Cold War philosophy believes that market thinking—rational choice procedures, sometimes augmented by game theory—constitutes the whole of rationality. Any other mental activity is either rational choice in some sort of disguise, or is irrational. Everything therefore has to be organized on market principles.
It is the word “everything” in that last sentence that shows we are dealing with a philosophy, and not a mere theory or ideology. As Kant pointed out more than once, you can’t base universal judgments on experience, so you have to have some sort of a priori argument for them—and that’s philosophical.
Cold War philosophy has had a particularly touchy history in the case of medicine. One thing which readers of Scare’s Chapter Six may notice is the way in which public health disappeared from the writings and concerns of Raymond B. Allen around the time the Cold War began. When Allen was still running medical schools (i.e. until 1946), he believed that the great challenge in medical care was no longer treating individual illnesses—that, he thought, was pretty well in hand—but setting up social systems for delivery of health care and, indeed of health itself, to Americans. His argument was explicitly pragmatic: health was assumed to be a good and the issue was how to deliver it in a systematic way.
As Scare shows, when Allen became a Cold War academic administrator, the pragmatism disappeared. Of course, he no longer had occasion to write specifically on medical issues, but in general he adopted the Cold War philosophical view that science aims at truth (or confirmation) alone. Allen’s turn was part of a broader, but tacit, cultural development in which American medicine came to focus on solving the health problems of individuals, rather than of communities (this turn can be summed up in a single word: “Flint”). This was only, as the Germans say, konsequent. It followed from the view that medicine has to be, basically, a market exchange between a (sick) consumer and medical science.
Medical care is one place where experience pretty clearly refutes Cold War philosophy: you have only to step across the Canadian border to see that single payer systems produce better health more efficiently than the traditional American panoply of insurance plans. But the Canadian plan, like the French and the British… does not allow for market choice. They are all single payer plans, and so appear to Cold War philosophy as irrational.
There are many reasons why market rationality does not apply very well to medicine. One obvious one is the lack of information available to the chooser: unless you are a doctor yourself, you don’t have a clue which treatments will be best for you. Most people rely on their doctors to provide this information, but this leads to a regress: how do you know your doctor is right? There are various web sites for evaluating medical practitioners—but how do you know which to trust? And so on.
Another is that consumers of medical care are highly constrained: they passionately want to have the most effective possible treatment, and are loathe to consider alternatives that may be less costly or inconvenient but also less effective. Since the more effective treatments often cost more than the alternatives, they opt for those. Cost even becomes, in their state of imperfect information, a proxy for effectiveness.
The Republican model for health care seeks to substitute market forces for governmental action in medical insurance: privately purchased insurance should replace Obamacare, with its mandate to purchase insurance from an array of government-approved plans. (Single payer schemes are of course out of the question: There is no alternative in a single payer system, and so rational choice among insurance plans is impossible.)
The problem with this is that no one has formulated a credible alternative to Obamacare (except,of course, single-payer). Republicans hate the mandate, but unless healthy (and often young) people are forced to buy insurance, the pool will be too expensive and costs will skyrocket. They also hate the government constraints on medical insurance plans, but removing them would lead to a proliferation of junk insurance (high deductibles and many exclusions, often hidden by needlessly complex prose). And let us not forget that Obamacare was arrived at by two very different paths: Barack Obama’s in 2009, and Mitt Romney’s in 2006. Alternatives, like unicorns, will be hard to find.
But on the premises of Cold War philosophy, they have to exist, because if setting a national medical plan is to be a rational exercise it has to come about through a choice among alternatives. Hence, a touching faith among Republicans: there is, somehow, an alternative to Obamacare’s mandate and governmental role—it just hasn’t been found yet. And hence “repeal and delay:” end Obamacare now and then wait for the alternative to show up, as it surely–surely–will.
But if an alternative to Obamacare which did away with the mandate and other government constraints were possible, one would think it would have been found by now. The Republican faith in a future alternative to Obamacare derives, not from experience, but from Cold War philosophy. And faith in a philosophy is a dubious thing.