Sunday, March 13, 2005
Some musings about universal health care
One of the great disappointments of the 2004 elections is that, while John Kerry would have taken another presidential whack at universal health care, George Bush will keep his promise to pursue a health care policy of "if it don't help my friends, don't fix it."
I recognize health care is a complex issue, and one of the complexities is how to measure the quality of health care. I couldn't tell you whether the health care I'm getting now is better or worse than what I was getting in the good old days, whenever those were. What I can say is that dealing with HMOs is often very frustrating, and that I don't often feel not well cared for from a customer service point of view. When it's your own health that's involved, it's hard not to take that far more personally than, say, lousy service at your auto mechanic. Still, bad customer care is not always the same as bad health care.
My guess is that, when push comes to shove, the main popular resistance to universal health care (opposition in public opinion, as to opposed to opposition from the private health insurance lobby) boils down to inegalitarianism. Sure, there's a lot of rhetoric about being able to choose your own doctor, and avoiding bureaucracy in getting treatment, but the predominance of "managed care" in our current system is making those aspirations a thing of the past even in the absence of a universal health care policy. The real underlying objection is the strong belief that people with more money deserve better health care.
The gut level opposition to universal health care is a fear that a universal system will raise the health care floor, while lowering the level of care available to those better off. This fear is not at all irrational – assuming that high quality health care is a scarce good, people with more money will only have guaranteed access to it in a health care market. If health care were distributed in a more needs-based, rather than means-based way, this guarantee (more money equals better health care) is eroded.
Why this should lead to objections from the great middle class rather than, say, the few percent of Americans who benefit from the Bush tax cuts, is as great a mystery as why many of those same folks vote for Bush and in essence place a stamp of approval on his tax cuts for the wealthy. We can speculate and say either that (1) a large percentage of folks in, say, the 35th income percentile on up are exceedingly optimistic about their chances of winning the lottery one day; or (2) many middle class Americans place themselves above the health care tipping point – the level of health care quality at which a decline would be experienced as more resources go to less financially well off Americans. It's a rational fear made irrational by a total lack of information about the two most relevant data – where is my health care quality on the spectrum of health care in the U.S., and where is the tipping point?
It's interesting (and I admit, wholly unoriginal) to think about the underlying justice issue. On some level, this aspect of universal health care is a smaller piece of a larger social contract that guarantees the value of financial wealth. Wealth means superior access to the good things in life, and a financial system of wealth means that those good things must be for sale in a market. Good health and a longer life are "good things." To offer good health and longer life on an egalitarian basis, irrespective of wealth, diminishes wealth somewhat. Any social good distributed on an egalitarian, rather than market basis, becomes something that "money can't buy" and thus reduces the purchasing power of financial wealth.
What's the point of being rich if you can't get better health care? What's the point of being middle class if you can't get better health care than poor people? There are probably only two versions of health care distribution that our society can tolerate: the plane and the boat. Our current system is probably like a commercial jet liner: first class for the rich, coach for the middle class insured, and the poor just can't afford to fly. Universal health care will be, at best, an early 20th century ocean liner: 1st class, 2d class and steerage.
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I recognize health care is a complex issue, and one of the complexities is how to measure the quality of health care. I couldn't tell you whether the health care I'm getting now is better or worse than what I was getting in the good old days, whenever those were. What I can say is that dealing with HMOs is often very frustrating, and that I don't often feel not well cared for from a customer service point of view. When it's your own health that's involved, it's hard not to take that far more personally than, say, lousy service at your auto mechanic. Still, bad customer care is not always the same as bad health care.
My guess is that, when push comes to shove, the main popular resistance to universal health care (opposition in public opinion, as to opposed to opposition from the private health insurance lobby) boils down to inegalitarianism. Sure, there's a lot of rhetoric about being able to choose your own doctor, and avoiding bureaucracy in getting treatment, but the predominance of "managed care" in our current system is making those aspirations a thing of the past even in the absence of a universal health care policy. The real underlying objection is the strong belief that people with more money deserve better health care.
The gut level opposition to universal health care is a fear that a universal system will raise the health care floor, while lowering the level of care available to those better off. This fear is not at all irrational – assuming that high quality health care is a scarce good, people with more money will only have guaranteed access to it in a health care market. If health care were distributed in a more needs-based, rather than means-based way, this guarantee (more money equals better health care) is eroded.
Why this should lead to objections from the great middle class rather than, say, the few percent of Americans who benefit from the Bush tax cuts, is as great a mystery as why many of those same folks vote for Bush and in essence place a stamp of approval on his tax cuts for the wealthy. We can speculate and say either that (1) a large percentage of folks in, say, the 35th income percentile on up are exceedingly optimistic about their chances of winning the lottery one day; or (2) many middle class Americans place themselves above the health care tipping point – the level of health care quality at which a decline would be experienced as more resources go to less financially well off Americans. It's a rational fear made irrational by a total lack of information about the two most relevant data – where is my health care quality on the spectrum of health care in the U.S., and where is the tipping point?
It's interesting (and I admit, wholly unoriginal) to think about the underlying justice issue. On some level, this aspect of universal health care is a smaller piece of a larger social contract that guarantees the value of financial wealth. Wealth means superior access to the good things in life, and a financial system of wealth means that those good things must be for sale in a market. Good health and a longer life are "good things." To offer good health and longer life on an egalitarian basis, irrespective of wealth, diminishes wealth somewhat. Any social good distributed on an egalitarian, rather than market basis, becomes something that "money can't buy" and thus reduces the purchasing power of financial wealth.
What's the point of being rich if you can't get better health care? What's the point of being middle class if you can't get better health care than poor people? There are probably only two versions of health care distribution that our society can tolerate: the plane and the boat. Our current system is probably like a commercial jet liner: first class for the rich, coach for the middle class insured, and the poor just can't afford to fly. Universal health care will be, at best, an early 20th century ocean liner: 1st class, 2d class and steerage.
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