Picketty Called It -- Part II

OK, why the social state?  A quick answer goes like this:  one should not confuse fly rods and health care.  The purchase of a fly rod is discretionary in every sense of the word.  Not everyone will want a fly rod, and for those that do, it seems perfectly legitimate that buyer discretion be left to market forces.  If one wants the brand cache of an expensive fly rod, and can afford it, go for it.  If one can't tell the difference (and I admit that my casting is not sophisticated enough to tell the difference) then perhaps one will forego the brand chache and go for a perfectly adequate, less expensive rod.  Regardless, no one NEEDs a fly rod.  I just happen to WANT one -- well, several -- but the state should feel itself under no moral or ethical compulsion to provide them to me or anyone else.

On the other hand, health care, I believe, is a moral and ethical entitlement of all men, women, and children.  I am not sure where, exactly, to begin making this argument, so let me begin where I have begun before.  If the fundament of morality is simple empathy and the golden rule, I would WANT to be provided with health care when I needed it, so to I might assume others would WANT to be provided with health care when they needed it.  I would want it whether I could afford it or not, and so too must assume that others would want it whether they could afford it or not.  The difference between wanting a fly rod and wanting health care is, of course, is a matter of universality.  Not everyone will want a fly rod, and no one needs a fly rod, but everyone, at one time or another in their life, will want and need health care, if not for themselves, then for a suffering loved one.

Having said that, modern medicine and health care is a science.  The vast majority accept the scientific basis of medicine.  The vast majority are astonished when parents, for arcane religious reasons, reject available treatment for their children because we know that a scientific hypothesis was formed around the cause of the malady, a treatment proposed and tested at various levels to demonstrate its effectiveness experimentally, and so we have great confidence that the administered treatment will be effective.   Consequently, we also know that NOT administering the treatment is tantamount to standing at the side the swimming pool and watching a child drown even though we might be perfectly capable of reaching down and saving her.  If we cannot save the child, we fully expect the lifeguard, one trained to do the saving, to jump in and save her.   We do not ask first whether the child deserves to be saved, or whether its parents have contributed premiums to the lifeguard association.  We simply and correctly expect the child's life to be saved.

In other words, to my mind, it makes little difference whether the impending cause of suffering is a virus or a swimming pool, if the means exist to save the child from its grip or alleviate its suffering, we simply and correctly expect all available effort, short of endangering one's own life, to be made.  Although it seems clearer when we are speaking of children, I would simply extend the argument to all sentient human beings.  I would expect all available effort to be made on my behalf, or on my child's behalf, and as a consequence of that expectation, I have a duty to others to make the same effort on their behalf.  Clearly, however, when it comes to health care, not everyone is able or qualified to save lives or alleviate suffering, and so we have trained others (life guards if you will) who take on that responsibility as a professional obligation.   We have, as it were, a health care system, and the same argument extends to the "health care system."  I would expect it to make every effort on my behalf, and consequently I have a moral and ethical obligation to make that system available to others.

It is here, of course, relative to that moral and ethical obligation, that questions around the social state come into being. The moral and ethical obligation assumes, I should point out, the universal availability of the "health care system."  I do believe it should be universally available, and because I believe it should be universally available, I also believe that it is the collective responsibility of the people as a whole, which is simply another way of saying that I believe it is a fundamental responsibility of the government.  During the last election cycle, I'm not sure who it was that shouted from the back of the crowd "let them die," but I am sure that I do not want to find myself feeling or saying the same.  I'm not sure precisely what Jefferson had in mind when he characterized "life" as an inalienable right.  I suspect, in the absence of 21st century medicine, he was thinking simply that one had the right to be free from the fear that government might deprive one of life without due process.  I am suggesting, however, in the presence of 21st century medicine, that "life itself," so long as the means exist to preserve it, is an inalienable right.   To my mind, the question is not "do we have an obligation," but how do we best fulfill the obligation?

Before I answer that question, let me back track a bit.  When we see a child drowning in a pool, we don't ask does it "deserve" to be saved.  We probably don't.  We do, however, find ourselves asking whether a chronic alcoholic "deserves" a liver transplant or a two pack a day smoker "deserves" the prolonged and expensive treatment for lung cancer.   I don't want to suggest that such questions are not legitimate, but we can quibble forever around individualized questions of desert.  For example, does an 80 year old man "deserve" a heart transplant, particularly when it might deprive a 20 year old woman?  What if the 20 year old is a heroine addict?  As an aside, we study literature and film to gain an appreciation of such particularized moral and ethical questions, but I don't want to slip into what would prove to be endlessly elaborated "what if" discussion.  I simply want to bracket such questions of "desert" for the moment and focus on one in particular -- does someone who doesn't "pay into" the health care system deserve treatment?

Setting aside a "pay as you go," there are basically two ways that we "pay into" the system in America today.  One is through taxes, that supports medicare and medicaid, and the other is through "insurance."   To "qualify" for medicare one must be at least 65 years of age and a citizen.  To "qualify" for medicaid one must be below a certain income threshold and be a citizen.  Such programs are "universal" in a the sense that all citizens, if they should meet the criteria, qualify.   The other is through "insurance."   There are basically two types of insurance as well, employer sponsored and government sponsored health care. Under the current design of Obama Care, if I understand its broad outlines correctly, in the absence of employer sponsored health insurance, the government offers health insurance as if it were employer sponsored health insurance -- that is to say, just as employers pay a portion of the health insurance premium, the government pays a portion of the health insurance premium.   Both are basically "proportional" -- here again, that is to say, employees and government sponsored individuals pay a percentage of the premium based on income in a way similar to the flat tax.

Back to the question -- does someone who doesn't "pay into" the health care system deserve treatment?  We live in a world, to use Picketty's words, where there is "free trade and circulation of capital and people."  To bring this home, my wife worked at one point in an emergency room.  "Aliens" would come into the emergency room, because there they could not be refused treatment.  They did not have a social security number, nor did they have employer based insurance, most working at numerous part time, minimum wage jobs that put them outside an employer's health care benefits.  For the most part, their maladies were not "life-threatening" and could have been treated just as effectively and much less expensively by a family practice physician or neighborhood clinic, both of whom could refuse treatment if the patient did not "pay into" the system.   They received basically "free care" much to the resentment of those who treated them and who had for their part paid into the system.  This raises all sorts of ethical questions, both for those who, lacking other choices, accessed the system in the only way they could, and for those who, fulfilling their moral and ethical obligation, had paid into the system.  These individuals fell through the cracks in the American social state, and partly because of that, their presence in the emergency room exacerbated what Picketty called "defensive nationalism and identity politics" -- the sort of resentments that the donald and others prey upon.

I still haven't answered the question -- does someone who doesn't "pay into" the health care system deserve treatment?  The answer is "probably not," if they fail to do so out of negligence, or willful perversity.  If you believe, as I do, that health care is a universal right, with a universal obligation, then we MUST contribute our share and the government is perfectly entitled to compel people to do so through appropriate taxation and sanctions.   Government must assume that everyone, when it is needed, will find some way to access the system, and consequently everyone has the reciprocal obligation to "pay into" the system.  The universality of the obligation to "pay into" the system brackets all questions of desert.  If all fulfill their obligation, whether through compulsion or consent, then we don't even need to ask the endlessly quibbling questions of need or desert.  We all have secured our right to the system through the fulfillment of our obligation.

The current system sorta fulfills this basic argument -- sorta.  It is convoluted, arcane, beset with incomprehensible and contradictory regulation that even the administrators of the program don't understand.   It is (here's the kicker) designed more to protect the income of private insurance and health care providers, designed more to fulfill the obligation of the individual to pay into the system, less to insure the system provides the necessary treatment.  Government, per se, is not the problem.  Our current ineffectual government is the problem.  Getting rid of or eviscerating government, however,  is not the solution to bad government.   In the absence of anything else, it simply makes for small bad government.   Building a better government is the solution to bad government, rationally deciding how best to secure our rights and fulfill our obligations, and that I will save for tomorrow.