Another View On Health Care: Maybe We Spend So Much Because We Don’t Want To Ration
As many proponents of the health-care reform being pushed by Obama and the Democrats tell us quite often (including our good friend Jacques), America spends more on health care, expressed as a percentage of GDP, than any other industrialized nation. Michael Kinsley puts a new spin on that stat: maybe it’s because we WANT to, when the alternative is rationing.
Here is a handy-dandy way to determine whether the failure to order some exam or treatment constitutes rationing: If the patient were the president, would he get it? If he’d get it and you wouldn’t, it’s rationing.
It may seem absurd to worry about whether wealthy or well-insured people get every last test and exotic or speculative treatment when millions of Americans have no health insurance and millions more have gaping holes in their coverage. But the well-insured happen to include virtually all the people making the key decisions about health-care reform — members of Congress and their staffs, the White House staff, Washington journalists, and so on. These people’s fears that they would lose the right to “choose my own doctor” (code for getting treatment with all the bells and whistles) helped kill Hillary Clinton’s attempt to reform health care in the early 1990s. Fear of rationing could kill Obamacare for the same reason.
Whether or not this makes sense is a question of taste, not policy.
David Leonhardt of the New York Times recently noted that spending so much on health care squeezes out spending on other things that we might prefer, and that is a form of rationing. On the other hand, the blogger Mickey Kaus argues that it makes perfect sense for a society growing richer (as ours soon will be again, we hope) to spend a growing share of that wealth on improving our health and longevity.
That is what we do as individuals. And what better to spend your money on?
The obvious retort is that it’s not just how much you spend, it’s what you get in return. Are our outcomes better for the increased expenditures? Does our satisfaction and/or longevity reflect the increased tendency to offer gold-plated coverage to those lucky enough to be insured?
I don’t have the answers to those questions, but I won’t pretend they don’t exist. Kinsley’s article, however, poses a great question there at the end that also needs answering…
Isn’t a system that leaves out 1 in 6 people entirely because it’s too expensive essentially the equivalent of de facto rationing, though? Maybe I’m being too cute. Maybe I should just say, isn’t a system that leaves out 1 in 6 people entirely because it’s too expensive at least as bad as, if not worse than, rationing?
More apt to the health care debate are the essential questions buried in Kinsley’s piece:
1. Should I have the exclusive and unabridged right to choose the health care I am to receive and can afford?
2. Am I responsible for anyone’s health care but my own?
My answers are yes and no, respectively. The public debate to date either ignores these questions or implies they are already answered No and Yes, again, respectively. The main argument for both rests on that tired old chestnut of “it’s for the greater good”.
And of the large and growing number of people who can’t afford health care? Or who can’t afford enough health care?
I think you assume too much in presuming that your opponents even frame the issue in the same way as you, let alone what their answers would be.
1) If your insurer won’t pay for Procedure X, having the theoretical “right” to choose to receive X is of little value to you, unless you happen to be in the fortunate situation of being able to pay out-of-pocket for X.
2) Under the proposals under consideration, none of this situation would change, except that you might choose to have the Governement be your insurer, instead of Aetna.
3) Even in countries with a single-payer (in almost all of the cases I’m aware of), one can buy “supplemental” (private) insurance, which covers things not covered in the standard plan. That might well include “Procedure X.”
Through the deductibility of employer-sponsored health insurance, you are already subsidizing my healthcare (and I, yours).
And that’s not even counting Medicare, Medicaid, the VA, Tricare, …
Whether I can afford it or not is my problem. That I am subsidizing already is no argument for continuing and expanding the subsidy.
I guess to be precise I should say that I don’t care if you or anyone else can afford health care and reject the notion that I am responsible for anyone’s care but my own. I have listened carefully for a very long time for an argument that convinces me of my obligation to pay for others, it has not been forthcoming.
I have also learned that my point of view is rare, however right I may consider it to be, and by remaining here in the US admit that I tacitly approve, but that is the trade-off I accept given my belief that anywhere else I might choose to live is, on the whole, worse.
So what do you think society should then do about people who can’t afford health care?
What is your argument that society is responsible for them? From what does this obligation you seem to assert derive? Do you argue from the utilitarian perspective, as Peter Singer does, that we are morally obligated to assist simply because we have the means to do so? Is it to assuage your guilt that some are less well off than you? Are you a signatory to the amorphous, all-encompassing “social contract”? Does your obligation flow from some religious teaching? Is Karma – what goes around comes around – your decisive principle?
I’ve been asking this question and listening for an answer for a long time (I think I am quite a bit older than you) and have yet to hear an answer that stands up to even moderate objective scrutiny. It is clear why I am responsible for myself. It is clear, through my marriage vows and contract, why I am responsible for my spouse. It is clear, through parentage, that I am responsible for my children. It is not clear why I have an obligation for you or anyone else.
I’m genuinely curious to hear your reply, but I will note that this is not part of any other debate on health care of which I am aware – no one asks this question, everyone assumes or accepts that they must do something; which I find fascinating.
[Whoops. I guess this part was meant for this, rather than the other, thread.]
Really?
You don’t care whether the guy sitting next to you on the bus has antibiotic-resistant TB? You don’t care whether the kids in your child’s class are vaccinated? You don’t care whether your co-worker drops dead of a heart attack, in the middle of your joint project?
Sure you do.
To pick an analogy, you subsidize free public education, through high school, for all your neighbours. Not only that, but you mandate that their kids actually attend school.
Why?
One need only look back to what the country was like, before the advent of universal public education. Most of the population was illiterate, fit only for the most menial of occupations, and everyone was poorer, as a result. You can’t run a prosperous, modern industrial society, without an educated workforce. So you are (or ought to be) more than willing to make the public investment in human capital, which is required for you to be able to enjoy the fruits that our technological society provides.
The argument for ensuring that your fellow citizens are not too sick, to be productive members of society, runs pretty much the same way.
Ah, so it is purely out of selfishness then? That is much different than Fargus’s appeal to sympathy.
If his appeal to your sympathy doesn’t move you, I assume an appeal to your self-interest might.
No, Steve, I think I’m asking a subtly different question than you’re answering. I’m not presuming (with the question) that we have the obligation to pay for everyone’s health care. Let’s say we don’t. Then what? Assuming society has some role and some self-interest in its citizens not dying in the streets, what is society to do with its sick and dead since it’s under no obligation to provide for their well-being? Leave them, for other people to get sick as well? Quarantine a section of the country and just dump all the sick people there? I’m genuinely curious what the world you propose would look like.
All these arguments leave out another question; does health care really have to be SO DAMN EXPENSIVE?
What if it is partly or even wholly expensive due to government intrusion? Even if at the end it’s from health insurance companies being venal…the government gives them the cover TO be venal. State insurance boards decide mandates, which can make the coverage cheap or much more expensive.
Is government going to do anything about defensive medicine? Anyone pretending it’s not a big deal is an idiot or an academic who doesnt’ take care of patients in the real world.
What about the very structure of health insurance? A government-put-in-place boondoggle from World War 2, because of businesses looking for a way to get around wage-and-price controls. And another wartime measure left in place.
Medicaid and Medicare distort the market. Government boards that allocate where hospitals can be build and how many MRI’s can be in proximity to each other. That distorts the market.
I can name 40 or 50 or 100 other ways the government screws up the market with intrusion and adds to the enormous cost.
I’m too tired but there are many way to hold down costs even without rationing, and one that gives people say in their own lives. but then, people have to turn around and have some responsibility, and then say, not use the ER for a cheap (i.e. free) pregnancy testing area or a bandaid station for paper cuts (and both are very, very true.)
I want everyone to be able to have decent care, but it is never FREE care, and cannot be. But we can make it more affordable so more can GET care. But they might have to pay SOMETHING, and be partly and reasonably responsible for a portion of it.
Much more to write on the subject. Suffice it to say, govt. should act as a guard over the whole thing, but let entrepreneurship take over.
“I’m genuinely curious what the world you propose would look like.”
As am I, but acknowledge it is no more than a thought experiment and that we will never know. Thanks for the clarification, the self-interest argument is different (than what I read in your previous comment) and valid. We can argue whether the proposed plans would fix the problem of ill people on buses and at work – there are plenty of each today when so few people don’t have health insurance, I doubt that would change much with the implementation of Obamacare.
By what standard is 50 million people, “so few”.
As a percentage of the total. It is even less when you subtract those that choose not to have health insurance. Lesser still when you deduct those that get health care treatment despite having no insurance.
But your argument implies that without health insurance – offered as an argument in favor of some sort of public, national health program – that I will be at greater risk and surrounded by sick individuals and unable to work because of rampant illness among my coworkers. Well, poppycock I say. I am already surrounded by sick people, and my work is affected by the occasional illnesses of my coworkers, both of which are occurring when 90% of the United States population has some form of health insurance, and will continue with or without health insurance for all.
You asked for a rationale for why you should be “responsible for anyone’s health care but my own?” I gave you one.
You are correct in saying that rationale, by itself, does not require universal coverage. 90% (or 75% or whatever) would suffice. The same is true for the parallel rationale for universal public education. There remain, even in our highly industrialized society, plenty of menial jobs. There is (by the same logic) no need to teach those people to read or write.