First, a powerful piece of framing, brought to you from Rockridge Institute:
[Framing explained here]
As noted in the diary, "Labor & Lakoff: Fighting for Single-Payer" by California Nurses Shum, George Lakoff and the Rockridge Institute have weighed in heavily on the health care debate . An article Lakoff co-authored with Glenn W. Smith (who posts occasionally at OpenLeft) at Salon, "Don't think of a sick child" begins thus:
George W. Bush doesn't want you to think of a sick child. Not Graeme Frost. Not Gemma Frost. Not Bethany Wilkerson. Not any of the real children affected.
He wants you straining your eyes on the fine print of policies, puzzling over the nuances of coverage -- whether you can afford premiums for basic, catastrophic, comprehensive or limited health insurance. Last week on "Real Time With Bill Maher," even Tucker Carlson kind of got it right, saying, "No one child is a metaphor -- he's a kid!" That's the point. They're all kids, each one, one by one. The question is, do you care?
The actuaries don't. And can't. Health insurance companies make their money by denying care. They maximize profit by authorizing as little care as they can get away with. That's what all those administrative costs -- as high as 30 percent -- and all that paperwork are mostly about. It takes a lot of people to justify denying care.
It's the opposite of the way the market is supposed to work: Make more money by delivering more product. The health insurance industry makes more money by delivering less product. It maximizes profits by minimizing care.
The logic here is as simple as it is compelling: by its very nature, for-profit health care cannot solve our national health care problem. Which, of course, is why the logic must be suppressed. And in a short paper, ""The Logic of the Health Care Debate" [PDF], Lakoff and co-authors Eric Haas, Glenn W. Smith and Scott Parkinson explain precisely how this is done--by the "third way" mechanism of neo-liberalism, sidelining the liberal argument for single-payer, so that it never gets made.
In this paper Lakoff explains the logic of the conservative view-based on a commodity view of health care, and the notion of individual responsibility, the liberal/progressive view, based on "the morality of empathy and responsibility, for oneself and others," and the neo-liberal view, which shares the liberal foundations in terms of proper ends, but is heavily invested in a rationalist approach that accepts the market as a means, and in the process loses sight of the means. Extended excerpts and discussion on the flip.
Ever since his work in Moral Politics (1996), Lakoff has been writing in terms of two basic cognitive models of political thought-the conservative Strict Father and the liberal Nurturant Parent. He has always written in terms of numerous variants within the two, as well as mixtures (people who use one model in some areas of life, and the other model in others), but this paper on health care represents the farthest he has ever gone toward breaking with the two-model approach. Technically, this paper doesn't break with that approach, in fact it validates a distinction between ends and means that he originally made in Moral Politics. But for all practical purposes, he presents us with three co-equally coherent models.
First, is the conservative approach to health care, which he introduces thus:
The Conservative Mode of Thought
In the conservative mode of thought, securing health insurance is a matter of individual responsibility. In this view, health care is a commodity that should be bought and sold through insurance policies in the market. If someone wants a commodity, they should work hard to afford it. In a free market economy - given that America is a land of opportunity - they will be able to do so. Anyone without health insurance for himself or his family just isn't working hard enough and doesn't deserve it. It's just like plasma TVs; if you want one, work hard to afford one. Otherwise, you won't get it, because you haven't worked hard enough, and you don't deserve it.9
From the principle of individual responsibility, it follows that employers should never be forced to provide health insurance for their employees. They might choose freely to do so in order to attract talent, but that should be their free choice.
Within the conservative mode of thought, the market is both natural and moral. Natural in that people instinctively seek their own profit and moral in that those who are most disciplined will be most likely to prosper. Market outcomes are therefore always moral and most practical, since the market optimizes the fair and efficient distribution of goods and services. Government interference comprises both the efficiency and morality of market processes.
Lakoff's discussion of the liberal/progressive approach is shorter, and is presented here in full:
The Progressive Mode of Thought
The progressive mode of thought begins with progressive morality - the morality of empathy and responsibility, for oneself and others. Others, because life is interdependent; "no man is an island." Translated into policy, that moral view defines two roles for government: protection and empowerment. Protection includes not only military, police, and fire protection, but also disaster assistance, public health, food safety, social security, and so on. The empowerment function of government makes business possible. It also makes it possible for individuals to pursue fulfilling lives. Government empowerment includes the development and maintenance of public roads and bridges, the internet and satellite communications, public education, the banking system, the stock market, and the courts. No business can thrive without government contributions in these areas.18
Progressive views on health care flow from this understanding of the moral mission of government. Empathy requires taking the viewpoint of the person cared for, the health care recipient as well as their family and community. From a policy perspective, health care is a matter primarily of protection, but also of empowerment. Putting these together, we get progressive requirements for a health care system:
Everyone should have access to comprehensive, quality health care (follows from empathy).
No one should be denied care for the sake of private profit (follows from empathy and protection).
You can choose your own doctor (follows from empathy).
Promotion of health and well-being, focusing on preventive care (follows from individual responsibility).
Costs should be progressive, that is, readily affordable to everyone, with higher costs borne by those better able to pay (follows from empathy).
Access should be extremely easy, with no specific roadblocks (follows from responsibility).
Administration should be simple and cheap (follows from empathy and responsibility).
Interactions should be minimally bureaucratic and maximally human (follows from empathy and responsibility).
Payments should be adequate for doctors, nurses, and other health care workers. Conditions of their employment should be reasonable (follows from empathy).
When people are harmed by either the unsafe practices or negligence of health care providers, the redress should be left to the courts - with no arbitrary caps on compensatory payments (follows from protection).
Finally, as indicated above, the neo-liberal approach is a hybrid, but one justified with it's own central logic:
The Neoliberal Mode of Thought
The health care system of the next decades may be determined by a mode of thought that is neither purely progressive nor conservative, but neoliberal. What we term "neoliberal" thought shares progressive values and the ethic of care. At the same time, it has an Enlightenment-based faith in universal rationality as logical, unemotional, and serving human interests. To argue on the basis of care would be emotional and hence irrational and weak. To argue on the basis of interests is seen as rational and strong. The neoliberal strategy is to serve the ethics of care by serving the economic and other material interests of demographic groups.
In neoliberal thought there is the belief that markets can be effectively regulated to serve those interests, which leads to recommendations for technocratic changes to existing markets as one means to achieve progressive ends. Under the domestic version of neoliberal economics, many progressive moral goals can be achieved through private enterprise as an efficient means to moral ends.
Though conservatism sees the market itself as defining moral ends, neoliberalism shares with conservatism the idea that the market can be efficient and serve moral ends. This is why neoliberal thought has no problem with health care solutions that involve profit-maximizing private insurance companies.
The neoliberal emphasis on "systems" often causes a loss of focus upon the progressive morality that lies beneath their political and policy solutions. Specific references to progressive values disappear from their messages. So do references to the government functions of protection and empowerment. Neoliberals may begin with the morality of empathy and responsibility for oneself and others, but their faith and focus soon shifts to the abstract, to complicated systems and intricate public/private solutions. Empathy, the moral force that holds together our democracy and the engine of community, is reduced to sentimentality and shunted aside.
It's worth noting that this rationalist devaluation of empathy in the Western tradition goes much deeper than the Enlightenment, which actually had a very significant strain of thought-dominant in the Scottish Enlightenment-that did not devalue empathy or what it called the "moral sentiments" in general. The mistaken bifrucation of reason and emotion in the Western tradition is one of the most debilitating myths that is especially pernicious for the advancement of progressive politics.
Lakoff continues, detailing some of the dangers inherent in the neo-liberal approach:
Neoliberal thinking can lead to a dangerous trap. We call it the Surrender-in-Advance Trap. With an exaggerated emphasis on system-based solutions, neoliberal thought may lead one to surrender in advance the moral view that drives an initiative in the first place. Those who pragmatically focus on appeasing what they assume will be unavoidable political opposition to their proposals also run the risk of moral surrender. For instance, assuming strong, possibly insurmountable, conservative resistance to government-based health care solutions, they will embrace profitmaximizing insurance solutions because they believe that 1) political opposition can be muted; and 2) the "free" market, properly regulated, can serve moral purposes, such as providing health care for all Americans. Proponents of these neoliberal solutions often overlook the fact that the very source of the health care crisis is the structure of insurance: the less care they authorize the more profit they make, and profits come first and are maximized.
But people using a neoliberal mode of thought do not view a market-driven, profitmaximizing approach as a surrender of any kind. They deeply believe that progressive moral principles can be served through neoliberal methods and forms of argument. We want to stress, however, that the consequence is dire whatever the motivation. The failure to articulate a clear progressive morality in favor of more technocratic solutions to profit-maximizing markets puts the progressive cause at a disadvantage on health care and other policy issues as well. It doesn't matter whether one is simply trying to avoid conservative and insurance company opposition or whether one truly believes in one's heart that the market will cure us. The progressive moral basis for providing health care for all-empathy and responsibility, protection and empowerment-is not stated. As a result, Americans don't get to hear the progressive moral basis for extending health care to all Americans, and they don't get to decide whether they agree with that moral premise. Americans only hear the conservative moral view. That moves them in a conservative direction, not only on this issue, but on all issues.
There is an additional danger. As a strategy, surrender-in-advance puts advocates in the weak position of starting negotiations by going half way or more toward what the other sides want. No one would think of taking that approach when bargaining in the marketplace.
The Arguments Summarized
Next Lakoff briefly summarized the three arguments. First, the conservative argument:
The conservative argument is straightforward, and it is based on the same ideas conservatives have been pounding into the public mind for three to four decades. Government is unreliable, inefficient, and raises your taxes. It can't solve the problem and it costs too much when it tries. It is also immoral because government handouts make people dependent and take away their incentive to work.
Private enterprise is both effective and moral, and strengthening markets generates wealth for the country as a whole. Therefore, there should be private health accounts with private insurance plans and no constraints on the authorization or provision of health care or prescription drugs. Further, there should be caps on lawsuits that might threaten the income of profit-maximizing health care authorizers.
Then, the liberal/progresive argument:
The progressive argument is straightforward and based on progressive views of morality and government: the values of empathy and responsibility, and the view that health care is a matter of fundamental protection - like the army or the police. Therefore, everyone deserves health care, and it is the moral responsibility of our government to ensure that it is available to all of us, its citizens. Profit should never interfere with the delivery of health care. And since health insurance profits are based on the denial of care, health care should not be a matter of profit-maximizing insurance. This progressive worldview tilts progressives toward single-payer or medicare-for-all plans. The problem for progressives is they have not been getting their moral perspective or their view of health care as government protection out in public effectively - even though polls suggest that a majority of the public seems to already agree with their position.
Then he summarizes how the neo-liberal argument-although agreeing with the liberal/progressive argument on the basics-ends up colluding with the conservative argument:
The sticky part of the health care debate occurs when neoliberals accept certain modified versions of profit-maximizing insurance programs with technocratic fixes of the sort described above, and then fail to announce (and repeat) the progressive moral basis of their goals, even though they implicitly agree with them. In so doing, they avoid addressing the fundamental tension between the progressive view that government has a moral mission to provide for the security, including the health security, of all its people and our current profit-maximizing health care system which works only by denying care to over 100 million Americans. Instead, neoliberals focus on rational arguments: how their plans maximize material interests of the lower and middle classes. In the end, neoliberals and conservatives are roughly in the same framing ballpark - maximizing material interests of some group-with progressives left in the bleachers.
As a result, the American people will not be given any real choice between the progressive and conservative moral positions. We will never know if those polls were right, if Americans indeed prefer a progressive alternative. The surrender in advance by the neoliberals means that any "compromise" will start with a capitulation to fundamental conservative values, and will be tilted even more strongly in a conservative direction as negotiations proceed.
What Is To Be Done
Finally, Lakoff concludes with a section on what we, as progressives can and should do:
The most important lesson for progressives is to keep their fundamental moral view front and center in their politics, in their policy deliberations, and in their hearts. Progressive morality is the morality of empathy and responsibility for oneself and others. These moral premises assign to government two roles: protection and empowerment. In the case at hand, we find that our moral foundations require us to recognize our responsibility to our own health and the health of others. Empathy allows us to recognize this responsibility to work together to protect our health and to act upon it. Democratic government is nothing more than an institution of our own making. It is under our control, an institution we charge with the mission of protection and empowerment. Health care security, from the progressive moral stance, becomes a key function of government.
The best way to proceed is to keep what we care the most about at the center of the discussion of health care security. What we care the most about is the actual health and well-being of flesh-and-blood people. Keeping this care in our hearts does not mean that temporary compromises will not be necessary. It means only that we don't begin with compromise.
Every part of our health care system should serve this purpose-health care security for all Americans-first. It comes before private corporate profits. It comes before the political fates of particular candidates or officeholders. Every plan we might concoct or discuss should be measured against this simple standard: does this improve the health care security of all our fellow citizens in concrete ways? Perhaps the most important word in that sentence is "all." System tinkering-eliminating pre-existing condition exclusions, adding mandatory coverage for this or that ailment, subsidizing (substandard) health care for the poor-will make a difference for many, but not for all. It will leave many more people with the kind of dissatisfaction that those with present health insurance have rightly been complaining about. Tinkering like that is more concerned with saving a system that has already failed than it is with the health of a society, indeed, with saving lives.
Note that there's a great deal of flexibility possible within the bounds of what Lakoff advises. That's the nature of thinking in terms of fundamental values and the conceptual systems that spring from them. The more we absorb these fundamental values, attitdudes, and the related conceptual frameworks, the more freely we will be able to improvise as needed without betraying our basic commitments.
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