A friend and mentor, former US Rep. Sam Coppersmith (D-AZ), recently wrote: "Individuals, acting rationally, help make a 'free market' in health care impractical, expensive, and inefficient." (This, and all of Sam's regular columns for the East Valley Tribune in suburban Phoenix can be read on his blog, Liberal Desert.)
Embedded in his analysis is the marketplace metaphor. This places health care in the same category as used cars (an example Sam uses to explain asymmetrical information). Such a metaphor makes conversations about choice, risk, profit, comparative advantage, etc., inevitable. One cannot have a marketplace in which everyone is treated equally for the general good. There is a reason there isn't a free market for police or fire protection or for the US military ("I'm sorry Mr. Loge, I see your subscription to Frank's Fire and Autobody only covers the first 40 minutes of carnage and we're already at minute 43. May I have your credit card please?"..."It's OK men, let the Canadian invaders take New Haven, their last check bounced – but protect Hamden at all costs, they have Premium Invader Repellent Coverage!")
Metaphors are important because they guide thought and ultimately action. Metaphors define the boundaries of a conversation or debate, they serve as intellectual curbs on the road.
In their 2000 article "The Meaning and Measure of Policy Metaphors" in The American Political Science Review, Mark Schlesinger and Richard R. Lau write that several metaphors have explained health care in America over the last 200 years: "community obligation," "marketable commodity," "professional service," "societal right," and "social benefits." Each metaphor implies certain outcomes and responsibilities; each metaphor inevitably guides the arguments – and their outcomes. Schlesinger and Lau find that both the "least sophisticated members of the public" (their term) and policy elites use the same metaphors, and that those metaphors guide their thinking and behavior.
If health care is a "community obligation," then it is up to the local community to provide a locally-acceptable level of care to those who can't afford it. If health care is a "right," then the government has to ensure we all get it (and probably get the same amounts of it). If it is a "commodity in the marketplace," then success is defined by profits (few companies that make high quality products on which they lose money are called successful).
What, then, is an appropriate health care metaphor? That depends on what the candidate wants to promote. The critical point (for my point) is that the selection of the metaphor should follow the selection of the policy. If a candidate uses a marketplace metaphor, the details about rights will be lost. If a candidate talks about rights then details of market forces won't be heard.
