TEDxSwarthmore – Paul Starr – The American Struggle over Health Care Reform

this past Tuesday March 27th I had the privilege of attending oral argument at the Supreme Court on the constitutionality of the Affordable Care Act and that morning I saw and I heard the clash of two different views of what makes a good society on one side were the attorneys opposing the law and the conservative justices who made it clear that in their view the government cannot require people to purchase health insurance even if they can afford it why if the law can require people to buy health insurance might it not also require them to buy a car or a cell phone one of the justices darkly suggested that the government might go on and require people to purchase broccoli a veiled reference some thought to President Barack Obama on the other side defending of the law stood the Solicitor General of the United States Donald Verrilli who maintained that health care is different the sellers of cars and cell phones and broccoli never have any obligation to provide those things for free but in the case of health care the uninsured can go into the market and very often they can get taken care of because the Solicitor General said of social norms to which we have obligated ourselves it was at that point that Justice Scalia interrupted and said and I quote so don't obligate yourself don't obligate yourself to providing that care the Solicitor General was I think taken aback um and he said he said I can't imagine the Constitution would require Congress to ignore this deeply held social ethic and it's not just a social ethic that leads to providers giving care for free a federal law actually requires hospitals to provide emergency care regardless of whether the people involved can pay for it you see the Solicitor General was saying that free care adds up it adds to the bills of patients who do pay it adds to the cost of health insurance in fact it adds about a thousand dollars a year to a family's cost for health insurance that cost gets transferred into interstate commerce and under the Constitution Congress has authority to regulate interstate commerce and the Solicitor General was saying therefore the Congress could set a minimum standard for health insurance now the justices we're looking for a limiting principle but clearly cars and cell phones and broccoli are not like that as much as you might like to go to the supermarket and say I am experiencing a broccoli emergency the supermarket doesn't have to give you any as much as you'd like to go to an electronics store and say I am having a texting emergency with my friends the electronics store does not have to give you a free cellphone bot health care is different the providers have a professional ethic there are laws there are obligations to give care to people sick and and suffering but Justice Scalia is right Justice Scalia is right if the providers don't recognize these obligations if they don't provide that free care there there won't be those unpaid bills and that that's a solution right why didn't Congress think about that that could have solved the whole thing at hospitals I could just let the injured bleed to death they could turn away the contagiously ill let them walk back out and infect other people well maybe a good society shouldn't do that and maybe even a self-interested society shouldn't do that if it has a modicum of intelligence and these different views of a good society came out in other exchanges on Tuesday Chief Justice Roberts pointed out that under the law the minimum required coverage includes maternity newborn and pediatric services and not everybody is going to need those one of the other justices expressed concern that healthy young men we're going to be asked to pay for things they do not need and it's true if you take a snake shot of a man in the prime of life he will certainly not at that moment need eternity newborn or pediatric care but if you think of a moving picture of that man's life things look different on the day he was born his mother needed maternity care he needed newborn care he very soon needed pediatric services and because women don't get pregnant all by themselves I think it's fair to say that men are responsible for the cost half the maternity newborn and pediatric services in the country um but Chief Justice Roberts is right we could say that just as men shouldn't be obligated to pay for maternity care women should not be obligated to pay for the treatment of prostate cancer oh we could go through all the services and divide them up by gender we could say that old people shouldn't pay for young people's medical problems and vice versa we could say that black people shouldn't pay for white people and white people shouldn't pay for black people we could do that we could say each individual should just pay for the risk that he or she represents as part of the groups with which he or she can be associated well there actually is a name for that conception of fairness that's actuarial fairness and under that conception people with chronic illnesses or other serious pre-existing medical conditions are going to be quoted very high prices for insurance many of them will not be able to afford that insurance but actually that's fair of course that was exactly one of the reasons for this legislation the Affordable Care Act and that legislation embodies a different conception of fairness in fact it's a phrase that's used in the repeatedly it's the principle of shared responsibility the idea that any of us who may be healthy at one moment may be diagnosed with a serious problem the next and so though we may feel invincible and not need health insurance we are at any moment right on the doorstep of the health care market and not completely outside it as the opponents of the law contend at this argument about different conceptions of fairness is not the first time Americans have been bitterly divided about health care in fact it's one of the striking things about our history the United States stands out in health care not only because we have some 50 million people without health insurance and not only because we have the highest costs of health care any place in the world by far now we also stand up for another reason we've been fighting about this issue we've been at each other's throats over this issue for a hundred years and none of the other rich democracies in the world is health care such a flashpoint of ideological conflict as it is in the United States conservative parties elsewhere accept the idea of a shared responsibility for the costs of illness that is not a controversial matter in most of those countries it's only in the United States that conservatives have come to view health care very differently have come to equate public responsibility or shared responsibility with a loss of freedom that's a distinctive phenomenon in the United States how did this conflict develop how did it take the shape that it has that's the subject of a new book of mine called remedy and reaction the peculiar Americans struggle over health care reform there it's not the case that Americans have these disputes and divisions in every sphere consider education we have public schools we have a kind of shared responsibility for primary and secondary education you don't hear people talking about public education as socialized education you don't hear that phrase socialized education because we have public schools because back in the 19th century we created them many Americans were concerned back then about how in a democracy we needed schools in order to have educated citizens they were concerned also about Americanizing immigrants and they saw the schools as a way to build the nation I'm not sure in today's ideological climate if we didn't have that legacy from the past I'm not sure we'd get public schools today but we have them and that's part of the point history passes things to us it passes institutions to us it passes ways of thinking about problems to us and in the case of health care we have a very mixed legacy from the past the way this issue unfolded in the first half of the 20th century left a very peculiar legacy in the United States the opponents of public programs for health insurance identified this idea socialized medicine with insidious foreign ideas identified it with enemy regimes at the time of World War one that was Germany later on it was the Soviet Union in each case the idea was that this was the entering wedge of foreign socialist ideas into the United States and the success that the opponent's had in that period kind of took the united states off the main track of development that other countries followed in health care and so we adopted a series of partial policies in healthcare we created a system for veterans we provided employees a very generous tax subsidy if they got coverage from their employers we passed the Medicare and Medicaid programs in 1965 that cover seniors and some of the poor and in that process we ensnared ourselves in what I call the American health policy trap well the trap was we did protect the majority of people the best organized groups in the society and in some ways these programs were very generous they were very generous to the healthcare industry they challenged an increasing portion of national resources into health care they tremendously enriched the industry these programs also actually obscured a lot of the cost people don't see those costs clearly that's partly what allowed them to grow as high as they have grown and then finally they gave many people moral arguments that they had earned their health care the veterans the employees who got it through work and the seniors who got it through all their working years they had earned their health care they were entitled to it can't be taken away and many of them said I don't see why I should be taxed to pay for anybody else for people who haven't earned their health care and so the argument over health care has taken on this rancor and violence which is so distinctive in the United States from other countries now I'm not saying this trap was absolute that we could never get out of it in the early 1970s we almost did when Richard Nixon was president at that time senator Kennedy was proposing a single federal health insurance plan and President Nixon said well we can't do it that way that'd be too much government let's have an employer mandate require employers to pay for private insurance that's the private sector oriented way to do it I think if Nixon hadn't I had only been wounded instead of destroyed by Watergate we might well have had some kind of national health insurance plan in 1974 it's possible but that moment was lost and year by year decade by decade the costs have grown the number of the uninsured has grown the battles have become bitter and bitter fast forward to the 1970s President Clinton I worked in the White House at that time okay let's go with an employment we'll have an employer mandate and private insurances way to get to universal coverage Republicans said no no that's too much government let's have an individual mandate that was the Republican proposal in the early 1990s and in fact for almost 20 years Republicans said the individual mandate was a good idea many prominent conservatives and Republican politicians whose names you know including Mitt Romney stood for an individual and they of course Governor Romney carried that out in Massachusetts and finally Democrats said ok you wouldn't do it these other ways we'll do it your way we'll do it with an individual mandate tax credits private insurance and now what's happened huh oh it turns out that this idea which so many conservatives had so fully endorsed has become a threat to Liberty what was once the embodiment of individual responsibility that's how Governor Romney referred to it has now become enough em'ly unthinkable unconstitutional now I can imagine that some people have undergone a philosophical process of rethinking those ideas and so we do have a philosophical disagreement in the country but there is also a political fact that the individual mandate became unacceptable the moment President Barack Obama embraced it and the political divisions have followed and unfortunately unhappy course oh I don't know what the result is going to be when the Supreme Court reaches its decision of course I don't know what the result will be of the election in November perhaps we're going to go on fighting on this question perhaps it'll be another hundred years it's astonishing I would never have thought that years ago when I first got interested in it it's a terrible prospect but at this moment there is a kind of shadow over this long effort to establish universal coverage and whether that shadow lifts whether we finally get to the destination I can no longer often it about thank you


  1. Always so disappointing to see someone who is clearly brilliant promote socialized health care while accusing republicans for apposing it simply because Barack Obama picked up that flag. There are many creative ways to create universal access to care without expanding an existing entitlement program directly responsible for the bloated cost and the erosion of our national health. I was expecting better.

  2. Many good points and questions raised.  But when will personal responsibility come into the conversation?  Half of our health care costs are due directly or indirectly to poor personal behavior CHOICES — eating too much, drinking too much, smoking too much and exercising too little.  You can't get better results or lower costs unless ALL Americans practice better personal behavior and are held accountable for those poor CHOICES.

  3. so sad of aknowlidging that this unfold ideological and economic debate on health care and social justice has colonized latin america and my country colombia making our socialized health systems crash and with that devastating effect million of poor citizens dying of negligence and violence…

  4. Excellent talk.  I find it appalling, as an American, that so many Americans see health care entirely as an economic matter and who pays for what. (Even though there is a powerful set of arguments for reform on economic grounds alone.)  Everyone else in the Western and most of the Asian world recognizes the moral importance of health care.  It is a moral disgrace that the richest country in the world has not had universal health care all these years and that so many people care so little for the well being of their fellow citizens that they fight this tooth and nail.

  5. Peoples first reaction to universal healthcare is "Why should I be paying an extra 1,000 dollars for healthcare?"
    Well, note that on average, U.S. citizens spend PLENTY more than 1,000 dollars on their healthcare. People would actually be SAVING money, not loosing it. Universal healthcare would technically be HELPING the economy.

  6. 1:11 – Stolen directly from Stephen Colbert.

  7. The deficit of a collective empathy, especially on the political right is utterly and jaw droppingly amazing for any of us who live in other industrialized nations, where health care is taken granted. That Americans are actually up in arms that someone wants to provide them access to health care seems crazy. This backwards notion that this some how impinges on their freedom rather than extend it betrays of a self-centred deficit of empathy that is at the heart of America's cultural malaise.

  8. Professor Starr is an excellent presenter and thinker.

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