JONATHAN COHN SEPTEMBER 16, 2011
The big drama of this week’s Republican debate was over whether front-runner Rick Perry would stumble. But the most interesting moment turned out to involve a man nobody thinks can win the presidency: Ron Paul.
CNN host Wolf Blitzer asked Paul whether he was prepared to let an uninsured 30-year-old with cancer die, just because that 30-year-old could not afford the treatments. Paul gave a long, convoluted answer about responsibility. But a handful of audience members were less ambivalent. They blurted out “yes”—as in, yes, they would let the 30-year-old die.
The self-selected audience that attends Republican debates isn't exactly representative of the country as a whole. But this also isn’t the first time I’ve heard people attack universal health insurance, in principle, because it supposedly absolves people of individual responsibility—whether it’s the responsibility to stay healthy, the responsibility to seek timely medical care, or the responsibility to make the right choices about health insurance.
Of course, the proper boundaries of responsibility are a frequent subject of debate in American politics. In the 1990s, the argument over welfare reform was all about responsibility—and whether people had an obligation to work if they wanted financial assistance from the government. The consensus was that, yes, those who wanted assistance needed to be more responsible about their own lives.
But attitudes about medical care have always been a little different. As a practical matter, few of us are prepared to allow a somebody die when life-saving treatment is available, just because that person isn't prepared to pay the bills. As Ezra Klein put it the other day, “we do not want to look in people’s pockets for an insurance card when they fall to the floor with chest pains.”
We've actually written this expectation into law: The Emergency Medical Treatment and Active Labor Act (EMTALA) prohibits hospitals that accept Medicare (i.e., virtually all hospitals) from withholding such treatment. But the idea that providers of medical care have this sort of obligation goes back much farther than that, as Howard Markel, a leading historian of medicine from the University of Michigan, explains: “It is part of the standard “social contract” doctors have long had with their patients and society at large… most famously it emerges from the teachings of Hippocrates—and in particular the Oath.”
I happen to agree with this attitude: We shouldn't let people die, just because they can't pay a medical bill. Partly that's because I recognize the role chance and misfortune play in our lives. A child born into a family without health insurance couldn't have done something different to get covered. Yet, as Paul Krugman pointed out on Friday, if that child gets sick, that child is going to suffer. An adult with an inherited conditions, even a relatively mild one, didn't choose to be born that way. But inherited conditions are pre-existing conditions—and can make it impossible for people to get affordable insurance.
To be clear, the people without the means to pay for medical care aren't always, or entirely, victims of circumstance. Years ago, when I started interviewing people about their experiences with the health care system, I always hoped to find that perfect story of somebody who, through no fault of their own, was wronged by the system. But those stories were less common that I'd expected. Frequently the people I met had made at least one mistake. Some didn’t spend enough time looking for charity or public insurance options. Some checked the wrong box on a form. Some stopped paying for insurance when they could have stopped paying for something else. Some ignored medical warning signs.
But you know what? We all make those kinds of mistakes in life. The problem for these people was that they happened to make a particular kind of mistake—a mistake about their health or how to pay for their medical care—that led to unusually severe consequences—like losing their life savings or, in the worst cases, losing their lives. Maybe the people in the audience on Tuesday would shrug and say those consequences are appropriate. I wouldn't. My definition of a decent society is one that protects people not only from bad luck, but also, in some circumstances, from their own bad judgment.