Wednesday, September 02, 2009

Health Care Philosophy

Over on her blog, Megan McArdle argues the philosophy of health care reform with John Holbo. The relevant passage, the Megan takes the time to respond to, is this one from Holbo:

In all seriousness: I realize I have been arguing, for several posts now, at an unsatisfactorily high level of abstraction. (I have seized on the strange case of McArdle because she started it, insisting on talking only at the philosophical level, thereby giving me an excuse to continue in that vein.) But there is a point. Philosophically, there just isn't a case to be made against reform unless it's this simple one: if you don't have any money, you shouldn't be entitled to any medicine. McArdle is very indignant when people accuse her of indifference to the fate of the poor, but - honestly - if it isn't that, then it's nothing. At the philosophical level.

Megan's response is long and detailed, getting in to some of the intricacies of pricing and rationing. But forget about rationing for a minute (as I fear the word has become a bit of a non-liberal boogeyman) and there's a much simpler response to Holbo's charge. Holbo, after all, is accusing all opponents of reform- or should I say, all opponents of these particular reforms- of having nothing to say but poor people shouldn't be entitled to any medicine, a charge that's just patently untrue.

First off, we already provide medical services for the poor, unless, as Will Willkinson so eloquently put it, Medicaid is just something I dreamed. What health care reform is supposedly about is not helping the poor, but helping the middle class and changing the structure by which individuals obtain health care.

But speaking at a philisophical level, let's unpack Holbo's statement and find the truth of it: Not that poor people shouldn't be entitled to any medicine, but that poor people shouldn't be entitled to some medicine. We can dance around it all we want, but proponents of markets and opponents of reform do need to deal with the fact that, yes, in a non-single payer system, the wealthy are going to pay for and receiver better health care than the poor (and better health care than the middle class as well). It sounds terrible to say that there is some level of health care out there that the poor just are not entitled to receive, but when you unpack all the words, what we're talking about really is the difference between capitalism and socialism. And make the argument if that's the argument you'd like to make, but I've yet to see a compelling reason why health care and health care alone, of all the sectors of our economy, is what needs to be socialized.

And speaking at a philisophical level, lets just return to our very basic Rawls (not a libertarian by any means) for a moment, where economic inequalities ought to be arranged to the benefit the worst off. If the choice we were given was between a single-payer system where everyone received the equivalent of X dollars per year of medical care and a market system in which the poor received vouchers or some other form of subsides to the equivalent of 2X dollars per year, the better system would be the market system with the subsides for the poor. You can play all the philisophical games you'd like, but without getting into the practical economics you can't say that philosophy demands rejection of markets and the embrace of any sort of government run system. I suppose there's an argument to be made for pure economic equality, but that's rarely heard any more, nor is it being made in regards to health care.

The real debate on health care that's not going on- as was mentioned in that New York Times piece on choice from last week- is about how ordinary Americans should pay for their health care. Because if you think about it, whatever system we wind up with, be it single-payer, market-based, or anything in between, run-of-the-mill, middle class Americans are going to need to pay for their own health care. Health insurance through your employer is still a benefit, whether or not it's actually taxed as one. The point is, the system would never survive if the rich were forced to subsidize the health care of 80 to 90% of the population and I don't think this is really what anyone is proposing. As I said, right now, we have a system where the masses only indirectly pay for their health care and all the various proposals for health care reform don't change that simple fact. Even a single-payer system wouldn't change the fact that the middle class are going to be paying for their own health care, albeit even more indirectly. Real health care reform would, as much as it was possible, get rid of the middle men and have those already paying for their own care to pay for it more directly.

Much of the real impetus for reform- be it for a public option, all out single-payer care, or even just a health insurance mandate- is in direct opposition to this notion that people should pay for their own care. The discussion is always about the costs to society as a whole and the idea of pooling costs so that, as I've discussed before, the young and healthy can subsidize the middle-aged and less healthy. And this is a big point that opponents of reform tend not to address. Socialized health care as a practical matter is rejected outright, but nothing is done to counter the socialized nature of the discussion. Leaving aside for a moment there's the question of what help to provide for the poor the very sick, why can't the vast majority of middle-class Americans pay individually for health care appropriate to their age and their lifestyle?


Anonymous rose said...

Off topic, sorry:

Cato had a piece today called "Thanks for the Wakeup Call Mr. President", detailing Obama's planned speech to K-6 students across the country coming up on the 8th and Arne Duncan's preparation instructions. Instructions included “reading books about Barack Obama” and schools are told to ask students how president Obama will “inspire” them in his speech before he gives it, and how they were inspired after Obama has spoken." That's the short version.

This deserves people's attention. It is disturbing.

3:33 PM  
Blogger lonely libertarian said...

Red Eye covered the story last night and Greg Gutfeld pointed out how much the media would have freaked out if this same sort of thing had happened under George Bush.

3:39 PM  

Post a Comment

<< Home