AMA Journal of Ethics^®

Why has it been so difficult for us in the United States to provide health insurance to every citizen? I believe we can get close to answering that question by examining the bitter divisiveness over President Obama’s effort at health system reform.

To a significant degree, the impediment to achieving universal coverage and the bitter political standoff arise from poorly handled tension between two basic values: individualism and solidarity [1]. This tension, a classical “good-versus-good” conflict, has been with us since Revolutionary War times. It undergirds American political and moral thinking the way tectonic plates undergird the earth’s surface. In 1782 our founding fathers chose e pluribus unum (“out of many, one”) as the national motto. But as of the twenty-first century, at least with regard to health policy, their optimistic aspiration is not being realized.

In 2009, in an effort to articulate the ethical dimensions of the health reform debate, the Hastings Center published a collection of essays: Connecting American Values with Health Reform [2]. The essays on liberty and responsibility highlight the underlying tension between individualism and solidarity. When we examine these values in depth, it becomes clear that they contain antithetical elements.

Appeals to “liberty” have been a central part of the opposition to health system reform [3]. In public discussion of health reform, liberty shows up most prominently as a fear that reform means “loss of choice,” “government takeover,” and “socialized medicine.” These reactions arise from the concept of negative liberty—the cherished right to do as we wish and be free from external control as long as we are not harming others. In the U.S. political tradition, negative liberty is enshrined in the Bill of Rights, the first 10 amendments to the Constitution.

But the concept of liberty has a positive meaning as well, exemplified in the Preamble to the Constitution, in which “We the people of the United States” commit ourselves to “promot[ing] the general welfare.” The First Amendment makes freedom of speech a fundamental negative right. But in order to make use of that right in a way that strengthens rather than divides our society, we must be able to speak effectively and reasonably—we need access to education; hence, state and national laws that protect our positive right to basic education. Individualism demands freedom of speech, but for individuals to speak together reasonably, to deliberate respectfully, to make laws—to act in solidarity—demands education. Without the positive libertyof access to basic education, the negative liberty of freedom of speech has little social worth.

The tension arising from our underlying commitment to both individualism and solidarity gives two meanings to the concept of “responsibility” as well. In movie after movie, macho heroes in the tradition of John Wayne take individual responsibility for solving problems, often breaking the law of the land to do so [4]. Superman and Spiderman take the image of the responsible solitary hero up a notch. But movies also portray responsibility as collective action, as in barn raising on the frontier or loving teamwork among soldiers. Superman and Spiderman can take responsibility on their own for catching criminals, but the day-to-day work of raising children in safety and imbuing them with our values takes community.

Healthy societies need both individualism and solidarity. True liberty requires both freedom from external constraints and developed capacity to use that freedom constructively. As individuals we need to take responsibility for ourselves and, at the same time, recognize and act on our interdependence with others. The fact that fundamental values like liberty and responsibility contain antithetical meanings doesn’t represent inconsistent ethical thinking on our part. Rather, the dual meanings ask us to understand and tolerate complexity and to work constructively with moral tension—good-versus-good conflicts.

This is what the U.S. was able to do in 1965 when Medicare was created. There was just as much conflict about health reform in 1965 as there was before passage of the Affordable Care Act in 2010. But what happened in the political sphere was dramatically different.

In 1965 the House and Senate deliberated about the complex issues and devised a compromise that received bipartisan support. In the Senate, 12 percent of Democrats voted against the Medicare bill and 43 percent of Republicans voted for it. In the House, 20 percent of Democrats voted no and 51 percent of Republicans voted yes [5].

But since the mid-1970s, our capacity for democratic deliberation [6], constructive compromise, and bipartisanship, has steadily diminished [7]. Although the Affordable Care Act represents a more limited change in health policy than Medicare did, the Senate vote was 100 percent on party lines, while in the House 13 percent of Democrats voted no and no Republicans voted yes.

The fact that the ACA’s legislative proposal to authorize Medicare payment for conversation between patients and their doctors about the values to guide end-of-life care elicited an entirely unfounded fear of government “death panels” shows how rigid ideological divisiveness impedes rational thought [8]. Every medical school teaches its students about informed consent and the ethical imperative for physicians to understand their patients’ values, especially for end-of-life care. But a proposal to reimburse physicians for these time-consuming, compassionate conversations triggered a firestorm of panic and outrage.

The impediment to guaranteeing universal access to health insurance results more from our diminished capacity for democratic deliberation than from a failure of ethical reasoning. Simply marshalling ethical arguments on behalf of universal coverage won’t solve the problem of the uninsured. Those who are primarily moved by solidarity values will continue to see their opponents as “uninformed, uncaring rednecks.” Those who are primarily moved by individualism values will see their opponents as “government takeover radicals.”

Health professionals can’t change U.S. political culture singlehandedly, but there’s a lot we can do. We’re the group the public trusts most. When Gallup asked how the public would rate the “honesty and ethical standards” of different groups, nurses (84 percent), pharmacists (73 percent), and physicians (70 percent) were the top three, with lobbyists (7 percent), members of Congress (7 percent), and car salespeople (7 percent) at the bottom [9].

We health professionals must become leaders in constructively managing the unavoidable tension between individualism and solidarity. In practical terms, this means moving beyond our traditional responsibility for the quality of care and taking responsibility for the cost of care because sharing in the cost of care for others is a flash point for those who value individualism above community solidarity. If we continue to make “us” (health professionals) responsible only for care and “them” (public and private insurers) responsible only for cost, we will add to the ideological rigidity that has stymied health reform [10].

The clearest statement of the roadmap we health professionals should follow is the “Triple Aim”—simultaneous pursuit of (1) improving the patient’s experience of care, (2) improving the health of populations, and (3) reducing the per capita cost of health care [11]. In order to support pursuit of the triple aim, the Affordable Care Act authorized Medicare to enter into Shared Savings contracts with Accountable Care Organizations—systems that coordinate physicians, hospitals, and other health professionals, to make sure that patients get the care they need in an efficient manner. ACOs that meet quality standards will share in the savings they generate.

When solidarity and individualism—tectonic underpinnings of our political and moral thinking—live together in a state of creative tension, the political landscape is vibrant and innovative. When they move into polarized opposition—as has happened in health policy—our national capacity to achieve universal access to health insurance is stymied.