Earlier today, the inimitable Mike Kole suggested that “it is inherently unjust to require someone else to pay for another’s expenses- for any reason.” This, in turn, brought to mind my Mom’s timeless admonition that “life isn’t fair.”
So, we’re talking about health care. At the moment, we have a system that flat doesn’t work very well. As a group, we pay more dollars toward health care and get worse outcomes than countries who have taken a more honestly socialized approach to paying for medicine. I’ve said it before, but I’ll mention it again, that health care doesn’t seem to respond well to market forces. For starters, you’re often effectively negotiating with a gun to your head. Even if you could get all the data, assessing it is a specialized skill and average citizens can’t effectively analyze the information for themselves. And, brother, you aren’t getting all the data. Call up your local hospital and ask them if you could, pretty please, get a copy of their charge master. That won’t happen. Lack of transparency, lack of knowledge, and lack of negotiating leverage puts sand in the gears of the market machinery. It’s just not very good at allocating resources efficiently in this situation.
O.k., so the current system sucks. Can’t the government screw it up even worse? All things are possible, but we do trust these people with nuclear weapons, perhaps a little faith is warranted.
Back to Mr. Kole’s proposition – it’s just not fair to take from one person to pay for the needs of another. And here is where my utilitarian impulses really go to war with my libertarian impulses. As I age, for some reason, the utilitarian is winning most of the ties. Utilitarianism, at its root, is the idea that the “right” course of action is that which will result in the greatest good for the greatest number. This isn’t necessarily at odds with libertarianism in a good many situations because, it seems, simply letting people alone to go about their business — so long as it doesn’t break the bones or pick the pockets of someone else — *does* result in the greatest good for the greatest number.
To me, therefore, liberty is a means, not an end in itself. The extreme example is suggesting that the government has no business imposing speed limits or rules about stopping and going on red and green lights respectively. Sometimes liberty has to be restrained in the interest of a well-ordered society in a way that tends to maximize the well-being of its citizens. That said, there is plenty of haggling to be done over the point at which order should yield to liberty. We — at least those of us outside of the private prison industry — don’t want to be a nation of prisoners, no matter how orderly a place that might be.
But what about taking my money to pay for someone else’s health care? Isn’t that unfair? Maybe. But, it’s unfair that some people contract diseases through no fault of their own. It’s unfair that people who live near heavy industrial plants have more respiratory problems than those who do not. It’s unfair that some people are not born to families who can give them educational resources that give them an edge in earning power when they grow up. It’s unfair that some people are born smarter than others. Life is rife with inequities. If we can fix some of them, but choose not to, we’d probably better have a reason. Economic inequality, to an extent, powers our economic engine. People working for their lives and people working to chase dreams of riches can be very industrious; particularly when compared to people who won’t fall behind if they don’t work hard and won’t get ahead if they do work hard. And the industriousness achieved through the carrot of wealth and the stick of poverty tends to result in increased prosperity overall.
I can even see calling for society to turn its back on the obese, diabetic smoker who ignored opportunities and information telling him to eat right, exercise, and stop smoking while choosing not to work and pissing away his resources on cigarettes, booze, and electronics instead of saving or paying for health care. Even if this strawman were representative of those who are sick without health care in this country, we could only save money if we steeled ourselves to simply letting such people die. Letting their health deteriorate with lack of care until they ultimately wandered into an emergency room on death’s door and then providing them with catastrophic health care services would end up being more expensive than providing care at some earlier stage.
In any case, I don’t think this is representative of the kind of people who can’t afford health care. The human body can fail a person in an amazing variety of ways. And I have my suspicion that environmental factors — namely the pollutants we breathe and processed chemicals we eat and drink — are leading to ever more exotic breakdowns. Other countries have shown that these risks can be managed without turning those countries into unlivable hellholes. We’re Americans. Maybe we can get the job done too.
Well said.
Your straw man is more common that you think, though. But I support the ounce of prevention even in the most extreme cases. I just took on a new patient today who fits this description. He had two recent hospitalizations and I’ve finished patching him up a second time. Diabetes way out of control, despite having a physician. He asked if I could do better for him, and I had to answer yes. Man, I hated to say yes. Some of these folks come in just sicker than hell, too heavy for a CT scan, too heavy for an MRI, surgeon doesn’t want them, etc. It’s really hard work, and harrowing too when it starts to go bad. Then you get this little Medicaid check, and oh well. But I do think I’ve developed a rapport with this man, and he’s more motivated, and I’ll make sure we’re motivated on my end, and hopefully the every-four-weeks hospital admissions won’t be necessary. Young man. A lot of years left to be sick if something doesn’t change.
We also need to get a little more comfortable with the end of life. A lot of money is often spent changing a 90 year old’s death date by a few days.
But for the vast majority in the middle, dumb luck, environment, and genes are the largest determiners of health. They get a diagnosis, and that thing, among other things, is a big financial anchor forever.
I really don’t trust anybody with nuclear weapons, especially people who want them, but that’s another topic isn’t it.
Perhaps if we weren’t spending billions maintaining, dismantling, designing, and protecting our enormous nuclear arsenal we would have a little extra cash to help out diabetics, the elderly, etc.
This is one of the very best analyses of this argument that I have seen. I, too, tend to be very libertarian, and I believe in markets, but as you point out, medical care is not an area in which markets (willing buyer, willing seller, both in possession of all relevant information)work. I also don’t think many of the people resisting reform understand how much our current, highly dysfunctional non-system burdens and distorts the American economy, and how much it burdens our global competitiveness.
The govt is already very heavily involved in health care– most importantly, through its subsidy of health insurance (not to mention a range of other, important but better understood factors). Arguably, the govt is the primary cause of our current problems in this market. In any case, it is not helpful to see contemporary American health care as primarily market-driven.
If one wants more govt in health care/insurance, why not run 50 state experiments rather than risking everything on one, grand, federal experiment?
And a lot of political ads get created when the Gov’ment says Grampa is old and needs to die. I don’t think our political system has the balls to let Grampa die without spending billions to delay his death by a few days.
Eric, I like your 50-state experiment idea. What I don’t know is how to get them to do it.
Political pressure, I suppose! This is another underlying reason for a state-based approach: Are we more or less likely to be able to influence things in Indy or DC?
Some potential downsides, off the top of my head:
#Less risk pooling
#Less leverage
#Less control over multi-state corporations
#Tough to pass once, let alone 50 times and then a 51st time once you settle on the “right” solution.
And, in any event, the states haven’t -by and large- taken the initiative despite health care having been on the political radar for the last 60 years or so.
-The gains in economies to scale are miniscule or non-existent– unless perhaps if you’re talking about the Dakotas (and they could go together if it was a big gain).
-Economic leverage: same.
-Political leverage: unless you’re a statist, you’re not a fan.
-Less control over multi-state: True, but the feds seem able to extend themselves over multi-state activities right now!
-Tough to pass: Is that necessarily a bad thing?
-The “right” solution: If a single, right solution existed– and if the federal govt and powerful interest groups would take us there– then yes. Both of those are difficult assumptions.
-Some states have tried– and have struggled. Shouldn’t this be a lesson to us? Nahh, let’s ignore that…
Beyond the lack of advantages of a federal approach, do you have any concerns about applying a relatively uniform solution to a complex problem and a heterogeneous population? Any expectations of inefficiencies from a program run by the federal government? Any concerns about interest groups negatively influencing public policy?
Looks like we’re done with the state vs. federal point.
It should also be noted– to Sheila and Doug’s point– that info problems do make it more challenging than normal to come up with optimal market solutions. That said, it should also be noted that the current health care/insurance market is VERY far from a free market system.
Eric,
What about just making all health insurance companies non-profit and eliminating the pre-existing condition rule?
Maybe a “Truth in insurance” document, much like the “truth in lending” document, that must go with every policy that spells out in common language what the buyer is actually getting?
I’m not saying heavy regulation, but more just keeping people from being screwed by the massive system that is in place. Much like a mortgage, health insurance is something that a normal person can’t completely comprehend all of what they are agreeing to. A simple, common summary of benefits would be helpful.
Jason, good questions…a few thoughts:
First, insurance would be a lot less complex if it was true insurance, covering only (relatively) rare, catastrophic events. Think auto or fire insurance. In contrast, today’s health coverage ranges from allergy shots to cancer– and would be equivalent to car insurance for door dings and oil changes. (And what a mess that would be!)
Second, pre-existing conditions are tricky. Part of it would be solved by getting rid of the portability problem and the connection of health insurance to employment. (We get health insurance through the firm since its bought with tax-free dollars– a subsidy that turns out to be, by far, the #1 problem in this arena.)
Part of it is a business question: from the perspective of the insurance company, we would have a tendency to get insurance when we get the big conditions. This is akin to requesting fire insurance as your house catches on fire. Not cool.
But given that we’ve decided to take money from some people to provide various things for less-fortunate people (and far more often, to redistribute a lot of money to those in interest groups), some sort of govt coverage of these things is probably inevitable, especially in any transition period.
I definitely agree that you can’t blame insurers for not wanting to sign up a house for insurance while it’s in the middle of burning down. On the other hand, to continue the metaphor, the fire department won’t stand by and just let it burn; they’ll put it out whether you can pay or not.
A person with a pre-existing condition is like the burning house. An insurer can’t make money insuring a known loss after the fact. But the public is not inclined to just let the fire rage, either. (The metaphor seems extendable too — obese smokers might be likened to people who build their house out of flammable material and refuse to buy smoke detectors.)