The central problem with the current health care debate is the ideological stalemate created by each party’s conception of health care as a product or service purchased by or provided to individual households. Republicans (at least those writing the various proposals being rushed to the Senate floor for immediate up or down votes) see health care like all products and services – most efficiently and widely provided by a competitive market. Democrats evidence more sensitivity to the enormous inequalities both in our income distribution and in the distribution of health-related goods and services generated by our current “system” and call for substantial subsidies for the poor and genetically disadvantaged.

Republicans want to incentivize individual responsibility by creating more efficient markets for health-related goods and services. Democrats want to solve market failures through public subsidies. “Pick your poison,” each side says. “You can’t have it both ways.”

This ideological rigidity is the inevitable result of failing to see health care in its full human reality. Consider two examples. In one, I stumble over a piece of firewood that I had not yet stacked, fall and break my arm. I get myself to an emergency room, perhaps by calling an ambulance. Over the next several months, I will require the services of a number of medical professionals and a wide variety of products to return to “normal” health.

In the second example, I pick up a grandson at his school, play tag and generally horse around with him and several of his mates at the school playground and walk him back to his house. Several days later, I am sniffling, sneezing and develop a fever. I become increasingly sick, but have no clear idea what caused my ill health or what to do about it.

In the first case, the cause of the problem, the responsibility for causing it and the means to solve it are all quite clear. And the most efficient way to pay for the goods and services required to effect the solution is equally clear – out of my pocket, either directly or through an insurance contract I may have obtained.

In the second case, all clarity about cause, effect and responsibility dissolves. My behavior immediately preceding the bout of ill health is virtually the same behavior I have undertaken on scores of occasions stretching back over several years. Did I acquire an airborne “germ” from my grandson or one of his friends? Did I acquire some virus from scraping my hand on the wood chips of the playground? Did I get some “uncommon” cold from a source entirely unrelated to my after-school adventures? Who knows?

The second case brings to light an entirely different formulation of health care, one not best understood in terms of markets and market subsidies. This second formulation is health care as infrastructure, as goods and services serving not individual but community needs. Health – like transportation, education, internet access – is something that when effectively provided to all, benefits all. Internet gurus have long touted the “network effect” – the more people on it, the more valuable it is to everyone. The same is true of health – the healthier everyone in my community, the healthier I will be.

This is not to say that all health is community health. People in healthy communities can and will get cancer and other diseases. It is, rather, to say that public health, the health of humans as communities (collections of people) is as important to overall health as individual health, the health of people (collections of cells and bodily systems). And it is also to say that no single human social system (markets or infrastructure) can by itself address the full range of human health needs. We need both.

We need responsible people carefully considering how their work, family and recreational behaviors affect their individual well-being. And we need them to face and bear, at least to some degree, the personal and financial consequences of unhealthy behavior. We also need research institutions constantly gathering and analyzing community health outcomes and connecting to public media and educational institutions to bring a regular stream of best practices into the consciousness of all members of society.

Until our political debate can come to fully understand, accept and address this dual definition of health care, it will continue to be irrelevant to our lives as we actually live them.

Charles Lawton, Ph.D., is a consulting economist. He can be contacted at:

[email protected]