All Commentary
Sunday, June 1, 2008

Coercion Is the Only Way to Ensure Health?

Ending Government Regulation of Health Care Would Improve Affordability

In his April 11 New York Times column, economist Paul Krugman discusses the minor trouble then-presidential candidate Hillary Clinton got into when an anecdote she told about a woman who died because she didn’t have medical coverage was found to be inaccurate. Clinton had used the story in support of her proposal for mandatory medical insurance. Krugman argued that, true or not, the story makes “a valid point about the state of health care in this country.”

On April 14 Krugman conceded that the woman did indeed have insurance, but he maintained that since many people do die from lack of insurance, his earlier column was worthwhile anyway.

I agree that the merits of Krugman’s argument do not stand or fall with the veracity of the anecdote. But while Krugman’s attitude seems to be, “Even if the woman was not uninsured, it’s still true that we need universal care to avoid similar tragedies,” mine would be, “Even if Clinton’s anecdote were accurate, it wouldn’t demonstrate that the only way for society to avoid such tragedies is through coercive national health insurance.”

Part of the problem in discussing this issue is the tendency to conflate several distinct concepts: the ideas that 1) everyone should have access to health care, 2) everyone is entitled to equal levels of health care, and 3) a coercive federal mandate is the only way to accomplish either of those goals. The first is true, but does not imply the second. I doubt that the second is true, but even if it were, it wouldn’t imply the third.

People sometimes mean different things when they speak of access. It would be strikingly immoral for there to be a class of citizens who were forbidden to seek medical attention. Happily, we do not live in such a society. But there are other senses of the word.

Do I have access to a Mercedes? Well, in one sense, yes—if I could afford to buy one, no one would be legally empowered to stop me from doing so.

But I can imagine someone arguing that since, in fact, I cannot afford one, I don’t have “access.” So the argument is not that some people are legally locked out of access to medical care, but that they cannot afford it and in that sense lack access. The very poor are already eligible for government-subsidized medical care, so this argument seems to be directed at uninsured people who make too much money to qualify for Medicaid. But how would mandatory national health insurance fix that problem? Mandating that people buy something won’t suddenly make it affordable.

Why don’t some people have insurance? They may work for employers who do not offer it as a fringe benefit. But they could still enroll in an HMO or in a Blue Cross-type insurance plan. Why don’t they? One possible reason is that they cannot afford the premiums. This means they choose to spend their money in other ways. (Remember, we are not talking about the seriously poor, as they are already covered by government programs.) When I say, “I cannot afford a huge flat-screen TV,” what I mean is that I choose not to afford it; I am saving my money for something else—a new lawnmower, my kids’ college fund, retirement, or what have you. I have assigned a lower priority to a new TV than to several other things.

But wait, comes the rejoinder, flat-screen TVs are a luxury no one needs, but everyone needs health insurance. (Technically, that’s not true, but let’s assume it is.) Then the problem must be that people are arranging their financial priorities erroneously. Mandatory insurance would solve that problem. It would rescue them from their own folly.

This is the core premise of what Krugman calls Progressivism. People do not choose wisely; therefore, for their own good, they must have some choices mandated for them. This premise, of course, is profoundly antithetical to the classical-liberal tradition, in which people’s autonomy and liberty are to be accorded the highest priority unless their actions infringe the equal rights of others. To assume that people cannot be trusted to make wise choices about their welfare is bad enough; it’s worse to add the assumption that a policy wonk is better qualified.

Even if we grant that some people who choose to go uninsured are foolish and ought to be compelled, that wouldn’t address the problem of those who make this choice not out of foolishness, but because they really are so strapped for money that they “cannot afford it” in the ordinary sense of that expression. The mandate then would have the effect of making those people even more impoverished. But at least they wouldn’t die from lack of insurance.

That’s Progressivism? But, a Progressive might reply, isn’t saving lives an important part of the government’s responsibility? Citing the Urban Institute, Krugman says that lack of health insurance kills 27,000 people a year. That’s awful, but the important question is why this happens. More precisely, does government policy make it easier or harder for people to afford medical coverage?

Krugman and Clinton are aware of the affordability problem, but they think the way to address it is through tax-financed subsidies. Here’s a different idea: create market conditions under which lower-income people could receive the coverage and care they currently cannot afford. Contrary to what many think, we have no free market in medical care. Government is pervasive, and that’s the problem. Removing current restrictions would go a long way toward changing this. For example, many routine services could easily be provided by physician’s assistants, nurse-practitioners, or, as they were in the old days, pharmacists.

Imagine if Jiffy Lube had to employ factory-certified master mechanics at $80 an hour to do oil changes. You’d likely get fewer oil changes because they would cost a lot more. But without regular oil changes, your car would be at risk for more serious trouble. When a big problem occurred, people would lament that it could have been prevented with regular maintenance. Some would propose that the government should require people to get regular oil changes even if they can’t afford them. But another approach would be to allow a free market in oil changes, which, as we know, keeps prices low, and enables everyone to get regular care.

Government has many other policies that restrict supply and make medical care artificially expensive. Let’s get rid of them. Why resort to force? Freedom works.

If saving lives is as important a part of the government’s responsibility as Krugman suggests, Progressives would do well to rethink their impulse to regulate behavior. Phrases such as “unregulated markets in health care” evoke the specter of either skyrocketing costs or substandard care. But ironically, that’s the dilemma created by government regulation. Costs for simple preventive care are kept artificially high, so some don’t get it. But unlike the inconvenience of a broken car, this can result in death. Coercion won’t solve the problem.

  • Aeon J. Skoble is Professor of Philosophy at Bridgewater State University.