The Indignity of the Health Care Bill (A Reply to Wight)

Mark D. White

You beat me to it, Jonathan--I was going to wait until the president signed the bill, but since you said your piece, I will too.

Universal health care coverage is a laudable goal--or, to be precise, universal access to coverage is laudable, since health care insurance should always be voluntary, with individuals bearing the risks of noncoverage. But this bill attempts to achieve this goal in the absolutely worst way imaginable (short of complete state control, which is a long-run inevitability), sacrifricing not only voluntariness but autonomy and choice, responsibility, patient- and physician-directed care, and technological and procedural innovation--all of which would be provided by a more market-oriented system than we currently have, not the bureaucratic behemoth this bill creates.

With all due respect, Jonathan, utilitarianism is what got us into this mess, for two main reasons. First, the overwhelming emphasis on costs: saving money at any cost to choice, dignity, and health outcomes. Of course, markets are also driven in part by costs, but in markets individuals can always choose to bear higher costs if they choose and are able--this choice is made for them by some distant bureaucrat working on a spreadsheet. Second is the fact that utilitarianism neglects the process by which outcomes are arrived at--in case, most relevantly, the aspect of autonomous choice. Without the proper checks and balances, utilitarianism breeds social engineering, endorsing control over personal decisions by bureaucrats and regulators who "know better" what should be done (as was my main point in our paternalism debates), and removing more and more control over personal decisions for individuals themselves--and what decisions are more personal than those regarding the health of you or your loved ones?

Regarding rights serving utility, such rights are no rights at all. For rights to be meaningful, they must trump utility or welfare in at least some nontrivial cases. Without rights, we are all pawns in the hands of the powerful, even if those in power will elected democratically (hence, Mill's warning about the tyranny of the majority). And the cynical, instrumental use of rights language to drive a utilitarian agenda which neglects true rights based on dignity is a travesty.

Universal access to health coverage could have been achieved at (actually) lower costs, and keeping with the principles of choice, autonomy, and dignity, if the many state-created barriers and distortions in the health care market had been reversed: removing or restructuring the tax exemption on health care benefits that created employer-based health coverage (which ties people to inferior jobs for fear of losing their benefits), loosening the restrictions on interstate purchases of health coverage, and reforming medical malpractice law to make sure both patients and the doctors they rely upon are protected.

But as it is, under the current proposal the government will inevitably ration medical resources through price controls, introducing more distortions into the "market" for health care. Less talented young people will go into the medical field, and less resources will be devoted to R&D for new medicines and technologies. Financial burdens for patients will be transformed into time costs, and bureaucrats will play a growing role in determining who gets what treatment and when--all in the interests of controlling costs, taking into account lives, health, and choice only in terms of their imputed monetary value.

In short, the health care system did need fixing, but the answer was less government, not more--and certainly not this much more.