In his comments on the Sommers et al. study, Philip Klein raises an important question about the ACA and freedom. This study reported that when RomneyCare insured the uninsured in Massachusetts, it saved lives. The Massachusetts study is discussed by Austin here and here, Adrianna here; and me here.
Klein notes that many conservatives have shifted their views toward accepting that being insured is good for your health, which Austin comments on here. As Michael Cannon notes, that’s good but it might not be not good enough. It’s important to work out whether the good effects of insuring people, net of any harms, are worth the costs. This is absolutely the right debate to have, from an economic efficiency point of view.
Klein points out that we also need to consider the effects of the ACA on human freedom.
It’s important to note, however, that [the Sommers study] doesn’t answer the broader philosophical questions concerning whether the federal government has a role in guaranteeing access to health coverage or whether the goal of expanding insurance justifies infringing on personal liberty.
Klein’s right: concerns about freedom motivate much of the opposition to and support of the Affordable Care Act. Klein is asserting—and I strongly agree—that economic efficiency is not the only metric of policy virtue. We care about other things too, freedom being one but also equity, among others.
Liberty takes two basic forms: negative and positive. Negative liberty concerns the absence of constraints, impediments, or interference. For instance, a person has freedom of property—understood as a negative liberty—if others may not take her property or interfere with her use of it. In contrast, positive liberty concerns the power or capacity to do as one chooses, or the power to act autonomously. A person has freedom of property—understood as a positive liberty—if she actually owns and controls some property. Bill Gates and I both have the negative liberty to own a yacht, but only Gates can afford a yacht. He has the power to do something I cannot, and in that respect, he is more free.
There are better examples of positive freedom. Suppose you were illiterate but gained the power to read, or were disabled but had your mobility restored by surgery. These new capabilities would vastly expand what you could do and the experiences that you could have. People who have been through these experiences describe themselves as becoming free. Positive freedom is, in one influential account, the space of possible human functioning afforded by our capabilities.
You are not necessarily forced to choose between negative or positive freedom. For example, gay liberation involved both the abolition of laws restricting same-sex behavior (expansion of negative freedom) and the evolution of cultural and normative space that enabled people to experience love and participate in romantic partnerships (expansion of positive freedom).
But sometimes there is a tradeoff. For example, child labor laws restrict the negative freedom of both employers and children themselves. Child labor, however, endangers children’s health and may prevent them from getting an education. Child labor laws allowed children to develop their full capabilities and therefore represented an expansion of positive freedom that more than compensated for the infringements on negative freedom.
Klein is, I think, primarily concerned about how the ACA reduces negative liberty, for example by coercing you to buy insurance or by taxing you to subsidize someone else’s insurance. It is uncontroversial that the ACA infringes negative freedom in these ways.
But the ACA might also expand positive freedom. Many people who were excluded from the insurance market because of pre-existing conditions, or who could not afford it, will now have an option to purchase it. For those who have obtained their insurance through their employer, the ACA may give them greater freedom to change jobs or retire. Finally, getting insurance may provide people with access to healthcare that restores their capabilities and prolongs their lives, thereby expanding their positive freedom.
Of course, how much the ACA infringes negative freedom and whether the ACA actually delivers positive freedoms will and should be contested. My point is simply that in assessing how the ACA affects freedom, we need to consider both negative and positive freedom.
(Thanks to Austin for the discussion that prompted this post.)