Is Ideology-Free Health Reform Possible?

Apparently the message of Tom Daschle’s confirmation hearing today was standard anti-partisan fare: “‘We will be guided by evidence and effectiveness, not by ideology,’ Mr. Daschle told the Senate Committee on Health, Education, Labor and Pensions.” I have no doubt that this is the correct rhetorical posture to adopt. But after listening to podcasts from an excellent Princeton/Woodrow Wilson School conference on health care reform, I think anti-ideologism has its limits.

At the conference, Len Nichols, Director of the Health Policy Program of the New America Foundation, gave the paradigmatically postpartisan perspective on health care. According to Nichols’ vision, both Democrats and Republican need to be far more open to ideas from one another’s best thinkers. He held out the Massachusetts plan for universal coverage as a model for melding Democratic emphasis on universal coverage with Republican commitments to personal responsibility, private insurers, and markets.

Yet I found the most compelling talks to be Uwe Reinhardt’s and Maggie Mahar’s. Far from preaching “middle of the road”-ism, both found fault with the incrementalism it usually results in. Mahar noted that the Massachusetts plan does not have a compelling model of controlling costs–and that without cost control it is virtually impossible to accomplish sustainable reform. Reinhardt underscored the degree to which policy elites in other countries consider the risk of bankruptcy due to medical bills in the US “obscene”–a value commitment hard to square with much rhetoric of personal responsibility.

I think it’s time for us to follow Jack Balkin’s groundbreaking work on ideology, and to realize that the goal is not to be ideology-free, but to recognize and correct for the inevitable biases that ideology can generate. As Balkin says of the cognate concept “cultural software,” ideology is “simultaneously empowering, useful, and adaptive on the one hand, and disempowering, distorting, and maladaptive on the other.” But it is inevitable, and the faster we can get clear on its role in health debates, the more substantive health care reform is likely to be.

Anyone familiar with my health law archives on this blog probably knows my convictions here: The US health care system wastes huge amounts of money, inflicts financial and physical distress on many vulnerable people, and has been excessively commercialized. Profits are too often put ahead of patients. We can learn from other countries that spend less, and have as good or better health care outcomes.

An ideological framework like that (or its mirror image on the right) is proabably necessary to motivate real action on the health reform front.


As Geertz says in his great essay Ideology as a Cultural System:

The differentiae of science and ideology as cultural systems are to be sought in the sorts of symbolic strategy for encompassing situations that they respectively represent. Science names the structure of situations in such a way that the attitude contained toward them is one of disinterestedness. Its style is restrained, spare, resolutely analytic: by shunning the semantic devices that most effectively formulate moral sentiment, it seeks to maximize intellectual clarity. But ideology names the structure of situations in such a way that the attitude contained toward them IS one of commitment. Its style is ornate, vivid, deliberately suggestive: by objectifying moral sentiment through the same devices that science shuns, it seeks to motivate action. Both are concerned with the definition of a problematic situation and are responses to a felt lack of needed information.

Ideologies do make empirical claims about the condition and direction of society, which it is the business of science (and, where scientific knowledge is lacking, common sense) to assess. The social function of science vis-a-vis ideologies is first to understand them–what they are, how they work, what gives rise to them–and second to criticize them, to force them to come to terms with (but not necessarily to surrender to) reality. . . .

Before we aspire to do away with the “ornate, vivid, deliberately suggestive” methods of ideology, we should remember commitment’s place in the world of health care reform. For me, that means universality–a strong commitment to a robust baseline of care for all–should be at the top of reformers’ agenda. Cost-containment is important, too, but its achievement needs to hinge as much on values of compassion and equality as on the number-crunching of technocrats. If bipartisanship becomes too technocratic, partisanship may not be such a dirty word after all.

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