Friday, Politico.com editor Fred Barbash posed this question to “Arena” contributors: “Does the ongoing debate about healthcare reform reflect a :"kind of culture war” that can be traced to a “fundamental difference in world views?”
Barbash then pointed to a thought-provoking piece by Bill Bishop, titled “Health Debate Runs Along Familiar Lines” which was published on Politico.com in March. http://dyn.politico.com/printstory.cfm?uuid=CD297E8F-18FE-70B2-A882654169CEAC57
Bishop, who is the co-author of “The Big Sort: Why the Clustering of Like-Minded America Is Tearing Us Apart,” argues that “The health care discussion reveals that the country is still divided along lines drawn more than 100 years ago. . . divisions in the country were never about specific issues . . .. They were about ways of looking at this world (and the next), and those century-old differences are now shaping the health care discussion.”
Bishop frames the age-old religious debate this way: “Do you get to heaven by your good works, by what you do for your brothers and sisters on Earth? Or do you find salvation by your individual relationship with God? Does the world get better through public acts or private ones?
“When Sen. Jim DeMint (R-S.C.) said recently that ‘this health care issue s D-Day for freedom in America’ he was talking from one side of this division. President Barack Obama says, ‘I am my brother’s keeper.’ That’s the view from the other bank.
“This isn’t a policy issue or a disagreement about strategy,” Bishop adds. “It is a fundamental difference in worldview. It’s a division in what people expect out of life, and it’s been part of this country for more than 100 years.”
He points out that “Religious historian Martin Marty described the late 19th-century split between what he called private and public Protestants. Private Protestants promoted individual salvation and personal morality.
By contrast, Bishop exatplains that “Public Protestants saw riots by workers [fighting for unions] as a failure of society. Pubic Protestants promoted the minimum wage and the 8-hour days . . . Public Protestants believed that either the needs of people would be met, or the kingdom of God [on earth] would never arrive. ‘Either society confronted social injustice or society would fall,’ wrote one prominent public Protestant. ‘It is either a revival of social religion or the deluge.’”
There were “two types of Christianity” alive in the country, Bishop adds, “Congregationalist minister Josiah Strong wrote in 1913. ‘Their difference is one of spirit, aim, point of view, comprehensiveness. The one is individualist; the other is social.’”
In my response http://www.politico.com/arena/perm/Maggie_Mahar_642F5006-E55B-4901-8D36-2340F6213AE3.html I tried to connect the dots between Private vs. Public Protestants and today’s progressives and conservatives.
Regular readers may not find many surprises in my comment on healthcare reform, but I suspect many would enjoy Bishop Paul Moore’s spectacular analysis (which I quote in the second paragraph of my comment), explaining where former president George W. Bush fits in the Private vs. Public Protestant debate.
Facinating! Yes- World views including the most powerful ones like religious views are largley influenced by issues surrounding mortality. They are definitely in play here on health care?
In my own view much of the conservative world view revolves around their being terrified of death which finds its way into many of their political positions.
If there is no literal heaven we better help each other out here and now for example.
Dr. Rick Lippin
Southampton,Pa
The world-view question is an important part of the challenge. Living in the buckle of the Bible Belt I see it first-hand with my family, friends and neighbors. (Conflating politics and religion is one of my pet peeves but don’t get me started…)
But there is another dynamic that I have not seen mentioned anywhere. I think most insured people have no true idea what health care really costs and don’t perceive health care inflation as any more of a problem than ordinary inflation. Those of us who have done our homework know better, but trying to wake up an insured person (or Medicare beneficiary, for that matter) is like talking to a wall.
In my younger days I recall studying Abraham Maslow and Frederick Herzberg, two big names in the olden days of industrial psychology. Maslow talked about a hierarchy of needs in all our lives, and Herzberg identified and classified them into two general categories that he labeled “motivator” and “hygeine” factors.
A subject that big cannot be summarized in a comment thread, but not to put too fine a point on it (1.) over the last thirty or forty years the majority of Americans have stopped thinking of health care and insurance as two distinct realities and (2.) an appreciation for what has become an undifferentiated phenomenon which was once a “motivator” has become a “hygiene” factor (Herzberg’s terms).
Even those of us who know better often use the terms “insurance” and “health care” interchangeably. The president’s recent change of locution reflects this muddy thinking.
Back when the Blues were born (I learned this from your book, Maggie) employees saw group insurance as a great way to stay our of financial trouble. In the case of auto insurance, once the consumer understands the potential consequences of driving uninsured he may complain about the cost, but will also pay the premium rather than drive uninsured. So group insurance was eagerly embraced by employees as a motivating factor in their jobs. Employers who wanted to kidnap good people from competitors lured them away with group insurance and it worked… until it lost its sparkle and became part of everyone’s expectation in the marketplace.
Little by little, aided and abetted by tax and accounting policies, the costs of health care have grown like cancer. And the insured class and their employers have fed the monster as it has grown. Employers pass the costs along in the marketplace and employees are shielded from those cost increases. As an employee, I can’t allow myself to fret when corporate costs increase. As long as I do a good job painting the widget or smiling through the telephone, delivering good customer service, I’m doing my part.
So we have come to the point that a group medical plan is no more a motivator than covered parking, reliable heating and air conditioning in the work space, and annual awards ceremonies. (I worked five years for a provider with five hospitals and I think the ceremonies were better motivators than the employee health care plan.) And those insured by the plans don’t have a clue how much their medical care rally costs.
And why should they? Here is a real example I got from talking with my sister last night. She and her husband are self-employed and have been for years. (You don’t have to tell them about the mess we’re in.) Waiting to see a doctor she overheard another patient complaining about his costs. “Last year my co-pay was ten dollars a visit and I had dental and vision coverage. But this year they dropped dental and vision coverage and my co-pay went up to twenty dollars. I don’t know what we’re gonna do.” Clearly, the guy had no idea about the magnitude of the problem and how very little he was contributing to it’s resolution.
For employers and their TPA’s it’s what I call “mushroom management of employees.” Keep them in the dark cover them with shit and harvest them when they’re ripe. And it seems to be working. Between employee ignorance, the lies and distortions spewing from ignorant gasbags, and pusillanimous politicians afraid to tell their constituents the truth, I fear for the passage of any meaningful health care AND insurance reforms.
indeed. if there’s no heaven, there’s some logic to the Lippin position of helping each other out now. but a very substantial group of Americans — perhaps a majority — think there is a heaven. Telling them they’re wrong probably isn’t a terribly effective strategy here.
Dr Rick, Hootsbuddy, Jim
Dr. Rick –Yes, I agree that an enormous fear of death is key to the American psyche. I think this is because we put so much emphasis on the individual–and so the diappearnce of an individual from the globe seems an apocalytic and terrifying event.
In cultures where the community is more important than the individual, death is not so frightening. I will die–but my community will still be there. . .
I also think many women fear death less because we reproduce– I will disappear, but my children, their children and their children will be here. I also think that many women are more firmly grounded in nature’s cycles.
George Eliot (actaully Mary Anne Evans) once said: “I am glad to know that the sunglight will be here when I no longer am.”
I feel that way about nature when I look at the sky on a beautiful day.
See also my comment to Jim re “heaven”
Hootsbuddy–
I agree that Americans don’t really take in how much our over-priced inefficient heatlhcare system is costing all of us.
As you say, employers pass the cost on in the marketplace, etc.
But here’s the thing– reserach show that even when patients have high out-of-pocket costs (are required to pay 40 percent of the cost of a $60,000 surgery or a $100,000
cancer drug, for instance, they want that drug, and will do whatever they have to do –borrow, take a loan against their home.
They may complain that the drug-maker is charging to much, but they will rarely question the surgeon’s fees
Nor will they question how much the hospital spent on 5 operating room so that all of the surgeons can operate at the time they prefer (8 a.m.) keeping all five rooms busy in the morning, and empty for the rest of the day.
I could go on . .
My point is simply that even when keenly aware of the cost, Americans believe that because it is so expensive, they must be getting the best care in the world. They believe that their doctor is top-drawer because he charges more. They brag about this: “OF course, Dr. Lewis is expensive, but it’s worth it. I trust him.”
This makes it very, very difficult to squeeze the waste out of health care. Notice that the Blue Dogs want to blindly raise Medicare fees for rural providers (their constituents) across the board, without regard to whether some fees are to high, (while others are too low) or some pay for services that provide no benefit to the patient.
Jim–
On Americans believing in heaven, I have to wonder. . .
Whey then are we so afraid of death? Whatever happened to the idea of the “good death”–and finally meeting your maker?
I’m not at all certain that the majority of Americans believe in heaven.
Though I agree, telling people there is no after-life isn’t going to help the cause of healthcare reform.
But I do think that one should tell people — rather than worrying about where we’ll end up after we die, we should concentrate on helping each other in this world–and then probably things will work out. . .
Maggie Mahar wrote:
“I also think many women fear death less because we reproduce– I will disappear, but my children, their children and their children will be here. I also think that many women are more firmly grounded in nature’s cycles.”
I always find it interesting the arrogance of statements like these sound to those of us couples (like my wife and I) who were not able to have children (got married too late in life). I would like to hear the reaction to your statement if you gave it in front of a group of couples suffering infertility as you spoke of the reasons for why needed health care reform is failing.
I recently came across your blog and have been reading along. I thought I would leave my first comment. I don’t know what to say except that I have enjoyed reading. Nice blog. I will keep visiting this blog very often.
Susan
http://ovarianpain.net
Susan–
Welcome–and thanks very much.
If worldview does impact how we see the health care debate (or any issue, for that matter), and undoubtedly it does, then the question for those who favor progressive solutions is how we react and adapt our message to those with different worldviews? We’re not going to change one’s fundamental worldview, so we have to help people understand our message within their own context.
The slope from “the good death” to Soylent Green is slippery indeed.
Thomas Sowell also figured this out, perhaps more fundamentally (A Conflict of Visions) — an old book I read in 1988.
The Conservative view sees human nature as more dangerous, the world as more adversarial, thus likes heavier “defense” spending, more separation from the “social”, etc.
The Liberal view sees human nature as more naturally cooperative, etc., and thus seeks more “diplomacy” and more “social” cooperation, etc.
I’ve included some material on this basic difference in my coming book, which itself is about broader issues.
Sheldon, Hal,Doc 99
Sheldon “adapting our message” sounds a lot like “packaging it in a way that people won’t understand that we’re talkign about asking them to make sacrifices to help others –i.e. pay more in taxes to help the poor.”
Once you begin “packaging” in that way, you’ve already lost the moral authority needed to create laws for a just society..
You’re no longer on the high ground.
As the Washington Post’s Pearlstein wrote recently: “Health reform is a test of whether this country can function once again as a civil society . . . Whether we can trust ourselves to embrace the big, important changes that require everyone to give up something in order to make everyone better off.”
People who insist “I’m not my brother’s keeper” will never Voluntarily agree to give up something in order to make everyone better off.
That’s why, rather than passing the hat, we have tax laws–and try to enforce them. That’s why we have to pass legisation that mandates that everyone buy insurance–no free riders, waiting until they are sick to buy a policy (knowing that under health reform, insurers will have to sell the a policy at the same price they charge healthy people.)
That’s what “good government” does– it creates rules for a “civil society”–despite the fact that some in that society are less than civil, and less than kind.
Hal —
It strikes me that people get the government (and society) that they believe in. This is what they deserve.
Some people even say that we get the after-life we believe in.
Doc 99– I’m not sure I understand what you’re saying.
I’m catching up to one of my favorite blogs in delayed fashion but still want to weigh in with a comment.
This post, along with most of the reader comments, are just what I needed to process and sort out the seemingly bizarre behavior at recent Health Care Town Hall forums. Thank you all.
As a nurse and a long-time fundamental reform activist I’m excited that we’re finally in the throes of national health system reform, but how it’s going has got me worried–and discouraged too, I’ll admit.
None of the opposition shenanigans (to put it mildly) come as a surprise after what I’ve witnessed up-close as an activist working for state level reform here in Massachusetts for 20 years and observing the 1993-94 Clinton reform effort.
The multifaceted morality-based motivators that are clearly at play in shaping the public’s response to reform efforts are intertwined with the money-driven motivators that are also omnipresent in the political and policy making processes that we somewhat blithely call “health care reform”. Of course most of these financial motives are assiduously kept behind the scenes. George Lakoff’s work has been instructive for understanding the culture wars dimension of our politics, for those who might want to check him out.
To risk stating the obvious, the moral dimensions of the money-driven dynamics of health system reform are huge. Here in Massachusetts a large group of health care professionals (over 2,000, in fact) sought to raise this issue as a way to shape the public discourse on and direction of health care reform. They were signatories to a piece titled “A Call To Action: For Our Patients, Not For Profits”. This piece was published in JAMA in 1997. We’re still trying to have a constructive impact on reform.
For those who’d like to read A Call To Action: For Our Patients, Not For Profits, you can find the article at
http://massdefendhealthcare.org
And why should they? Here is a real example I got from talking with my sister last night.