I have spent significant time on this commentary section pointing out the flaws in the current health system and in recent reform efforts. And I ask myself constantly, do you have some better ideas? It is a complex problem, and in the next few posts I will do my best to provide a comprehensive but succinct set of ideas around health. To some extent the idea of a “health system” is descriptive and to some extent prescriptive. Even absent any external factors (really just governmental payment and regulation) there would be a system in the sense of an ability to describe common activities and features involved in how people address their health, and subsets of those activities and features for subgroups in the population. The presence of government payment and regulation implies a proactive effort to shape how health is handled. The bad part of this governmental effort is the unavoidable presumption that somehow the people who are leading it are so smart that they can come up with the best or even a good approach. This hubris is what continually undermines “reform” programs.
So when we think about health, the first question should be, do we really need a system in the proactive sense? We should honestly recognize that if we answer that question in the affirmative, we are implying that there is a good solution that a few people can design, a solution that is better than that which would exist solely from the interactions of individuals making their own judgments about how to manage their health. While it realistically be too late to go back to that pure market approach, understanding the fundamental limitations of alternatives is critical. Any intentional effort to create a health system is subject to ever-present human limitations. We aren’t that smart; we can’t predict the future effects; one size does not fit all. That leads me to conclude that any government interference in the otherwise free interaction of individuals in regard to health should be limited to the absolute minimum necessary to achieve whatever objectives government thinks it is trying to accomplish.
So what should be our objectives as a nation, a group of individuals residing in the same geography and who have created and maintain a societal governance structure, in regard to health? Presumably we should want each individual to be in optimal health, and to receive the health services necessary to achieve that goal. And already we see the tensions between different values. Why should “we” collectively have anything to say about what anyone else does in regard to their health? What if someone wants to be in poor health or wants to engage in activities which will certainly cause their health to deteriorate–smoke, drink, use recreational drugs, eat too much of the wrong food, ride a bike or motorcycle without a helmet, etc., etc. And our responses are wildly inconsistent, careening between paternalism and libertarianism. We have the absurdity of trying to stop people from eating trans fats or drink large sodas, while at the same time we allow tobacco and alcohol use and increasingly the use of THC, even as studies make it clearer that that substance has very negative health impacts.
Those who think we need substantial government intervention in health hold a fundamentally paternalistic view–people are too weak or ignorant or whatever to make their own best judgments in regard to their health. As a subsidiary justification, they would suggest that some health behaviors may have negative effects on others–getting drunk and driving a car is an obvious one. And when government isn’t just regulating health behavior, but is also paying for some health care, these poor health behaviors can act as a tax on other individuals. Those who hold more libertarian views are supportive of individual’s right to engage in whatever behaviors they choose, regardless of consequences to themselves. This group is less clear on how to handle the impacts on other members of the society. And both groups tend to be willing to protect individuals from the financial consequences of their own poor health decisions.
If we think we are going to have proactive health system, these tensions need to be dealt with forthrightly and stated as basic assumptions and principles for the system. In my view, people should generally be able to engage in whatever health-impacting behavior they want to. We should ensure that people are fully educated about and aware of the negative consequences of those behaviors. And we should make individuals bear the full financial and other impact of those decisions. Want to smoke tobacco–better figure out how you, not other people through the insurance or tax system, are going to pay for treating lung or throat or other tobacco-caused cancers. Want to ride that motorcycle without a helmet, better know how you will pay for a lifetime of care when you become paraplegic after an accident. And so on. The only way for people to be encouraged to act more “responsibly” is if they know they will bear the full financial consequences of their behavior and they see examples of what happens when people are put in that situation. It might be ugly, but as long as we see people constantly bailed out, there is no incentive not to engage in the same behaviors.
And if a person’s health-related behaviors have a reasonable chance of imposing any material non-financial burden (non-financial, because the person should bear all financial consequences) on other people, then it should be regulated by government. No person has the right to put material burdens on another, health related, financial or other types. When we live in circumstances in which we constantly interact with others, there do have to be rules, agreed upon by all of us as a whole, that limit behaviors which may harm others. Once we collectively agree on these fundamental rules, values and objectives; then we can think about what a proactive health system, one which is regulated by government, could look like. More tomorrow.