11/19/2009 05:12 am ET Updated May 25, 2011

A Failure of Citizenship and the Health Care Debacle

If a nation expects to be ignorant and free, in a state of civilization, it expects what never was and never will be.

Thomas Jefferson penned those words in an early debate on the role of government in education.  He went on to say:  “Universal education is the most effective means of preserving democracy and good government.”

Nobody would accuse Jefferson of being a Communist, particularly because Marx would not be born for another 40 years.  Yet here was one of our Founding Fathers advocating a “government takeover” of education.

Jefferson also advocated a “government takeover” of the military by relieving the militia with “regulars” during time of war.  In his first inaugural address, he said somewhat subtly:

“A well-disciplined militia, our best reliance in peace and for the first moments of war till regulars may relieve them, I deem [one of] the essential principles of our Government, and consequently [one of] those which ought to shape its administration.”

Jefferson was no extreme radical in the cabal of staid Founders; his ideas were mainstream among his brethren.  The idea that our central government can and rightfully should “take over” certain critical functions in society is embedded in the very foundation of our country and codified in our Constitution.  This should put in context the idea that our government can have at least some role in guaranteeing access to basic health care for all Americans.  We are after all the only democracy that does not offer such basic care to all citizens.

But here we run into a terrible problem.  The health care debate cannot be understood in historic context because many Americans have never heard of Thomas Jefferson.  Extrapolating from state surveys, only 14% of American high school students can name who wrote the Declaration of Independence.   Nearly 75% do not know that George Washington was our first president.  More than 90% could not pass the exam given to immigrants who wish to become citizens.   No wonder that Jay Leno has so much material for his Jay Walking segment.  We can say that our educational system has failed when the vast majority of American students do not know enough to pass an exam to qualify as American citizens.

We cannot expect to be ignorant and free, and this reality is manifesting itself clearly in the health care debate.  Our health care system is destroying us from within, threatening our economy and our future.  Yet with our incredible ignorance of our history, we lose critical perspective and the ability to have a rational discussion of government’s proper role in solving the problem.  Any reasonable debate is drowned out with absurd accusations of socialism and Communism and outright fabrications and fear mongering about death panels and a government takeover.  Ignorance leads to comments like “keep your government hands of my Medicare.”  The debate is not founded in reality, reason or history.  Ironically, many of those who claim to defend the Constitution most fiercely have never read the document.  That lack of familiarity with our founding document gives rise to the bizarre and false notions that universal health care is Communist or in some way counter to the governing principles of this country.

The “public option” of offering Americans the ability to choose an insurance program backed by the U.S. government is nothing close to a government takeover of health care, and in fact is well within the ideals of government contemplated by our Founding Fathers.  But we cannot possibly know that if we do not even know the names of any of our Founding Fathers!

And just as we are ignorant of our history, we ignore basic facts about our health care system.  The biggest lie perpetrated by opponents of reform is that the United States has “the best health care system in the world.”  We do not, and not by a long shot.  People fear “rationing” without recognizing that the worst kind goes on right now.  Insurance companies dictate what surgeries, diagnostic tests, preventative care and curative procedures can be done, taking the decision out of the hands of your doctors.  For those with no insurance, health care is rationed by wealth.  Those who can afford good care get all that is available; those who cannot often die.  Close to 25,000 Americans die each year from treatable medical conditions because they lacked access to proper care – that is rationing by any definition.

Even with all of that rationing, our health care system is the most expensive in the world.  We spend twice as much per capita as any other wealthy democracy.  We devote nearly 17.6% of our GDP to health care compared to the next most expensive systems in Canada and Germany (10.6%) and Switzerland (10.4%). 

We are not getting a good return on our investment.  We are not healthier and do not receive better health care.  Compared to Australia, Canada, Germany, New Zealand, and the United Kingdom, the United States ranks last or next-to-last in the five primary dimensions of a properly functioning health care system:  quality, access, efficiency, equity and quality of life.  The United States is the only developed country in the world that does not offer universal health care.  We are ranked 26th in infant mortality among industrialized nations. We are ranked 24th in healthy life expectancy.  That means the citizens in 23 other countries on average live longer healthier lives than Americans.  That hardly makes us the best in the world.  Our overall health care system is ranked 37th globally, behind Malta, Colombia and Oman.  We have some of the lowest satisfaction with our system, with only 40% approving, compared to 91% in Denmark and 81% in Finland.  The United States is the only country in the world that has medical bankruptcies. 

This is the “best health care system in the world” that people are defending.  This is the system that people fear will be reformed.

Much fear of reform is based on ignorance of our history and the willful ignoring of inconvenient facts that do not conform to political or religious convictions.  Any claim that our health care system is the best is factually incorrect, proven wrong across multiple dimensions.  But with that basic falsehood as a premise for discussion, the debate gets derailed before a dialogue can even begin.  Why reform something that is already the best?  With unfounded fears of socialism as a basis for debate, we eschew our history and focus attention away from potential solutions.

So I offer a radical proposal to move forward, recognizing that ignorance is a fundamental constraint to progress.  Since one must be a citizen to vote in this country, all voters should be required to demonstrate the same knowledge necessary to become a citizen.  All potential voters should be required to correctly answer the same questions as those on the naturalization test prior to registering to vote. There would be no limit on how many times the test could be taken until completed satisfactorily.  This test requirement would ensure that every voter has a minimum basic understanding of our form of government and the principles on which the country was founded.  The quality of political discourse would almost certainly improve.

Why should the accident of birth confer upon someone the privilege of voting?  We are not an aristocracy in which our bloodline determines our fate.  Why should voting be any different?  Voting should be seen as a privilege rather than as a consequence of where one is born.  Voting should be a right earned rather than conferred by fate or the accident of citizenship.  Voting should be a right that is gained upon acquiring basic knowledge about the country in which one is voting. 

I am not demanding much.  Here are some sample questions from the naturalization test: 

  • Name one branch of government.
  • What is the highest court in the United States?
  • Why does the flag have thirteen stripes?
  • Name one author of the Federalist Papers.
  • What do we call the first ten amendments to the Constitution?


Some may object at this point that my proposal is discriminatory, favoring the wealthy over the poor (and therefore Republicans over Democrats).  But that is not the case; those high school surveys prove that ignorance of our history knows no socioeconomic boundaries.  Anecdotally, as a trivial aside, note that many of those folks on Jay Walking fall into the category of White middle class.  My proposal would in fact level the playing field because anybody, regardless of social status, can easily obtain the naturalization test in multiple languages and study the provided answers.  The language debate is a false one; knowledge of our history and government is more important than the language in which it is acquired.  The only qualifications for voting would be citizenship and enough motivation to learn the simple outlines of our history and about our form of government, knowledge necessary to make minimally informed decisions.  I strongly suspect that an electorate better versed in our history would not be yelling “socialist” and “government takeover” every time the president mentions a public option.

But yes, my proposal does discriminate – against those who do not know enough to qualify as citizens.  That is fully consistent with the fact that we currently discriminate between citizens and non-citizens, only allowing the former to vote.  Since we comfortably make that distinction, we should apply the knowledge test universally.

We are witnessing a tragic, horrific, pathetic decline in basic education.  We are producing a generation unaware of even the most basic truths of our history.  Almost half of our students do not even know that the United States borders the Atlantic Ocean on the east coast.  The majority cannot name how many branches of government we have.  We could not possibly expect a student demonstrating such colossal ignorance to evaluate the subtleties of government’s proper role in providing access to health care. Instead we can expect a knee-jerk reaction, like “socialism!”

Of course many who oppose health care reform are well aware of our history and are familiar with the Constitution; many are highly educated.  Well-informed opposition to reform can come from many sources, including legitimate concerns about cost, efficiency and fairness.  Open discussion is welcome.  These are complex issues with no easy or painless answers.  But widespread ignorance is skewing the national debate, preventing us from exploring reasonable solutions. 

Ignorance has now become an existential threat.  We must take dramatic action to combat the trend.  All citizens whether recently naturalized or descendents of Mayflower pilgrims, rich or poor, must demonstrate they know the basics about the United States before being allowed to vote.  We cannot expect to be both ignorant and free.  And time is running out.