Letters

To the Editor:

Paul Menzel and Donald Light ("A Conservative Case for Universal Access to Health Care," Jul-Aug 2006) tell a story that is plausible.However, based on my twenty-five years of experience as a policy analyst interested in access to health care, I find it inaccurate for a number of reasons.

First, the article is organized around the word "conservative," with references to "the" conservative outlook and "the" conservative case, but the authors don't adequately specify what conservative means. In American political discourse, the word is an umbrella term that includes social conservatives, fiscal conservatives, libertarians, big government conservatives, small government conservatives, neoconservatives, and more. These groups differ significantly in their moral and political values, and I suspect that the group "European conservatives" is equally heterogeneous. The term "liberal" is even less clearly specified in the article; it seems to mean anyone who isn't a conservative. This terminological ambiguity undermines their thesis.

Personally, I think it is not useful to describe health policy in terms of simple, values-based "liberal" and "conservative" positions for and against universal access. Menzel and Light acknowledge that many self-described conservatives are in favor of universal access to needed health care. I would go further and argue that the article's opening statement ("For decades, advocates of implementing universal access to needed health care in the United States . . . have been talking largely to each other") is trivially true because most Americans—whatever ideological label you assign them—are in favor of universal access to needed health care. This rhetoric has been ubiquitous in political documents across the ideological spectrum since at least the 1930s.

Where Americans disagree is on the meanings of "access" (a term that the authors note is not the same as "coverage" or "insurance") and "needed"; on the role of the federal government in making universal access happen; on the amount they personally should have to pay for it; and on how urgent it is to get the job done. Positions on these issues are complex and don't fall into two clearly defined groups. I agree that a conservative can make a values-based case for universal access. In fact, over the years, a number of conservative policy analysts have done so, advancing the very arguments that comprise the article's values-based conservative case. Even on the key issue of mandating insurance coverage, there have been proposals from self-described conservatives for achieving universal coverage that involve mandates, as well as proposals from self-described liberals that avoid them.

But it bothers me that in presenting their case, the authors repeatedly identify as "conservative" values that are not unique to conservatives. For example, individual freedom and responsibility, the prevention of free riding, and efficiency and the avoidance of waste are also core values of political and social liberals—in fact, they are core American values. Similarly, the article's "conservative case" for universal health care looks very much to me like the liberal case. The arguments the authors invoke are exactly the same ones that have been made by many liberal advocates of single-payer, managed competition and a range of hybrid public-private health care reform approaches over the last several decades.

That brings me to my final problem with the article. Having laid out (quite well, I think) the standard moral and economic arguments for universal coverage that liberal and conservative health policy analysts have been making since I entered the field, the authors conclude that what we need now is serious dialogue. If liberals would just let go of their self-righteousness—if conservatives would just recognize the implications of their own moral values—then we could get somewhere. The conclusion refers back to the opening claim that the people in favor of universal access have been talking to each other and not to the people opposed to it, and it implies that the talking should be about moral values.

Dialogue is good, and the moral case for policy change must be made over and over because new people are always joining the public...