For the past seven months, Americans have watched and weighed in as Congress considered the continued existence of the Affordable Care Act (ACA). Last Thursday, the Trump administration announced that the government would stop subsidizing insurers for making premiums and deductibles more affordable for low-income customers.
Most of the discussion to date has been about whether these plans are good for families, and if so, which ones. But what if insurance had another value, beyond protecting individuals from financial and health risks? What if it was good for democracy?
Here’s how we’ve talked about insurance up to now
This year’s debates about health-care reform have produced some memorable sound bites. In March, House Speaker Paul D. Ryan (R-Wis.) said: “The fatal conceit of Obamacare is that ‘we’re just going to make everybody buy our health insurance at the federal government level.’ … The people who are healthy pay for the people who are sick. It’s not working, and that’s why it’s in a death spiral.” In September, Trump economic adviser Stephen Moore told CNBC’s John Harwood that “people want insurance for their own families, not other people’s.”
Ryan and Moore’s harshest critics suggested that neither of them understand how health insurance works. But their comments reveal something else: Their baseline assumption is that individuals evaluate the worth of health insurance based on self-interest and personal economic calculus.
It’s true. People do want health insurance to protect themselves and their families, and oftentimes we articulate this in financial terms. Congressional Democrats have appealed to this idea in opposing ACA repeal. Their refrain is that families shouldn’t go bankrupt if someone becomes sick and that no one should die because they cannot afford medical coverage. They argue that keeping the ACA, or making it more inclusive through reforms, will protect individuals and families medically and financially.
These are important considerations, as any person who has ever lived on a budget and needed to go to the hospital knows. But they’re not the only ones.
There’s also an argument for the broad value of insurance for democracy
Daniel Defoe — a 17th- and 18th-century businessman and writer best known for his novel “Robinson Crusoe” — argued that insurance is a public good.
In An Essay Upon Projects (1679), Defoe evaluates (among other ideas) “friendly societies,” mutual aid associations formed by ordinary people. In these voluntary organizations, members paid fees to create a pool of assistance that would be available to any member who needed it. Friendly societies provided, in a word, insurance — fire insurance, livestock insurance, life insurance and health insurance.
Defoe generally approves. He argues that friendly societies have outsized potential to help protect members from the “miseries … and distresses” the future might hold — and to make life better for everyone. He even suggests these insurance pools may even harbor the potential for world peace.
Why such a bold claim?
Defoe’s argument for the positive potential of friendly societies depends on two values they embody: solidarity and equity.
Friendly societies promote solidarity because they encourage interdependence among individuals. Members regularly paid dues and fees into a common pool, with no knowledge of whether they would ever draw on them as individuals, on the off-chance they would need help themselves one day.
Defoe focuses on the larger picture, though. He stresses that these societies were a social project, one that offered security to the group (or to use his word, “mankind”) through solidarity. The political value of friendly societies is that they bonded people together against a risky future.
Defoe also identifies equity as a core principle of the friendly society, although a challenging one to achieve. He worries about whether friendly societies were organized fairly and shares ideas for promoting equity within them. He suggests, for example, that people in high-risk professions form their own insurance pools instead of banding together with people in lower-risk jobs.
But Defoe still praises friendly societies for at least trying to live up to the principle of equity. He says, “To argue against the lawfulness of [friendly societies] would be to cry down common equity as well as charity: for it is kind that my neighbor should relieve me if I fall into distress or decay, so it is but equal he should do so if I agreed to have done the same for him.” When we make such solidaristic commitments to our fellow citizens, we commit to treating them equitably. Defoe saw social insurance as one way to inject more equity into society.
Of course, “friendly societies” are a far cry from vast insurance companies
Defoe’s ideas about friendly societies might seem out of step with the concerns of 21st-century Americans. He was talking about small voluntary groups, and most Americans today buy insurance from large, for-profit corporations. Even those who turn to social welfare programs like Medicare and Medicaid interact with large bureaucracies. Is his defense of insurance as a relationship of solidarity and equity still applicable to us?
In a mass democracy like the United States, solidarity and equity are hard values to realize, but they are ones we still hold. We can see that, for example, in what Tennessean Jessi Bohon said when she stood up in a town hall in February and argued for the ACA’s individual mandate: “As a Christian, my whole philosophy in life is to pull up the unfortunate. So the individual mandate, that’s what it does. The healthy people pull up the sick.” She supported her position using the value of solidarity. (As an aside, Bohon’s link between the mandate and Christian charity would have made sense to Defoe, too.)
We’ve also seen appeals to equity. For example, when Planned Parenthood supported passage of the ACA, they did so based on the principle of fairness, arguing that by subsidizing birth control and mammograms it corrected a gender imbalance in health care costs. Similarly, when Sen. Lindsay O. Graham (R-S.C.) reflected on why the ACA should be replaced, he said that it didn’t recognize that different states have very different needs. He argued it isn’t equitable.
These scattered comments point us toward a conversation about the social value of insurance. Although politicians and policymakers will continue to appeal to individual self-interest as they try to gain support for their reforms, they might also wish to explain how their plans embody democracy’s social goods: solidarity, equity and fairness.
Emily Nacol is an assistant professor of political science at the University of Toronto. She is the author of An Age of Risk: Politics and Economy in Early Modern Britain (Princeton University Press, 2016).
