Health care, as we speak about it today, is a completely modern phenomenon. Hippocrates aside, if you go back maybe 150 years, doctors had no effect on their patients: your chances of recovery if you did see a doctor were identical to your chances if you didn’t. “Health care,” or the medical profession, emerges along with modern science and the application of the sciences to everyday life in the forms of hygiene and nutrition. And medicine has been a rich source of tropes for the framing of modern dilemmas, as recognized by the very widespread claim that, in our thinking about moral, political and ethical issues, “therapy,” and the associated categories of “healthy/sick,” “normal/pathological,” etc., has displaced notions of sin and guilt, good and evil.
It makes perfect sense, then, that progressive politics has always seen the incorporation of health care into the cradle to grave welfare system of the modern state as the jewel in the crown of the expert-centered organization of life central to such politics. The nationalization of health care makes state power potentially unlimited: not only directly medical issues, involving coverage, treatment, price of medical services, training of practitioners, research and innovation, etc., come directly within reach, but all questions indirectly bearing upon health do as well. And which questions don’t bear indirectly upon health? Whether it’s what parents tell their children about homosexuality, the hamburger you had for dinner, or the availability of birth control and, increasingly, social situations such as bullying, shyness, etc.—all affect health, all impose potential costs on the system, all sprout new forms of expertise and regulation. To use a medical metaphor, whether health care is centralized or decentralized is a life or death question for the free society.
The libertarian answer, to privatize medicine and insurance and render them sets of voluntary exchanges, is good as far as it goes. Libertarians rightly argue that what we call health insurance today is not really insurance in any meaningful sense—it is simply a way of pooling costs in government mandated ways, and in ways that makes the real costs of medical procedures inscrutable. Health insurance should be like car or home insurance: a premium in exchange for coverage for specified health care needs. But this analogy is limited—the sum total of bad things that can happen to your car or house is known in advance: if your house is worth 300,000$, then the insurance company knows that no catastrophe can exceed that. But there is no such ceiling when it comes to your body—if your insurance company agrees to cover “cancer treatments,” must that include a decade of increasingly expensive treatments with ever diminishing effect? Who decides? A court—according to what criteria? The doctor—which one? It seems that at some point, some irreconcilable disagreement between the parties is very likely, generating enormous resentment and terror as our media-saturated society is flooded with images of beloved parents and grandparents cut off from their treatments either by evil insurance companies or daughters and sons afraid of going broke. Politics is sure to channel such resentments, compromising the independence of independent arbiters of insurance contracts.
Such a system could only work if a significant majority of the members of society could openly accept the basic unfairness of life chances and death. We would have to be able to look on, with equanimity, as insurance companies withdraw support from dying patients, including those we love and ultimately ourselves; as grown children decide that funding their children’s education is more important than a few more years of life for their own parents, etc. And, of course, such equanimity would have to coincide with an acute awareness of the unprecedented character of all this, including the heart-wrenching possibility that a few more years might have lessened or even eliminated your particular dilemma. We don’t have to go back further than the lifetimes of many living today to recall when “health care” involved very few decisions, and certainly not the impossible ethical ones we are constantly confronted with today: you accepted your fate, you made people comfortable as they accepted the inevitable. Even as some reliable treatments became widespread and childhood mortality almost eliminated, aging, sickness and death still provided the proverbial contours of our existence—the problem is, they still do.
Here, it seems to me that the much maligned (especially by conservatives) “therapeutic culture” might come to our aid. Despite the vituperation and ridicule heaped upon the therapeutic, is there any reason to assume that the distinction between, say, “good” and “evil” is any more originary than that between “healthy” and “sick”? If we take the most basic distinction to be the one distinguishing sacred from profane, why is that distinction more adequately modeled on one binary rather than the other? They are just different ways of framing the more inclusive distinction between whole and rent—integrity vs. corruption, working vs. impaired, fixed vs. broken, etc., being other versions. To be healthy is to be whole, to retain one’s integrity, to be articulated, symmetrical—all are near synonyms for wholeness, which means to have a formal reality embodied in your physical one—just like the central object once we have all pointed to it and agreed to let it be.
The therapeutic culture, by way of its victimary turn, has also created our ability to, it seems, confer healthiness upon ourselves and each other. Perhaps the one product of the victimary culture that deserves to survive is our sensitivity the ways we describe “disabilities” (I, like I suspect most of us, cringe upon hearing—or remembering hearing, since you never do anymore—an older one, the unmarked term of my parents’ generation—like “crippled,” much less the brutal terms for mental disability: moron, idiot, even “retarded,” the more humane replacement for the preceding, and which is currently the object of a vigorous campaign across college campuses to proscribe “the ‘R’ word”). It is really marvelous to see what people confined to wheelchairs (and the blind and deaf) are often able to do now, and our Gnostic, often cloying insistence that they can do it has certainly supplemented the prodigious technological innovations we must credit. We have also seen the emergence of an entire culture concerned with ways of coming to terms with disease, decline and death and the ability to turn, once all resources have been exhausted, from attributing responsibility to others (the doctor, the insurance company, the hospital, the state…) to simply seeing to the integrity and dignity of the patient and her loved ones. There is, we might say, a “healthy” way to finally let go.
The individualization of the sickening, recovering and dying processes thus introduced will not only guarantee our constant chafing at the restrictions and cookie-cutter categories of homogenized health care systems but further facilitate another process which I believe is inevitable, indeed, already well underway: the pluralization of therapies. Why shouldn’t the government or insurance company pay for, say, Native American cures? Because they haven’t been scientifically verified? You would have to have a very naïve faith in public confidence in the modern cult of professionalism and expertise to imagine that answer will hold the fort for long. There will be more and more things government and insurance companies will have to and can’t pay for—but, at least, it’s possible to imagine the emergence of insurance companies which cater to the eccentric and desperate. So, as government presence recedes, health care decisions will devolve to the individual, producing more flexible norms of expertise. Does someone really need 6 years of medical school, 10 years of internship and residency, to help me with my aching back or cough? I doubt it and, more importantly, more and more people will come to doubt it, especially when they are the ones weighing costs. In the end it will be obvious that our health care needs are better met in this more differentiated manner, and on the open market, with practitioners, inventers of medical technologies and promoters of new methods engaged in competition with a close eye on the actual costs of skills and procedures.
At the same time, such a process will generate, in the short term and perhaps longer, inequalities and mistakes that will seem monstrous to many. There will be plenty of cases of people purporting to fix backs breaking them, of con men hawking fake treatments without fear of the regulator or licensing board, of new, prohibitively expensive treatments conspicuously available for a while (a long enough while to count the dead resulting from “health apartheid”) to only the very wealthy. And the question for us, as a civilization, will be: can we abide that? Health problems, today, have come to be experienced less as “acts of God” or the inevitable workings of Nature than as a kind of violence, uniquely, unpredictably and terrifyingly directed at individuals, violence to which we are all ultimately equally vulnerable—violence from private and public greed and callousness (insurance companies, doctors driving Mercedes, companies pumping carcinogens into the environment, pencil-pushing bureaucrats putting rules over compassion, etc.). The demand for universal health care, or at least coverage, taps into a kind of originary terror. We would have to be able, to make ourselves whole, to suspend that attribution of violence, and learn to use our greater powers of physical healing as metaphors to enable healing of a more transcendent kind.