Ideally, I would like to see free universal healthcare in the US. I don't give a rat's ass whether someone is "deserving" of it, or whether it's a "handout" (or, worse, a "government handout"); every free citizen1, no matter how "worthless", should be able to receive basic healthcare2 at some basic level regardless of ability to pay.
The problem is how to pay for it, which raises the question of how much it will cost. This in turn depends on what criteria we choose for our "baseline". Without further research, however, it's difficult to say what the actual costs for any given set of criteria would be; some measures which might cost more at first will produce savings in the long run (e.g. "preventive care") or even in the short run (e.g. a service that is universally available can be delivered more efficiently than one which is only available under certain circumstances because of the overhead involved in determining who is qualified and avoiding "cheating").
For now -- at least as a temporary measure, until a better solution either can be devised or evolves from the marketplace -- I think this should be paid for mainly by progressive income tax. (Our tax structure as of 2010 is insane, thanks largely to Bush's tax cuts for the wealthy plus two pointless wars.)
Free Market Solutions
As an anti-authoritarian and a fan of resiliency through redundancy in system design, I agree with the Libertarian view that decentralized, market-driven solutions often produce better results than ones that are centralized and/or government-run, and that it is worth encouraging development of such solutions.
I do not, however, agree with the popular Libertarian position that we should therefore (a) reduce government-run healthcare benefits rather than expanding them, and (b) de-regulate the healthcare marketplace to allow the "invisible hand" to magically create one or more solutions which will -- eventually and hypothetically -- provide affordable healthcare for all.
Consider the following:
- This has never worked when it has been tried. (Has it ever been tried anywhere besides the US? It certainly isn't working here.)
- A totally unregulated marketplace is no more a marketplace than an ignited puddle of gasoline is an internal combustion engine. A marketplace requires rules in order to operate, and someone has to enforce those rules. If you can come up with some mechanism by which participants in the market regulate it in a reasonable manner, I'll listen -- but I'm not going to just sit back and hope it will happen. (Also: how is that not "government"? How can we prevent "self-rule" from becoming as bureaucratic and abusive as the despised "government"? Show me a proposed design.)
- You don't move out until you have somewhere to stay. Libertarians always seem to be arguing that we should move out now so they can knock our house down, and that there's bound to be another (newer, better-designed, more efficient) one built pretty soon once the lot has been cleared -- no assurance that there will be room for us, much less that we'll be able to afford the rent.
"Were too disorganized to design a solution" is not a good response. "The Marketplace" doesn't create solutions out of thin air; it takes creative entrepreneurs and thinkers to come up with those ideas. When you can point at a solid-sounding idea or three which would work if only certain troublesome regulations could be removed or changed, then you have something to talk about.
Why It Isn't Working Now
The reason why the free market hasn't been able to solve the problem of providing universal healthcare under the present circumstances should be more or less obvious (to anyone but the deregulation-obsessed, I suppose): because the incentives are decoupled from the ability to choose.
I have all the incentive in the world to choose an insurance company that is affordable and yet will pay my claims in a reasonable way. However, I can't choose that company, for several reasons:
- Health insurance is typically tied to employment, and most employers have a contract with exactly one insurance company.
- I'm aware that some Libertarians are against this system too -- but wouldn't forcing companies to provide a choice of insurers require more regulation, rather than less? Or are there regulatory barriers which could be removed?
- The company I choose now -- assuming I'm in a position to do so (few people are, see point #1) -- may be the one which denies my claim 2 years from now. At that point, I become uninsurable (pre-existing condition), so my experience with that company no longer affects the market. Of those few who customers have any kind of choice, only those who have taken the time to carefully research the marketplace before choosing will affect it.
- It may be argued that it is the employers who make the "marketplace" decisions in this system -- but again the incentives for them are rather different. How much are their choices based on service quality and how much are they based on back-room deals?
Another area where incentive and choice are decoupled is in the actual services. If I'm in an emergency, do I get to choose which hospital to use? Which doctor? Can I get my bandages from Target instead of buying them in house for ten times the price? Yes, a lot of the time there is choice -- but the number of choices one cannot make overwhelms the number one can, and that is where the system fails to be a market.
A secondary reason why "competition" may be driving prices up instead of down is all the extra advertising the different insurance companies do in order to convince you that they are best -- without actually providing any data. If we were to make one regulatory change which might improve the situation without any direct expenditure, it would be to require insurers to quote the percentage of claims denied (or some other damning statistic) in every commercial.
Advertising for government-run care is not nearly so lavish (and often can be done more cheaply) -- and yet their services retain at least some accountability via the election process. Yes, that process has become broken lately... but we're all in trouble if it can't be fixed, so that's no reason not to design around it. Perhaps there could be additional channels of accountability build into the system -- did any of the foes of Obamacare suggest this as a compromise? I doubt it.
Creation of this page was inspired by this discussion on 2010-11-19.
Healthcare for the incarcerated is a separate matter, and doesn't seem to be a subject of much debate, so I don't really have any firm opinions about it yet.
Actually, I go further than that: I think everyone should be entitled to a basic level of food, clothing, and shelter. This applies even to people I personally find worthless -- if only so they can't use basic living expenses as a an excuse to panhandle. I want to be able to turn away panhandlers and charity-solicitors in the firm knowledge that they have a place to stay that is comfortable, humane, dignified, safe, and in all ways adequate to basic human needs.
Yes, we still have some way to go on the idea that the government could provide services that were humane and dignified -- but unconditionality would go a long way towards making that possible.