View 584 August 17 - 23, 2009 (original) (raw)
Monday, August 17, 2009
In theory there has been some progress over the weekend, with the "public option" being eliminated from the health care proposal. In practice that is nowhere near certain. It remains in at least one House bill, there is no actual agreed bill, and a Senate-House "conference" can put almost anything in at the last moment. And Howard Dean wants to "do it right" which will have the "public option" in it "when it is signed in December."
The health care debate will continue. It's time to start from first principles and see what's being debated. It's bigger than "health care."
Health Care Essentials
Assertion: everyone has a right to health care.
Questions: from whence does the right come, and on whom falls the obligation to provide it or pay for it? How is that obligation acquired or imposed?
The are knotty questions. At one time when the US was considered a Christian nation they would not have been asked; everyone knew there was a general obligation to take care of the needy. The federal government may not have had any such obligation (or power) but in general the states did, and most of them tried to provide some minimum safety net. California used to have a fairly extensive welfare system -- but it was available to California residents only, and residents were required to prove they had lived in California for more than a year (and that they were here legally). New York also had a generous welfare program, but had no residency requirement at all. Eventually the Federal Government stepped in and between Congress and the courts all state residency requirements for welfare, voting, and everything else, were eliminated. This was considered progress.
Query: did this put an obligation on the Federal Government since it substituted its judgment on the matter for the state legislatures? Doe the Fed have to fund the programs it has imposed? What about illegal immigrants: whose problem are they?
But the essential question remains: who grants the rights, and on whom falls the obligation to pay? Assume the states have the constitutional right and power to grant the rights and assign the obligation under some residual sovereign powers inherited from the Crown, where did the Federal government get the power to impose this on the states?
Note we have left moral rights and obligations out of this. We are thoroughly modern now, and there are no obligations from Western Civilization, Judeo-Christian principles, or any other religious obligations. We have only legal obligations. All cultures are equal, including, I presume, the worship of Baal. We prohibit sacrificing our children to Baal, providing that they have already been born; one presumes that having a priest of Baal in an abortion clinic is not prohibitable.
But if everyone is entitled to health care, are we all entitled to equal levels of health care? For example, is a face lift "health care"? One can make the case that for some disfigured people it probably is; and one can make the care that it's required for people in certain professions. But what in those cases does "entitled" mean? Are all of us required to pay the fees for yet one more face lift of an aging movie star? Not that she would ask for it -- but why shouldn't she?
Or take another example: a 100 year old grandmother who needs a pacemaker. Should she have it? Is she entitled to it?
And that brings us to another important question: what does "entitlement" mean? What does the right to have something mean? These are not trivial questions. For example: is everyone entitled to a diamond tiara? Surely that depends on what it means to be entitled? If by "entitled" or "right to have" we mean that it is not illegal to go buy one, then yes, enthusiastically we say that everyone has that right; but if by "right to have" we mean that someone else is obliged to pay for a yacht, or a diamond tiara, then I suspect no one believes in that right.
Same for the 100 year old grandmother's pacemaker. No one would dispute that she has the right to buy that medical service, even if her grandchildren, expecting that money as an inheritance, object. If the grandchildren are wealthy enough to buy that service for grandmother, surely they have that right even if many would think that foolish. Note that in some single payer health care systems, the grandchildren do not have that right, and might even be prosecuted if they evade the system and send Grandma to a hospital in Thailand for the procedure; but I think we in the United States can agree that Grandma can buy any medical procedure she or her heirs or friends are willing to pay for.
But if we define "right to have" as "obligation for someone else to pay for" the pacemaker, we have a problem. Do we mean everyone? What about a 110 year old veteran who has been in a coma for 9 years and is kept alive on tubes, and whose only sign of conscious life is that he will squeeze his great grandaughter's hand sometimes? Or make up your own example: I am sure you can come up with a case you will assert does not have the right to an expensive procedure. So who decides? Whatever you call the decision process, the decision will eventually be made by the equivalent of a death committee, even if that committee is a Harvard Professor of Ethics. One suspects that this question and others like it will generate a lot of new work for ethicists.
However we answer these questions they don't go away. If we define "right" not as meaning "you're free to have it if you can afford it" to "you get it without paying for it so someone else has to pay" we are going to have to make some fundamental decisions, because there is no way in this economy in which we can give everyone all the health care that they think they are entitled to. The demand for a free good is infinite, even if most people will be reasonable in their demands. Some won't be. Some will demand tummy tucks, face lifts, pacemakers for the 110 year old veteran, daily pep talks for the morbidly obese, etc.; some will demand things that most of us simply won't be willing to pay for -- and there has to be a mechanism for deciding who gets what.
The Matter of Equality
If we aren't going to let everyone have everything they want and are willing to pay for, then there will be inequalities. By definition. Assume a costly new procedure is developed, one so expensive that there is no question of providing it for everyone, but which significantly prolongs life for those with certain conditions. (We can all think of examples, I suspect.) If everyone can't have it, then should anyone be allowed to buy it? Do we ration this by money?
We ration Cadillac automobiles by money. We ration caviar by money. But no one's life depends on having a Cadillac or a diamond tiara: how can we ration life? Worse, the quality of our publicly provided health care is significantly lower than what is available in private clinics and hospitals. The rich get better health care than the poor! That logic has led to some systems forbidding private clinics and hospitals. It is the logical end of the system.
Freedom is not free. Free people are not equal. Equal people are not free. Niven can afford more than I can; should I be resentful?
Insurance and Rights
The current debate confuses the principle of insurance and the matter of rights. This should be obvious. In an insurance-driven system in which insurance companies cannot refuse you for pre-existing conditions, the best strategy would be to avoid insurance as long as you're well, then at the first signs of distress rush out and buy the best and policy you can get. They can't refuse you. You may or may not change to a lower-cost policy if you're cured.
Insurance Transfers
The real problem with our current health care system is that you can't change jobs. I will let a long term subscriber state the situation:
Dear Jerry,
While this is likely not the most important aspect of a possible national health care plan, I have a question. Just what would happen to job/economic stability if no one was tied to a current employer by the availability of health benefits?
I could imagine an awful lot of people, living in quiet desperation in their current jobs, up and quitting to try somewhere else if they were not tied to an employer by health benefits and pensions. Since pensions were pretty much done away with in favor of 401K's and the like, health bennies have been one of the key reasons many haven't changed jobs.
Back when I was younger and actually hot at what I did, I was courted by several contractors. All offered me better pay and perks but they could not protect me from a pre-existing condition clause in their insurance plans. (I have doozy of a pre-existing condition.) If insurance were not such an issue I would have gone in a heartbeat! Now I am grinding out my heart in a government office flunky kind of job and waiting for another 5-10 years to head out and do other things after retirement. It was the health benefits that tipped the scale.
R
This is what needs fixing; indeed, if this were fixed I think that would take care of nearly half our health care problems. The other large item is related: when you lose your job you lose your insurance, and the COBRA program (and if you haven't read the mail on that one, do so) while vital, isn't a full answer.
If I were concerned with fixing health care, these are the two matters I would concentrate on. They involve people with jobs -- taxpayers, productive members of society -- who have some real problems. The costs of fixes are reasonably easy to estimate. We do not need to go to a single payer system to fix those problems. The impact on what people have now would be minimal. Insurance companies can adjust their rates to reflect the "transferability" or whatever it takes, and if need be could be subsidized during the adjustment period.
I haven't seen any of this discussed.
Those Not Covered
The last health care problem is those who don't have any coverage at all, either because they don't work at all, or they work for a company that doesn't provide health care. This needs discussion -- and certainly doesn't warrant changing everything else before Christmas in a mad rush to nationalize the system. It's a knotty problem, but before we tackle it, we need to answer the questions asked in the first part of this essay. Who has the right to what, and on whom are the obligations to pay? And whence came those rights and obligations? Until we have clear answers to those questions, we'll get nowhere.
And yes: I understand that those questions have some importance to the transferability/continuation problems discussed above, but I'd argue there are major differences.
In any event, there's enough here to discuss in an attempt gain some clarity.
There is also a lot of mailon this subject (as well as some good stuff on other matters).
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If you are weary of the health care debate -- aren't we all, but then most troops are weary of the combats they find themselves in -- you may find this interesting:
Burt Rutan takes on Climate change
http://rps3.com/Pages/Burt_Rutan_on_Climate_Change.htm
Via: http://wattsupwiththat.com/2009/08/16
/burt-rutan-engineer-aviationspace-pioneer
-and-climate-skeptic/-- Dave Taht
It will take a while to get through this Powerpoint slide show, but the data are worth your attention if the subject interests you. As usual, Burt is thorough.
While you are on that subject
"Any improvement we can have in understanding how the earth's orbital parameters affect our coming in and out of ice ages can certainly affect the models used now too."
<http://www.abc.net.au/science/articles/
2009/08/14/2655852.htm>--- Roland Dobbins
It seems to me obvious that we don't really understand climate modeling, and spending much money as directed by the output of those models is senseless. Better would be to spend more on gathering more data and building better models.
As to my own view, I am far more afraid of ice than warm; and I see no reason to believe that ice is not at least as likely as warming.
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