Fred: Crafting a Better System

Thanks, Mary Kay-- We need another family reunion, I haven't seen you in eons!

Back to some of Bruce's points: markets are surely more "efficient" (by which we mean what? I suppose, delivering a quality product at the lowest reasonable cost?) than ossified monopolies. But, pace the acolytes of my erstwhile colleague Milton Friedman, not every arena of life is really appropriate for market systems, and I think health care is one of them. Maybe others don't think so, but I feel that as a community--in this case, a national community, but the point would be the same if we limited it to our own local community--as a community we have an obligation to ensure that *everyone* can be as healthy as possible. It's partly idealism, a commitment to equality of opportunity (b/c if one is ill, one can't really compete), but it's also profoundly realistic, because as I pointed out many emails ago, if one's neighbor is ill his disease might spread to you, too, and more generally, widespread illness undercuts the productivity of the whole economy.

It's one thing to say that those who work harder should be rewarded, and those who are lazy or inept should lose out. In that case, we can rationalize the resulting differences in wealth as the reward to the "virtuous" for hard work, insight, etc. I don't have a problem with that. But when it comes to health issues--it's a different matter. Some people, through no fault of their own, face serious health challenges that others just don't. Look at my cousin Mary Kay: is she to blame for her diabetes? Hardly! But when you make health care something that must be paid for, then the unlucky in matters of health simply have to pay more than those blessed with good genes (or good luck in avoiding injuries). I doubt anyone in our discussion group would be in favor of eugenics, but by making health care something people have to pay for (and hence have insurance for) we adopt a policy that is almost like eugenics, in that we inevitably discriminate against those who get sick or injured or have chronic health problems. This is because the market-based, profit-oriented health insurers will inevitably try to reduce their costs by insuring only those who are healthy, and avoiding ("like the plague," to use a phrase curiously appropriate to this discussion) anyone who can be predicted to have higher health care costs. Either they won't insure such people, or they will charge them astronomical rates, which means many people of modest means can't afford the health insurance/care they need.

So the challenge, it seems to me, is to craft a aystem that provides acceptably good health care to *everyone* in our society: rich or poor, young or old, healthy or chronically ill. We are, comparatively, a rich society: it's little short of obscene that we, alone among developed nations, adhere to this "your money or your life" approach to health care. It's often said that the US has the "best doctors and health care in the world." This is true--if you are rich. This is why a lot of very rich people from other countries come to the US for medical treatments--they can afford to pay handsomely for it out of pocket, and do. Hospitals now compete for their business.

But I always thought the ideals of America were "land of opportunity" and the "level playing field." It seems to me that our current health care system, rather than leveling the playing field in health matters as much as possible, and thereby allowing all citizens are healthy enough to pursue whatever opportunities life affords them, is a cruel betrayal of those ideals--cruel especially to the poor and those of modest means. It's a system that exploits everyone's need for health care so as to maximize profit for the insurers (and some others), and treats those who need serious help but can't afford it as expendable. Uninsurable. "Your money or your life." As a society, we can do better! The question is, how?

There are some other points Bruce made that I'd love to comment on--you're a great interlocutor, Bruce!--but I need to get back to my "day job"...

Best, -Fred