so appeals to the traditional American ideal of self-reliance. That seems like a better debate to have than a head-on discussion of taxes, which is where a positive liberty debate would leave us.

This is the introductory essay in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

The atmosphere was tense. Representatives of the insurance industry were huddled in one corner.  The other members of the Task Force on Genetic Information and Insurance, mostly academics and consumer representatives, were bunched across the room. As chair of the task force, I was in the middle, trying to make sense of the disagreement, which was growing more intense by the minute.

Our mandate was to provide recommendations about what health insurers should and should not do with genetic information. This was the early 1990s; there wasn’t much information available about an individual’s genes, but the avalanche of genetic information was gathering strength. The first few pebbles had arrived recently, and ever larger ones, such as the tests for genes linked to breast and ovarian cancer, would appear soon. We had time—not a lot, but some—to plan for how private health insurers would deal with information about our genetic risks for diseases, from the rare and inexorable progression of Huntington’s disease to far more common ones such as Parkinson’s, diabetes, and heart disease. Health insurers were accustomed to shaping policies according to the risks people presented. If someone with cancer was like a house afire, someone with a genetic risk of cancer was a house with a smoldering pile of rags in the corner.

The standoff in that room, though, was puzzling. We asked the insurers if they believed that everyone should have access to insurance whatever their risks: Yes, they agreed, everyone should have access to insurance. So, they were in favor of universal access, right? No, they adamantly insisted, universal access would be the death of the  industry. Finally, we understood what frightened them: to insurers, universal access meant that people could sail along without any insurance coverage until the day they became ill, when they could march into the insurer’s offices and demand to be covered.

That’s not what we had in mind, we explained. Everyone should have to pay their fair share and, when they needed care, their health insurance would be there to cover the cost. We described it as universal participation.  Fine, said the insurers, we can agree with that.

Among the lessons I learned from chairing the task force (including: Don’t fly from England to San Francisco and expect to control a contentious meeting), one stands out for this collection of provocative essays: understanding what’s at stake in a public policy debate is as vital as it can be elusive.

Connecting American Values with Health Reform is our effort to identify what is at stake amidst the swirling confusion of proposals for delivery systems, financing, cost control, and other details necessary for any practical reform. These details, though, are instruments carrying with them the impedimenta of history, habit, and interests.  To see things afresh, it helps to return to foundational questions: What do we want health reform to accomplish? What values should our institutions and practices be built upon, embody, and achieve?

The language of values has another virtue: Unlike health policy mavens, most Americans are baffled by the alphabet soup of program acronyms, economic models, and the difference between cost-benefit and cost-effectiveness analyses. Heck, most of us can’t explain the difference between Medicare and Medicaid. But we all understand what values are, and we can defend our preferences among them. Which leads to another reason The Hastings Center undertook this project.

Values can be wielded like cudgels to batter your opponents. That, unfortunately, has been all too common in recent political discourse. But values worth taking seriously — including all the values addressed in this collection of essays – are far more subtle, multifaceted, and interesting ideas that can cross political boundaries. Liberty, Bruce Jennings reminds us in an echo of Isaiah Berlin’s classic formulation, includes both freedom from and freedom to — and each of those meanings of liberty deserves attention in health reform. Liberty can mean the freedom from the imposition of a particular health plan and physicians; but it also demands a health care system that does not deny a would-be entrepreneur the freedom to pursue her vision, a freedom not available to the parent of a child with diabetes, for whom health insurance would be unaffordable outside the protective umbrella of a large group policy.

We chose the authors of these essays to represent a broad spectrum of beliefs. We assigned each of them a particular value to address, but we did not tell them what to say about it, other than to display the complexity residing within each value and spell out the policy implications of taking that value seriously for American health reform.

In reading these essays, I found moments of great illumination and insight along with occasional areas of disagreement; familiar ideas displayed in new and revealing aspects; new arguments, distinctions, and concepts. I was provoked, enlightened, and occasionally surprised. I hope that other readers will have a similar experience.

Most of all, I came away convinced that values are the beating heart of health reform, that these authors have begun a marvelous conversation about those values, and that the implications for American health reform are concrete and vitally important. A handful of ideas stand out.

First, simplistic understandings of values are deceptive and harmful to private insight and public discourse. Liberty, properly understood, is not the opposite of equality; justice, not the opposite of liberty; and responsibility, both personal and social, is crucial to the full realization of liberty and justice. Efficiency, an instrumental value rather than an end in itself, is intimately related to quality, solidarity, stewardship, and justice.  Core American values, rather than existing in ineluctable tension with one another, form a sturdy, mutually reinforcing foundation for health reform.

Second, when we acknowledge, as we must, that our goal is health, we are obliged to think much more broadly than our patchwork system of health care. Healthy children, healthy adults, and healthy communities are the outcome of many factors—from decent housing and safe areas for play and exercise to good jobs and schools.  Health care, crucial for episodes of acute illness and for the care of chronic diseases, is a significant but not dominant determinant of a community’s health. As responsible stewards of community resources, we should invest our finite public funds according to where they will do the most good. At times the best investment for health may be in education, job creation, or environmental protections, not in health care.

Third, the practice of individual underwriting in health insurance—making it harder to get the sicker you are — should be given a prompt funeral and buried with a stake through its heart. A concept such as actuarial fairness — which makes good moral sense in commercial insurance where risks are voluntary and the losses measured in money — has no place in deciding who gets access to the health care they need.

Fourth, efficiency and communal responsibility are essential if we are to have an affordable, effective, and sustainable health care system. This will require, at a minimum, systematically studying and improving the quality
and effectiveness of what we do in the name of health care. It will also require restructuring incentives so that providers are rewarded for results rather than for the numbers of procedures or tests they perform. There is good evidence that such changes would also lead to a higher quality of care.

Finally, the concept the task force developed more than fifteen years ago—universal participation—may be one whose time has finally come. The core idea is simple enough: everyone should be responsible for participating in whatever way is appropriate; when anyone needs health care that is reasonably effective and not financially ruinous, the care will be there for them. I was delighted to find the concept, if not the term, endorsed so often in these essays.

Whatever combination of private and public programs we choose, it’s a good time to connect American values with American health reform.

Thomas H. Murray is the President of the Hastings Center.

Liberty without equality is a name of noble sound and squalid result.
—L.T. Hobhouse

This essay appears in the Hastings Center’s Connecting American Values with Health Reform Collection, available here.

America is the child of John Locke, the great philosopher of liberalism and natural rights. This commonplace observation holds a key to understanding the politics of health reform in the United States. The tradition of liberalism (in the philosophical sense of the term) is still the context of our political morality, our constitutional law, and much of our public policy. Liberty is the fundamental value of American politics; not the only one, to be sure, but the fundamental one nonetheless. Liberty has been central to the ethical justification for health reform in the past, and it will continue to be in the future.

As a fundamental value in American life, liberty has several interesting characteristics. It is talked about a lot; the word itself is often used, both in political and everyday speech, but even when the word is not spoken, the idea is there. Liberty is pretty much synonymous with freedom and, in bioethics jargon, with “autonomy.” Liberty often goes incognito, its resonance embedded in other values or ideas that on the surface seem to be about something else. For instance, liberty resides in terms like privacy, choice, property, civil rights, entrepreneurialism, markets, dignity, respect, individuality. Values so ubiquitousare often taken for granted and not sufficiently scrutinized. They therefore have great political power yet are vulnerable to cynical misuse and manipulation.

Liberty is no exception, and we need to think carefully and critically about its history, meaning, and political implications. Properly understood, liberty should be compatible with other ethical values that have often been pitted in conflict with it, such as equity. Such a conflict has been thought to arise, for example, when allowing all individuals the freedom to accumulate as much as they can undermines the capacity of the entire society to ensure that each individual receives a fair share. Why is this clash between appropriation and redistribution seen as a clash between liberty and equity? In order to set up this conflict in the first place, one must conceive of liberty as the unbridled expression of possessive individualism. But this is not the only or the most fruitful way to understand liberty. Herein lies my principal point: progress in establishing an ethical and political justification for health reform depends on reconciling liberty and equity, at least in the arena of health affairs. We must break out of the ideological grid that sets liberty and equity in opposition, indeed in a zero-sum relationship such that one of these values cancels out the other. The health reform conversation has to be reframed at the grass roots level so that a new way of seeing what liberty is and what it requires will grow out of that conversation. One tenet of this movement should be that equity in access to health care, reduction in group disparities in health status, and greater attention to the social determinants of the health of populations and individuals are all policy goals through which liberty will be enhanced, not diminished.

What Liberty Has Meant

The history and politics of health reform is an object lesson in this regard. In the past, appeals to the value of liberty have most often been made by opponents of governmental involvement and structural change. In the street language of American politics throughout the twentieth century, the main threat to liberty was “socialism” (a.k.a. big govern­ment), and the key plank of the in­dictment against health reform plans, from Woodrow Wilson through Bill Clinton, was the specter of “socialized medicine.” The main ally of liberty in the same period was free market competition. Health reformers strug­gled (mostly in vain, it must be said) against this interpretation of liberty. They countered with an appeal to the language of rights and to the counter­vailing value of equality. (Equality’s aliases are equity, fairness, social jus­tice, solidarity.)

Stepping back, we can see that health reform has been caught in the same web of dichotomies and con­flicting values that have ensnared every other facet of progressive and welfare state measures during the last century. Some of the worst snarls in this intricate web are: (1) individual responsibility and choice versus social assistance; (2) market initiative and competition versus governmental reg­ulation and bureaucratic red tape; (3) efficiency versus entitlement; (4) au­tonomy (rugged individualism) ver­sus elite paternalism (Big Brother, the nanny state, father knows best); and finally, at the personal, gut level, (5) fear of losing current benefits and quality services versus guilt based on a sense of justice and concern for those excluded from the current sys­tem, especially children and the “de­serving” poor. I believe that we will never be able to resolve these di­chotomies or untangle this web. In­stead, what we need to do is to change the subject and reconceptual­ize the terms of these past dead-end debates.

The most recent large-scale health reform effort in the United States, during President Clinton’s first term in the early 1990s, featured each of these snarls. No doubt there are many reasons why this plan was defeated in Congress, perhaps not the least of which was that big business ultimate­ly decided that it could get a better deal to hold down health care costs from a private managed care ap­proach than it could from Clinton’s combination of managed competi­tion and a global health care budget. But at the level of public opinion, the debate tended to center more around individual liberty versus social equity. A mainstay of the attack on the Clin­ton plan—policy experts dismissed this as obvious nonsense, but it had a significant political effect—was the fear of losing personal liberty, and in particular, fear of losing the freedom to choose one’s own doctor and to control one’s own health care. The television advertising campaign against the Clinton plan, sponsored by a health insurance industry trade group and featuring the concerned middle-class couple Harry and Louise, focused on the loss of liberty and the erosion of quality that the plan would bring about. These pro­fessionally produced ads used the concept of liberty very artfully.

What is it about liberty that turns it into an arrow in the quiver of op­ponents of health reform? Is there a way to reframe it and to develop an alternative way of using it? Is there any reason to think that such a refor­mulation would have any traction in forthcoming political debate and the policy process? These will become in­creasingly important questions, I be­lieve, in the round of health reform debate that is now beginning.

What Liberty Should Mean

The concept of liberty has two dif­ferent facets, which are usually referred to as “negative liberty” and “positive liberty.” Negative liberty is about being free from obstacles or constraints: it is about having free­dom of choice—even the freedom to make mistakes and poor choices. Having personal security and civil rights ensures negative liberty. Posi­tive liberty is about being free to have options—being enabled or empow­ered to make choices or realize per­sonal goals. Having the right to free­dom of speech is a negative liberty; having access to an education that gives you something thoughtful to say is a positive liberty. Positive liber­ty is about having others do some­thing for or with you that gives you the opportunity to change your life or achieve your goals. In a nutshell: negative liberty is about “don’t tread on me”; positive liberty is about “I need you to help me up.”

The libertarian interpretation of liberty and the privatized market model of health care err by focusing too exclusively on the negative side of liberty. Health care is inextricably bound up with the value of liberty, not simply because it prevents illness from limiting your life decisions, but also because it enables you to use your freedom more richly, to live your life in more meaningful and worthwhile ways. Health care is not simply about preserving you from the “outside” interference of others or of disease; it is also about obtaining the active assistance of others so as to en­hance the types of activities you can pursue and the kinds of relationships you can have. Thus, health care is as much about positive liberty as it is about negative liberty. And what is true of health care is true as well of health itself, or of health status.

The positive, relational, and en­abling side of liberty is what links it to equity. The zero-sum relationship between liberty and equity is an opti­cal illusion that comes from an exclu­sive focus on negative liberty. Positive liberty is the concept that reminds us that the well-being of one individual is not a function of isolation but of context, community, and mutual in­terdependency. Equity is about mu­tual flourishing; negative liberty is about individual flourishing no mat­ter what the condition of others; pos­itive liberty is about the connection between individual flourishing and mutual flourishing. Positive liberty reminds us that no single individual, no matter how wealthy or powerful, can really be free except in a context of social justice and the common good.

Policy Implications

The health reform debate of the coming years will have a broader focus than past reform debates. It will not just be about acute-care health insurance reform and access to clini­cal, treatment-oriented medical ser­vices and technologies. Instead, it will take up the larger structural determi­nants of health and health promo­tion. The access to acute care and high technology clinical services is very important to particular individ­uals at particular times, but such ac­cess has been shown to have little ef­fect on population health as a whole. And even at the individual level, the most important and challenging pol­icy goal is access to health, not mere­ly access to clinical medical care. Building a system that generates or promotes health requires that people have access to many specific and pos­itive aspects of their natural and so­cial environments. Achieving greater health for the whole population—a healthier nation—will require large-scale social reform and institutional transformation. These changes point in the direction of a more global kind of equity and social justice.

The role of liberty will change in health reform debates when two things happen. First, we must see that health reform involves equitable ac­cess to the social preconditions of health, as well as to health care. Sec­ond, we must see that when anyone lacks such access, the liberty of all (not just of those who experience the inequity) is compromised. This, I be­lieve, is where the health policy con­versation is going in the years ahead, and as this shift occurs we will re­think the meaning and uses of the value of liberty in political argument. Liberty rethought can then be one of the touchstones for a democratic, grass roots movement for health re­form that will demand health justice in a nation of free and equal persons.

Bruce Jennings, MA, is director of of the Center for Humans and Nature and a senior consultant at The Hastings Center. He teaches ethics at the Yale School of Public Health.