Clinton's Protection Racket

The price of health-care "security"

Richard D. Mohr from the January 1994 issue

A Sign

President Clinton prefaced his September 22 televised speech to Congress on what he called the "principles" of his national health-care plan with a request for a moment of silence for the 47 people who earlier in the day had drowned in an Alabama bayou after a train derailment. It was a nice touch; it seemed a caring touch. But it was hardly an honest one. He failed to mention that the innocent victims had been killed by a federal bureaucracy: Amtrak. If federal bureaucracies can't run trains without killing masses of people, should we entrust our bodies to their care?

The speech proper began with Clinton showing the nation a freshly minted plastic card which all citizens and legal aliens would be required to carry. The card would guarantee health care, but it would also do something else. What "conservatives" even at the height of the McCarthy era could not mandate in the name of national security, with the stick of a national identity card, the Clinton health plan would achieve with the carrot of a health card: federal surveillance, placing every citizen at the call of government.

My chief worry about Clinton's national health-care plan is not its thinning effect on the nation's wallet. If taxes were all that it took to realize national health care, I'd be for it. But even if the numbers could magically add up, I'd still be against it. My worry is that the plan will reconfigure the way the country conceives of itself--that its costs will be to the nation's soul. In particular, I think the plan likely to have a devastating effect on civil liberties, those elusive and always fragile rights by which individual liberty is preserved and which the Declaration of Independence announced as the very purpose of good government: "to secure these rights governments were instituted among men." Clinton's health-care plan, I fear, is totalitarianism with a happy face.

Security as a Good

Health card in hand, Clinton laid out the goal of the plan: to provide security. Everything else in the plan was to be evaluated based on whether it helped achieve this end. Clinton left vague--taking it as obvious-- what sort of good security is. He wisely shied away from speaking of health-care security in the language of rights. For if health care is a right to demand things from government, absurd consequences follow. Suppose that some pill that costs $2 billion will save my life. If health care is a right, the government will have to provide it to me. But no one thinks I have any such legitimate claim on government. Health-care security is not a right.

But neither is security something that is simply good in itself. To suppose that security and its friends, permanence, unity, and order, are, without more, goods so great that the government may coercively impose them is a view that might properly be called aesthetic fascism. No, security is a good only because it enables people to carry out their life plans, the courses of action that they have chosen for themselves, and to carry out these plans in ways that respect other people's ability to do the same. No one can conceive or carry out a life plan in a state of chaos. Security is good to the extent that it promotes personal independence, the most important dimensions of which have constitutional standing in the fundamental rights of speech, religion, privacy, and due process.

This understanding of security gives us a yardstick for measuring the success of a health-care plan: Its cost cannot be the very things that justify its existence. And the nature of power in the modern era virtually guarantees that the costs to liberty of generating health-care security far exceed the liberty that government- provided health care might promote. Indeed, even in our current messy, non-comprehensive system of government-subsidized health care, we may already be beyond that point of diminishing returns to liberty.

Thinkers as politically and analytically diverse as Alexis de Tocqueville, John Stuart Mill, and Michel Foucault have all noticed that power in the modern era does not operate on a model of a king hamfistedly knocking off those he doesn't like. In that medieval model, if you simply avoid the king's wrath, you are free to do as you please. Power today does not have the discrete, isolated, avoidable forms of king or namable tyrant. Rather, it is diffused and permeating; it is ever more ramified and sinuous but all the more penetrating and controlling for pulsing at the capillary level of society. You cannot avoid its lacy netting, spread everywhere. Power now operates more by lure and surveillance than by pushing and shoving. It controls more often by gaze and attitude than by threat and violence.

Indeed, the more bureaucratic your setting, the more likely that you are to be controlled in millions of small ways rather than in any one big way--say, by a gun held to the head. You are no less controlled, but you are less likely to notice. Explosion-accelerated lead may be the most effective way to kill the body, but committees--requiring, as they do, being nice to evil--are the most effective way to kill the soul.

In a bureaucracy, how well you do has nothing to do with talent, skill, effort, and creativity. Rather, it has nearly everything to do with how you get along with others. This explains how even honest cops support and make possible the corrupt activities of cops on the take. How much worse, then, is the problem of conformity in administrative settings. Bureaucrats are the shock troops of convention; committees, the weak acids where individualism is inexorably dissolved and dispersed into community values. They are the sinkholes of the moral landscape, the mass graves of ideas.

And of the various possible national health-care plans, Clinton has chosen the most bureaucratic, the one dubbed by its adherents "managed competition." The oxymoron is telling. A contradiction is built right into the title: Competition is a dimension of freedom, while management is a dimension of coercion. By contrast, the euphemistically titled "single-payer" system--socialized medicine like the Canadian system, in which health care is both provided and paid for directly by the government--at least has the advantage of a reduced bureaucracy. Single-payer systems, supported by such left-leaning Democrats as Rep. Pete Stark (Calif.) and Sen. Paul Wellstone (Minn.), add new government health-care bureaucracies but eliminate both the huge HMO bureaucracies and the insurance-industry bureaucracies. The Clinton plan, on the other hand, adds three new bureaucracies to the current messy system.

First, everyone is forced to join something called a health-care "alliance." These are still largely mysterious, quasi-governmental bureaucracies that both oversee and compel the arrangement of insurance- industry-run HMOs. They operate at the state level. In turn, there is to be a new, seven-member National Health Board, which through an elaborate bureaucracy evaluates, oversees, and regulates all other elements of the system: the alliances; those paying for the plans (employers, the self-employed, the government); those delivering services (basically HMOs and a handful of struggling free-lance doctors and hospitals); and patients. Finally, Clinton proposes a new quasi-judicial bureaucracy to deal with the welter of legal challenges that will arise along every filament of the national health-care web.

There will be some consolidation in the system but not of a helpful, freedom-generating kind. According to a New York Times analysis, the vast majority of the country's 500 or so insurance companies will go out of business, leaving the field to the five largest. The variety, odd interstices, and looseness at the joints- -collectively, the sites for choice--that a large number of companies doing business of the same type provide will be wholly lost in the new system. Indeed, the Big Five insurance companies will be so similar in their government-mandated "standard package of benefits" and so closely monitored and controlled by various boards that they will hardly be independent of government. In turn, government, by putting all its chips on only five companies, will hardly be independent of them. The resulting tangle will not be a Soviet-style government running of business. Rather, it will be like the interpenetration of big business and government in contemporary Japan or, even more so, in 1930s Italy. We will have arrived at the corporate state.

A Lesson from History