Some questions, because they are flawed questions, can only yield flawed answers. Why did the better side lose the Civil War? Why haven’t people recognized the artistic incompetence of The Beatles? Isn’t it about time the president outlawed all unethical behavior? Because these questions are all predicated on significant misunderstandings (ethical, aesthetic, and procedural) they yield invalid answers.
Today’s health care debate has been, and, I suspect, will continue to be, unproductive because it continues to be driven by a flawed but politically expeditious question: Don’t all Americans have the civil right to comprehensive health insurance?
I count four flaws in this question.
The evocative language of civil rights is driving much of the health care debate.
In the context of American civic discourse there is no more powerful way of driving forward an agenda item. In describing it as a civil rights issue, health insurance is quietly woven into a marvelous American story of liberty: the struggle for independence, abolition of slavery, women’s suffrage, and desegregation.
Placing health insurance into this story quickly generates a mandate for the government, as a matter of ethical principle, to take up the task of securing the right. By placing the federal government at the center of necessary action, swift federal legislation becomes a virtual necessity to redress discrimination. All this, of course, depends on the conviction that health insurance is a civil right like the right to life; but how can that be when rights are the a priori natural realities of human persons and not contextual, prudential judgments?
If health care is not a right then much political talk today is parasitic on genuine past and present civil rights concerns. (see Bernie Sanders, “Health Care is a Right,” The Huffington Post, June 8, 2009). So, is it a right?
The central role of consumer-based competitive markets in creating quality, affordable health care is absent from the question above.
It is absent, I suspect, because its presence would nudge the federal government out of the center of a proposed system. Meanwhile, the potent vocabulary of civil rights makes economic prudence a secondary concern, and keeps the government as Rights-Protector at the center of the discussion. Civil rights language then becomes a way of sidestepping central economic questions.
Economics should be at the center of the health care debate. Competition really does lead to affordability and demand does produce supply. When many people want and will pay for a good or service, businesses will seek to provide it at an affordable price. When several businesses enter a sector of the market they create competition, and in an effort to make their business profitable by attracting more customers, goods and services become ever more affordable. Right?
The question above puts the federal government at the center of the debate.
Someone might say, the market has already failed to produce quality, affordable health care, and so the government must step into the void. But that is a highly debatable point. The history of American health care has created an injudicious, wasteful consumer of goods and services called Medicare. In the world of consumer-based markets, Medicare acts as a gigantic customer, which skews our market. When a senior takes an eye exam and Medicare pays for it, it is Medicare and not the patient who is the customer of the service. Here is a crucial reason why health care is unaffordable.
When one outsized customer as a matter of policy out-buys the good or service in question, it weakens the downward pull on prices that competitive markets produce. Why does the eye exam cost so much? One reason (and there are others) is because the eye exam doesn’t exist in the real world of competitive markets. Think of it this way: if the six coffee shops in Wayne had all of us for customers, but also in addition one undiscriminating, multi-trillionaire tycoon who bought more coffee than all of us combined at whatever price the six shops claimed coffee costs these days, we wouldn’t see any downward pull on prices. As consumers, we’d have virtually no influence on the swelling cost of coffee. But if that trillionaire went away, it would be supply and demand that would drive down prices creating both profit for the shops and affordability for us.
Comprehensive health insurance is the irrational framework for our entire health care debate.
With the ballooning cost of health care, who can afford to pay for an eye exam or a basic check-up or, for that matter, a trip to the ER to have a cut stitched up without health insurance? What many have concluded from the high cost of basic procedures is that what is needed is more help in paying for them: government-provided, single payer, comprehensive health insurance. But there is a gap in this logic.
In the September issue of the Atlantic Monthly, David Goodhill (a Democrat) compared auto-insurance with health insurance, provoking the telling observation that auto-insurance covers only catastrophes like car wrecks, but not gas, car washes, and routine service. If the latter were covered by insurance, their costs would surely rise because the insurer would add new and unnecessary paperwork, labor, and process to these routine goods and services. Rather, subject to the forces of the market, these goods and services live in a dynamic space between profitability and affordability, while protection against catastrophic events is provided by auto-insurance.
The medical insurance industry (with the federal government playing the role of enabler) has turned most health care goods and services into prohibitively expensive luxuries, the prices being absurdly high because of lack of competition (think Medicare). Why not subject routine medical goods and services to the forces of the market to make them more affordable, while leaving catastrophic events and the safety net for the poor to some revised version of a health insurance system—even one that’s government run? In other words, delete “comprehensive” and we might get somewhere. No?
I’m just asking because I think better questions might yield better answers, and that might make for an all-together healthier system.