It may seem a little odd to have left this basic question for the fourth installment in this series, but should Americans have health insurance or should every individual or every family be on its own? Should medical care always be paid for out-of-pocket?
P.O.L. writes:
I believe that a poor child should not have access to an M.R.I. if his family can't afford it. It is not that I wish any harm on the child, but I don't believe that his family's indigence justifies stealing from others to pay for it (a.k.a. taxation) or enslaving the physician. The problems in the system we have now are largely the product of government intervention. The employer-centered model is encouraged by excluding employer-paid insurance premiums from employees' taxable income. This tax incentive means people over insure. If people had to bear the full cost of the medical services they received they would buy less, thus reducing demand and, hence, price. They would likely also insure only for high cost conditions and not routine examinations. I would guess that a large part of the administrative cost results from dealing with insurance companies for routine matters. If people insured rationally, the primary care physician would largely be dealing in cash transactions that wouldn't involve insurance companies at all. If a gas station had to arrange with my auto insurance company for payment every time I filled my tank, gas would be more expensive too.
Let's leave aside any moral considerations and simply think about the economic ramifications of this argument. I think that it is certainly true that "if people had to bear the full cost of the medical services they received they would buy less, thus reducing demand and, hence, price." That point seems inescapable. Very few of us could afford surgery or an extended stay in the hospital. Intensive care would be out of the question. How many of us could afford to pay for outpatient care like chemotherapy or cancer radiation treatments? Or even a stress test? Demand for these services would certainly drop, almost to the vanishing point. Advanced medical services would be available, if at all, only to the very wealthy. For the rest of us, we would simply have to bear our afflictions as best we could and die at our appointed time, which would be considerably moved up on the calendar.
I think that the point is driven home by P.O.L.'s own example. A simple M.R.I. upon a child who has had severe headaches or a seizure could identify a condition which is easily treated and cured, and that child could grow to adulthood and become a productive member of society. Without access to medical care, children's injuries and diseases will go untreated, resulting in disability or early death. Those of our children lucky enough to live to maturity would suffer the same fate as adults unless they earn not just a good living but a great one.
I don't think that this would be an efficient method of purchasing and distributing health care. I don't think that a country that left every individual and every family to its own resources in procuring health care would be able to produce goods and services at the rate that other countries could. Such a country would be at a competitive disadvantage in the world economy. The first sign might be when other countries are able to produce automobiles at lower cost because those other countries have found a less costly yet more effective method of keeping their workers healthy and productive.
I am serious about putting moral considerations aside in this discussion. We too often tend to focus on the intent and motivations of others rather than upon the consequences of our own preferred policies. We have a tendency to engage in namecalling and characterization instead of reasoned analysis. I also wish that in discussing this matter we could ignore party affiliation and ideology. This is not a sporting event where we cheer for our team to win because we identify with that group – when they win that makes us a winner. ("I'm from Ohio, Michigan sucks!") Health care reform is perhaps even more important than Ohio State-Michigan! In the end, what matters more to you: whether your political party controls the government, or the state of your health and the health of your family? Let's assume that we are all imperfect people but that we all want to make our society better, and let's discuss whether the ideas that are on the table will accomplish that.
Next week I'll begin to compare the various competing plans for health care financing reform to each other. In the meantime, here is an excellent website maintained by the Kaiser Foundation comparing the elements of the leading proposals for reform.
{ 2 comments… read them below or add one }
You seem to suggest that I argued that people should not insure themselves. I made no such argument. In fact, I said people likely would insure against high-cost conditions. It is my belief that the questions of whether to insure and how much to insure are decisions that should be left to each individual to decide and not imposed upon him or her through the coercive powers of the state. If people want to insure themselves, they should be free to do so. If they choose not to insure themselves, they should not have to. Even if people want to insure themselves for routine exams and insurers are willing to go along, they should be allowed to do so (although I do not understand the concept of insuring for a cost that is virtually certain to be incurred). I think individuals are in the best position to evaluate their own medical risks, life circumstances, and resources to tailor medical coverage that best fits their needs.
You also suggest that only the wealthy would have access to advanced medical services. I don't understand why you think that. The average worker today has medical coverage. If an employer ceased paying premiums, most employees would demand a pay increase to offset the loss of benefit. The employee could then decide how they wanted to spend the additional money. I would expect most people to continue to use all or a part of their increased wages to pay for medical coverage.
I don't think you can really put moral considerations aside completely. Even if you evaluate the situation in economic terms, you are still making a moral decision about what we should value more: economic competitiveness, individual liberty, or some other notion of societal good. I don't agree with your economic competitiveness argument, but even if I did, I don't believe America's economic competitiveness is a value that would justify the deprivations of property and liberty that individuals suffer under mandated government health care programs.
To illustrate the existence of the moral question, let's use the poor child who cannot afford an MRI as an example. I would note that it does indeed suck to be poor. The poor have limited resources and have to make difficult decisions about how to use them, often having sacrifice things that would greatly improve the quality of their lives or possibly even extend their lives. But, this is how I evaluate the child's situation. I first ask myself, "Would it be OK for the child's father to go to someone's house and by using force threaten to throw the person into a prison cell for a term of years if they did not turn over money to pay for the MRI?" To me, the answer to that is no. I then ask, "Would it be OK for the child's father to access that person's bank account without his or her consent and take money out to pay for the MRI?" To that, I again answer no. Finally, I ask, "Would it make a difference in my response to the previous two questions if the father employed agents of the state to do it on his behalf rather than doing it himself?" I again say no because I fundamentally don't see a difference. I understand that other people might answer differently. Some may think that the dire condition of the child justifies the father's actions. Others may think that the fact that the imprimatur of the state makes right that which might otherwise be wrong. In any case, whatever decision is reached, I think the ultimate judgment involves moral considerations.
RE: "I am serious about putting moral considerations aside in this discussion."
Without moral considerations we may as well limit the discussion to the natural selection processes of the animal kingdom. Survival of the fittest. Thinning the herd by abandoning those too feeble to keep up. Lick your wound to keep it clean and if it doesn't heal, wander off into the brush to die quietly.
If you remove moral considerations, all that should be left is logic. Either equally offer all available treatment options to the general population or discontinue use of that option. Either hold the entire population accountable for it's lifestyle or eliminate all forms of restrictions on foods, drugs, and tobacco. Either tax the population equally to provide a uniform healthcare system or standardize healthcare insurance premiums and coverages for anyone earning a paycheck and say 'sorry about your luck' to anyone not working. Either shift 'defense' spending to medical/pharma research or stop searching for new treatments for conditions that have either current treatments or are 'uncureable'. There are no guarantees that the next million or billion spent on 'research' will eliminate the common cold, cancer, or mental illness.
As you said, we are all imperfect. That also means that some of us will just be less/more healthy than others and will live and die more or less painfully than others.