30th December 2011
Jerry Pournelle speaks some inconvenient truth.
Any discussion of conservative principles and health care has to begin with some facts. One of those facts is that the courts have in essence nationalized a form of universal health care: they have decreed that emergency rooms cannot turn people away for lack of insurance or other means to pay for the treatment they demand. Moreover, there is, I think, a general consensus among the American People that the spirit of this mandate is acceptable: people should not die in hospital waiting rooms while trying to prove they can pay. Of course that seldom happens, and often the treatment demanded is not urgently needed, but we are agreed that people ought not be denied emergency care.
That simple principle works with some populations with strong moral and ethical principles that include limits on what they think they are entitled to. It works in many American communities to this day. It may work in Massachusetts for all I know. It does not work in Southern California, where eleven hospitals have closed their emergency rooms, and the once world class trauma center network we had is nearly forgotten. The hospitals close their emergency rooms because they can’t afford to keep them open: the alternative would be to close the whole hospital. (Another alternative, triage in the waiting room doesn’t work and subjects the hospitals to crippling law suits. The Courts in essence won’t permit it.)
And that is the essence of the “health insurance problem.” Insurance is not welfare, and requiring equal premiums for all insured – granting the ‘right’ to insurance for those with pre-conditions at the same premium as those in good health – is not insurance at all. The obvious strategy for those with crippling pre-conditions is to buy the insurance, while for those in good health it makes sense to buy no insurance at all until symptoms appear, then rush out and buy it. Given that rational economic strategy of the customers, the obvious rational strategy of insurance companies is to declare bankruptcy, and for their executives to get into some other line of work, possibly as welfare administrators.
The reductio ad absurdam of this process is something like the National Health Service in Britain, where health care is a universal right, health care workers are employees of the government, and everything is as efficient and cost-effective as the United States Postal Services. Whenever the government gets involved, the process becomes politicized, and what’s right perforce gives way to the outcome of political power relationships. The poster child for this is Detroit, that bastion of civilizational success.
Health Insurance became widespread largely because it was a way for employers to compete for good workers during a labor shortage in a time of wage controls: the business could deduct the insurance payments as a cost of doing business, while the insurance benefit was not taxed as income for the laborer. The result was widespread insurance among the employed, and that led to the situation of establishing one’s insurance status when being admitted to hospital – and that led to the horror stories of people dying in the waiting room while filling out forms. And that made health insurance a political problem.
But the political problem never really addressed the question: Who must pay for what? What are you obligated to pay for my health problems?