Wednesday, August 12, 2009

Jerry Pournelle: The Health Care Debate

I think this is an interesting perspective and worthy of consideration. He presents several hurdles we must to overcome with our plan.

- Steve


The Health Care Debate

The health care "debate" has become frantic, which probably means that it will fail just as Hillary-care failed. It's just as well. Whatever one thinks about the obligations of the society to provide "health care" -- and the definition of that term is probably the key issue -- it's pretty clear that it isn't going to be solved by rushing things through. When the Clintons tackled this problem they tried to assemble a brains trust to come up with a comprehensive scheme. That didn't work, but at least there was a unified plan. Handing this problem to the rapacious wolves in Congress and telling everyone to rush along, pass enormous and complex laws with provisions stuck in by anyone who can manage to get into the room, is almost certainly not the proper way to allocate 15% and more of the Gross National Product.

The "debate" will go on, and get even more rancorous; it's not over. It will probably fail this time, but even that's not assured; and the hydra will be back another time. There are too many people who "feel" for those without health care, and who haven't thought a lot about the consequences of the various plans.

One problem is that definition of "health care". There's another problem with the notion of "insurance." The demand for a free good is infinite: you can't just say "everyone is entitled to health care without limit." There is no end to what one can do with enough money. If a study shows that having a private room with 24/7 professional nursing care gives one a better survival chance -- as it almost certainly will -- there will be no lack of lawyers willing to sue on behalf of the poor and homeless demanding that if anyone gets that kind of attention (even if they pay for it themselves) then everyone ought to have it. If a kidney transplant is good for the rich, is not everyone entitled to it? What about pacemakers? What about new procedures? Universal health care without limit is a free good which will generate infinite demand. There have to be limits.

How are those to be set?

Free people are not equal and equal people are not free: if I cannot spend more on health care than you even though I have the money, that is a limit to my freedom and liberty; but if I can, then that is an infringement of equality. If I can't afford it, why should you have it? The pressure is toward equality over freedom in matters of health and life. Without infinite resources this conflict is inevitable.

As to insurance, think about the notion that there is to be no exclusion or increase in premiums for pre-existing conditions (that seems to be common to all the proposed plans). Obviously under that situation the optimum strategy is to keep your money until you get some catastrophic disease, then rush out to buy insurance.

The solution to that, we are told, is to require that everyone buys insurance. That creates the pool from which payments will be made. The pool will be finite: there is sure to be more demand than the pool can cover (at least it has always been that way, and we've been shown no counter-examples). That means limits -- rationing. How will that rationing be accomplished? By whom? Using what criteria? Will we forbid some highly expensive procedures? If not, who gets them and who does not? Those are complex questions, and rushing in to pass a bill that hires a bureaucracy to figure it out is probably not the solution. From all evidence, bureaucrats will work for their own benefit first, then that of their clients -- nearly every bureaucracy that ever existed has worked that way, so why should this one be different?

So there we are. When there's a real plan with real answers and mechanisms (as opposed to a set of goals and hopes) we can consider it. Will most of us be better off under it than we are now? It is certain that SOME will be better off under the various proposals, but who and how many isn't anywhere near obvious until we have an actual proposal in hand. It may be that most of the middle class will be worse off for the benefit of the poor and homeless (and the bureaucracy). We can then decide. But surely it will be better to know just who benefits, and how, and what the costs will be?

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