This article first appeared in the St. Louis Beacon, July 10, 2009 - Health-care reform should begin with three questions:
- Should the system be primarily government driven or market driven?
- Which citizens should get government sponsored care?
- How much government care should those citizens receive?
Walk into a government office and watch the people work. Is that the bunch you want handling your body?
While 90+ percent of government workers are surely morally upright and eager to do the right thing, we must admit that most of them are not the world's most eager beavers. I recently had to business with a department of the city of St. Louis.
My observations when I walked into the City Hall office were as follows: Several of the workers had no papers out on their desks and were just gabbing with one another. One or two were fussing with their hair. And most significantly, not one seemed to be hustling. At the least, this is a bunch that leaves at 5 p.m. sharp even if the job is not quite done. This is a bunch that, due to desire for self preservation, enacts zillions of rules and regulations that only they understand and that cumulatively make getting things done impossible. This is a bunch that seems to cause endless irritation to consumers.
When the subject is life-saving medical treatment, these issues will matter a great deal.
And will our best and brightest young people go into medicine when it is a government-run bureaucracy? I think they will avoid it like the plague. And not just that the money won't be as good, but also because the atmosphere will be stifling. We will miss those people when our lives are on the line.
And what of government influence peddling? When the politicians and bureaucrats take over, resources will be allocated by insider deals and political infighting.
Most significantly, how can the government know how much health care is the right amount to provide? There is no absolute answer to this question, and the answer can only be found through the price system. The price system will direct the allocation of resources such that people's desire for care will match their willingness to pay for it. (The merits of this argument assumes the reader is not silly enough to think that an infinite amount of health care is the correct amount and recognizes that all resources are scare, and a system must be in place to allocate the resources). The price system allows millions of individuals to engage in private transactions and for the outcome of that process to produce the correct, that is the "market," amount of care.
The fact that under a market system some patients will have more and better care than others does not bother me. That will be the case under any system. In fact, under extreme government command and control systems only the people running the system have good care, and everyone else is tyrannized and treated like a slave.
Competition will lead to better care, sane insurance plans and lower costs. I trust the people to work it out and I conclude that the system should be primarily private.
Now to question two: Which citizens should get government sponsored care? This is a hard question. Let me begin by asking another question. Should a perfectly able bodied single adult who has chosen not to work and who has no resources to pay be able to walk into a health-care facility and get workers there to care for his needs? Those who say health care is a "right" will answer yes. But I say no.
Why does one individual have any obligation to provide another with health care without getting paid to do it? What is the source of such obligation within the human circumstance?
Perhaps the real problem is that the health-care system has become so successful at making people better that we just can't imagine a fellow citizen carrying on without access to all of it. But no able-bodied citizen has the right to demand that another able bodied citizen pay for his or her personal needs. America's promise is that each citizen will be able to pursue happiness in his own way. A nanny state only interferes with the core of that promise.
So if we reach the conclusion that health care is not a right, then we ask whether anyone at all should get free care? Even a "Big Meanie" like I am agrees that a rich country like ours can afford to provide as least some care to the disabled, the children of the poor and the aged.
I select the disabled, the children of the poor and the aged because those are the groups who are incapable of taking care of themselves. I do not include poor adults. I am sorry for those people, and I am confident that charity will help them in some situations, but it is only when people are left alone that they emerge from poverty.
Now question three: How much government health care should the disabled, the children of the poor and the aged receive? The disabled should probably get solid basic care. We all have compassion for the disabled. Surely no one chooses to be disabled. But should we give a heart lung transplant to a life-long smoker with lung cancer? I don't think so. I would give a level of care so that the lower middle class will not face a moral hazard such that lower class persons are getting better care than they are just because they are disabled. A broken arm? Sure, fix it. Life long dialysis? Hell, no.
The children of the poor should also receive basic care only. We again have to be mindful of moral hazard. Should a poor child receive a liver transplant if a paying customer doesn't get one? I think not.
I add a wrinkle for the aged who can't pay. I would again give them basic care but I would give palliative care only to aged demented. I am trying to be compassionate, but spending huge sums from the public trough to prolong the life of those who have lost the ability to think makes no sense to me.
By now many readers are surely wringing their hands over the fact that I am proposing that society make choices about who gets health care and how much instead of just giving everyone as much as they need. But there needs to be a check or all we will get is health bills, and we will go broke. Any system that just gives everything to everyone is going to be a disaster. Charity will take up some of the slack. The Shriners, for example, for years provided free care to children. They are not going away soon, and they are merely one of many such groups.
Can this proposal be implemented? Absolutely. No ideas are beyond reach. We live in a representative democracy; and if these ideas are good, they can be enacted.
Bevis Schock is an attorney in private practice in Clayton.