Monday, July 20, 2009

The Third Pole of the Health-Care Debate

In the current debate over how health care in the U. S. should be funded, no one seems to be talking in a first-principles way about the moral underpinnings of the system. As I've said before, technology and engineering are so heavily involved in modern health care that I think engineers are disingenuous if they say they don't have a dog in this fight.

Sometimes situations can be clarified by going to extremes. I will pick three extremes which I think represent the poles of what we could do about health-care funding, and then see what conclusions we can draw about the moral bases of each.

The first pole is the extreme-libertarian solution: get government totally out of health care and let people figure it out on their own. This would mean shutting down Medicare and Medicaid, selling off all government-run hospitals, and letting the chips (and the patients) fall where they might. I think even the most extreme libertarians might blanch at ending such long-established practices as the licensing of doctors, but maybe not. One of my cousins is a libertarian, and he hasn't blanched in years. Surprisingly, this solution might not make much difference to those who are employed at firms that provide good health benefits. But for retired people who have come to rely on government-paid health care, there would be big problems, as well as for many who can't afford private care or insurance for it. This solution maximizes individual freedom from government actions, but if you're poor or retired or both and can't afford medical care, you would be out of luck. This shows the radical individualism of libertarian philosophy, and why it is inferior as a total guide to life.

The second pole is the extreme-socialist solution as is done in Cuba, for example: free health care for everybody. Of course "free" means the government pays for it all, and Except for the sick folks that documentary filmmaker Michael Moore took along with him to Cuba as an example of how much better their health-care system is than ours, I'm not aware of a huge surge of people who travel to Cuba for their marvelous medical institutions or services. The fact is that any government, especially Cuba's, has finite resources, and when resources are allocated by bureaucrats rather than markets, the results are often less than optimal, even if there are enough resources to begin with, which in the case of Cuba is doubtful. This solution removes a person's economic status from the equation, at least in theory, but requires rationing, waiting lines, and a pretty low average level of quality. Besides which, it seems that government-run health care systems tend to encourage a psychological dependency on the state which some think is mentally unhealthy in the long run. As with most "free" offers, free medical care often comes with political enslavement.

Most debates about the subject seem to be focused on just where between these two poles we ought to land. But I think that leaves out a critical factor, which I will dignify with the designation of my third pole. It's not easy to think of a name for this pole that will not evoke negative connotations. Perhaps "charity" in the older sense of "love" would cover it. Many private and public hospitals provide services to indigent patients whose costs they absorb, which means that everybody else who uses the hospital helps pay for it. Historically, the idea of caring for the sick without consideration of cost was a founding principle of many medical institutions with religious backgrounds. Many hospitals were staffed by nuns who took vows of poverty. And I think when this motivation is present, it forms the best of all foundations for individual careers and institutional principles. Would you rather be treated by a doctor who went into the business because he wanted to help people, or because he could make a pile of money? Yes, skill is part of the equation, but skill is more than mere technical proficiency. Being a quality of character, charity does not fit easily into economic calculations or political structures. But the first two poles either discount it totally or regard it as an unreliable and suspect motivation that is best ignored in favor of government-run solutions to the problem.

Many religious leaders, up to and including Jesus, made healing a vital part of their ministries. I do not have all the answers to our health-care problems, but I think we should consider making more room for and encouraging those who provide care in the neighborhood of the third pole—people and institutions who help patients because it is the right thing to do, not just because they can make money at it or because the government compels them to. If the debate can center more around this idea, I think the outcome, whatever measures it takes from the other two poles, will be better than otherwise.


  1. Good post:

    My two cents: Perhaps a sort of chartering system, with government funding going directly to local entities, like hospitals, or doctors cooperatives that agree to give the sort of aid you talk about in return for something like block grants, or some other sort of funding without the onerous amount of red tape and paperwork currently with Medicare/caid. That would take over the function of the government run programs, and the younger folks, and others that are able, could go with the health savings account option if they wish. Give people the option to have total control. Give them back all payroll taxes that had been going to funding their 'participation' in the programs (throw in SS refunds as well). I suspect that not everyone would do this, that would allow continued funds for funding the charters.

    But, for those that want to take over responsibility for their own medical and social security, this would allow them to do so.

  2. Interesting! I recently read an article in The New Yorker that looked at health care costs around the nation, and discovered that one of the biggest determinants was the mentality of doctors toward profit and treating medicine like a business.

    Of course my boyfriend, who's goal is to apply to medical schools soon, said to me recently, "Well without earning at least six figures no one is going to go into medicine - med school isn't cheap!" A particularly insightful comment about how interrelated education, medicine, and politics are.