Map of life expectancy at birth from Global Education Project.

Thursday, June 25, 2015

Why exactly is the ACA bad again?

Now that Roberts and Kennedy have decided that it's better to be generally regarded as sane and responsible than it is to be popular with the willfully ignorant wingnuts who vote in Republican primaries, this seems a good occasion to revisit some basic truths about how the world works.

Pruger, Ruger and Annas in NEJM happen to get published on this very day a reflection on the underlying doctrines, both philosophical and constitutional, that fuel the controversies over health care policy in the U.S. The courts have found no affirmative right to health care in the constitution, but only what they call "negative" liberties to refuse health care, or to opt for abortion. However, there is no actual right to abortion, or contraception, or any other medical service or good, if you can't pay for it. Over the years Congress has taken various patchwork measures to extend an affirmative right to some amount of health care for various groups of people in various ways, but conservatives resist these efforts.

So I'm going to repeat an exercise I've done here before, but not for several years. That is to deconstruct the so-called "free market" dogma that the libertarian right uses to confuse people about the nature and meaning of liberty. In the first place, the claim that there even exists something called the free market that allows us to achieve individual freedom and justice without the oppressive hand of government is nonsense. Markets are social constructions that cannot exist without massive, sustained government involvement. Government writes and enforces all of the rules that structure the market, from property and contract law to the issuance of money to the charters of corporations and the status of employees. All of these rules can be written in innumerable different ways to benefit one or another class of people.

That aside, free market fundamentalism rests on various assumptions which are taught to college freshmen as if they are facts, whereas none of them is ever true. This is particularly obvious in the case of health care (or medical services, which I would prefer to say but nobody will go along with me).

The first is the self-evidently ridiculous assumption that all of the costs and benefits to society of a transaction are felt by the parties to the transaction. This is the assumption of no "externalities." In fact 100%  of economic transactions involving every conceivable category of good and service produces externalities, but if you don't see this in the case of health care, you aren't just misinformed, you are willfully blind. Here are a few:

  • People who have curable infectious diseases can infect others. Everybody benefits when infectious diseases are prevented, or detected and cured.
  • People who are healthier are more productive and better able to support themselves and their dependents, to add to the common wealth, and to pay taxes.
  • People care about other people. When their friends and family members are sick and can't get health care, they become distressed and sad. They may have to quit their own jobs or neglect other dependents to take care of their sick relative or friend who, with health care, would be more self-sufficient.
I'm sure you can easily think of more.

Here's another really obvious false assumption. Health care is not an ordinary good like food, clothing, shelter or  transportation among which people can freely choose to allocate their resources. We all have wildly different needs for it, over our lifetimes and at any given time. It isn't a question of "personal responsibility" or "individual choice" whether you get lymphoma or are poisoned by a "grocery manufacturer" (that's what they call themselves) who was not subject to sufficiently burdensome and oppressive government regulation. You might even be born with a disease, or a genetic predisposition to disease. That is why it is completely obvious to anyone who is not delusional that the "free market" cannot possibly produce justice in health outcomes.

Sure, medical services contribute only a portion to health outcomes -- more than previously but maybe only half or less. Still, if you care about the other determinants of health you'll be for all the other stuff you are against -- guaranteed full employment and income for people who can't work, excellent education for all, environmental regulation, workplace safety, tobacco control, gun safety regulation, you name it. "Personal responsibility" is in there somewhere but only if people have the opportunity to exercise it, which in general, they don't.

I will continue this, but I have already proved that libertarianism is utter bunk. It is internally incoherent and obviously inconsistent with observable reality. The controversy over health care is a very easy way to prove that, even if the corporate media don't understand it.

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