Health & Healthcare

I was inspired by a recent online discussion (discussion is being charitable), to put some of my disorganised thoughts on healthcare down in something close to a coherent form. Well after finishing, I hope it can be described as such.

I honestly never gave much thought to healthcare as a political issue prior to it becoming a major issue in the United States during the Obama Presidency. This is mostly because publically funded healthcare is just assumed to be the role of government in most modern countries and the debates usually come down to how much funding/reform is needed in the system as it is. As such the the discussions (again, being charitable), in the US were very interesting because it was the first time I began to think about whether publically funded healthcare was a good idea in any form. This led me briefly to the hard libertarian perspective but I have since been slightly drawn back from this.

The first thing to get out of the way are the false dichotimies and the horrible hyperbole that goes around when it comes to discussing healthcare. For example the idea that healthcare reform is the choice between helping people and/or allowing them to bleed to death on an emergency room floor. The idea that if you don’t support public healthcare you simply don’t care about the livelihood of your fellow citizens. I have actually heard this sort of thing and some of the propagnda (as in memes), that you see really is ridiculous. So if I am going to discuss it with anyone, I am definitely going to avoid people who can’t think past the current framework and especially the more hysterical.

The next thing is to define terms a bit. I have used “publically funded” and by this I mean that healthcare is provided to all through tax revenue. I mean systems like the NHS, Medicare (Australia) and whatever you would call the Japanese system in English. These systems vary but they all have similarities. This isn’t my original observation but I certainly think it is wrong to call this “health insurance”, simply because it isn’t insurance in any sense of the term. To illustrate an example, covering what is described as ‘pre-existing conditions’ cannot be properly called insurance. You can’t insure against something that has already happened or exists. Misleading with semantics is the same as lying and I won’t do it.

Somwhat related to this and important to get out of the way is what is commonly referred to as ‘Obamacare’. One of the things that became clear (and extremely irritating), as the debate in the US raged on was the sides people were taking, between the system as it was and ‘Obamacare’. Looking at both I was quick to curse a plague on both houses. Both were obvious monstrosities of competing interests and neither arrangement was anything like how it was defined. The system that existed prior to Obamacare already had legal obligations that had to be followed and Obamacare as it exists is nothing like systems in other countries. What’s worse is the proponents seemed to know this and wanted it anyway. It was all a horrible, horrible mess and I doubt if more than a handful of people commentating on it from any side were actually familiar with the thousands of pages of legalese that made up the legislation.

Apart from those of a libertarian bent, there is a lot of support for public healthcare on the political right and especially the alt-right. It is also an uncontroversial subject among mainstream conservatives in countries like Australia. In Australia, any minor suggested reform will result in some of the invective mentioned above. Part of this support seems to be pragmatic as it is an issue that the general public is very concious of. So regardless of one’s views, it is pretty much a no-go zone to any politician subject to the electoral cycle. This seems to be increasingly the case in the USA too. So if only for pragmatic reasons, publcally funded healthcare is increasingly a bi-partisan issue.

Like with many issues, this leaves me in an extremely lonely position but one I’m still happy to defend. Something I tend to think of a lot on big issues is the long-term consequences of actions. In the world we live in with short-attention spans, non-stop entertainment and seven day shopping weeks; only a three to five year election cycle seems like a long time. So when I consider issue, I want to think not about whether it will work now but whether it will work in fifty or one hundred years. The same thinking that should come with making any major life decisions.

The problem with almost anything that is publically-funded is the new incentives it creates. First on a person to person level. So everyone who works is paying into the system and paying blindly. So for example an obese alcoholic with the same income as a vegetarian marathon runner will be paying the same amount into the system. But one will likely be costing the system a lot more than another. This is repeated millions of times with billions of variations in any large population. The practical result is that people who show personal restraint with their health  will be paying more to cover those that do not. Most people (including me), would be okay with the system if the money going in was going into a pool to help those that genuinely need help such as those who have disabilities whether by birth or by accident. In practice, it will also be subsidising and therefore incentivising poor lifestyles. Though not completely, it lessens the consequences of bad choices and can possibly even reward these choices. You can tell people this but as mentioned, due short attention spans and the impersonal way the system works, it is hard for people to fully understand. It will take a long time to see the consequences.

The next problem is the incentives created within the medical profession itself. I don’t hear people talking about this much but it could be even worse than the above. The major problem is incentives made with costs. If you are guaranteed to have your bills paid then there is little incentive to lower costs and every incentive to increase them. Likewise, there is an incentive to keep patients coming back and indeed coming in whenever they feel ill. Exactly the same goes for pharmaceuticals. I will endevour to avoid personal anecdotes but I have certainly observed this in Japan. I won’t go into specifics but I had a procedure done that required me going under general anesthetic. It was unusual for someone my age to have this procedure and despite a result showing no serious issue, I was asked to come back in a year to have it done again. So although I was in fine health and I was at low-risk due to my age, I was still given medical advice to undergo it again. The only person that benefits with this is the one receiving the cheque.

Coupled with the incentives and disincentives and resulting corruption is that such a system discourages innovation. There is no incentive to drive down costs and equally no incentive to improve health or in the worst cases – to create anything that would genuinely eliminate an illness. Someone might point out that medical advances are still regular but I would point out that the USA still has a robust private industry and that many countries have a private system for those that can afford it. Like everything I am talking about here, I am considering long-term and not short-term.

Another major problem is something I used to hear Mark Steyn repeat often and that is that it fundamentally changes the relationship between the citizen and state. Some might claim that it doesn’t but if the state is paying for your health, then they have a say over what you do with your body. It may be politically unhelpful to say so but it doesn’t make it any less true. All the talk of personal rights such as with a woman’s right to commit infancide are lost when you sign over your healthcare to the state. It may not be exactly the case now but the government will have more incentive to legislate with regard to your food consumption, lifestyle and considering how health costs sharply rise with age, eventually over your life itself. It is already arguably so in some countries.

Lastly there are a potpurri of other problems. One is the emergency room which will be a hectic place at the best of times. Even in countries with publicly-funded healthcare, people do bleed out on emergency room floors at times and many other bad things happen. Speaking of Australia I know that each weekend sees some emergency rooms filled with drunks and drug addicts who can put medical personnel in serious danger at times. Then there are the perpetual problems of bed shortages, and demands for improvements; often asking the impossible. Then there are also the hypochondriacs and worry warts who clog up doctor’s surgeries and emergency rooms. The important thing to take from these smaller issues are that no system, however robust, will be immune from problems. No system will be ideal.

So what is my solution? My solution is ideally more organic. It certainly wouldn’t be a perfect system but neither are the current forms. An ideal system would be one that requires personal responsibility, helps the genuinely needy, encourages innovation and disincentives corruption. No system will ever do any of this perfectly. So I believe every family should be strongly encouraged to pay for genuine emergency health insurance. That is insuring against a catastrophy or contributing to a pool to cover for tragedies, accidents and disasters. I believe that anyone who is able should pay for their own care which would also encourage better habits. Doctors should be encouraged to offer free services to those who lack money as they reasonably can and charities should be empowered to also offer assistance as needed. In short, government healthcare would be a vastly reduced and simplified basic safety net for the most vulnerable citizens that would rely on charities and private businesses to keep it running.

This is a smattering of ideas and it doesn’t adhere to any specific ideology. It is simply one that I believe strikes the right balance for better and worse and more important than anything, would be a system that wouldn’t slowly become inefficient and unmanageable over the long-term as current systems are currently in the process of doing. Once again, it isn’t perfect but it is surely more sustainable than the ever growing and ever confusing monstrosities that exist now.

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