Friday, May 11, 2007

Opposing Universal Health Care On The Basis That It's A Service?

Over at MedRants, Dr. Centor has posted an essay suggesting that universal health care is wrong because it involves the provision of services as opposed to, for example, guaranteeing a freedom.

The essay first asserts that recognizing a right to services would be a "positive right", with a finite supply of service providers unable to fulfill an unlimited demand. I don't dispute that, but it is no different from any other service we expect from government. For example we expect the government to provide police and fire services, but nobody realistically expects those services to be without limit. The notion that we would not impose any limits whatsoever on health care is a red herring - no nation, no matter how broad their national health plan, provides unlimited health services, and I have yet to see a serious health care proposal which calls for unlimited services.

The essay next asserts that to recognize a right to health care services would depart from traditional notions of morality.
We acknowledge an obligation to help the needy, but that obligation is unconditional only in certain circumstances: with family-members, people we have previously agreed to help, or certain kinds of immediate need that appear in our presence—such as the child drowning in a puddle as we’re passing by. If we had more general obligations to aid strangers that were absolutely unconditional—if we HAD to give our money to the street-person asking for it once we confirmed that he needed it to gain something he had a right to—our own negative rights to choose what to do with what is ours would be nullified; a conclusion most of us could not accept.
This argument is again a red herring, given that we already extend significant benefits to the poor through a wide range of government programs. It also confuses legal duty with moral duty. While we may not have a legal duty to assist anybody with whom we do not have a status relationship, we traditionally have recognized broader moral duties. Consider, for example, the long tradition of provision for the poor as practiced through religious institutions, whether through food aid, shelter, counseling, legal assistance, or (yes) charitable hospitals. My grandparents took considerable pride in the fact that their church would provide food, clothing and shelter to any passing vagrant who made the request, without any further regard for whether that person was "deserving" of the charity.

At its heart, this argument is that the poor are undeserving of medical care - that if you can't get good health insurance coverage from work, and can't afford to pay out of pocket, you should suffer through whatever health consequence comes your way. That's not good public policy given the possibility of contagion, but also because of the fact that if you create a context in which the poor cannot get treatment for disabling, debilatating, degenerative, or disfiguring conditions, you all-but-guarantee that they and their families will remain impoverished.

The author does recognize a "a conditional and limited duty to help" the needy, but in such a way that service providers are unaffected. That is, his greatest fear seems to be that any national health plan "not to endanger production and nullify the negative rights of producers" - which I read as a somewhat nuanced way of saying, "If you do this, make sure my salary doesn't go down." And at its heart, that seems to be author's fear - that a national health care plan will result in lowered physician compensation as one of the mechanisms of broadening supply while containing cost. Our "private" system already does this, as do Medicare and Medicaid - most medical care is provided within the context of that false market, with the insurer negotiating or dictating rates paid for particular services, so apparently the concern is one of degree.

I note that this doctor is silent in regard to the common practice of billing uninsured patients significantly more for the same service than would be paid by an insurance company. Can anybody point me to a similar physician's lament of national health care, which also acknowledges the unfairness of a system in whcih the poor, uninsured and underinsured often pay more for health care than wealthy, insured people "pay" (through their insurance)?


  1. To some extent at least, the problem is two-fold. The health care providers don't want a "reduced ability to charge" (which you address in your essay) and the people who do want universal health care don't want to see a "reduced right to services" which seems to be what happens with universal health care (either through a rationing of the types of services available, a la Oregon or a rationing of the quantity of services which results in the chronic long waits complained of in England.)

    I still think we need to scrap the whole "quality of care" system we now have in place and allow for the use of "nonphysician" driven systems. (Most of the PAs I have worked with in the past were more than adequate to the tasks assigned and were honest enough to "hand off" when they were not.)


  2. There is no shortage of service providers in England, provided you are willing to pay for the services out-of-pocket or through private insurance. (More details here.)

    Waits, unfortunately, aren't normally associated with the types of service a P.A. could be expected to provide. The waits tend to be for medical imaging studies, limited by the number of machines available, and for surgical services.

  3. Sorry if I wasn't clear, I was pushing the PAs as a way to keep the current "quasi-private" system but lower the costs. Not as a way to reduce the length of the waits under the socialized system.

    It was interesting to see the Canadian journalists take on the new Michael Moore movie on health care in America . . .


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