When discussing the politics and ethics of health care policy and reform, one often hears claims or suspicions about the “special importance” of health care. To my mind, the strongest suspicion can be expressed thus: health care is of special importance because of the special importance of health; health is important because of all the important goals it enables us to pursue; but if health is instrumentally important in this way, it must sometimes be rational to trade health off against the other goods and goals that give health its value in the first place; but if such trade-offs are rational, what business is it of the government to require individuals to pay some bureaucratically-determined amount for health, when this has opportunity costs for the other goals individuals can pursue?
This is a strong argument. But there are also strong rebuttals. It is widely understood, for example, that if you enable individuals to choose their own coverage levels, those with high risks or perceived high risks will gravitate to generous coverage, which will drive up the price of that coverage, which in turn will give those with low risks an incentive to buy other, less generous coverage. This drives up the price of the generous coverage even more, since such a high proportion of individuals with that coverage will end up needing to draw on it to pay for medical care. To avoid this so-called “death spiral,” laws are needed to keep healthy people’s dollars in the same insurance pool as sick people’s dollars, so the former can be drawn upon when the latter are not enough to pay for the care the sick need.
This is a successful rebuttal to the conservative argument only if it is indeed justifiable to force those with low health risks to subsidize, out of their income, the medical care of those with higher health risks. This is a values question par excellence. Answering it requires us to explain why certain groups of people have legally enforceable duties to certain others. It may also require us to subject the prevailing income distribution to moral scrutiny, since those with higher risks might not need the assistance if their income were higher. Providing health insurance may therefore be an instance of using one policy arena to compensate for imperfections in another. Answering the values question would also require us to explicitly address the restriction of liberty entailed by a system that forces one group to subsidize the medical care of another. These are perennially nettlesome issues.
Some health care commentators seek to side-step these questions by having us focus not on the special importance of health or health care, but rather on the “point” of health insurance. Here is a recent example from the only health policy blog I read religiously:
[L]et’s permit insurers to design their policies free of ObamaCare’s mandated benefit levels and free of state regulation [...]
What’s the first thing the new nationally-chartered insurers would do? Rush out cheap, high-deductible policies, allaying some of the resentment that the mandate provokes among the young, healthy and footloose affluent. [...]
[T]hese folks could buy the minimalist coverage that (for various reasons) actually makes sense for them. They wouldn’t be forced to buy gold-plated coverage they don’t need so the money can subsidize the old and sick (the hidden tax logic of ObamaCare).
This goes the wrong way in two respects…[...]
Second, what is it that people think they’re buying when they purchase insurance? If it’s not a vehicle for the healthy to subsidize the sick, then what’s the point?
Did you catch it? Here’s the argument (as I understand it) set out more explicitly:
1. Opponents of government intervention in health care markets object to measures forcing some to subsidize the medical care of others.
2. But virtually everyone, including these opponents, wishes to purchase health insurance in some form.
3. But insurance just is a vehicle for the healthy to subsidize the sick.
4. So to be consistent, opponents should either withdraw their objection to redistributive health care policies, or else refuse to buy insurance.
Is this a good argument? I will return shortly to examine it more closely. For now, let me leave you to ponder an argument that strikes me as intriguingly similar :
1. Opponents of income maintenance policies maintain that they should not be forced to pay for another’s wages/income.
2. But opponents of income maintenance policies buy televisions without complaining.
3. But the purchase of televisions just is a vehicle for some (namely, those who buy TVs) to pay the wages of others (namely, those who labor to make televisions).
4. So to be consistent, the opponents should either withdraw their objection to income maintenance policies, or refuse to buy televisions.
What say you? Do these two arguments stand or fall together? Or is it possible to reject the Television Argument while continuing to embrace the Point of Insurance Argument?