I want to put forth here a philosophical discussion of healthcare funding in America. Before meaningful, long-lasting reform can be accomplished, Americans need to decide as a people whether the responsibility to pay for health care lies with the individual citizen, or should be shouldered by society as a whole.
There are definitely some things, in any society, that are simply better to be paid for collectively. For example, having each individual pay for and build the roads that he wants to travel upon simply would not work; there are obvious benefits to sharing the streets, and sharing the costs involved.
On the other hand, history has proven that when a society tries to have all things in common (as in the case of communism) dysfunction of all kinds tends to ensue. Although desirable in theory, the imagined equality under these types of systems rarely materializes in real life. A case in point is the former USSR and its communist system of government that eventually collapsed in on itself. Hitting closer to home, even covenant-bound Latter Day Saints couldn't pull this off effectively, on a relatively small scale when they attempted to live the united order.
We are a capitalist society (at least for the time being). Capitalism is, in part, governed by the principle of laissez-faire, which means, literally, "let it be," or "let it alone," (ironically enough, in French). With capitalism, it is generally accepted that, for the most part, people and markets should be free of government interference or control. Laissez-faire is by no means absolute, however; many industries are regulated by the government, to ensure quality or stability, or to prevent monopolization. Although there are some who think there should be absolutely no government regulation of commerce, etc, most reasonable people agree that some oversight is needed and helpful, particularly in certain sectors, like those that involve the basic safety, well-being, and yes, health, of the people. My dad, as a relevant example, worked for many years in a utilities sector, where the government has a certain involvement in ensuring that folks in rural areas have access to adequate, high quality telecommunications services on a more-or-less equal basis with those living in more urbanized regions.
These economic issues aside, there are other philosophical issues at stake with regards to health care funding. For example, while it is generally not considered unjust for grocery stores to deny people food because they can't pay for it, there is a sense that an injustice has occurred when a person in need of health care, particularly lifesaving health care, can't afford it and is, therefore, unable to obtain it. Of course, food is equally necessary for that person's existence, but is not necessarily considered something the person should be entitled to have when in dire need.
For a real-life but hypothetical example of this, consider a destitute person, about to starve, who walks into a grocery store and demands a meal; he likely would not get anything from the store's inventory without making payment (although a compassionate grocer might direct them to a food bank). On the other hand, the same person could walk in to any emergency room of any hospital in America at any time, and the law requires that the person be treated, regardless of ability to pay. Even I was irked the other day when I heard an uninsured patient's story about having been diagnosed with pre-cancer of the cervix, and then being told by her unapologetic gynecologist to raise enough money to pay for the surgery, and then come back. By the time she saved enough and returned, the cancer had advanced and spread, and was much more difficult and risky to treat.
Therein lies the dilemma for me. I am, in a way, of two minds. On one hand, I don't believe that providing every needed service is an appropriate undertaking for a democratic republic with a capitalistic economy. Nor, for that matter, do I trust our government enough to feel confident turning over health care to it. On the other hand, I don't quite feel right about denying health care to folks who can't afford to pay for it, particularly lifesaving care. If I had lived 150 or 200 years ago, I probably wouldn't have had a philosophical problem with it. But, in my heart of hearts, being who I am in the year 2009, I do.
This interesting shift in the collective thinking of Americans has been shaped over the years, without doubt, by the way health care has been paid for in America (see installment 1 in this series). In short, most of us have gotten used to somebody else paying the costs of our care; our employers pay for it while we work, and the government takes over when we retire. As a whole, we haven't needed to include health care costs in our personal budgets very much; once our basic needs for food, clothing, shelter, and the like have been met, we have been free to spend our surplus on things we wanted, like vacations, vehicles, cell phones, and other luxuries. We don't tend to "save up" for medical care, or include those costs in our planning. I see this every day in my practice when patients who "can't pay their bills" make me wait while they talk on their cell phones.
While there is definitely a certain percentage of Americans who simply could not afford insurance no matter what financial adjustments they made, I believe there is another group, probably a larger group, who choose not to purchase insurance. If asked, most in this group would, undoubtedly, say that they don't have it because they can't afford it. And, in their own minds, they honestly can't. A review of their budgets, however, would reveal that, with a shift in priorities, they could afford the premiums, although this would require that they sacrifice some things that they have come to view as essential "needs."
At certain points in my own life, I, by the way, have fallen into this group. I chose that approach during college, for example. At times, when my wife and I were first married, we went without insurance. We didn't try too hard to prevent pregnancy, knowing that if she became pregnant, she would qualify for Medicaid, and that the government would pick up the tab. Why did we do it this way? Well, we were all healthy, and not likely to incur major medical expenses. (All insurance is, after all, a gamble, and when one is young and healthy, the odds are a lot longer.) Plus, looking back, I think I knew in the back of my mind that if something catastrophic happened, there was an adequate safety net there. I didn't have to live in fear that I wouldn't be treated; I knew that, when push came to shove, I would be, regardless of my ability to pay. If I wanted to have health insurance, I would have needed to work more hours, and cut back on the credits I was taking in school. This would, of course, have resulted in a significant delay in my career track, probably by 2-3 years, at least.
Although I never spent much energy investigating the implications of "going bare," in the back of my mind I also knew that medical bills really couldn't ruin me financially, because I didn't own anything of value. I had a good sense that, in the end, if some unanticipated thing happened to me or my family, we would qualify for government aid because we had no significant assets that could be taken away to pay the bills. Was that the wrong approach for a responsible citizen to take? Perhaps. (Ask not what your country can do for you...) Was it a good decision, purely in terms of finances? Sure! In a health care system funded mostly by insurance dollars, is it going to work if very many people choose that approach? Not on your life!
So, at this crossroads in the history of American health care, one major decision we should be making is whether we believe, deep down, that health care funding is an individual or a public responsibility. It is a difficult question, and, unlike the issue discussed in the first article I wrote on this subject, I don't think this issue necessarily has to be answered in "either/or" fashion. Perhaps this one can have it both ways; I'll elaborate my own ideas on this further in the fourth installment.