The Values That Shape the Health-Care Debate

Few policy issues have racked the U.S. as profoundly as health-care reform. This is perfectly understandable. The system that the controversial new legislation changes was perfectly suited to the Founding Fathers' core principle—that individual rights and responsibilities trump everything, even societal benefits. Staunch individualism informs everything from our foreign policy to the way we dress, and our love of free markets is its strongest economic expression.

In health care, those values translate into outstanding medicine—for some. If you have insurance or are wealthy, you will receive the best health care in the world. The notion of sacrificing individual and unfettered access to excellent doctors, facilities, and drugs on the altar of universal care seems positively un-American.

But our founding principles are evolving. As nations mature and develop a common identity, they become more cohesive. People begin seeing themselves not as a society of individuals, but as individual members of a society. The trend is anthropological, not partisan, and it's gaining momentum. When our sense of group identity is fully entrenched, health-care reform will become widely popular.

Americans' sense of personal empowerment dwarfs that of citizens of other highly developed industrial countries. A Pew Global Attitudes Survey in July 2009 asked people around the world whether they agreed or disagreed that "success in life is pretty much determined by forces outside our control." Sixty percent of Americans disagreed, compared with 48% of respondents in France, 43% in Japan, and just 29% in Germany.

Emphasis on Individualism

In the U.S., where the bootstrapping immigrant is a cultural icon and business entrepreneurs receive generous financial incentives, success depends on individual strength, savvy, and dogged persistence. The reverse also holds true. In an earlier Pew survey, Americans by a margin of six to one said that when people don't get ahead, it's their own fault, not society's. These values reflect a relatively new society still steeped in the romance of conquering the frontier in a land of boundless opportunity.

Our current health-care system seems to fit this view. No procedure is too expensive or benefit too marginal not to be covered by insurance. As for individual choice, the Kaiser Family Foundation reports that people in the U.S. care more about their right to choose a familiar doctor or hospital than whether those providers have good credentials or deliver good results.

Similarly, while Americans know that preventive medicine saves money and lives, they hate being told what to do. Health-care professionals may suggest that we quit smoking or get more exercise—but legislating healthy behavior goes against our cultural grain. This is even truer if it involves legislating industry. In fact, penalizing overweight people with higher insurance premiums sits better with most Americans than the idea of requiring fast food chains to cut the calories in favorite menu items. In a perverse application of social Darwinism, successful individuals develop the financial means to prolong their lives even if their own lifestyle choices would limit their longevity.

What will it take to change us into a nation that embraces universal health care, even at the expense of unlimited personal freedom? The answer is another question: When will America view itself as a society? We're already close to the tipping point, and three forces will gradually push us over the edge:

Generational shift

Today's 18-to-34-year-olds take equality for granted and worry more about overall social welfare than did their parents. As health-care costs soar and more people lose insurance, young people will vote their conscience.

Geographic pressure

Densely populated states with major urban centers on either coast already lean toward broader access to health care. Maine, Vermont, and Massachusetts have already enacted universal health-care laws, and in early February, California's state senate passed legislation that would guarantee care for all residents under a single-payer system. It stands to reason that people living in close proximity will tend to meld into a society faster, so the support for health-care reform in populous states isn't surprising.

New norms

Thanks in part to widespread media coverage and greater public interest in health, people are now more aware of the connections science has found between lifestyle and health. Throughout America, people know that smoking increases cancer risk and obesity spells diabetes. And as drug prices rise, they also realize the costs of treating chronic, preventable conditions, such as high blood pressure and cholesterol, will also rise. The more such awareness grows, the more Americans will want a health-care system that emphasizes prevention over cures.

If rewiring our cultural DNA sounds like a challenge, consider that we've done it before. The civil rights movement brought greater parity to women and African Americans. Furthermore, two government-sponsored social programs that Americans consider part of their birthright—Social Security and Medicare—have existed for only 75 and 45 years, respectively. In fact, these programs spearheaded America's transformation into a true society with a dependable social safety net. As taking care of the old was the first step, taking care of the young is the next step. This has already led to the Children's Health Insurance Program.

In the end, can a system that fully embraces an individual's rights provide unlimited care for all and also provide for America's fiscal success? No, it cannot. The real question is: What compromises are we willing to make—or have made for us?

Policymakers should realize that the battle over health-care reform isn't only about policy details or insurance exchanges. It's not about money. It's not even particularly partisan, as the President's recent struggle with his fellow Democrats in passing the new health-care bill clearly demonstrates.

Passions run high because people perceive that their national identity is at stake. Is the U.S. still a nation of individuals, or have we evolved into a unified society? When the latter becomes reality, universal health care will seem as American as apple pie.

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