NRO has now posted the second of its online debates between yours truly and Chris Hayes. We discussed the notion of a right to healthcare. The question of rights is immensely difficult, as Chris would agree. In our brief discussion, we barely scratched the surface of the relevant issues. And because I’m pretty far from a trained political philosopher, I’m wary of wading too deeply into this territory. But why not?

My basic argument, rather crude in hindsight though it does reflect my gut instincts, is that a right to healthcare implies a right to health. Consider the ongoing debate concerning the cost and efficacy of medical care. If decency demands that the state provide medical care, this inevitably raises the following question: if the state is left holding the bag, so to speak, surely the state can demand that one lead a basically healthy life, hence the ever-expanding imperatives of public health. A right to healthcare implies a right to health, or rather an entitlement to health. If this isn’t a recipe for an unlimited state, what is?

The Polish sociologist Zygmunt Bauman coined a useful phrase: “the gardening state.” One of Bauman’s central ideas was that the advent of modernity in Europe was fundamentally about the surrender of freedom for security. A world that seemed chaotic and crazed and unpredictable was rendered well-ordered and sane and predictable through the emergence of a hierarchical bureaucracy that offered interpretive order. James Scott’s brilliant Seeing Like a State referred to projects of legibility and simplification — when they state encountered things it could not understand, it rendered them legible, even if that meant running roughshod over valuable informal arrangements. The nationalization of language in France is an excellent example of what both Bauman and Scott are talking about, and the same goes for the projects of ethnographic ordering undertaken by Soviet anthropologists in the 1920s. Ethnicities were literally invented as a means of managing “difficult” populations. The gardening state has to be weeded, occasionally.

Yet the gardening metaphor also has an attractive aspect, particularly to those of a social democratic bent: it implies that the state exists to help humans flourish by gently pruning and liberally applying compost and all the other things that conscientious gardeners do. In Gwendolyn Mink’s The Wages of Motherhood, she describes the various ways in which the New Deal was informed by social workers who aimed to transform family life by encouraging male breadwinner families, discouraging female entry into the workforce, etc. This is an example of the gardening state at its most ambitious and intrusive.

The critique of the gardening state is normally associated with the post-modern left, though of course it has had considerable resonance with libertarians of all stripes. But it also underlies a number of conservative causes, including Ward Connerly’s Racial Privacy Initiative, an effort to ban the classification of individuals in the State of California by race or ethnicity. (Interestingly, republican France has a strong taboo against racial classification, though the country’s dirigiste tradition has certainly involved heavy intervention in the intimate sphere, as reflected in the école maternelle system, etc.) And of course discomfort with the gardening state has a lot to do with conservative objections to sin taxes on high-fructose corn syrup, a notion that has grown increasingly popular on the left and the right. 

Here’s a worthwhile question: once you socialize pensions, as in Social Security, must you effectively socialize reproduction? The pay-as-you-go structure of Social Security relies on increasing productivity and a growing population. Should we thus embrace pro-natalist policies to keep the program viable? That was the provocative argument advanced by my friend and colleague Phil Longman. I’m a fan of certain pro-natalist policies, and I’m aware of how pro-natalism strikes many as troublingly illiberal. Because falling birthrates are a sufficiently serious public goods problem, if not in the United States than certainly elsewhere in other advanced economies, I’m willing to put those qualms to the side. It is important, however, to set limits with the dangers of the gardening state in mind, hence my concerns about the idea of healthcare as a right.

As Chris noted in the debate, providers are obligated to provide emergency treatment to those who seek it. This is a kind of right. And on prudential grounds, we need to pursue a variety of measures — structural reforms to our healthcare financing regime, some of which I’ve gestured at below; public health campaigns, etc. — but I’m wary of following the logic of the gardening state to its conclusion. 

In True Security, a fantastic if slightly dated book by Michael Graetz and Jerry Mashaw, the authors outline a healthcare reform that is dedicated to basic economic security: no family will go bankrupt due to an economic shock caused by a serious illness. This strikes me as an attractive, limited ideal. It still begs the question of whether socialization can ever end there. But we’re more likely to keep the role of state limited if we eschew rights-talk and instead think of the state’s role in healthcare as fundamentally about managing economic risk.

Less abstraction to come, I promise. I blame the online debates!