Should the Healthcare System be Universal?

Posted on March 26, 2008
Filed Under Fixing American Healthcare, Healthcare economics |

As noted in a previous post, there are three basic principles we are going to have to resolve before we can decide on any plan to fix American healthcare. The first of these is: Should the healthcare system be universal? That is, should our reformed healthcare system apply to every individual legally residing in the United States?

DrRich is truly distressed to report that the answer to this question can only be: Yes.

DrRich is constitutionally predisposed against a universal healthcare system. By “constitutional” he refers not only to his own inherent biases, but also to the document produced by our nation’s founders. In that document our founders took pains to preserve individual liberties against the opposite extremes of anarchy and tyranny, and recognized that an indispensable component of personal liberty is personal responsibility.

The personal responsibility that makes personal liberty feasible includes the responsibility to provide for oneself the necessities of life, as well as those nonessential things one typically consumes during the course of one’s lifetime. A society founded on liberty and economic freedom, for instance, requires that products and services consumed by individuals, such as Caribbean cruises, ice cream, food, clothing and healthcare, should be provided by the individuals who are consuming them.

To be sure, in a compassionate society arrangements can and should be made on occasion to support individuals whose circumstances prevent them from supplying themselves with certain necessities of life, such as food and shelter. Healthcare will also often fall into this “necessities of life” category, and therefore a compassionate society will find it salutary to provide such care to some of its citizens on occasion. (Some of what we now deem “healthcare” has aspects more in common with Caribbean cruises than food and shelter, and we seem to have an increasingly difficult time differentiating the essential from nonessential varieties; we will leave this problem aside for purposes of the present discussion, and instead take it up later.) But the desire to help certain of its citizens who are unable to gather some of life’s necessities - a charitable desire that redounds to the civility and well-being of the whole - is a far cry from the duty, or even the desirability, of providing the necessities of life to all people, or even to certain categories of people defined by some arbitrary characteristic (such as age).

There are, of course, philosophical problems in taking what ought to be the responsibility of individuals and handing that responsibility off to society. You can find discussions of these problems by reading the founders. But DrRich is no philosopher, and besides, it appears to him that roughly half of America believes today that society ought to provide the necessities of life to all its citizens. Not wanting to cause unnecessary turmoil among his readership (DrRich being a lover and not a fighter), he will leave philosophy aside and instead rely on the economic question. For, while bad philosophy often smolders for many generations before bringing down a culture, bad economics will do it much quicker.

We have detailed in a previous post the astoundingly dysfunctional economics of American healthcare, and how the fiscal obligations to which we have already agreed are leading us inexorably to destruction. The idea of a further expansion of those fiscal obligations at this point is beyond absurd. (”Beyond absurd,” that is, in the sense that it’s beyond absurd to shoot yourself in the head while falling to your death after jumping off a cliff. Putting a bullet in your brain might normally be considered absurd, but actually it adds very little net harm once you’ve already leapt off a cliff; that is, it’s beyond absurd.)

So, you may be asking, if making the provision of healthcare a societal obligation is morally, philosophically and economically undesirable, then why would DrRich assert that any reform of the healthcare system should be universal?

It’s not because healthcare is necessary for life (since necessities of life ought to be the responsibility of individuals), nor because healthcare is a right (since there is no such thing as a right that requires forcibly reducing the rights of others; such a thing is properly labeled not a right but a tyranny), nor even because healthcare is very desirable (since, after all, so are Caribbean cruises). No - our reformed healthcare system will have to be universal not because of any positive attribute of healthcare itself (not because healthcare, being good, ought to be provided for everybody), but rather because of the negative character of our current healthcare economics.

Because the healthcare obligations we have already signed up for promise fiscal ruin in the foreseeable future, the one non-negotiable requirement of any meaningful healthcare reform we may undertake will be (must be) to restore some real hope of economic stability. (Anything else we may do, including insuring the uninsured, sending men to Mars, defeating terrorism, or achieving energy independence won’t matter if society collapses under the weight of its accumulated healthcare debt.) And saving our society from economic collapse requires a solution that applies to everybody.

In a previous post we saw that the underlying cause of our impending healthcare fiscal crisis is our systematic failure to establish limits. That failure derives directly from our decision - taken over the past 60 years - to collectivize healthcare expenditures. Whether directly (through Medicare and Medicaid), or indirectly (through tax-deductible “private” insurance premiums), the taxpayer is subsidizing virtually all healthcare spending in the U.S. While this arrangement might be fiscally acceptable if we were on a pay-as-you-go basis, the fact that our present unfunded obligation for Medicare alone reaches $34 trillion demonstrates that we are not. By saddling future taxpayers with an enormous fiscal burden that guarantees societal disruption - slapping away that small hand that reaches up for ours - we reveal ourselves as being something other than compassionate conservatives, or compassionate liberals, or compassionate anything. If we fail to limit our appetite for healthcare expenditures that benefit only ourselves, we will be revealed in a decade or two to our own children and grandchildren (not to mention to future historians) as among the most morally repugnant generations in history.

Any real healthcare reform will have to be universal not in order to spread the benefits of healthcare evenly. It will have to be universal because real healthcare reform, fundamentally, will have to be an assertion of limits on publicly-subsidized healthcare. Anyone whose healthcare is subsidized by present or future taxpayers will have to receive their healthcare benefits under this new system of limits. Since it is difficult to imagine anybody today whose healthcare is not so subsidized, any meaningful healthcare reform will have to apply to everybody; it will have to be universal.

Stated another way, healthcare reform must be universal in order to accomplish the one thing that such reform absolutely must accomplish - setting the limits that will allow rising generations of Americans a fair chance at maintaining societal stability. Universality is not required by a concern over healthcare benefits; it’s required by the need to establish real limits.

In future posts we will look at the Fuchs/Emanuel universal voucher system (DrRich’s original assignment), to see how well it meets the “universality” criterion herein defined.

But first we need to consider the second principle that must be resolved before we can effectively reform American healthcare - should our healthcare system be designed to enforce equality, or should it instead permit Americans to exercise their autonomy as individuals?

Note: This is the third in a series of posts that discuss healthcare economics, and the three basic questions we will have to answer before we can devise a way to fix American healthcare. The fourth post in this series, “Should We Aim For Equality or Autonomy in Healthcare?” can be found here. The first post in this series can be found here.

Comments

4 Responses to “Should the Healthcare System be Universal?”

  1. anonymous on March 27th, 2008 8:47 am

    where would you start to make cuts? you would make a list ala oregon and all procedures would be covered above the cut line? everything below the line would not be covered?
    no more primary prevention icd’s? have to survive two cardiac arrest to qualify? have to have every medicine known to mankind before you get a stent?
    if we stopped wasting all the money on certifications and preauthorizations and coding and billing we could probably provide a lot more care to people. of course we would have to find jobs for the 1.5 fte’s each clinic would suddenly not require. entire divisions of hospitals would be reassigned. could be bad for the economy?

  2. DrRich on March 27th, 2008 12:03 pm

    Anon,

    The rationing needs to be done openly, under a system of rules established and administered transparently. The rationing would apply to any healthcare that is subsidized by the taxpayer. Individuals would be free to purchase supplemental healthcare with their own money.

    A full description of such a system can be found in my book, or here:

    http://guthealthcare.com/fixing-it/an_american_solution_to_the_healthcare_crisis.html

    Of course, we could just continue rationing covertly. Among the deadly effects of covert rationing, however (as I have taken pains to demonstrate on this site) is that it doesn’t actually limit spending. In fact, it creates waste and inefficiency, and actually increases overall healthcare expenditures.

    Rich

  3. Simon Jester on March 27th, 2008 10:03 pm

    How about starting on preauthorizations on the expensive health care (MRI, ICDs, etc.) and leave the less expensive interventions alone? Part of the reason that the British NHS hasn’t already gone down in flames is that they still teach their medical students to do a good physical exam, whereas physical exam is a formality at best in the States before the CT and the MRI. Granted, we would have to shoot most of the lawyers before we could use the best diagnostic tools avialable (HINT: it fits between the earpieces on a stethoscope).

  4. anonymous on March 31st, 2008 12:47 pm

    as far as i know, we are preauthorizing the vast majority if not all of mri and icds etc. what other tests/procedures would you consider preauthorization for?

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