Freedom, Responsibility, and Solidarity in American Health Care

This past Thursday Republicans in the U.S. House of Representatives passed the American Health Care Act (AHCA), a bill that, while technically not repealing and replacing the Affordable Care Act (ACA), would be a significant transformation of the U.S. health care system. The AHCA’s supporters claim that it makes health insurance more affordable by lifting unwieldy regulations on the insurance market and creating more competition. Its critics claim that the bill would eliminate coverage for millions of Americans by cutting the Medicaid expansion put in by place by the ACA and by placing individuals with pre-existing conditions in high-risk pools in which insurance coverage would become unaffordable.

In March, when the Republicans presented an earlier version of the AHCA, I wrote that the argument of the bill’s supporters that it promotes greater freedom for consumers in the health care marketplace depends on a very limited view of freedom. While the bill’s advocates claim that greater choice on the health care marketplace will be sufficient to make health care more affordable and accessible, I argued that “choice” is illusory unless people are also provided with the basic material goods needed to fully exercise freedom in social life. As I wrote, “A truly free health care system is one that not just one that takes advantage of the benefits of the free market, but also one that provides the institutional conditions for free participation in society through decent universal coverage.”

The debate over the AHCA in the days leading up to Thursday’s vote further illustrates the inherent flaws in the market-centered, quasi-libertarian argument for the AHCA. On Tuesday Republican Congressman Mo Brooks of Alabama stated in an interview with CNN’s Jake Tapper that:

[The AHCA] will allow insurance companies to require people who have higher health care costs to contribute more to the insurance pool. That helps offset all these costs, thereby reducing the cost to those people who lead good lives, they’re healthy, they’ve done the things to keep their bodies healthy. And right now, those are the people—who’ve done things the right way—that are seeing their costs skyrocketing.

Brooks here is claiming that different health outcomes are the result of different lifestyle choices, such that those who have “done things the right way” are healthy, whereas those who have made poor choices suffer from health problems. Obviously our lifestyle choices, such as our diet, exercise habits, etc., can have a profound impact on our health, but it is equally obvious that we can suffer serious health consequences because of factors we have no control over, such as genetics, infectious diseases, or the poor choices of others. It is hard to see how a child with a congenital heart condition, a woman with breast cancer, or the victim of a drunk driver suffer because they have failed to “lead good lives.”

Brooks seemed to recognize the absurdity of his statement, immediately adding: “Now in fairness, a lot of these people with pre-existing conditions, they have those conditions through no fault of their own.” But what is important is that the AHCA is designed as if this was not the case, as if only Brooks’s previous statement were true. The bill allows for relatively paltry subsidies to assist those placed in the high-risk pools afford insurance, therefore recognizing some social responsibility for others’ misfortune, but these subsidies in no way eliminate the massive gap in expected costs for the healthy and sick.

Brooks’s comments illustrate a fundamental weakness in the argument that free market outcomes are fair because they allow individuals to succeed or fail based on their own choices, rather than having the government pick winners and losers. The moment one admits that conditions that are no fault of one’s own have a significant impact on these outcomes, as Brooks does, the argument that the market alone provides fair outcomes and equal opportunity falls apart. One is left instead with an ideology of liberty and fairness that serves as a mask for a kind of social Darwinism in which the survival of the fittest is the rule, or a reactionary conservatism in which attempts to address historical inequalities are themselves dismissed as unjust. For example, I once debated a libertarian who admitted that the United States’ history of slavery and racial discrimination had disadvantaged African-Americans in relation to whites on the basis of their race, but he nevertheless argued that it would be racially discriminatory and unfair to attempt to address these disadvantages; instead, we ought to treat social outcomes as if people were individually responsible for them. Thus racism (or any injustice or inequality) was with one hand recognized but with the other waved away and immunized from challenge.

Individualism is so pervasive in our culture that it is hard to imagine an alternative way of thinking about things, a fact reinforced by individualists’ success in caricaturing those alternatives. Sociologically speaking, however, it is indispensable to recognize that our lives are in fact conditioned by things beyond our control. We have no control over the genes we inherit from our parents. We have no control over the economic and social resources our families are able to provide us as we grow up. We can’t control how the ups and downs of the economy might affect us. And in many cases we have little or no control over health conditions arising from infectious diseases, cancers, accidents, etc. Contrary to certain caricatures, admitting these things is not abandoning individual agency. Rather, we exercise agency in the midst of conditions we did not create, and the outcomes of our actions are caused by an inextricable mixture of our own agency and the conditions that shape it.

Individualism fails at the theological level, as well. As I have written elsewhere, we owe everything to our God the Creator. Dependency is a fundamental characteristic of human existence, just as much as, if not more than, agency. The recognition of this theological truth leads to a quite different outlook than one focused entirely on individual efficacy and responsibility. Likewise, God creates each of us in relationship with others, first of all with our parents, but also in relation with the entire human race. This relationality is in a sense prior to our individual agency, and individual agency is only empowered through our prior dependence on others.

Christian theology also tells us, however, that we share in a kind of solidarity in sin. Sin is not simply a matter of individual wrong-doing and responsibility. Rather, we inherit a sinful condition that we share with all our fellow human beings, and this sinful condition permeates and infects all our relationships, both interpersonal and social. Biblically speaking, this shared sinful condition is why we all suffer from illness and death, as well as from social maladies like poverty and racism.

We cannot simply read a health care policy straight from these sociological and theological truths, but they do suggest an alternative way of approaching the policy issues quite different from the individualism behind the AHCA. For one, we ought to be careful about attributing illness and suffering solely to personal choices, recognizing that they are reflections of a shared human condition that affects each of us in different ways. Of course, sometimes poor decisions do lead to ill health, but even here we must be careful because those choices are sometimes shaped by conditions outside the individual’s control that we do not fully understand. Second, in recognizing our dependence on one another and on God the Creator of us all, we ought to encourage a solidarity that works to ensure that people have the material and social resources needed to be full participants in social life. In other words, we ought to work toward establishing the common good.

Such a Christian outlook does not eliminate individual responsibility, but rather re-imagines it. Yes, we have a responsibility to “lead good lives” and “do things the right way,” and yes, this involves taking responsibility for our own health. But not one of us exercises responsibility for ourselves without first being dependent on countless others, and therefore part of our individual responsibility is to work with others to ensure that we create social institutions in which people are not hindered from achieving their goals by factors outside their control, like poverty or illness, but rather are empowered to act responsibly and in a spirit of solidarity. This means we ought to work toward a health care system in which individuals are not left to themselves, but rather in which we all share the burdens so that everyone has access to adequate health care no matter life’s vicissitudes.