Please stop talking about the “right” to healthcare
A path forward for the US healthcare system — finding common ground and common-sense solutions
Our healthcare system needs a serious overhaul — a virtually unanimous opinion from both sides of the aisle. Simply stated, the United States spends much more on healthcare than other high-income countries, yet continues to have worse outcomes. Despite wide agreement on the problem, we cannot seem to put aside philosophical arguments and agree on a solution. In his TED talk, Robb Willer argues we have more productive political discussions when we frame our opinions using the values-based language of those we disagree with. So, how do we frame the argument for healthcare reform to provide affordable universal coverage? We can start by not discussing the right to healthcare.
For many Americans, rights exist to protect their individual liberty from government intervention. This protective-minded view of rights differs fundamentally from the entitlement-minded view of rights — the right to bear arms versus the right to clean water. Invoking rights when discussing healthcare reform with protective-minded people does nothing but invoke fear of greater oppression from an already over-reaching government. What about their individual freedom to see a doctor of their choosing and decide their course of treatment? Patients have very broad liberties in the current system, and protective-minded individuals see every governmental intervention as a threat.
Invoking entitlement-minded rights also highlights the perceived violation of fairness to the protective-minded individual. Extending a national right to healthcare means hard-earned tax dollars going to people whom some view as lazy, exploitative, and/or undeserving.
Aside from alienating protective-minded individuals, the declaration of healthcare as a right does not make sense pragmatically. Healthcare changes daily with new practice guidelines and increased treatment options (read: increased cost). Defining healthcare is analogous to holding water in colander. What does the right to healthcare include? And what happens when patients start suing for increased care? We simply cannot afford to offer all available care to everyone. Codifying the right to healthcare risks writing a blank check we cannot cash.
Beyond the financial arithmetic, we must also recognize our current struggle with the equitable implementation of the most basic rights. Case in point: as a middle-income white male, my right to free speech differs greatly from that of a low-income Black male.
So, how do we move forward? (1) redefine healthcare reform as economic policy, recognizing the shortfalls of free-market forces in healthcare; (2) develop a system which protects the American people against the follies of the federal government.
Healthcare as economic policy.
A healthy economy requires a healthy workforce. In 2016, the nonpartisan Milken Institute estimated lost productivity due to chronic diseases cost the US 2.6 trillion dollars (a staggering 13.7% of GDP). Diving slightly deeper, half of the lost productivity stemmed from hypertension and type II diabetes — entirely preventable diseases with very inexpensive and effective treatments. Direct healthcare costs will also increase; the Congressional Budget Office projects federal spending on healthcare will nearly double from 5.2% of GDP in 2019 to 9.3% of GDP in 2049. We have a central banking system to protect the US economy and the US dollar; we need analogous systems to protect against runaway healthcare spending and illness-related losses in productivity.
Why hasn’t the free market sufficiently controlled healthcare spending? Market forces work when informed consumers have options and price transparency. Searching Amazon for a hairbrush provides over 4,000 options, each with the price clearly stated and tens of thousands of reviews on the top results — options, price transparency, information. Patients, as the consumers of healthcare, lack all three.
For the vast majority, insurance and geography eliminate options. With the exception of small subscription-based primary care practices, no price transparency exists within the system. The problem extends to the physicians providing care, who rarely know the cost or the patient’s financial responsibility for their treatment. Even supposing we can fix the first two problems, we will never have an informed consumer. The complexity of modern medicine necessitates physicians practice within defined specialities; a cardiologist does not have the information to make decisions about the optimal treatment for ovarian cancer.
We clearly need intervention; continuing with the current systems risks compromising the economic stability of our country. In developing an intervention, however, we must address concerns of availability and instability raised by protective-minded individuals.
A semi-autonomous single-payer.
In 1913, after the Panic of 1907, Congress established the Federal Reserve System to develop monetary policy and protect the health of the US economy. Mirroring modern debates over the ownership of healthcare, Congress disagreed on whether the public or the private banking system should own and control the needed central bank. Eventually, Congress agreed on a largely-autonomous system with mixed public-private governance. The Federal Reserve Banks hold special legal status as federally-created instrumentalities — neither entirely governmental nor private.
To protect the longterm economic health of the country against politically-motivated bad actors and the relatively-rapid turnover of elected officials, each member of the Fed Board of Governors requires Senate confirmation and serves a single 14-year term. To balance public and private interests, a public-private board of directors manages each bank. Specifically, each board consists of three members appointed by the Board of Governors (public), and six elected by the private member banks in the district (private; three from within the banking industry, and three outside the banking industry).
I believe the best option for healthcare mimics the structure of the Federal Reserve. An appointed board of physician-experts in public health would oversee a set of district insurers. Each insurer would have a board jointly appointed by the board of physicians and the member healthcare providers, again including members both internal and external to the healthcare system. Dividing the program between federal districts allows for both meeting district-specific needs and testing novel approaches.
I also believe a Fed-like system mediates the two important concerns many Americans have about a single-payer system. One, a Fed-like health insurer protects against governmental intervention. A Medicare-for-all policy leaves our medical care, ulimately, in the hands of the president (and consequently, does not protect against tyranny of the majority). What happens when the president decides to stop payments for immunizations over fear of Autism? Or birth control payments for religious concerns? We should not accept a system so vulnerable to the follies of the current political climate.
Secondly, a Fed-like health insurer would not change the current access to healthcare. Hospital systems and providers would remain private and operate largely as they do now. Each district insurer would set the covered care, reimbursement rate, and patient copay based on the district tax revenue. Providers could still take private money for non-covered services, but would have the ability to refuse services without guarantee of payment. Yes, the wealthy will receive better care (but they already do, and no reasonable system will remedy the benefits of wealth).
A successful and generally-supported national healthcare plan will require a pragmatic economic justification to not alienate those with more conservative politics. Additionally, we need a system which addresses adequately concerns of governmental overreach and access to care. I propose we learn from the Federal Reserve, and that Congress mandate instruments (neither governmental nor private) to administer a common set of coverage to all Americans.
I am grateful for the review and comments from Hollie McCrea-Olson.
