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March 15, 2017
March 2017 | Sandro Galea | Online Exclusive
Ever since President Barack Obama’s 2010 signing of the Affordable Care Act (ACA), conservatives have objected to the law on the grounds that it infringes on the freedom of Americans. Much of this criticism has centered on the ACA’s individual mandate, a requirement which, with some exceptions, imposes a fee on those who do not purchase health insurance. In 2011, Robert Moffit, senior health policy studies fellow at the Heritage Foundation, called the mandate “an unconstitutional violation of personal liberty” that “strikes at the heart of American federalism.” Republicans have long stated their intention to “repeal and replace” the ACA. Last week, they unveiled their replacement plan: The American Health Care Act (AHCA). The AHCA would eliminate the individual mandate and has been touted as a means of returning freedom to consumers, a sentiment echoed by House Speaker Paul Ryan (R-WI), who recently tweeted that the AHCA “restores power to you.”
In the United States, we have historically placed a high premium on freedoms, such as the freedom to speak, to assemble, to bear arms, and, as the conservative argument often goes, to live unencumbered by government overreach. Notably, all of these are freedoms “to”—that is to say, they represent our freedom to perform an action or to access a resource with minimal restriction at the federal level. We can trace many of these freedoms back to the Bill of Rights, a document which, when written, initially excluded a number of groups from its full protections, including women and African Americans. Our history has been characterized, in large part, by the struggle of these groups to access these protections and to widen the scope of their own liberty. As a result of their struggle, the American definition of liberty has been broadened to include many additional freedoms “to,” including the freedom to unionize, to vote, and to marry, regardless of race or gender. This freedom “to” focus has become central to the American notion of self, and a powerful political organizing tool. Not only will we fight for this vision of individual liberty, we will defend it from perceived threats even when doing so puts us at physical risk. Our annual gun death toll—over 30,000 people per year—is a tragic example of this defense of liberty, reflecting the resistance even modest regulatory efforts can encounter in a society that defines rights primarily in terms of what we are empowered to do and to own. The health care debate may turn out to be another example of such resistance. Rhetoric notwithstanding, the practical implications of the AHCA mean that between 6 and 10 million people will likely lose coverage if it is implemented.
As the political debates around the AHCA gather steam, it seems appropriate to pause for a moment and consider that the overriding narrative that is driving the move towards the AHCA, the powerful impulse towards freedoms “to,” is readily countered by the importance of another kind of freedom: freedom “from.” This means freedom from the conditions that undermine the well-being of populations, like socioeconomic insecurity, environmental hazards, and the threat of preventable disease. This freedom “from” is equally part of the American quilt of values as is freedom “to.” In many ways it has animated the US since its founding. The Declaration of Independence argues for the rights to “life, liberty, and the pursuit of happiness.” None of these fundamental rights are possible without health, which is itself not possible without the country being structured in such a way as to allow these freedoms to flourish.
In 1789, the conservative political philosopher Edmund Burke spoke to the importance of building these structures, and the challenge of reconciling individual liberty with the creation of laws and regulations meant to safeguard well-being. For Burke, true freedom did not mean a world of unlimited individual license, where government takes no notice of the health and safety of its citizens. Rather, it meant:
[T]hat state of things in which liberty is secured by the equality of restraint. A constitution of things in which the liberty of no one man, and no body of men, and no number of men, can find means to trespass on the liberty of any person, or any description of persons, in the society. This kind of liberty is, indeed, but another name for justice; ascertained by wise laws, and secured by well-constructed institutions.1(p405)
In our current political moment, Burke’s defense of “well-constructed institutions” is perhaps more relevant than ever. His ideal of “the equality of restraint” recognizes the need to build social, economic, and political systems that create the context for individual liberty, giving everyone a chance to thrive. He understood that these systems are necessary to ensure that one person’s liberty does not trespass on that of another, and that such a trespass is, in fact, an injustice. Burke’s advice has particular importance at this political point in time. The raging AHCA debate has been almost exclusively concerned with the importance of freedom “to” rights without accounting for the fact that we cannot be truly free if we are sick, burdened by medical debt, and unsure where our next treatment will come from. This reality has long been central to the work of public health, informing initiatives like motorcycle helmet laws, portion controls for sugar-sweetened beverages, and indoor smoking bans. Far from being restrictive, these moves were designed to enhance liberty through the promotion of well-being. It is worth noting that all of these measures encountered pushback from those who saw them as threats to individual liberty.2,3(p227) Notwithstanding this resistance, they all have the potential to contribute to a country where more people can enjoy the freedom that comes with living a healthy life. By reducing the chances of injury or disease, they help to free populations from the costs and constraints of poor health.
The ACA, despite its flaws, represents a similar opportunity. The Republican alternative, by rolling back coverage, does not. Though proponents of the AHCA have made the case that it will lead to greater individual freedom, this freedom chiefly consists of the chance to be sicker and more financially vulnerable in times of need. While some may indeed view this as a kind of liberty, it is not one we should embrace, particularly not when there is a better option at hand.
Sandro Galea, MD, DrPH, a physician and an epidemiologist, is dean and Robert A. Knox Professor at Boston University School of Public Health. He previously held academic and leadership positions at Columbia University, the University of Michigan, and the New York Academy of Medicine. Galea’s scholarship has been at the intersection of social and psychiatric epidemiology with a focus on the behavioral health consequences of trauma. He has published more than 700 scientific journal articles, 50 chapters, and 13 books, and his research has been featured extensively in current periodicals and newspapers. His latest book, Healthier: Fifty Thoughts on the Foundations of Population Health was published by Oxford University Press in 2017. Galea holds a medical degree from the University of Toronto and graduate degrees from Harvard University and Columbia University. He also holds an honorary doctorate from the University of Glasgow.
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Health and Taxes and the Values at Stake in the ACA Debate
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