Health Care Reform and the Public Option in Theory and Practice


Those who favor providing health care to all shouldn’t necessarily oppose the “public option,” but they will be unable to support a bill if it endorses and entrenches the taking of innocent human life through abortion.

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Opposition to the health reform plans being put forth by the White House and the Democrats in Congress has centered on antipathy to the so-called “public option.” In my view, the reasons for this opposition are not uniformly sound. Indeed, insofar as the opposition is largely based on theoretical or ideological opposition to “government-run” health care, it has been relatively weak. But insofar as it has been based upon practical concerns for this administration’s and this Congress’s agendas, legitimate points have been made which need to be more adequately addressed as part of the large-scale effort at reforming health care in the United States.

Opposition to the public option at the level of theory seems in large part to reflect an animus towards the removal of health care from the sphere of the market and the kinds of healthy competition that drive that market. Critics are probably right in claiming that the public option would drive some insurers out of business, and that for-profit insurance would be at a great disadvantage in competing against the state, which, by the additional provision of resources, could always undercut the competition and provide the most attractive of the various public and private options.

Often embedded in opposition to the public option is an additional antipathy to the idea that health care is, or should be, a political entitlement, and that it is, or should be, considered to be a natural or basic human right. The proliferation of entitlement rights strikes many as problematic—such rights are rarely well-articulated, the means necessary to deliver them are rarely well investigated, and the assertion of such rights is often used more as a club to beat opponents in debate than as a serious tool for political discourse.

Nevertheless, the assertion that there is something like a natural right to health care that should be made into a political entitlement in at least some circumstances does not seem unreasonable. As I have argued in Public Discourse before, human beings have natural “Good Samaritan” duties to others to come to their aid when their needs are great. Health care needs are among the most significant and urgent of our needs as human beings whose lives are, in large part, bodily. Those needs thus ground duties on the part of others to provide aid when they can and when the need is great. The political state exists in part to assist people in fulfilling their responsibilities more effectively than they might otherwise be able to, and it exists in part to assist those incapable of meeting their own needs, and whose needs are not being adequately met by others.

Given this, the fact that a public option as part of a solution to the problem of inadequate health insurance for the poor and lower middle class is public—that is, involves government intervention—is not terribly worrisome. Were the public option able to do its job successfully, then government would be doing its job.

Nor are worries about diminishing competition convincing, for two reasons. The first is that health care is in some respects not the sort of thing for which there can be a genuinely free market. Health care decisions are made under great uncertainty, and those with knowledge—professional physicians—have an overwhelming advantage over their clients that renders the exchange of healthcare for money unlike the exchange of other commodities in a free market. Nor does the introduction of insurance schemes restore health care to the context of free exchange. Insurance companies must find ways to reduce the power of doctors without empowering patients to the point that they begin to thwart the ability of insurance companies to make a profit. Given that the health-care needs of the patients are the foundation for society’s health care duties, intervention into this triangle of patient-doctor-and-insurance company by the state to level the playing field in favor of the patient does not seem intrinsically unreasonable.

Second, the dominance of American health care by for-profit physicians and insurance companies seems at least somewhat in tension with the professional ethic of medicine. If that profession is seen as a vocational commitment to a form of service oriented around the basic human good of health, then service, duty, and responsibility, rather than competition, should play a greater role in conceptualizing how health care should be provided. Physicians and insurers in other developed countries are, it is true, simply not as wealthy and as well compensated as they are in the U.S. It is not at all obvious that this is a bad thing, from the standpoint of the medical profession.

Theoretical or ideological objections to the public option—that is, principled objections—seem ungrounded. But there are other reasons to be concerned here and now about the public option being put forward. Four such concerns are especially pressing.

The first is its effectiveness in dealing with the specific problems that need to be dealt with. Would the public option really redress our health care system’s injustices in an economically effective way? Justice in health care cannot be achieved by implementation of a plan that threatens to impose unsustainable costs—that would only defer our problems downstream and make them ultimately more intractable. Critics of the “economic prudence” of the public option, such as Ramesh Ponnuru and Yuval Levin, have raised real and troubling objections to the current proposals. These objections need to be answered with equally compelling answers and arguments by supporters of a public plan.

Does the administration and Congress have answers to the critics of the economic feasibility of the public option? I do not know, but this raises the second problem. There simply has not been enough information provided, enough honest debate, or enough time to consider the merits of the public option. Nor has there been adequate comparison of this possibility with other suggested ways of reform, including more private but more transparent ways of financing health care. Nor has there been adequate consideration of alternative forms of government intervention that focus on public health concerns such as obesity and food options. The stated effort to get health care reform passed by August could only have been predicated on the supposition that the nation should simply trust the administration and Congress to come up with a just and efficient plan. But that is a wholly inadequate way to move reform along. It is true that at some point a decision will have to be made about how to proceed, but the lack of transparency to this point has been striking, and it demeans citizens who reasonably want a voice in our national deliberations.

A third point, however, is that the lack of transparency has tended to shade into something worse: dishonesty. Is the public option merely one step towards a single payer system? Would it pose a threat to existing insurance companies? Would there be adequate safeguards to ensure that only qualified citizens, and not illegal immigrants, were eligible? These and other questions have been answered with an apparent disingenuousness and lack of frankness that is more than a little disturbing. The goals that different answers would give evidence for are, in each case, debatable and should be debated—perhaps there should be coverage for, e.g., the children of illegal immigrants. But proponents and opponents need to know what, in reality, they are arguing about.

Nowhere has the lack of candor been more grievous than on the public option’s treatment of abortion. Current federal law prohibits the use of taxpayer money for abortion, and the architects of the public option have relied on this to duck responsibility for speaking forthrightly about the final configuration of the plan. That plan, in all likelihood, would include abortion coverage financed through patient premiums, rather than government subsidies. But the plan would still be a public plan, administered by the state. The money contributed by any premium payer would go towards the funding of abortion, and, as Cardinal Rigali has noted, “funds paid into these plans are fungible, and federal taxpayer funds will subsidize the operating budget and provider networks that expand access to abortion.”

Such considerations have led even mainstream media outlets like Time magazine to note that the proposed reforms would “mark a significant change in the Federal Government’s role in the financing of abortions.” Yet the President has referred to such concerns as “myths” and “fabrications.”

It should go without saying that abortion is not a form of health care. That alone should remove it from the realm of the debate. Defenders of the public option, or of any other reasonable proposal for health care reform, need to decide where their priorities lie. If health care reform turns out to be a way of expanding an entitlement right to abortion, it will alienate many people, and, in all likelihood, not move forward. If the concern of the proponents of health care reform really is to address the genuine inefficiencies and injustices of the current system, while maintaining the federal government’s hands-off approach to abortion, then reform might be a genuine possibility. Whatever the nature of the reform, some people will be unhappy with it, for varyingly good and bad reasons. But government involvement in abortion is not simply a reason to be unhappy. It is, as many pro-life but also pro-reform leaders have indicated, a dealbreaker.

Christopher O. Tollefsen is Professor of Philosophy at the University of South Carolina and a senior fellow of the Witherspoon Institute. His latest book, co-authored with Robert P. George, is Embryo: A Defense of Human Life (Doubleday, 2008). Tollefsen sits on the editorial board of Public Discourse.

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