What alternative do you propose to universal health care, on the European model? Whatever the problems there, everyone is guaranteed basic care, no one there is bankrupted by medical bills, and everyone seems (by and large) happy with it.Not, perhaps, the most temperately phrased question, but one that deserves a good answer. Zach's answer is a good and honest one, he lists off nine reasons ranging from the legal to the economic to the moral why one would be hesitant about "universal health care". I encourage you to read his post. But always being one to gild the lily (or at least to run on at length) I thought I'd add my own thoughts as well.
How, as a Catholic, can you oppose that?
Just...explain to me why it would be so horrifying to just have universal health care in the United States. Yes it would cost money, and yes, taxes would go up - but so what? Isn't working people not being bankrupted by hospital bills ever again worth a few more percent at tax time? Isn't a society where everyone can go to a doctor when he's sick better than a society where he delays going because then he won't eat or won't be able to buy gas, or can't pay his car payment or whatever?...
The reply, "we ought to care for each other in the community" sounds good - heck, I even agree with it. But the price of modern health care is too much for that kind of community-provided care. I have no idea what an MRI machine costs, but I can't imagine my local parish can fork over than kind of cash....
I'd like to start off by taking the last claim first. Is modern health care so insanely expensive that it's simply unreasonable to expect that a community could pay for its health care bills? Well, our parish is made up of 3,000 families. A large parish, perhaps, but far, far smaller than your average insurance pool. From dealing with small business insurance a while back, I can tell you that $500/mo is a fairly normal-to-low all in cost for insuring a family. So let's say that our parish became a community medical collective and assessed every family to pay $500/mo to meet everyone's health care costs. Let's also say that the parish absolved 1/3 of the families from paying anything, because their incomes were too low. So 2000 families each paid $500/mo into the parish medical fund. How much does that work out to? One million dollars per month. It's amazing what a large number of people all chipping in together can add up to. (As per Matt's rhetorical question: My friend Google tells me that MRI machines cost about one million dollars. A parish could buy one every month.)
But I don't realistically expect to see parish-based health care cooperatives any time soon, so let's leave that aside and answer the more general question: Why are conservatives down on "universal health care" according to the European model? And can one be so as a Catholic?
I think there are a couple main reasons:
1) The need for personal responsibility in providing for others.
In his post, Matt throws around lots of worries that people will be bankrupted in paying for doctor's bills, that people who are sick will have to decide whether to see a doctor or make their car payments, etc. Let's look wider for a moment in order to understand the principle we're bumping up against here. Why do we pay rent or mortgage? Why do we pay for our cars? Why do we pay for clothes and food and books and computers and game systems and beer? Is it fair that someone should have to choose between paying his rent and his car payment? Should he have to decide between his mortgage and food? Why do we pay for things? Why don't we just get all that we need?
Well, there's a practical reason: Fully collective organizations of society have not, historically, worked well at all except in the case of small religious communities.
But there's also a reason rooted in human nature: The natural state of man is one in which he works in order to provide for himself, his family and his community. At a biological level, we are descended from primates that lived in small social groups, and survived on the basis of group members foraging for food and sharing food with their dependants. At a religious level, when Adam and Eve were expelled from the Garden, God told them that from that point on they would live from the sweat of their brows. In both senses, we are meant at a very deep level to provide for ourselves and our families through our own work -- and even though we now live in a far more complex economy our senses of health, self-respect and well-being are directly tied to toiling in order to provide for ourselves and our dependants.
Money is how, in a complex economy with extensive specialization and trade, we pay for each other's time and labor. And so, paying for things with money that we earn through our labor is how we are at a fundamental level meant to provide for ourselves and those who depend on us.
What are the necessities of life? Food, shelter, clothing, medical care, education.
If our purpose and happiness in life consists of providing the necessities for ourselves and our dependants, we should want to see the connection between our labor and the provision of these necessities be as direct as possible. Toiling to provide these for the ones we love if not something that keeps us from being human, it's what makes us human.
Now I am not a radical individualist or libertarian. Most certainly, this does not mean that those who cannot at some point afford shelter should be homeless, that those who cannot afford food should starve, etc. As I kept reiterating above, one of our main duties in life is to provide the necessities for ourselves and "our dependants" and "those we love". As Christ taught us in the story of the Good Samaritan, we are called to love all those around us who are in need. We are social animals and social creatures, and as such we have the natural and moral duty to care for those in our communities who are in need. We absolutely need to have provisions for providing food, housing, clothing and medical care to those who cannot at this time provide it to themselves.
However at the same time, all those who are in any sense able bodied (and able minded) have not only a duty to avoid being a burden to others unnecessarily, but a human need to provide for themselves through their own work. So while we have a human duty to help those currently unable to provide for themselves, we also have a need as a society to help as many people as possible provide for themselves rather than relying upon help. We have a duty to avoid incenting dependency.
Now some readers may be frothing to rejoin: "But what about our current system? People don't pay for health care now. Massive, impersonal insurance companies do." This is true, but only in a sense. After all, the fact that my money resides in a massive impersonal bank (in which it is directly deposited by my employer, and which cashes the checks which I write to pay my bills) does not mean that I do not in fact earn my money and use it to pay for things. Similarly, I know that by holding the job that I currently do, I earn as a form of compensation a certain level of heath coverage, which I provide to my family as the head of my household. Many people do indeed pick our specific jobs and stick with them because they know that the benefits they can thus provide to their families are more valuable than the higher salaries they might be able to get elsewhere.
However, I do agree that our current system is overly indirect. And indeed, I think that some of the inflation of the cost of basic care is the result of that indirectness. As such, I would strongly favor a change to a system in which we pay for basic care more directly (either our of pocket or through small community health care pools -- no larger than a parish) and where we carried insurance only for large medical expenses. However the fact that our current system is very much imperfect does not make me want to adopt a European-style system, which would be a move in the opposite direction from what I believe we need to go in.
2) The need for checks and balances to prevent abuse.
People often complain about insurance companies denying coverage for certain people or certain procedures. That is unquestionably a problem. However, all honest analysts agree that a completely government run system would also involve denying coverage for a number of high expense/high risk procedures. The difference is that under a government system the fox is in charge of guarding the hen house.
I recall hearing a while back about a woman who was approached by Michael Moore for his documentary Sicko. He wanted to interview her about how her insurance had refused to pay for a procedure for her husband. She called the insurance company and said: "Remember that procedure you turned us down on? Michael Moore wants to interview about my experience. Are you sure you don't want to reconsider?" The insurance company, whose profitability relies in part in maintaining a positive public image, caved and paid for the procedure. Similarly, the government routinely (indeed, sometimes unwisely) steps in and rules that certain procedures must be covered by insurance.
All this works because people can switch insurance companies, and because the government regulates insurance companies from an outside perspective. Those checks and balances would be lost in a government run program. The result would probably be (as is currently found in the differences between health in the US and in countries with socialized medicine) that people would get better routine and preventative care under a government system, but those with truly serious illnesses would have worse outcomes than under the current system.
3) Hesitance to make irrevocable change.
Once people start to get something "free" from the government, it's nearly impossible to ever scrap the system and move to a different model. No matter how bad the government system is, it's "free" (as in paid invisibly through paycheck withhold and probably mostly by people richer than you), it's there, and no one wants to deal with the inherent uncertainty of privatizing.
As such, any suggestion of going to a European system for US health care is a suggestion of heading down a one way street. We won't get to change our minds without a total fiscal melt-down or political collapse.
It is, thus, a change I am very, very hesitant to make lightly. I'd happily commit lots of my own personal money or government taxes to a program designed to provide basic healthcare only to those who can't pay for their own first. That would meet the immediate need, without committing us irrevocably to a path about which I have grave doubts.
By proposing instead a full switch to a European-style system, progressives do themselves no favors when it comes to building bridges. (Which is, incidentally, probably why none of the viable Democratic candidates proposed such a program -- no matter how much they might have personally preferred such a move.)
19 comments:
Regarding your last point, Ramesh Ponnuru made a very similar argument. Once the program exists, good luck getting rid of it.
Just a couple of annecdotal comments:
I had a friend, a doctor in the Air Force, who was stationed in England and got to see socialized medicine up close. He said there was no way he'd want to practice medicine in that sort of environment.
When my husband had a rare form of lymphoma I was on an email list of patients and caregivers for that particular disease. Many of the list members who lived in Canada told us that it was difficult for them to get timely treatment. And in fact, if the government run health care system didn't approve a particular treatment, you weren't allowed to get privately even if you were willing to pay for the entire cost of treatment yourself. Many made trips to the U.S. for treatments.
This doesn't sound like the sort of system I'd want to live under. I'd be afraid that in no time at all treatment for the elderly or handicapped would have a low priority or would be denied as not cost effective.
The Blackadder Says:
My problems with universal health care start with the name. No system of health care is really universal, and people are denied care in Europe and Canada as well as in the United States. The term therefore serves less as a description than as a bit of propaganda, like No Child Left Behind, or the Fair Tax.
Whenever I hear Obama or John Edwards or anyone else whine about X million people in this country don't have health insurance, I have a pretty hard time getting worked up. Surely, there are some who are hard off.
But as a twenty-something who worked hard to get a good job with good insurance, I can't help but to notice all of my peers who don't have insurance. There's my brother who sits around playing video games and in his garage band all day. I've got a cousin-in-law who hasn't held a job for six straight months in her entire life. In fact I don't know when the last time she was actually employed was. There's highly academic friends who see work as below them so they string together internships while making enough waitressing to pay the rent.
A lot fewer people would be whining about health care if they followed this simple maxim: Get a freaking job!
The market works well, if we would just let it work. Health care costs would fall dramatically if we would do just four things: (i) allow individuals to take the same tax deduction for health insurance that businesses can already take, (ii) create a national market for health care insurance instead of a bunch of state by state markets, (iii) drop all the mandates that require health insurers to include in their plans things like coverage for depression and birth control and let the market decide what plans should include, (iv) disallow the charging of different rates for the same services to different people.
There are three other little tweaks that would also help: (1) force doctors and hospitals to provide a written menu of their charges for various services, (2) open more medical schools and create more doctors, (3) define a "Basic Plan" that includes a standard and reasonable minimum set of coverages and require all insurers to offer it at whatever price they wish - this allows easy price shopping by consumers.
The problem is that every one of these changes will kill a sacred cow of a very powerful lobbying group: insurers, or doctors, or hospitals, or medical service providers that want their service to be required in all health insurance plans, etc.
The problem is not that health care is somehow immune from market forces. The problem is that powerful lobbying interests have convinced our elected representatives to pass laws that sell us out and make them rich by protecting them from market forces.
Dandelion,
I suspect you're dead on with your suggestions on turning health care into a real market. i, ii, iv and (1) are the ones that have struck me as particularly key in the past.
The other thing that would probably be fairly key would be authorizing RNs (or some other class of less expensive medical personnel) to do basic diagnosis and dispense a limited range of prescriptions -- so that people don't have to pay for 30min with an MD in order to get their kids an anti-biotic for an ear infection.
To address some things briefly:
(i) allow individuals to take the same tax deduction for health insurance that businesses can already take,
Even proponents believe this is more symbolic than real.
(ii) create a national market for health care insurance instead of a bunch of state by state markets
This is more a marketing issue. Differencing in premiums advertised are more reflective of the percentage change allowed in the quoted price and the underwritten price. When we get to hc expenditures per capita, we see a relatively narrow band between the states unlike the quoted premium differenciations you see in many state to state comparisons.
(iii) drop all the mandates that require health insurers to include in their plans things like coverage for depression and birth control and let the market decide what plans should include,
This is more an accounting issue and on the issurance side tends to make things more expensive. In California, insurance premiums went down after earthquake coverage became compulsory, assuming you took both earthquake and homeowners insurance.
(iv) disallow the charging of different rates for the same services to different people.
This is already against the law. Cash discounts for prompt payment are not.
(1) force doctors and hospitals to provide a written menu of their charges for various services
Hospitals are required to do this by law.
(2) open more medical schools and create more doctors
There is no indication that we have a shortage of doctors. Most agree we have too many specialists.
(3) define a "Basic Plan" that includes a standard and reasonable minimum set of coverages and require all insurers to offer it at whatever price they wish - this allows easy price shopping by consumers.
This is presently required by most states. Typically a state will require a standard quote be filed with the state outlining the plan and its costs for a standard individual. This quote can be modified by underwriting. Employer sponsered (not purchased) plans have more options.
(iv) disallow the charging of different rates for the same services to different people.
This is already against the law. Cash discounts for prompt payment are not.
(1) force doctors and hospitals to provide a written menu of their charges for various services
Hospitals are required to do this by law.
I believe that Dandelion is referring to the well known practice of having negotiated prices with insurance companies, and then having much, much higher rates for individuals. Effectively, this would mean telling health care providers that they must pursue a list price only strategy rather than a negotiated relationship sale.
It is, in a sense, a market restriction, but one designed to create an open competitive market, rather than a closed competitive market.
(2) open more medical schools and create more doctors
There is no indication that we have a shortage of doctors. Most agree we have too many specialists.
"Shortage" is a relative term, but in general if one increases supply while the demand remains fixed, the cost goes down. It's a fairly straight forward point.
Those are cash discounts, not trade discounts.
There are several economics arguments involved regarding doctors. Given the incredible cost and time commitment to be a doctor, adding uncertainty to the ability to recieve recompense would seem to act as a disincentive to pursue becoming a doctor. Whether the incentive of easiness to receive a degree is enough to overcome that is disincentive is a question that shouldn't be addressed so flippantly. As it presently stands, some who can't get into American medical schools go overseas to receive medical training and then are recognized in the U.S.
Those are cash discounts, not trade discounts.
Not necessarily, at least in Texas. There was a while when we were first here when I was paying cash (at the counter, in advance) for doctors visits, and although our local clinic chain offers a 10% discount off list if you buy their membership card, you still pay the "list" price. Now that I have corporate insurance, I get the statement from the same clinic showing how much the clinic billed and how much the insurance paid. The insurance is often paying anywhere from 50% to only 10% of the list price for the care.
So if it's a "cash discount" it's one that not necessarily available to people who pay cash -- and is received by insurance companies that pay on Net 30 terms.
On increasing the supply of doctors:
I'll certainly grant that it's not a simply problem, so I'm sorry if I was being flip. Also the current glut of specialists is pretty much a result, I think, of the desire of doctors to make sure that they get a secure position which will pay off their medical school expenses.
One can't simply push up the supply while the cost of becoming a doctor is the same and the means of getting to a doctor is the same. I suspect that one of the best ways of dealing with the issue would be either expanding what kinds of care an RN can provide, or else having a two tiered MD system where it was signficantly cheaper and easier to become a generalist than to become a specialist.
Hmmm. Now you've got me curious on what the regulations on this are. Though googling around mostly turns up a bunch of places trying to sell insurance.
The one that particularly sticks in my craw is that I recently was looking over statements from our two year old's checkup and the total amount billed for all her vaccinations was around $300, of which the insurance company paid around $30. I think one of the vaccinations they paid something like $3. Now, I'm dead sure we never paid less than $30 for any given vaccination when paying cash.
I'd always assumed this was simple price negotiation. (For instance, at the technology company I work for our large corporate customers often pay only 50% of list price.) But if there are laws restricting that and it's some other kind of discount I'm wondering what it is and why individuals generally don't get it.
Do you know of any good online resources about this?
I suspect that one of the best ways of dealing with the issue would be either expanding what kinds of care an RN can provide, or else having a two tiered MD system where it was signficantly cheaper and easier to become a generalist than to become a specialist.
There are already programs that offer student loan forgiveness to GPs willing to practice in remote areas; AFAIK this doesn't apply to specialists unless they're willing to practice as GPs. The problem is that they can't make enough money, in a dispersed rural practice, to cover their malpractice insurance.
Thanks for the link and response, DC. I'm at work currently, but I will respond more completely later.
DC,
We don't have choice in our insurance. I am employed, therefore I have to take my employers insurance plan. I cannot eschew my employers plan for another (nor could I afford to, but the reality is that I am not allowed to). This is different from direct deposit, because once the money is under my control, I can do whatever with it.
Health insurance is not really subject to market conditions, I am only the user. I don't make the purchase decision.
To an extent, but you do choose your employer -- and often the benefits involved are a very key part of picking an employer. I know several people who sought and stuck with state or federal jobs because the benefits offered were so good (and their family situations required extensive benefits) despite the fact that the actual salary was below market.
Similarly, many people decide between small business/startup positions and positions at large stable corporations based on the difference in benefits.
Finally, good employers often do offer several different plans. For instance, at the corporation that I work for you can pick a PPO or a health savings account with high deductible insurance. You can also pick one of a number of deductible/copay options under the PPO.
Smaller companies may not offer as much choice, but again, that is one of the things that employees should consider in changing employers.
So it's not as much of a choice as I would like it to be. (I'd much rather see a completely individual or community based insurance system with assistance as necessary for those not able to afford it.) But there is definately choice.
I would hardly call it a choice. In the situations I have been looking for a job, I generally only have 1 or 2 offers to pick from at any given time. Benefits may factor into the choice, but are never part of the negotiations. I either accept what they offer in health insurance or I don't. As a regular employee, they can't make a special exception for me. Exercising my 'choice' by leaving my current employer and going to a different one can only be exercised so often, and with a great deal of hassle. I can't just switch like I do with auto insurance, housing insurance, ect.
Correct. It can be difficult and the choices can be limitted.
Though this would only be worse if we had to leave the whole country in order to try to get different coverage.
I am sympathetic towards a policy of public funding for healthcare, but very skeptical of those wielding political power controlling the system and making the pertinent healthcare decisions. I tend to distrust power structures, especially when matters of life and death are involved.
An underlying problem in this debate is that the powers of the US government are ill or vaguely defined. Our government does much it doesn't need to, much of which it shouldn't do, so when an increase is made of the scope of government power, it adds to the confusing jumbled mess of proper jurisdiction and authority and tyrannical (even if benevolent) usurpation.
We may need to have a big government; we do need to have clearly defined powers of what government can and cannot do.
Before opting for Naationalized Health Care I ask you to go to www.haveblackstonewilltravel.com and read the section Heghmann v. Sebelius. Have all the facts before you make a decision. I welcome your comments at Twitter.com/Montesque.
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