The Brass Tack

Let's get down to it.

Voters and people, or what is paternalism

Posted by srconstantin on July 26, 2009

The first thing I noticed about Matt Yglesias’ comment on health care is that it seemed paternalistic:

The larger issue here is that while some medicine is very high-tech and cutting edge and so forth actually most medical problems in people’s lives are extremely banal. Little kids get sick all the time and their parents are worried. People fall and break bones or sprain joints and at a minimum need to be checked for concussions. People need strep throat tests and depending on how the test checks out, they may need antibiotics. And it seems to me that with this kind of thing—your banal basic health care for people with minor everyday problems—there’s an extremely strong case for UK-style direct public provision .

So, essentially, he’s saying that we need, through public provision of health care, to create a certain approach to health care as a society, namely one that puts more priority on preventative and “banal” care for everyone, instead of the heaviest spending going to heroic treatments for the very sick if they’re rich enough. That’s paternalistic in the sense that it takes a position on how we should all spend our money, on what our social priorities should be; ordinarily I would argue that the government should be agnostic on such questions. Why not let people decide for themselves what they want and value?

But “what do people want” becomes a complicated question in a democracy. For example, people want universal health care. A slim majority of voters think it’s the government’s responsibility to ensure adequate health care, and 77 percent of Democrats do. Obama’s specific health reforms have polled well. On the other hand, when polled about their own personal health insurance, most people don’t want to change, so health care reform has been sold aggressively as an option that doesn’t require a change of doctors or insurance plans. To some extent these desires are in conflict, as the addition of a public option priced below the market rate will make employers less likely to provide health coverage and insurance companies less able to stay in business. And this is odd: although 72% polled supported a new optional “Medicare for all,” 63% think it will make the quality of their own health care worse.

What’s up here? Are voters simply illogical (as the National Review post would suggest)? I think, rather, that people think differently in their capacities as voting citizens versus private individuals. People vote based on cultural, moral, and tribal factors that often don’t line up well with pure economic self-interest. Rich people voted against their economic self-interest this year (though they don’t always; rich states trend Democrat but rich people in poor states trend Republican.)

So it’s not impossible that what people want for their country, as voters, is different than what they want for themselves, as consumers. They may not think of it directly as a sacrifice of their own quality of health care for the sake of others; it’s simply that civic and personal issues occupy different spheres of thought. After all, the marginal impact of your vote on your own tax burden, or the sorts of public services you receive, is negligible, while the impact of your political views on how you see yourself morally and how your associates see you can be quite significant.

Anti-paternalists think that only the views of the private individual, the consumer, are genuine. The views of the public citizen who has opinions on what’s best for the country are irrational, imaginary, “feel-good” busybodying. I think, for example, that pricing carbon is a good idea because it’s the most efficient way to prevent climate change damage. I voted for a guy who endorsed it — in fact we all did, since both Obama and McCain supported a cap-and-trade bill. On the other hand, anything that raises the price of the power for my laptop or my long showers or my delicious beef jerky is entirely against my self-interest. Why is my vote more phony than my consumption habits? If a majority votes for a system that yields one societal approach to health care, is that less genuine or less democratic than the different societal approach that arises from the private consumer choices of those same individuals?

I’ve been reading about Lincoln and his cabinet, and a period when partisan politics was even more a national sport than it is today, and reading the diaries of men of that time, I’m convinced that the opinions people hold in their civic capacity, opinions that appeal to a moral worldview and general welfare, are as genuine and potentially as well-reasoned as opinions about private self-interest. Most people with an active interest in politics are not agnostic on social priorities, on the kind of national landscape they’d like to see. We’re all busybodies to some degree; we’re not agnostic as to what we think of our neighbors’ choices. And if government were required to be so agnostic, you could imagine a paradox where consent for a policy was unanimous, but it was wrongly paternalistic because it imposed a set of social priorities.

“What do the people want?” has two answers, a civic and a private one; if they differ, then giving people what they “want” in one sense reduces their freedom to pursue what they “want” in the other sense. Though I don’t want to reduce people’s individual rights, there are times when we have to choose between whole systems (shall we have Medicare for all or not?) and not putting the question to a vote denies people the freedom of choosing between systems. I’m not sure we ought to privilege one kind of “want” completely over the other.

Edit: from Postbourgie, a scary personal story on why it really sucks to have no health care due to changing jobs.

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3 Responses to “Voters and people, or what is paternalism”

  1. jacksmith said

    LEAD, FOLLOW, OR GET OUT OF THE WAY. (Thomas Paine)

    We have the 37th worst quality of healthcare in the developed world. Conservative estimates are that over 120,000 of you dies each year in America from treatable illness that people in other developed countries don’t die from. Rich, middle class, and poor a like. Insured and uninsured. Men, women, children, and babies. This is what being 37th in quality of healthcare means.

    I know that many of you are angry and frustrated that REPUBLICANS! In congress are dragging their feet and trying to block TRUE healthcare reform. What republicans want is just a taxpayer bailout of the DISGRACEFUL GREED DRIVEN PRIVATE FOR PROFIT health insurance industry, and the DISGRACEFUL GREED DRIVEN PRIVATE FOR PROFIT healthcare industry. A trillion dollar taxpayer funded private health insurance bailout is all you really get without a robust government-run public option available on day one.

    YOU CANT HAVE AN INSURANCE MANDATE WITHOUT A ROBUST PUBLIC OPTION. MANDATEING PRIVATE FOR PROFIT HEALTH INSURANCE AS YOUR ONLY CHOICE WOULD BE UNETHICAL, CORRUPT, AND MORALLY REPUGNANT. AND PROBABLY UNCONSTITUTIONAL AS WELL.

    These industries have been slaughtering you and your loved ones like cattle for decades for profit. Including members of congress and their families. These REPUBLICANS are FOOLS!

    Republicans and their traitorous allies have been trying to make it look like it’s President Obama’s fault for the delays, and foot dragging. But I think you all know better than that. President Obama inherited one of the worst government catastrophes in American history from these REPUBLICANS! And President Obama has done a brilliant job of turning things around, and working his heart out for all of us.

    But Republicans think you are just a bunch of stupid, idiot, cash cows with short memories. Just like they did under the Bush administration when they helped Bush and Cheney rape America and the rest of the World.

    But you don’t have to put up with that. And this is what you can do. The Republicans below will be up for reelection on November 2, 2010. Just a little over 13 months from now. And many of you will be able to vote early. So pick some names and tell their voters that their representatives (by name) are obstructing TRUE healthcare reform. And are sellouts to the insurance and medical lobbyist.

    Ask them to contact their representatives and tell them that they are going to work to throw them out of office on November 2, 2010, if not before by impeachment, or recall elections. Doing this will give you something more to do to make things better in America. And it will help you feel better too.

    There are many resources on the internet that can help you find people to call and contact. For example, many social networking sites can be searched by state, city, or University. Be inventive and creative. I can think of many ways to do this. But be nice. These are your neighbors. And most will want to help.

    I know there are a few democrats that have been trying to obstruct TRUE healthcare reform too. But the main problem is the Bush Republicans. Removing them is the best thing tactically to do. On the other hand. If you can easily replace a democrat obstructionist with a supportive democrat, DO IT!

    You have been AMAZING!!! my people. Don’t loose heart. You knew it wasn’t going to be easy saving the World. 🙂

    God Bless You

    jacksmith — Working Class

    I REST MY CASE (http://krugman.blogs.nytimes.com/2009/07/25/why-markets-cant-cure-healthcare/)

    Republican Senators up for re-election in 2010.

    * Richard Shelby of Alabama
    * Lisa Murkowski of Alaska
    * John McCain of Arizona
    * Mel Martinez of Florida
    * Johnny Isakson of Georgia
    * Mike Crapo of Idaho
    * Chuck Grassley of Iowa
    * Sam Brownback of Kansas
    * Jim Bunning of Kentucky
    * David Vitter of Louisiana
    * Kit Bond of Missouri
    * Judd Gregg of New Hampshire
    * Richard Burr of North Carolina
    * George Voinovich of Ohio
    * Tom Coburn of Oklahoma
    * Jim DeMint of South Carolina
    * John Thune of South Dakota
    * Kay Bailey Hutchison of Texas
    * Bob Bennett of Utah

  2. Kevin Waterman said

    I nearly wrote up a comment on this a couple days ago but ended up passing on it then. Since you’ve invited me to though I most definitely shall now.

    The first point (not really related to the meat of the post, but still wanted to throw it out there), not all of us voted for a guy that endorsed pricing carbon. I cast my vote for Bob Barr and so did at least 5 or 6 other people.

    On to more substantive matters. I think there’s a slightly false assumption when you say “Anti-paternalists think that only the views of the private individual, the consumer, are genuine. The views of the public citizen who has opinions on what’s best for the country are irrational, imaginary, “feel-good” busybodying.”

    As one who would likely fall into the anti-paternalist category, I am dismissive of the public citizen’s views not because I consider them less genuine, but because they are not justified. For me this boils down to two things: exclusivity and a disdain for democracy.

    First the idea of exclusivity. One of the reasons I favor individual liberty in all circumstances is that it doesn’t preclude other, less free possibilities. A free market system doesn’t preclude socialistic communes, but by its very nature a socialist economic system inherently excludes the possibility of a free market commune. Building off of this, I don’t think your paradox “where consent for a policy was unanimous, but it was wrongly paternalistic because it imposed a set of social priorities” is really a problem – if consent is truly unanimous then the action ought to not require government action to be realized.

    Second, disdain for democracy. Like most limited government advocates, I have an intense disdain for democracy, finding it to be nothing but rule by the mob. Therefore I simply don’t have a problem with allowing strong strictures on government action (sort of, or perhaps precisely, what you’re referring to when you describe a govt being agnostic on our neighbors’ choices), even in the face of an overwhelming majority in favor of the policy. (Alongside this there’s also a good deal of faith in allowing open competition in the marketplace of ideas, without government gaming the competition in favor of one lifestyle or another)

    And to close, I’d just like to throw out on other point. I’m not sure that the divide you highlight between the private consumer and the public citizen really exist. While individuals can (and often do) act against their fiscal self-interest, I’m pretty sure it’s a basic truth that no individual ever acts against their self-interest. It’s simply a matter of how much the individual prizes the moral satisfaction (or avoidance of moral discomfort) versus the economic gains of a policy that goes against their fiscal self-interest.

    Not sure that I’ve said much other than my own personal quibbles with a lot of paternalist thinking, but hopefully it’ll be of interest.

  3. thebrasstack said

    Thanks — I’m not always totally convinced myself of what I put in these posts; I’m trying to find my way.

    I shouldn’t have forgotten third party candidates; have to remember not to generalize.

    What you’re getting at with exclusivity is partly true, but I think it’s not the whole story. Suppose a majority wants some policy which needs total (or at least more than 50%) participation to work. If the government enforces this policy, then you’re right, dissenters aren’t free to opt out. But if the government doesn’t enforce the policy, then supporters can’t necessarily realize their goal without government action. If a majority supports a minimum wage, for example, the existence of a minority that pays lower wages will undercut the majority’s business and cause their policy to fail. Leaving people free to choose individually can, depending on the policy, leave the majority unsatisfied.

    There’s also the related issue of coordination problems. I am willing to spend some money on public goods (roads, education, and yes, other people’s health care.) But I’m not willing to spend that money all by myself if nobody else will chip in; I need a credible commitment from my neighbors that they’ll pay too. At the moment, taxation is our best attempt at creating a credible commitment — we agree that we can be sent to jail if we don’t pay. Yeah, I know it’s a little dodgy, since I don’t directly consent to things that the majority votes for but I don’t. Rawls gets around this, roughly, by saying that a just society has institutions that reasonable people would implicitly consent to live under, like the democratic system. Sometimes that seems right to me and sometimes it’s puzzling. But at any rate, this should explain why consent can be unanimous (or at least very high) yet it be impossible to realize the policy without government action.

    You’re right, the tension is between individual freedom and democracy. I do think we ought to put more weight on individual freedom than most of our elected officials do now. But the fact is, many of the things people want necessarily involve coercing their neighbors. A dramatically reduced role for democracy means a dramatically reduced level of satisfaction, since almost everyone is part of some majority supporting some coercive policy. If we take people at their word when they say they want universal health care and are willing to pay for it, then letting them be “freer” in this regard will leave most citizens disappointed. That’s fine if you don’t have a utilitarian bone in your body; myself, I’m not so sure.

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