As America debates the new GOP proposal to dismantle/repeal/replace the Affordable Care Act, the bill’s supporters have lauded the ways that it will restore choice to American citizens.
To that end, it’s worth considering the 1960s debate around Medicare, a program opposed at the time by political conservatives and independent groups, including the American Medical Association. Ronald Reagan recorded a message in opposition to the dangers of “socialized medicine” which you can listen to and read here.
Notice that the argument about socialized medicine presented by Reagan and the AMA isn’t just about “compulsory” healthcare for all elderly Americans, but about the potential for government control over all aspects of our economic lives. As Reagan says:
The doctor begins to lose freedoms; it’s like telling a lie, and one leads to another. First you decide that the doctor can have so many patients. They’re equally divided among the various doctors by the government. But then the doctors aren’t equally divided geographically, so a doctor decides he wants to practice in one town and the government has to say to him, “You can’t live in that town. They already have enough doctors.” You have to go someplace else. And from here it’s only a short step to dictating where he will go.
This is a freedom that I wonder whether any of us have the right to take from any human being.
I know how I’d feel, if you, my fellow citizens, decided that to be an actor, I had to become a government employee and work in a national theater. Take it into your own occupation or that of your husband. All of us can see what happens: Once you establish the precedent that the government can determine a man’s working place and his working methods, determine his employment, from here it’s a short step to all the rest of socialism — to determining his pay, and pretty soon your son won’t decide when he’s in school, where he will go, or what they will do for a living. He will wait for the government to tell him where he will go to work and what he will do.
The slippery slope here is not the one that leads to rationed care and death panels, but one where the government can eventually tell everyone what their education and occupation will be. This language of socialism and the loss of choice obviously meant something different during the Cold War, when the American ability to choose from the abundant products of the free market was central to the argument that the American way of life was superior to that of the USSR.
It’s notable that a) nothing Reagan detailed in this passage happened as a result of Medicare, and b) the AMA has come out very strongly in opposition to the proposed AHCA bill. Still, the framing of the AHCA bears similarities to what Reagan presented; the danger is not that you will lose health care, but you will lose choice.
The idea that the government will, by taking choice away, eventually sap our ability and desire to choose altogether, touches deeper American fears about individuality, independence, rational thought, and masculinity. Excluding women, non-white Americans, and young people from the franchise was rooted in arguments about their inability to make independent, rational choices.
But the centering of economic choice as the ultimate marker of freedom in America has a more recent history we would do well to think about when we hear the language of choice today, particularly as unfettered economic choice is put forth as the only guarantor of freedom. What does it mean to be free to choose and how should the government ensure that freedom?
[Note: None of this is to suggest that the Democratic party has been internally consistent on these issues either. But this framework of choice is not central to their view of the government and its role in the economics of health care, so I’ve not addressed it here.]