I Am Hassle, For We Are Many

Starting in the 2012 cycle and in a much more serious way in the 2014 cycle, the Republicans decided that they could square the circle of their conscience clause position on sexual ethics with Democratic #waronwomen attacks through pitching over-the-counter oral contraception. Somewhat surprisingly, the left was not especially enthusiastic about this. The way I’ve been thinking about this is that both liberals and conservatives are addressing hassle. The emerging right-wing position is that the state requiring you to get a doctor’s scrip is unacceptable hassle and some nontrivial number of women have lapses in contraception because they can’t or don’t see their gynecologist, but would have found it easy to visit CVS or Walmart and pay $20 for oral contraception.

The emerging left-wing position has two aspects. The more overt aspect is that some people can’t afford $20 for pills. This is one of those arguments too stupid to put forward credibly, but God bless them, they make the effort. The real aspect to this is that they conceive of contraception as health care and so it is symbolically important that it be covered by insurance as this helps frame it as health care (which is covered by insurance) versus a consumer good (which is out-of-pocket). Economic sociologists call this kind of framing “relational work” (a concept associated w Viviana Zelizer).

However the real left-wing position that is not just #waronwomen “throw the damn incense at the emperor you atavistic theocrat” symbolism, but actually practical is also an issue of hassle. Increasingly health care runs up against limits not of what physicians can do, but “patient compliance” or how diligent patients are at sticking to their treatment. This is most obvious with things like substance abuse or diabetes, which theoretically don’t require medical treatment at all but only lifestyle changes (stop using, go on a diet, etc). However it’s almost impossible to get people to do this, which is why the preferred treatment for morbid obesity is no longer jogging and ricecakes but cutting out most of your stomach and the most promising therapy for opiate/alcohol addiction is Naltrexone.

Similarly, with birth control there is a huge gap between typical use and perfect use. Most forms of birth control, including withdrawal and rhythm, are fairly effective with perfect use, but surprisingly ineffective with typical use because most people are, ahem, boundedly rational. This includes oral contraception, which requires women to take daily pills and which they apparently neglect to do fairly often. Hence the push is to go away from oral contraception and towards more long-term birth control (IUD, NuvaRing, D-P, and sterilization) none of which require people to be especially diligent either during the sex act (like withdrawal or condoms) or on a daily basis (like oral contraception or rhythm). The way you see this in the public debates over Hobby Lobby etc, is distinguishing that they didn’t cover “the most effective forms of birth control” (read: IUD) and which actually are out of reach for out of pocket expense.

So basically, both right and left recognize that the obstacle to effective birth control is hassle. The right’s version is that making it OTC would eliminate the hassle of having to visit the gynecologist to get a scrip. The left’s version is that encouraging a switch from oral contraception to IUD would eliminate the hassle of having to take a pill every morning. There is a philosophical microcosm in that both sides are right about hassle being an obstacle to effective usage, but they emphasize those hassles they find illegitimate. For the right there is a negative liberty issue to the state throwing up the roadblock of a doctor’s visit to getting the pills. To the left your own nature is an obstacle to be solved with technocratically-administrated nudges that obviate the need for individual responsibility on a daily basis and to which you have a positive liberty entitlement.