Barrier to better health care: Republican definition of freedom

Republicans oppose the health-care law's insurance mandate because it curbs freedom. Do they oppose traffic lights, too?

If traffic lights were invented today, the Republican Party would be against them.

After all, aren't traffic lights a perfect symbol for government imposition on individual freedom? The government takes our money to build and maintain them, and then uses them to tell us when we can stop and when we can go.

But anyone who drives in a city knows how necessary traffic lights are. In fact, they increase our freedom of movement, making it possible for us to move at a reasonable pace through a crowded city. Try driving through cities in parts of the world where they don't have traffic lights or where the social norm is to ignore them. Who has greater freedom: Those unrestricted by traffic lights who sit for hours in a traffic jam, or those who obey the law, and get where they want to go?

This thought experiment about traffic lights points to how simplistic and wrong-headed current Republican rhetoric about freedom is. Freedom is about rights, choices, and opportunities. Government action, whether through laws or taxes, does not necessarily restrict freedom. As with traffic lights, it can enhance freedom, and we need to be thoughtful, not reflexive, in how we view what we ask of government.

Take a more complicated and politically contentious issue: the mandate to purchase health insurance. This is clearly an imperfect mechanism, as private insurance is an imperfect product. Nevertheless, does an insurance mandate really take away freedom, or does it enhance it?

What kind of freedom do we really want?

The answer becomes clear when we consider the kinds of "freedom" that the status quo – a lack of such government involvement – imparts. How many of us want the freedom to face medical bankruptcy, or the freedom to be denied coverage (and care) because of a preexisting condition? And how many of us see dying, due to lack of insurance, from a treatable or curable disease as an acceptable cost of individual liberty?

As with traffic lights, there is a trade-off; we cannot get something for nothing. The only way to have a system that guarantees necessary care for those in need – to give us the freedom to live our lives without that fear – is to make sure everyone is included in the system.

Broadly speaking, there are only two ways to do this: by requiring everyone to purchase insurance or by using a tax base to have government provide that coverage for all. There's an argument that the tax-based (single payer) solution might be even more liberating – but we need not make that argument here.

As for the notion that the new health-care law robs us of freedom because it is a mandate, let us not forget that we as a society created our government to make our choices and we used this mechanism to do so. This was an exercise of our freedom!

Freedom starts with the opportunity to make choices, including the choice of whether to act individually or collectively. A choice once made sets us on a more limited path – but are we not freer for making choices rather than remaining forever frozen in a prechoice world of possibility but no fulfillment?

Many of us, after all, choose to marry. This decision substantially restricts us and increases our responsibilities. Yet the responsibilities marriage entails also give new meaning to our lives. Liberating ourselves from every commitment and every shared responsibility would not be freedom. It would leave us each isolated and unfulfilled: freedom as truly nothing left to lose.

This does not make the health-care law right or wrong. The problem is that the rhetoric prevents us from making that judgment. We need to take back the meaning of freedom from those who cheapen it with simplistic bromides.

Similarly, Republicans will tell us that any attempt to understand or act on notions of social responsibility – whether we talk about health care, poverty and crime, or history and the roots of terrorism – is to deny individual responsibility and excuse evil. But this is rubbish – and let us again use a simple but real-world example to explicate this.

Thousands of people die every year because of infections they acquire in hospitals – and many of these occur because doctors don't wash their hands! Clearly, here is an egregious act of irresponsibility. It is unconscionable that a doctor would fail in such a simple duty. Even liberals would agree.

But what is the remedy? After all – no one is perfect. Doctors sometimes forget to wash their hands, or they neglect to because they are too busy. By all means, let us find ways to remind them and hold them accountable. But it also turns out that the simple act of placing sinks closer to the patients dramatically increases the rates at which doctors wash their hands!

Move the sinks

So, is moving the sinks a surrender to carelessness and to evil? If you think so, fine. But in the meantime, doctors will remain imperfect humans, and if we leave the sinks where they are, waiting for doctors to attain perfection, more people will die. Attach whatever political label to me you choose – I would move the sinks.

I know of no one on the left of the political spectrum who accepts the right's characterization that they are against personal responsibility. They believe in both personal and social responsibility, as these are complementary, not competing, notions. Trying to address major public problems with just a greater push for personal responsibility is like tying one of our hands behind our back. We must leverage social responsibility, too, enabling us to use both hands to tackle our toughest problems.

If public schools or public drinking water and sewer systems were invented today, would Republicans oppose them, along with the traffic lights?

According to the simplified notion of personal responsibility, people should take it upon themselves to get educated, keep their water clean, and properly dispose of household waste. It sounds good in theory, but would you live in a town that had no schools, and no water or sewer treatment, but gave every household the "freedom" to manage these concerns on their own? Probably not. Thankfully, citizens across America have the freedom – through government – to manage these problems collectively. A century ago, that is what they did, and we are all the freer for having school, water, and sewer systems run by our cities and towns.

So when Republicans dismiss any government or collective action in the name of freedom and personal responsibility, think of traffic lights and hospital sinks, and use your own freedom to think more carefully and rationally for yourself.

Anthony L. Schlaff, MD, MPH, is director of the Master in Public Health Program at Tufts University School of Medicine. The views expressed here are his own.

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