People have different ways of talking about the ethics of health care policy.
The question is how these ways of talking relate to concepts that have been developed within academia, especially economics.
- Sometimes in ordinary conversation people do not refer specifically to the concepts that economists articulate — but their meaning seems to be identical.
- At other times, people refer explicitly to economic and theoretical concepts — but on closer inspection, these people are actually talking about entirely different ideas.
The concept of “moral hazard” provides an example.
- Conservatives express a skepticism toward the idea of healthcare as a right, which they consider unfair to those who work hard for what they have; and although they do not explicitly talk about “moral hazard”, it consistently seems identical to what they mean.
- Conservative populists, in contrast, use libertarian language to express their frustration at being forced to buy health insurance; but on closer inspection, they are not libertarian and they do not oppose the idea of healthcare as a right.
The concept of “moral hazard” in economics refers to the lack of incentive to guard against risk where one is protected from its consequences.
For example, if the government bails out banks during a crisis caused by irresponsible bank lending, then in the future it becomes MORE likely that banks will again make bad loans.
In daily life, people express opinions that sound similar to the concept of moral hazard. On closer inspection, sometimes they are indeed talking about moral hazard and at other times they only seem to. For example, the surgeon Atul Gawande returned to his hometown of Athens, Ohio to see how people felt about the idea of health care as a right. The sentiments expressed by some of the more conservative residents sound a lot like a wariness of moral hazard.
https://www.newyorker.com/magazine/2017/10/02/is-health-care-a-right
In fact, the whole idea that government would get involved in the financing of health care bothered him. One person’s right to health care becomes another person’s burden to pay for it, he said. Taking other people’s money had to be justified, and he didn’t see how it could be in cases like this.
“Everybody has a right to access health care,” he allowed, “but they should be contributing to the cost.” He pointed out that anyone could walk into a hospital with an emergency condition, get treated, and be billed afterward. “Yes, they may have collectors coming after them,” he said. “But I believe everybody should contribute for the treatment they receive.”
A right makes no distinction between the deserving and the undeserving, and that felt perverse to Maria and Joe. They both told me about people they know who don’t work and yet get Medicaid coverage with no premiums, no deductibles, no co-pays, no costs at all—coverage that the Duttons couldn’t dream of.
“I see people on the same road I live on who have never worked a lick in their life,” Joe said, his voice rising. “They’re living on disability incomes, and they’re healthier than I am.” Maria described a relative who got disability payments and a Medicaid card for a supposedly bad back, while taking off-the-books roofing jobs.
Complaints about people unethically exploiting taxpayer-financed healthcare programs seems identical to the concept of moral hazard. Again, this attitude is also associated with political conservatism.
But conservatism is not identical to what has been called “conservative populism” (although the distinction between these two factions has eroded since 2016). Gawande did not seem to encounter or engage with conservative populists in his visit to his hometown in Ohio. Notably, the “free riders” that conservatives lament are abusing government programs often seem to be … conservative populists.
During the 2016 elections, the BBC News did its own anthropological fieldwork, and engaged with Trump supporters in small-town North Carolina. As with the conservative voters that Gawande conversed with, health care as a right was a hot issue. Unlike conservatives, however, the conservative populists did not have a problem with the idea of universal health coverage provided by the government. Their beef was instead with the Affordable Care Act of 2010. More specifically, “Obamacare” mandates the purchase of private health insurance — and conservative populists cannot tolerate government mandates. As a matter of principle, this would seem to reflect a libertarian desire for minimal government. However, the conservative populist does not have a problem with the idea of universal health coverage in itself.
Conservative populists are not classic libertarians any more than they are classic conservatives. It is difficult to understate just how economically hollowed-out these rural areas have become — yet unlike the individualistic, rational libertarian, the conservative populist will not move to a less blighted area because their hometown is everything to them. Instead, they blame: foreign countries like China, establishment “elites”, and foreigners in their midst. In one case, with the closure of factories, the only good jobs in town were janitorial and were monopolized by Hispanics who had settled on this niche long before the collapse of the local economy. Locals stated that once Trump was elected, the Hispanics would be sent back to Mexico, and locals could then take their place as janitors and custodians (the journalist noted that the Hispanics were actually American citizens). Instead of a libertarian individualist, the rural conservative populist is best understood as tribal. Sometimes tribalism is starkly individualistic, and other times it is collectivist and xenophobic (for example, there is the Arab saying “Me against my brother; me and my brother against our cousin; me, my brother, and my cousin against the outsider.”)
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Another distinction between the libertarian and the conservative populist pivots on the concept from economics of “negative externalities”.
In economics, an externality or external cost is an indirect cost or benefit to an uninvolved third party that arises as an effect of another party’s (or parties’) activity. It exists when the production or consumption of a product results in a cost to a third party. Air and noise pollution are commonly cited examples of negative externalities.
https://en.wikipedia.org/wiki/Externality
Libertarians believe in minimal government in contrast to anarchists who believe in abolishing government. The libertarian believes that government is necessary to protect citizens from negative externalities (as well as to compensate for positive externalities, such as the broad benefits to society from schools and churches). In contrast, the conservative populist is intensely preoccupied with his own rights — but not the rights of others. For example, in the 2017 Netflix documentary “Trophy” about staged big-game hunting in South Africa, an American “hunter” states that according to the Bible man has dominion over nature, and therefore he can do whatever he wants to animals. This type of rationalization typifies how the conservative populist uses orthodox language to defend his own transgression of the orthodoxy. It could be that the libertarian streak that distinguishes American conservatism from its European counterpart is largely an illusion in that that so much of what seems to be classic American individualism is something more complicated. The true American libertarian might be a rarer and more elite character such as an urban professional or a corporate executive as opposed to the less esteemed yet assertive small businessman or worker (or “Karen” who insists on personally complaining to the manager). That is to say, the establishment of the Republican Party (and of the Democratic Party in a qualified way since the 1990s) are libertarian in orientation, and this diverges from the traditionalism of the European conservative establishment (such as the “Tories” in Britain and the Christian Democrats on the continent) which has its own collectivism and is not so adverse to big government. In Europe, the traditionalism of conservative elites trickles down and stabilizes society and promotes social cohesion, whereas in the USA the libertarian philosophy of the business elites sinks deep into the society at large and provides a framework which ordinary people can use against the establishment. This is very much in line with a major theme in cultural studies about how ordinary people slyly and surreptitiously utilize to their advantage the structures of domination that are imposed upon them by authority. However, in the case of the American lower classes — and Americans more generally — when they adopt the libertarian rhetoric of the business elites, it’s also a case of drinking the ideological Kool-Aid and imagining oneself akin to the affluent, educated, and isolated suburban individualist.
In sum, the main distinguishing characteristics for the conservative populist in terms of health care as a right are:
- They don’t object to it in principle, but
- they just don’t want to be forced to buy it.
- They are wary of outsiders accruing public benefits, and
- they mobilize libertarian rhetoric to diminish the rights of others.
So, the libertarian rhetoric of the conservative populist masks a very different set of values from that of the classic libertarian.
All of this puts into question the standard view that Americans have a libertarian bent because they inherited the rugged individualism of frontiersmen like Davy Crockett, Daniel Boone, and Andrew Jackson. First, Americans might trace a certain spirit of independence to the frontier, but the frontier represents community just as much as individualism. Second, it is the capitalist leadership that had the true libertarian ethos, and Americans engage in this libertarian ideology — and sometimes utilize it against the elites.
The rural conservative and the conservative populist are similar to one another in having a starkly communal and collectivist orientation so different from the individualistic libertarian ethos. An article in the New Yorker magazine from 2016 explains that West Virginia’s culture in particular is unlike the rest of the USA in terms of its commitment to community and its fervor for Trump. A recent arrival to a town in West Virginia described how he found out that a local church was praying for him every Sunday; it was not even his church and he had never met those parishioners. But the flip side to this communal spirit is communal hostility. A Black man told of how when his family moved into the West Virginia suburbs, on the street in front of his house there was always a car parked with a few white men keeping the family under constant surveillance, and of how cars would drive past their home and the passengers would shoot at the house. In rural West Virginia, people live in isolated valleys populated by their relatives, and in some cases they have been in those valleys for generations. They have also been staunch Democrats in all that time, and their switch to Republican Party is a wrenching decision. For them, Trump represents everything that the Democratic Party once stood for. Rather than being corrupted by Trump (as the leadership of Democratic Party believes), Trump has shown them the way home.
https://www.newyorker.com/magazine/2016/10/10/in-the-heart-of-trump-country
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Another distinction between the conservative and the conservative populist is the attitude toward authority, with conservatives respectful of and compliant with legitimate authority figures and conservative populists suspicious and resentful of authority.
During the initial phase of the vaccine rollout, the New York Times reported on vaccine hesitancy in rural West Virginia, with some people expressing complete suspicion of vaccines. One person they interviewed said that he would avoid any vaccine and instead put his faith into apple cider vinegar, which he swore cured every affliction that he had ever suffered from. A community leader explained that a distrust of authority — both political and medical — among people in the area ran deep and went back centuries. In fact, he explained that these people are the descendants of what Americans refer to as the “Scotch-Irish” or “Scots-Irish” who originated from the chaotic and violent border regions of Scotland and later settled in Northern Ireland, and so their hostility to authority dates back to long before their immigration to the New World. They may have once been Presbyterians and Democrats, and now they are Evangelicals and Republicans, but their core anti-elitist attitudes and values have not changed that much.
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Another fundamental distinction between the conservative, the libertarian, and the conservative populist is the types of mentality that ground their self-justification.
Conservatives — and liberals — base their agenda on moral concerns, whereas libertarians argue that individual rationality is the proper basis of public policy. As a result, liberals and conservatives sometimes regard libertarians as sociopaths.
.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3424229/
It should be added that progressives like Barack Obama are similar to libertarians in that they regard reason as the proper guiding principle of public policy — although for progressives, this rationality is collective and managerial (for example, Obamacare and public health generally). Perhaps this technocratic tendency of progressives can be off-putting to both liberals and conservatives, who might both regard it as amoral. Indeed, one frequent Republican slur against Obama was that he was a narcissistic sociopath and con-artist.
Perhaps populism on both the left and the right is based on passion and emotion rather than on either morality or reason. The difference between the far-left and far-right might be in the types of emotion that they exhibit. For leftists, it is intense, breathless idealism, and for the right it is rage. In sum:
- Progressives and libertarians frame their views in terms of rationality.
- Liberals and conservatives establish their values on a moral basis.
- Populism is based on emotion.
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In sum, ideological differences that can be obscured under rhetoric. In fact, hiding such divisions is part of the hard work of any political party because political parties are always coalitions. Consequently, identifying the deeper values of all the factions in society can help to forge public policy that would appeal to a broad swath. In terms of avoiding moral hazard as an issue in health care, there are at least three groups of people who are generally perceived as deserving of health care as a right even if they are not directly paying for it:
- military veterans (especially combat veterans);
- the elderly; and
- children.
Medicare for children is especially of interest because funding for early childhood development might be one of the most effective ways of promoting health. Human lifespans have expanded in the developed world for the past century, but the reasons for this might not be intuitive. It has been asserted that the primary reason is not because improved conditions for adults. Rather, humans live longer thanks to improved prenatal health and improved health in the first two years of life — not just during the child’s life, but during that of the child’s mother. Therefore, if a female receives proper care and nutrition while still a fetus in the womb and during the first two years of her life, and later her own offspring do as well, then lifespans begin to grow. This would be the scientific rationale for Medicare for infants. Aside from the policy objective of improved health, such a policy would form a basis of cross-ideological understanding and improved social cohesion. (Of course, there is a question whether Americans actually want social accord because ideological conflict serves as a source of identity when community withers as it has in the USA, and is also a source of entertainment. Some people want to be polarized and do not want to solve problems.)
