Democratic health care vs. democracy

President Obama has confessed that he'd aim for a Canadian-style, single-payer health-care system if he were "starting from scratch." Of course, nobody gets to start from scratch. We've always got to start from here. In the case of health-care reform, we've got to start from a mess—a mess that is the unintended and unwanted result of a so-far irreconcilable conflict of visions about the status of health care as a basic human right.

Since Lyndon Johnson established Medicare and Medicaid more than 40 years ago, it has looked as if the Democrats were almost home. Simply expand Medicare to cover everyone and Americans would, at long last, find shelter in the mansion of universal health care. But the stubborn American public (not to mention insurance, pharmaceutical, and physician interest groups) has persistently refused to pull together for the big final push.

It's not that sandbagging Americans have a competing ideal in mind. It's that they fear the much-hyped mansion will be, in fact, a hovel. They worry about socialism, rationing, and waiting and suffering in line. They fear losing the freedom to choose their own doctor or losing a loved one to bureaucratic money-saving measures. They worry the taxman will take more while they get less in return. Run a poll and you'll find Americans favor health-care reform. But try for universal care, and you'll find it's not the reform Americans favor. On the whole, Americans hate their health-care system. Individually, they like their health plans pretty well.

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Obama knows all this. He knows there's no starting from scratch. And yet, like most Democrats, he continues to believe that justice is best served by a single-payer, government-dominated universal health-care system, and he's not ready to give up on justice.

Obama insists that health-care reform legislation include a "public option"—a new government-run health plan. The public option is pitched as an exciting, fresh choice on the humdrum health plan scene, a real can-do go-getter sure to push plodding private plans to cut costs, improve services, and generally do their very best. Alas, this makes no economic sense. Obama knows government-run firms tend to be more bureaucratic and wasteful than privately owned alternatives, which is why he says he doesn't want to run GM. But efficiency's not really the idea.

In a candid moment in front a friendly audience, Yale University political scientist Jacob Hacker, one of the leading proponents of public option–style plans, explained the general strategy this way:

"Someone once said to me that this is a Trojan horse for a single-payer. Well, it's not a Trojan horse, right? It's just right there! I'm telling you. We're gonna get there. Over time, slowly. ... We'll do it in a way that we're not going to frighten people into thinking they're going to lose their private insurance. We're going to give them a choice between public and private insurance, we're going to let them keep their private employer-based insurance if their employer continues to provide it."

The idea is that, over time, slowly, employers won't continue to provide it.

This is risky business. There are lots of ways this gambit can go awry. The legislative meat grinder that delivered us our current Frankenstein system hasn't gone anywhere. So why risk an even more monstrously convoluted and unaffordable system with this Hail Mary pass for single-payer coverage. Why is it that liberals think they need to trick Americans into swallowing something they keep spitting out?

For the same reason that conservatives object to putting the right to own a gun up for a vote. Rights are the things we take off the table of democratic deliberation. For American liberals, it is an unfortunate fact of history that the U.S. Constitution was penned before health care was widely recognized as a right. And, for liberals, the transformation of the American system of government through the New Deal and the Great Society implies a modern social compact, an unwritten "second Bill of Rights." To finally secure a system of universal health care is to finish the noble work of the progressive founders of our modern state.

Yet none of this logically implies a single-payer system. There are excellent alternative reforms that would rely on dynamic competitive markets coupled with means-tested assistance for those who can't afford proper care. Most Americans can afford to buy their own insurance and health care. Shouldn't the government focus narrowly on those who can't? Why create a universal food program when you can just give the poor food stamps?

"A program for the poor is a poor program," as an architect of our Social Security system put it. How can we be sure that taxpayers will vote to finance adequate care for those who have no option other than the government safety net? A right to health care seems to imply a guarantee. But the American public, which includes many who deny that there is a right to health care, cannot be counted on to guarantee it. The closest thing to a guarantee, then, is a universal, one-size-fits-all program that gives everyone an incentive to ensure that benefits are a fitting size.

The fact that American voters have repeatedly resisted a move to any system of universal health care underscores for many liberals the danger of leaving the protection of basic rights to the discretion of the democratic public. And so, in one of the profound ironies of American politics, even the Democratic Party abjures the fundamental democratic responsibility of honest persuasion when it comes to nailing down its contested vision of our basic rights.

Nobody gets to start from scratch. And that means sometimes things that shouldn't be on the table are on it. If so, how do we take them off? Not by lying to one another. The worth of trust and cost of mutual hostility are too high. Our democratic burden is to help others see what we think we see. And if we fail, we keep trying. We might try this sometime. Maybe, then, we could find a way to trust one another enough to create a health-care system that really delivers for everybody. Until then, we'll get the system we deserve.