Health Insurance

Posted: March 10, 2010 in Braak, Politics
Tags: , ,

I know that I’ve said before that I don’t like it when we get really involved in politics here at TQP, because I’m displeased with the number of crazies that appear from the woodwork.  This is true; I have trepidation even as I’m writing this.  However, I’ve been puzzling over something for a while, and I want to try and address it using the secret weapon of the Writer:  Language (the thing that means stuff).

Is health insurance a fundamental right?

So, there are two basic questions we need to ask whenever we talk about political policy:  “Can we do this?”  and “Should we do this?”  The bifurcation of the issue is part of the problem, since it leads to muddy arguments; if, whenever I’m challenged on Can, I retreat to a defense in Should, none of us will ever get anywhere.

Today I’m largely ignoring Can.  This is an implementation problem, and it’s ancillary to the question that I’m asking, which is Should.  Should we insure all of America?  Is it morally appropriate to do this?  Do we, as a nation, have a responsibility to do so?

I’ll tell you what got me thinking about this.  There’s a columnist for the Philadelphia Inquirer, a man named Michael Smerconish, who recently generated a small amount of fuss (as befits a columnist at America’s eighteenth-rated newspaper) when he officially “left” the Republican Party.  In his column, he talks about his dissatisfaction with the party, but also indicates a number of areas of disagreement he has with the Democrats and with Barack Obama.  Among those differences he says this:

And he [Obama] never closed the deal with me that health insurance is a right, not a privilege.

I think this is a fair point to raise, and I think it’s common when we deal with the first half of our policy issue — Should we do this?  There are many people that oppose a national healthcare system for precisely this reason:  they do not believe that health insurance is a basic right.

What especially interests me, though — and I think this is a position that many opponents of healthcare reform also share — is the preceding paragraph:

I believe that if someone like Khalid Sheikh Mohammed has actionable intelligence on future terrorism, you try the least coercive methods to extract it but ultimately stop at damn near nothing to get what you need to save American lives.

“Damn near nothing to get what you need to save American lives.”  That sounds an awful lot like “the American government has a responsibility to protect the lives of its citizens.”  What, exactly, is the moral structure that permits someone to countenance torture — with is both grossly ineffectual and grotesquely unethical (and therefore by both of our measures the absolute worst kind of policy we can institute) to protect American lives from terrorists, but NOT giving someone a hundred bucks so he can see a doctor?

It can’t be a question of scale.  Terrorists killed 2,976 American citizens on September 11th; heart disease kills almost two hundred times that many Americans every year.

Is it an issue of fault?  Certainly, some people are more susceptible to disease because of their lifestyle, but many others are not.  It’s not like if you’re a hard, diligent worker with good morals and what have you that you’ll be less likely to have a heart attack.  And, as painful as it may be to suggest, the same can be said for victims of terrorism; we do not blame the victims of the World Trade Center attack for working in a building that was a well-established terrorist target — for willingly choosing a lifestyle that was at a comparatively high risk for a terrorist fatality; their protection by the military is not contingent on that.  Nor should it be; by the same token, we can’t really blame people — in an era where information on health is unclear, and everything has poisonous nitrates in it — for living a lifestyle that makes them comparatively prone to heart disease.  And we especially can’t blame people who suffer from things like Juvenile Onset Diabetes or Multiple Sclerosis.

Maybe it’s an issue of efficacy, but that seems unlikely; “preventing terrorism” is a pretty vague plan of action — we may say for sure that we know we Should do it, but we’re not always certain precisely how we Can.  But we know what to do about heart disease; we have a lot of things we can do about heart disease — every dollar we spend treating it is guaranteed to be spent more effectively than a dollar spent preventing terrorism.

If we accept that the government has an ultimate responsibility to protect American lives, why should we rate the lives that might be lost to terrorism more highly than the lives that might be lost to coronary disease, cancer, tuberculosis, measles, scarlet fever, cholera?  If the government doesn’t just have the power, but has the responsibility (as Smerconish suggests) to levy taxes to support destruction, killing, and torture in order to protect its citizenry (all of which are essentially immoral activities), then why doesn’t it have the responsibility to levy taxes to support medical care (which is, at least, moral)?

I suppose you could draw a distinction between “health care” and “health insurance”, but this seems like folly.  Health insurance is how we get health care, and we don’t expect people to bankrupt themselves supporting the War Effort; how can we expect people to bankrupt themselves paying for health care?

Based on this, it seems pretty clear that we Should be doing it; I think if we accept that, then it covers a lot of the questions about whether or not we Can do it.  Can we levy taxes to provide for medical care?  Of course we can; we do it all the time to protect American lives.  That’s what taxes are for.  Can we intrude into people’s lives?  Well, it depends what you mean by “intrude.”  If you mean, “can we spy on you and come into your house and tell you how to behave and how to live”, then no, obviously we can’t do that.  But if you mean, “provide a service to American citizenry that everyone is responsible for but no one is required to use”, I don’t see why not.  It’s not like you can pay less in taxes because you don’t think terrorists are going to get you.  I opposed the wars in both Iraq and Afghanistan, but I still paid my taxes to support the army, and shouldn’t I have done that?

There’s debate on that score, plainly, but I think I know what Michael Smerconish would have said.

  1. SB7 says:

    I don’t want to be one of those guys coming out of the woodwork, but since you’re approaching this with more rationality and maturity than I usually see on blog posts about health care (and I include there both those I agree and disagree with on this issue) I thought I’d respectfully register my dissent. I’ll try to keep this as short as possible.

    (1) There’s a matter of agency to address when comparing prevention of disease and prevention of terrorism. Only a national government can reasonably provide national defense. An individual’s health is more amenable to individual action, as well as efforts by their family and friends, by charities, and by sub-national communities.

    (1b) I totally concur on the relative scale of the problems. We spend money on terrorism and drugs and other things way out of proportion to their actual risks. I’m not sure that’s a good argument for spending more money on some other thing, but we definitely aren’t budgeting according to risk now.

    (2) I disagree with Smerconish: we do not have a right to be protected from terrorists. In fact, we don’t even have an actionable right to be protected from common criminals. See, I dunno, Warren v DC.

    (3) More generally, I don’t put much stock in “positive” rights, preferring a “negative” conception of liberty. I won’t go into all that now, since I think that’s a discussion that would quickly spiral out of control, so let’s accept that we’re coming at this from very different first principles.

    (4) I wouldn’t be so quick to conclude that health insurance as a mechanism is inseparable from health care as a goal. I really appreciate you keeping the “Should?” and the “Can?” separate, but I think you’re backsliding a little in taking your conclusion about “Should?” to make implications about “How?”

  2. Cancer kills more Americans than terrorism, but there’s more money to be made short-term in fighting terrorism.

  3. braak says:

    (1) This appears to also be a question of scale, though. A large organized body is more effective at defense than a small, disorganized body–which is why a national standing army is more effective than a group of small militias. Equally, an organized body of healthcare providers is more effective than when each individual is responsible for their own health; this is how we ended up with health insurance providers in the first place. Why is the principle of gross (i.e., large) organization effective for an army, but not effective for a healthcare system?

    I suppose if we’re arguing that healthcare can be effectively provided for at less than a national level, maybe, but I’m actually not satisfied that this is true. Certainly in terms of health insurance–insurance is one of the few products in which the bulk of the cost is paid for by those who do not avail themselves of the service–a vast risk pool is going to be more effective and versatile than several small ones.

    But, again, those are implementation issues. The real question, from a moral issue, I suppose is that if we’re accepting the question of agency as a basis for what should be provided for, how do we evaluate precisely how much citizens are responsible for their personal protection from terrorists? We can, after all, buy our own guns and do our own racial profiling. We could all just move away from New York City and Washington, and make our risk from foreign terrorism negligible.

    (1b) This is also an implementation issue, I guess, though it seems to me that if we retain a health insurance industry, we’re all going to be paying for health insurance, somehow. That is, maybe “we” as in the federal government isn’t paying for it, but “we” as in, regular people who have jobs, will still be paying for it. Not only do I pay for my own health insurance, but I also pay for all the health insurance of anyone who works manufacturing a product that I buy.

    (2) I’m not sure I agree with the interpretation of Warren vs. DC. I think not permitting individuals to hold the police liable for failure is different (if only slightly) from not having an actionable right. I hope that this decision was an issue of practicality–the police would be entirely unable to function if they could be sued every time their response was deemed inadequate.

    I think that the implicit moral justification for the existence of the police in the first place, however, remains the safety of its citizens. If the existence of a paid police force is not at the very least a deterrent to certain crimes, then I’m not sure what it’s for at all.

    (3) Okay, I can accept that.

    (4) I’ll admit that this was a bit of a backslide. The fact is that my interest is in healthcare; if we dispensed with health insurance entirely but were able to distribute healthcare to my satisfaction, I’d be fine with that. At present, however, I’m not sure what the best way to do that would be.

    Certainly, I’ve never heard of any system like that that functions with any degree of efficacy, but the world is full of things I’ve never heard of, so that’s not much proof of anything. In this particular case, though, whether or not healthcare is a fundamental right is presented in the context of health insurance reform, so that’s where I’m coming from.

    Also! Thanks for your clear and moderate response! I am anticipating the crazies to start showing up later.

  4. Moff says:

    SB7 (quite personably and reasonably) raises some points worth talking about, IMHO, but as they’re fairly nuanced (and as I do not have time to discuss health care today, alas), let me just say: This was a great post, and it was worth risking the crazies over.

  5. wench says:

    I suppose the distinction I’ve always made between police and military protection and disease treatment has been the human element.

    People attack people. Men attack women, women attack men, the French attack the Germans, whatever. Despite this, we presume that people *should not* attack people – that there is a moral wrong involved in any assault, and that not everyone is able to protect themselves from said attacks. The little old lady cannot necessarily protect herself from the thug; Norway cannot necessarily protect itself from China; whatever.

    Conversely, we see disease as something outside morality, outside the scope of free will and choice – it’s not someone deliberately setting out to make your life unfair; it just is, like an act of G… oooooh! That’s where it comes in.

    Disease as an act of God.

    I wonder if that’s where we fail? Does our nation see “natural” events differently than human events? I was going on the premise that natural events didn’t have malice behind them, they were within the scope of what a person could be expected to deal with in their lives; therefore these events were not within the area of responsability of the government. (Mostly because as soon as the government is paying for something, they want to control it – so as soon as the government gets involved in medical care, we will loose the right to decide what’s best for ourselves. It’ll stop being Uncle Sam Wants Your Help, and start being Daddy Sam Knows Best So Shut Up And Hold Still.)

    Right. Topic. Disease = normal and within scope, while assault by another person or nation was *not* within that scope and so was the legitimate purview of the government.

    The End.


    This is a diversion, and my main point is done, so feel free to stop reading here.

    I want to point something out.

    Not everyone feels the government ought to protect us from other people.

    I’ve learned some stuff from living in Australia. It’s a wonderful beautiful country, and mostly people live in safe, lovely homes, and nobody is allowed to own guns, and violence is mostly confined to a few drunks and criminals.

    Except in my town, where violence is endemic at night – and sometimes during the day – or really, anywhere you’re mostly out of sight of people. And yet the populace of this town, like the rest of Australia, live under the assumption that the average individual is both not responsible enough to own a weapon and not responsible for their own protection. They honestly feel that a person should not need to protect themselves in any fashion. That’s the government’s job, not yours. The fact that in this town the government is failing to do so does not seem to be changing their minds; they get raped and beaten and sometimes murdered, but cling to the concept that the government ought to be the ones taking care of this mess. God help anyone who says “maybe we should have pepper spray”, too – that’s just meeting violence with violence and perpetuating the problem!

    In the US, it’s presumed that everyone is smart enough to own a weapon unless they’ve proven otherwise by committing a crime. It’s assumed that you have the right to defend yourself – even an obligation, in some cases, such as when you go wandering out into our vast bear-infested tracts of untamed land. In the US, as a society we’re only partly dependent on the government for self-defense. We take some of that responsibility onto ourselves. We rely on the government for prosecuting criminals, and storing them for a while; but we don’t always assume that the police are going to be there all the time for everything we need.

    Coming from the US, I honestly did not comprehend the difference between the two attitudes until last year. Now I get it – it’s a demarcation line of responsibility. The Aussies hold the government responsible for more than Americans do. And in most places it works – but here it fails, and fails, and fails again – yet the insistence that the government “do something” remains. There’s a deep distrust of the idea of personal responsibility for any aspect of violence here, even the defensive sort.

    Perhaps that’s where American mainstream media comes in: we’re acclimated to the concept of personal violence in a way some other countries aren’t. We mostly have a framework of ethics to cope with it, and a clear understanding on an individual level of what sorts of violence are acceptable and what are criminal.

    Lately this seems to be breaking down – lately, as a society, we seem to be relying more and more on the police, less and less on ourselves.

    It seems to me like a social reversion to childhood. Part of being a grown adult is recognizing where responsibility lies. We are all responsible for ourselves and our children, in every respect – actions, care and feeding, social roles – until said children become adults themselves. To say you can’t care for yourself by yourself anymore is to give up part of that adulthood, to trade it off for safety.

    A hundred years ago, we assumed that we would die, that death came regardless of age and income, that some diseases were incurable. Today we have much higher expectations from medicine, and the mechanism which supports those expectations – hospitals, specialists, equipment – is both enormous and expensive. Too expensive for any one person to manage. Too expensive for any one family to handle. So we use insurance to distribute the cost around a group, betting that only some members will accumulate those costs at any one time.

    It actually seems to be coming down to an old sci-fi trope, when you simplify the definitions. Insurance and the medical industry are the pill that extends your life. Literally, in this case – access to modern medicine extend our lives by decades. But it’s expensive, and only some people can afford it wight now. So what do we do with it? Do we make everyone pay, and give it to the masses? Or do we leave it as a product, and give it only to those who can pay for it?

  6. Dmart says:

    Based on this post and the discussion so far, I think you should write about politics MUCH MORE OFTEN.

  7. braak says:

    @Wench: But, why shouldn’t we apprehend person-to-person violence as part of the scope of the natural world? It is, after all, natural. Moreover, it’s likely, and, double-moreover, the means to “prevent” it are readily available. Not only that, but we do offer certain protections against the natural world; we’ve got an entire branch of government that, at least when it works effectively, is meant to offer aid and recompense to people who are the victims of natural disasters–under the hypothetical premise, I assume, that a society in which everyone is alive is likely to be a more functional society than one in which most of the people are dead.

    And, while I can understand your position, consider Philadelphia: we were, for about two years running, the murder capital of the country. We’re still near the top, I think, but the explosion of unsolved homicides has kind of petered out at this point. When Philadelphia wanted to make additional restrictive gun laws to prevent unlicensed handguns from proliferating around the city, the state of Pennsylvania denied them the right. When legislation was introduced into Pennsylvania to add restrictions to the sale of firearms in the state, it was rejected.

    Why? Was it because the belief that individuals ought to be responsible for themselves, and if they were worried about gun violence, they should just get guns? Possibly, but this seems more than a little impractical; there are actually a select few circumstances in which having a gun will actually prevent you from being killed by someone else who has a gun. And, plainly, the proliferation of guns did not actually reduce the number of people who got shot–there’s guns all the shit over this city, and people were still getting shot.

    We weren’t permitted to restrict handgun ownership (in this case, actually it was a restriction on licensing, not really on owning) because of a mindless devotion to the Second Amendment, which is actually rooted in a kind of paranoia about the government: we, as citizens, need guns in order to protect us from fascist death squads, or something. I don’t know, precisely, because it’s never really happened; even if the stories about what happened in New Orleans after Katrina are true, Louisiana has some of the least restrictive gun ownership laws in the country, it’s got two handguns for every person, and still well-armed and organized armies can basically do whatever they want.

    (The fact of the matter is, despite America’s belief that everyone is smart enough to own a gun, Americans are NOT smart enough to own guns. We aren’t even smart enough to own cars, which are actually the leading cause of death in the US.)

    But this is kind of beside the point, because the idea that the government is meant to be–even if only partly–responsible for its citizens’ well-being is firstly: written into the constitution; and, secondly, predicated under a notion that when it can be reasonably expected to take action, when causes and consequence are clear and straightforward, it is within both the powers and purview of the government to take certain actions to prevent harm to the citizenry.

    The fundamental question that you describe is true, but I’m still not altogether sure why there’s a question about it: the government refusing to make health insurance available is as much a way of interfering in the lives of individuals as making it available. That is, the act of refusing to make it available is tantamount to the act of choosing to restrict it, since we have the means to make it readily available. The only circumstance in which, based on the way we currently treat moral issues of individual life, we should NOT make it readily available would be under circumstances in which we could not do it effectively.

    Finally, I object to the idea that demanding that government protect individual safety represents a reversion to childhood; there are actually enormous practical reasons to establish a society in which individual members aren’t required to be constantly afraid for their lives and to defend themselves personally–the desire for government intervention is only childish if you actually think of it as a parent, as opposed to an organization that you pay for and that you help manage in order to intervene for the purpose of achieving practical social effects.

  8. Lord Wackadoo says:

    Has anyone yet suggested that we send our most terminally ill and morbidly obese to the front lines on the war on terror?

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