On Freedom and Health Care

Last week the Republicans in the U.S. House of Representatives presented to the public the American Health Care Act (AHCA), the health care plan they propose to replace the Affordable Care Act (ACA). The bill received a serious blow when the Congressional Budget Office (CBO) reported that the plan would lead 14 million people to lose their health insurance within one year and 24 million people within ten years. The fate of the AHCA is in serious jeopardy.

One of the selling points for the AHCA proposed by the Republicans is that it would promote greater freedom for consumers in the health care marketplace. Admittedly, in a handful of states the Affordable Care Act has left people using the individual insurance exchanges with only one or two options (although much of the blame for this lies with the Republicans themselves for sabotaging the “risk corridor” designed to encourage insurance companies to stay on the exchanges during the temporary period in which the insurance pools stabilize). But the Republicans have been rightly criticized for drawing on a hollow notion of “freedom”: unless quality health insurance is affordable to all, people have as much freedom to choose quality health care as they do to drive a Rolls Royce or Ferrari.

Of course, many advocates for the AHCA or other market-based health care reforms argue that once stronger market mechanisms are operating in the health care market, competition will drive the price of insurance down and make it affordable to most, if not all, people. Although it is certainly true that competition would put downward pressure on the price of insurance, it is an act of faith to assume that this would be sufficient to make quality insurance universally available. The CBO, which is sensitive to these concerns, did not find this to be the case. And the fact that the AHCA itself uses various devices like subsidies (based on a combination of age and income) and high-risk pools to control out of pocket spending shows that the Republicans themselves implicitly recognize that the free market is imperfect at best.

Rather than get into the weeds of policy, however, I want to look at how different understandings of the notion of “freedom” can impact the health care debate. Both the Catholic and liberal traditions have a rich history of reflecting on freedom that are relevant for this discussion. Early in the twentieth century, for example, liberal thinkers like T.H. Green and L.T. Hobhouse began to recognize the problems of understanding freedom solely in terms of the ability to choose this or that without outside interference for reasons quite similar to those raised in the contemporary debate over health care. These liberals argued that civil and political freedoms such as the right to free speech and to political participation are largely meaningless if one is lacking in the material capacities needed to fully exercise those freedoms. Therefore, things like adequate housing and health care are prerequisites to a fully free citizenry.

This way of thinking is not alien to the Catholic tradition. For example, in his 1963 encyclical Pacem in Terris, Pope John XXIII affirms that each person has “the right to bodily integrity and to the means necessary for the proper development of life, particularly food, clothing, shelter, medical care, rest, and, finally, the necessary social services” (#11). In his 1991 encyclical Centesimus Annus, Pope John Paul II claims that people cannot truly exercise freedom without access to property as a means of supporting oneself (#13). Although his main point here is to defend the right of private property against collectivism, the passage also makes clear that any notion of freedom is hollow if people do not have the material means of acting on their choices. (The Italian Catholic philosopher Rocco Buttiglione makes this point in more detail here.)

The Catholic tradition, however, gives greater attention to the social nature of the human person than does the liberal tradition. This attention to the person’s social nature is reflected in the concept of the common good. A person’s exercise of freedom is not just dependent on a set of individualized goods such as food and health care, but also on social goods shared in common with other members of society. The Second Vatican Council’s Gaudium et Spes provides a well-known definition of the common good: “The sum of those conditions of social life which allow social groups and their individual members relatively thorough and ready access to their own fulfillment” (#26). Here we see the notion that individual fulfillment and liberty is dependent on the establishment of certain basic social conditions—a set of social institutions, legal frameworks, and social services that enable human flourishing.

John Paul applies this same sort of thinking to the free market itself. His encyclical Centesimus Annus certainly provides the most robust defense of the free market in the Catholic social tradition. But he also insists that the free market cannot be understood as simply the interchange of free individuals, but rather market exchanges must be “circumscribed within a strong juridical framework” (#42). Elsewhere he points out that there are certain goods, both individual and collective, whose satisfaction cannot be left up to market mechanisms, and indeed whose fulfillment is necessary for the proper functioning of the market since they “constitute the essential framework for the legitimate pursuit of personal goals on the part of each individual.” Although the market is a powerful tool in promoting the common good, John Paul warns against “an ‘idolatry’ of the market, an idolatry which ignores the existence of goods which by their nature are not and cannot be mere commodities” (#40).

Therefore, Catholic teaching suggests that it is perfectly legitimate for health care policy to rely on the market to control costs and improve the quality of health insurance. But at the same time, health care policy cannot rely exclusively on the market, nor can real access to health care be dependent on market power without first ensuring that all people are empowered to act as fully free agents in the marketplace. As John Paul notes, the central problem is that people are excluded or marginalized from participation in the market economy (## 33 ,58), a problem the market itself cannot rectify. Any notion of freedom that ignores the material and social conditions necessary for people to exercise real agency is empty. 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. Therefore, a health care policy that promotes free choice in the health care market while leaving millions of people uninsured because they can’t afford the insurance on offer, does not truly respect human freedom.