A colleague who practices family medicine in

Las Vegas told me about his clinic’s cleaning lady, who came to him in

desperation about her uninsured husband. He had a painful rectal

fistula—a chronically draining infection. Surgery could cure the

condition, but hospitals required him to pay for the procedure in

advance, and, as unskilled laborers, the couple didn’t have the money.

He’d lived in misery for nine months so far. The couple had nowhere to

turn. Neither did the doctor.

The litany of misery was as terrible as it was routine. An internist

in my Ohio home town put me on the phone with an uninsured

fifty-five-year-old tanning-salon owner who’d had a heart attack. She

was now unable to pay the bills for the cardiac stent that saved her and

for the medications that she needs in order to prevent a second heart

attack. Outside Philadelphia, there was a home-care nurse who’d lost her

job when she developed partial paralysis as a result of a rare

autoimmune complication from the flu shot that her employers required

her to get. Then she lost the insurance that paid for the medications

that had been reversing the condition.

Tens of millions of Americans don’t have access to basic care for

prevention and treatment of illness. For decades, there’s been wide

support for universal health care. Finally, with the passage of

Obamacare, two years ago, we did something about it. The law would

provide coverage for people like those my friends told me about, either

through its expansion of Medicaid eligibility or through subsidized

private insurance. Yet the country has remained convulsed by battles

over whether we should implement this plan—or any particular plan. Now

that the Supreme Court has largely upheld Obamacare, it’s tempting to imagine that the battles will subside. There’s reason to think that they won’t.

In 1973, two social scientists, Horst Rittel and Melvin Webber,

defined a class of problems they called “wicked problems.” Wicked

problems are messy, ill-defined, more complex than we fully grasp, and

open to multiple interpretations based on one’s point of view. They are

problems such as poverty, obesity, where to put a new highway—or how to

make sure that people have adequate health care.

They are the opposite of “tame problems,” which can be crisply

defined, completely understood, and fixed through technical solutions.

Tame problems are not necessarily simple—they include putting a man on

the moon or devising a cure for diabetes. They are, however, solvable.

Solutions to tame problems either work or they don’t.

Solutions to wicked problems, by contrast, are only better or worse.

Trade-offs are unavoidable. Unanticipated complications and benefits are

both common. And opportunities to learn by trial and error are limited.

You can’t try a new highway over here and over there; you put it where

you put it. But new issues will arise. Adjustments will be required. No

solution to a wicked problem is ever permanent or wholly satisfying,

which leaves every solution open to easy polemical attack.

Two decades ago, the economist Albert O. Hirschman published a historical study of the opposition to basic social advances; “the rhetoric of intransigence,”

as he put it. He examined the structure of arguments—in the eighteenth

century, against expansions of basic rights, such as freedom of speech,

thought, and religion; in the nineteenth century, against widening the

range of citizens who could vote and participate in government; and, in

the twentieth century, against government-assured minimal levels of

education, economic well-being, and security. In each instance, the

reforms aimed to address deep, pressing, and complex societal

problems—wicked problems, as we might call them. The reforms pursued

straightforward goals but required inherently complicated,

difficult-to-explain means of implementation. And, in each instance,

Hirschman observed, reactionary argument took three basic forms:

perversity, futility, and jeopardy.

The perversity thesis is that the change will not just fail but make

the problem worse. The futility thesis is that the change can’t make a

meaningful difference, and therefore won’t be worth the effort. We hear

both of these lines of argument against the health-care-reform law. By

providing coverage for everyone, it will drive up the system’s costs and

make health care unaffordable for even more people. And, some say,

people can get care in emergency rooms and through charity, so the law

won’t do any real good. In fact, a slew of evidence indicates

otherwise—from the many countries that have both universal coverage

(whether through government or private insurers) and lower per-capita

costs; from the major improvements in health that uninsured Americans

experience when they qualify for Medicare or Medicaid. The reality is unavoidable for anyone who notices what it’s like to be a person who develops illness without insurance.

The jeopardy thesis is that the change will impose unacceptable costs

upon society—that what we lose will be far more precious than what we

gain. This is the sharpest line of attack in the health-care debate.

Obamacare’s critics argue that the law will destroy our economy,

undermine health care for the elderly, dampen innovation, and infringe

on our liberty. Hence their efforts to persuade governors not to

coöperate with the program, Congress not to provide the funds authorized

under the law, and the courts to throw it out altogether.

The rhetoric of intransigence favors extreme predictions, which are

seldom borne out. Troubles do arise, but the reforms evolve, as they

must. Adjustments are made. And, when people are determined to succeed,

progress generally happens. The reality of trying to solve a wicked

problem is that action of any kind presents risks and uncertainties. Yet

so does inaction. All that leaders can do is weigh the possibilities as

best they can and find a way forward.

They must want to make the effort, however. That’s a key factor. The

major social advances of the past three centuries have required widening

our sphere of moral inclusion. During the nineteenth century, for

instance, most American leaders believed in a right to vote—but not in

extending it to women and black people. Likewise, most American leaders,

regardless of their politics, believe that people’s health-care needs

should be met; they’ve sought to insure that soldiers, the elderly, the

disabled, and children, not to mention themselves, have access to good

care. But many draw their circle of concern narrowly; they continue to

resist the idea that people without adequate insurance are anything like

these deserving others.

And so the fate of the uninsured remains embattled—vulnerable, in

particular, to the maneuvering for political control. The partisan

desire to deny the President success remains powerful. Many levers of

obstruction remain; many hands will be reaching for them.

For all that, the Court’s ruling keeps alive the prospect that our

society will expand its circle of moral concern to include the millions

who now lack insurance. Beneath the intricacies of the Affordable Care

Act lies a simple truth. We are all born frail and mortal—and, in the

course of our lives, we all need health care. Americans are on our way

to recognizing this. If we actually do—now, that would be wicked.