And there, in a nutshell, is the fundamental ideological and philosophical foundation of the debate on SCHIP and other healthcare issues. But amidst the posturing that sees Bush and his Republican supporters painted as heartless and cruel, which they are, and Democrats as pushing “socialized” medicine, there are a number of assumptions being made that remain unexcavated by media with the attention span of a bumper sticker.

The most basic question to ask, of course, is: Should healthcare be profit-driven or non-profit? It’s a crucial question because whether or not people can make a profit off of something so universally needed as healthcare will influence our views as to the health system’s goals. Obviously, the argument against profit-driven healthcare is that it involves an unavoidable (in principle and in practice) conflict of interest that pits making money vs. patient care. But does this mean that we should jettison profit from the system? I’d say yes, but is it justifiable to advocate non-profit solutions?

Clearing Up Misunderstandings

One of the key misunderstandings implicit in attacks on non-profit healthcare solutions is that non-profit does not mean free. That is, just because healthcare providers don’t make a profit doesn’t mean that they don’t get paid for their services or only get paid peanuts. I’m not saying that this is what opponents of non-profit healthcare really believe, but suggesting that profit doesn’t have to be the arbiter of a system’s value.

A related misunderstanding involves whether non-profit healthcare is socialist or not. If we go down that particular path, it all depends on how “socialism” is defined. Is it the forcible redistribution of wealth – the great conservative fear – or is it, in more benign terms, a system in which the means of production and the goods produced are collectively administered? It may be splitting hairs; then again, dragging in so complicated a beast as socialism and pitting it vs. capitalism brings out a glut of issues that aren’t necessarily important for this discussion. Why? Because of the concept of insurance.

Setting aside the foaming at the mouth the word “insurance” is liable to evoke thanks to insurance companies, the concept of insurance in itself is very sensible; shared costs, shared risks, shared benefits. It is the same concept that underlies all healthcare systems.

Before following through on this point, let’s take a brief detour to consider how pop-conservatives, those staunch opponents of publicly-run healthcare, often turn to the value of community and self-reliance as the solution for handling problems. Mr. Noonan’s recent editorial in praise of the value of cooperative community work in dealing with the fires argued just this point. So I’ll ask this: What greater example of community cooperation, in economic terms, is there than insurance? People pool their resources in preparation of a disaster (Note: taxes are one way of doing this); everyone has equal access to the pool if and when needed. As I said: community.

Private vs. Public

Now we can return to the fact that insurance underlies both public and private conceptions of healthcare and point out that for-profit actually undermines the community aspect. If private corporations run the healthcare system, the people are consumers whose power rests almost solely in their purchasing abilities, a rather limited power given the complexities of American healthcare and the near-monopoly of healthcare corporations. On the other hand, public healthcare involves a very different kind of relationship between the people and the government by virtue of the fact that the government is (supposed to be) the people. Government officials are directly accountable to the people – the community – for how they operate. Through elections, if not direct democracy initiatives, the people have a direct measure of involvement in running the healthcare system. This is, of course, an oversimplification. But I think the point is clear: Pop-conservatives who support community-based initiatives should logically support public healthcare precisely because it does represent the values of community.

Another point often missed is that, assuming that objections to big government stem from individual liberty concerns, government isn’t simply about governing. Insofar as that goes, I would agree that there is too much government, although my proposals for trimming it would be quite different than pop-conservative suggestions. However, government is also about “administration,” a function quite distinct from ruling. While administration can lead to any number of problems – bureaucracy, for one – it also doesn’t entail the same politics of power that come with governing. Conclusion: Government, as administrator, need not be inconsistent with small government principles. Nor does it have to mean less freedom in where a patient gets his or her healthcare. In fact, there is less patient choice under an HMO system than in publicly-run healthcare system like in Canada.

When it comes to SCHIP, it’s one thing to oppose the Democrats’ bill on pragmatic grounds if the bill’s language doesn’t accomplish what it is intended to accomplish. But to dismiss the bill because it allegedly moves away from private medicine is more flimsy ideological posturing than meaningful reasoning. In the meantime, the problem of healthcare in the U.S., both in general and in regards to SCHIP, is no closer to being solved.