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Another Brick in the Wall

I generally try not to add to the din on specific political matters or pending legislation, but Arizona Proposition 101, the Freedom of Choice in Health Care Initiative, is peculiar enough - and perhaps perverse enough - to warrant this exception.

I admit that I'm not sure I fully understand the ramifications of this proposed initiative in actual practice. Health care lawyers tell me it is poorly worded and constructed, and has the potential for all sorts of "mischief" that will generate legal challenges for years to come - in other words, a "lawyer's dream."

I also admit that while I find Prop. 101 to be unnecessary and even a potential detriment to providing access to quality, affordable health care, I share its framer's concern with the heavy and occasionally inept hand of government in trying to cram physicians and patients into some type of monolithic public insurance scheme. There should be as few barriers as possible between physicians and patients, and on that score I would include private as well as public insurance plans. But that's a subject for another time.

With regard to the initiative itself, it's worth pointing out that the freedom to choose is dependent on freedom from restrictions on exercising choice. For example, you can't very well pay for medical services directly or enroll in a private health plan of your choice if you don't have any money. Libertarians and others who stress the primacy of individual liberty are focused on the former (positive) dimension of that term, and not its latter (negative) dimension, which leads directly to a focus on social justice, or fairness.

To a greater or lesser degree, all so-called "civilized" societies today collectively decide on some acceptable balance between freedom and fairness, and choose to pass laws (mandates, taxes, etc.) to ensure that balance. In the case of Prop. 101, the freedom of individuals to collectively discuss the pros and cons of social balance through robust public debate is effectively choked off in the a priori assertion of positive over negative freedom, which is stated as given ("all persons should have the right to make decisions about their health care") but not proven.

But really, all these philosophical distinctions are quickly lost in a shrill political climate fed by the media, which distill all complex and contentious issues to polarized sound bites ("freedom vs. socialism," "universal single payer vs. free-market private insurance"), all the better to incite the populace and sell advertising.

I mean, who isn't for freedom of choice in health care? We're all Americans, right?

Well, if public opinion and focus group surveys are any indication, a great many Americans would trade more freedom of choice in a heartbeat for freedom from catastrophic medical debt, rapidly rising healthcare costs, and denial of coverage for preexisting conditions, among other things. In today's bloated, inefficient and often ineffective American "sick care" system, the desire for security and control trump individual autonomy and freedom. Employer-based insurance is declining, public programs are swelling and breaking the bank, and people are fearful. It's not freedom they're hungry for. It is effective solutions to their immediate problems.

Alas, Prop. 101 offers nothing in the way of constructive help. Anything goes, so long as it's not "the tyranny of government," pay or play mandates, and the like. Presumably its framers are fine with all the free riders who could potentially show up in the emergency room when they "choose" not to participate in some "particular health care system or plan" and then - horrors - get sick and don't have the means to pay for their own care.

If we're really serious about freedom, perhaps we ought to give providers the same freedom of choice to deny medically necessary care to these free riders and toss them back out on the street. It would be inhuman, cruel and uncivilized, but at least we all would be able to exercise our freedom of choice.

No one in their right mind would suggest this, of course, but you see where an emphasis on unfettered freedom takes you.

As it stands, I expect Prop. 101 will pass, and would be (pleasantly) surprised if it didn't. "Freedom of choice" always plays well on the sound stage of America's solipsistic consumer-driven culture, and many voters won't get beyond the title to an exploration of the initiative's consequences, which, at least as far as I can tell, are unknown at this point.

For all of that, I'm afraid that this proposed constitutional amendment is just another brick in the wall of health care confusion. We desperately need to stop filling in that wall so we can see a clearer way forward to the other side.

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*The Drift reflects the views of the author, and does not represent the official view of SLHI's Board of Trustees and staff.