OK, some of the conservatives who are arguing to repeal the ACA are heartless opportunists. But all of them? Probably not. So, what mindset could possibly justify such an action?
Let’s start here: Do you believe that everyone deserves to own a car? Not just that they have the right to purchase one if they can, but that they have a right to have a car, and if they can’t afford it, then it is up to us, their community, to provide it.
Keep in mind that if you answer “No, people don’t have a right to car.” then some people, probably a lot of people, will go without one. And that means they will not be able to get a good job that requires a commute. They won’t be able to take their children to enriching after school programs. If they need to go to see a doctor right away, but not in such a hurry that they would call an ambulance, they will have to spend hours on public transportation while they are sick. They will feel undervalued by a society that glorifies car ownership, and the joy and freedom and convenience that it brings.
Not convinced? Me neither. Car ownership isn’t a right. (It does, however, point to a responsibility on our part for good mass transit.)
When you decide some good or service should not be available “by right,” you are accepting the fact that some people won’t have access to that good or service. That is what happens in a marketplace. Some people win and some people lose.
And that isn’t just a side effect of a market. That is crucial to the good functioning of a market. It is the competition to win, to avoid losing, that stimulates the best response from the marketplace, that creates the efficiencies for which markets are praised. If there are no losers, then the market won’t produce what it promises – efficiency and a promotion of liberty. (More on this can be found in earlier blog posts on “Vouching for healthcare,” parts 1 through 5. These were posted in September of 2015 through June of 2016.)
So, now think like a conservative. You don’t believe that the government has a responsibility to provide health care to everyone. It is not a right, but a service to be purchased in a marketplace. This will mean that some people have less healthcare, and some people will have more. Losers and winners. Since you are not heartless, you will be in favor of some kind of “safety net” so that the worst off are taken care of to some extent. But it can’t be an extensive governmental program or you won’t get the benefit of the marketplace.
And it is those benefits that you want very much to achieve. You want to lower the price of health care, increase the quality of health care, and, overall, create a better match between the true needs of health care consumers and the health care that is available.
If people compete for health care, this will stimulate health care providers to offer care at a lower price. It will also encourage providers to offer better care, care that is most appropriate and of higher quality. By empowering the health care consumer, we get higher quality and more appropriate health care at a lower price.
And some health care providers will get very good at giving high quality care at a reasonable rate. They will expand their capabilities, thereby employing more people. And their increased size will bring economies of scale that will benefit their employees, their investors and everyone who purchases care from them. The benefits of a marketplace trickle down to all of us.
Unlike manufacturing, where the benefits of bigness were shipped oversees and trickle down in other countries, health care is confined to a locale, so the benefits of the marketplace will accrue to the specific community where the care is given.
Health care costs are rising at two or three times the rate of inflation. We pay the most (by far!) of any rich country for our health care, without a corresponding increase in the quality of our lives. In fact, cheaper care in a number of other countries produce better results. A well-meaning conservative would argue that we could lower health care costs and increase the quality of our health care outcomes by empowering the consumer, by eliminating the government programs for health care and returning it to the marketplace.
The cost to society of these benefits is to accept that some people will not get sufficient care. But, to use a cliche, the fact that some people will suffer from a lack of health care is not a bug, it is a feature of the marketplace. It is the price we pay for all of the benefits we reap from returning health care into the marketplace.
You and I accept the idea that some people’s lives will not be as rich as ours because we don’t give everyone a car. A conservative believes that we, as a society, would be better off if we accepted some health care disparities in return for lower costs and higher quality.
That is why the central issue of this debate has to be “Is health care a right?” If so, then the community, through its agent, the government, must assure that everyone gets care. If not, then we are left to fight over how much disparity we can accept.
I think American public has made clear to Congress that they aren’t willing to have millions of people, real people, our relatives, friends and neighbors, lose their health care in exchange for the illusive promises from “returning care to the marketplace.” And I think Americans are very, very close to accepting the idea that health care is a right, not a privilege.
By the way, keep in mind that the ACA, even when fully implemented, was going to leave 30 million people in the US without health insurance. By passing the ACA, we as a country decided that we could live with one of out ten of us not having care. How did that happen? In part, because people didn’t understand that this would be the result, and in part because we didn’t have the public discussion in 2009 about whether health care was a right.
Yes, some of the players in this drama are mean-spirited and heartless. Shame on them and their supporters. But some conservatives think they are doing what is best for society as a whole. They are wrong in two ways. First, health care doesn’t work well in a marketplace. And, more importantly, it is a birthright that the community should promise to every child born. This means that markets are a very bad way of assuring that everyone gets care. (Evidence – the one big problem with the ACA is the health insurance exchanges or marketplaces.)
Ultimately, if we engage in the debate over whether health care is a right, we are going to have to face the question about where rights come from, which many of my liberal friends don’t want to talk about. I have proposed to start that uncomfortable conversation at the next annual meeting of the American Public Health Association. Lets see where that leads.
Addendum as of October, 2017: My proposal to talk about "where a right to health care comes from" was rejected by my colleagues in the Ethics Section of APHA. That is the fourth time I have tried to have this conversation at the APHA Annual Meeting, and the fourth time it has been rejected. I give up.
