This week New England is coping with a blizzard, an event that can obscure some of the signifiers of social class. People pay less attention to clothing labels when they’ve got their heads down, hurrying to get indoors. Government reflexively expands during bad weather, as mayors and governors try their best to avoid fatalities on their watch—keeping emergency routes clear, providing shelter to the homeless, and leaning on utility companies to restore electricity and other services. If the storm is bad enough, there will still be deaths, but public servants try to save as many lives as possible.
Is this system moral? The question arises in light of Friday’s Washington Post column (“End Obamacare, and People Could Die. That’s Okay.”) by Michael R. Strain of the American Enterprise Institute. Strain hopes that the Affordable Care Act (ACA) is soon eliminated, either through a Supreme Court decision or the actions of a Republican president and Congress after the next election. If you feel the same way, Strain reassures you (not that you needed reassurance) that you occupy the high ground: “Repealing Obamacare could—although wouldn’t necessarily—result in more people dying. But it clearly would not be immoral.”
A weaker man, or a squish, might have written that taking health insurance away from millions of people “would not necessarily be immoral” or “would not clearly be immoral.” Strain does not stand for debate here. Killing Obamacare “clearly would not be immoral,” now matter how it happens and no matter whether there’s an alternative to put in its place. (What does the American Enterprise Institute consider immoral? The progressive income tax.)
Strain writes that repealing the ACA is just one more public policy trade-off, the kind that free societies make all the time: “In a world of scarce resources, a slightly higher mortality rate is an acceptable price to pay for certain goals—including more cash for other programs, such as those that help the poor; less government coercion and more individual liberty; more health-care choice for consumers, allowing them to find plans that better fit their needs; more money for taxpayers to spend themselves; and less federal health-care spending.”
But eliminating a public-policy goal—universal health coverage—is not the same as reallocating funds among different goals. We could abolish all childhood nutrition programs, including school lunches, and shift the savings to college scholarship programs. Some might consider this a wise change, better for instilling a work ethic and preventing dependence on government. Nevertheless, abandoning the policy goal of minimizing childhood malnutrition carries moral implications, and they don’t go away just because this decision might lead to more funding for a different public good.
Other than a reduction in government spending, a permanent goal of libertarians, the “trade-off” from abolishing the ACA is something like vaporware, to be forgotten at the moment of revenge against Barack Obama. In response to Strain’s column, the New Republic’s Brian Beutler writes (behind an airtight paywall), “If the Supreme Court eliminates ACA subsidies in three dozen states this summer, the federal government will indeed spend less on health care. But none of the other tradeoffs Strain lists will happen. The savings will not be plied into programs that help the poor or be returned to taxpayers, individual liberty will not increase, and a wider array of health plans will not materialize. Millions will lose their coverage, insurance markets will collapse, and the public dividend will be a slightly lower budget deficit.”
Beutler writes that repeal would represent “an enormous bait and switch” on Americans who followed the rules of the ACA, and “the moral implications of this outcome are hideous.”
Strain also argues that the ACA is based on an unattainable objective: “Should society have as its goal that the government prevents all deaths from any health-related ailment other than natural causes associated with ripe old age?” He writes, “There are limits to the proper amount of scarce resources, funded by taxpayers, that Washington should redirect toward health care.” (For the second time in the essay, he mentions “scarce” resources rather than “limited” or “finite” resources. No matter how much wealth accumulates in the United States, no matter how many McMansions are built or how many $1000 bottles of wine are drunk, our society’s resources are always “scarce” to a libertarian.)
Again, Strain describes a trade-off, noting that we’ve learned to tolerate car accidents as the price of personal freedom and a functioning economy: “There were more than 30,000 traffic fatalities on America’s roads in 2013. If we didn’t accept that risk, we’d lower the speed limit to a rate at which accidents simply don’t kill, such as 10 mph.”
Well, we do require drivers to purchase car insurance, which is a way of redistributing money from the lucky to the unfortunate victims of accidents, and that’s the same principle behind mandatory health insurance. And I’m not sure that being able to see a doctor is analogous to a speed limit; a better comparison would be the banning or rationing of unhealthy food, which is not a consequence of the ACA.
A better analogy would be the privatization of emergency services that respond to car accidents. We’d get something like our pre-ACA health care system if we abolished the 911 phone line. Motorists could join the American Automobile Association or another fee-based service if they want help in case of an accident. (You’d need a platinum-level plan to get the jaws of life.) If you didn’t have coverage, you might get help from a Good Samaritan, but you couldn’t expect it as a right. We’d have two classes of citizens, one with a higher risk of death or injury on every highway trip, and it would be appropriate to question the morality of such a system.
Or consider the death penalty. Even most (not all) proponents of capital punishment agree that it would be immoral to execute a person who was innocent of the crime for which he was convicted. So we have an extremely expensive, byzantine, and time-consuming appeals process to reduce the chances of killing someone who was wrongly sentenced. Even so, we can’t be certain that a deadly mistake won’t be made. And one could argue that we get rid of the costly appeals process and execute prisoners at the moment of conviction. In a “world of scarce resources,” more mistakes in the application of the death penalty could be a trade-off in which millions of dollars become available for investigating child-abuse cases or improving prison conditions. That possible trade-off does not mean such a policy change “clearly would not be immoral.”
We can’t prevent all tragedies—whether people dying in catastrophic storms or individuals suffering from lack of access to basic health care. But deciding to accept more tragedies as a matter of public policy is clearly a moral issue.