February 6, 2011 1 Comment
A conversation which started over on Christine’s journal provoked me for several reasons. Admittedly, the fact that this is a bunch of folks who are not in fact Americans and do not in fact live in the US hassling over how we pay for health care bugged me, but this is not my primary concern. I understand how folks who have not become accustomed to the US principles of limited government, Federalism, and freedom of action and expression could take issue with our approach, and so I’ll leave that aside for now, and merely make note of the lack of understanding which is shown by erstwhile fellow travelers among our allies.
The bigger concern I have is a lack of comprehension regarding what it means for something to be a right, or for something to be provided.
In the lexicon of the United States, when we refer to rights, we mean the ability to choose to do something in an unhindered manner. That is, we treat those things which are rights as being sacrosanct from governmental interference (except inasmuch as governmental action is required to prevent actions of third parties from preventing the exercise of those rights.
An example: the first amendment to the US Constitution reads:
Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the Government for a redress of grievances.
Notice that this limits the ability of the government to act, but in no way limits the power of private citizens. For instance, an employee of soft drink manufacturer Foobev is fully able to purchase a full-page ad in the New York Times declaring the Foobev products to be quite inferior to those of the competitor Barbev. However, Foobev is entirely within their rights to terminate said person’s employment immediately and with prejudice.
Further, the aforementioned employee can purchase a forum for his thoughts – but there is neither an obligation on the part of the New York Times to provide such an ad for free, nor to even accept an ad of this type (presuming that Foobev is a major advertiser). The freedom for the employee to exercise his right of speech does not confer an obligation to act on the part of any other person in the country, and it also does not immunize him from the consequences of that exercise.
Now on to my point: in the US, access to health care is considered a right. Hospitals are not permitted to turn away anyone who darkens their door, and must provide service in triage order to all comers regardless of ability to pay. However, a bill is then sent to the individual to pay for services rendered. There is, in the form of medicaid, a payment approach used to assist those who cannot afford regular care, and it more-or-less works, for some value of “works.” In the case of the truly indigent, the costs are eventually written off by the hospital, but the bills will linger in the credit-collection system for years like a dormant basilisk ready to rear its head at the slightest sign of increased income.
As someone who has been through the ringer of private collection services, I can conclusively state that it sucks.
However, it sucks less than the alternatives.
One of the large problems with medicaid is that because the reimbursement rates are lower than commercial rates, doctors attempt to limit the number of medicaid patients they serve, and the highest-end doctors opt out of the medicaid system entirely. In fact, in Washington DC and elsewhere, a large number of doctors have opted entirely out of the insurance system, and moved entirely to fee-for-service medicine. They can do this because they are offering services which you can’t get in the traditional system, or because they really are that good, or because they believe that the traditional system limits their ability to practice medicine at the level they feel it should be practiced.
Why can they do this?
Because they are free agents – they are not employees of the government, and their customers are free to choose to partake of their services or not. There has been occasional discussion of moving to a Canadian-style or UK-style single-payer government-run health care system (this is NOT the plan which was put into effect last year, and has never been seriously considered); however, the flaw in any discussion of this type of system is this: what precisely will compel physicians to accept patients who do not accept insurance now to see patients who receive this government-provided medicine?
Any successful means which could force doctors to participate in this system would amount to a huge taking of their liberty: they would in fact no longer be free agents – they would have to surrender their agency to the government such that they would effectively be transformed from private citizens into indentured servitude.
Now, here in the US, we are not so keen on the idea of servitude – there was a relatively famous war about the issue – so there is a good reason why this doesn’t fly.
Further, if we decided that we wanted to do something with similar affect but via more palatable means (for instance, the government could open health centers in lots of places and fund these via taxes with no out of pocket expense), we would be faced with the additional concern of performing yet another redistributive action onto society. We would, in effect, be taxing everyone to provide a baseline level of care for anyone who didn’t want to pay for something better. Now, a decent moral argument can be made to do just such a thing – but none of the folks who have been passing laws have been making that argument. Worse, we will quickly devolve into two tiers of medicine – that which the government provides, and that which people pay for independently (c.f. the public and private school systems). Even worse, no matter how strong the moral case is, we would run the risk of national bankruptcy by embracing this strategy on a large scale – we already live beyond our means, so deciding that we need to live further beyond our means is hardly a fiscally sound idea.
The verdict is not yet in on the best approach, but partisanship from those who are not in fact vested in the outcome is not a helpful addition to the discourse. The headline of this post is the famous acronym coined by Robert Heinlein in The Moon is a Harsh Mistress: there ain’t no such thing as a free lunch.