Blackcap Blog

Published at 17:02 on 22 September 2018

As promised in my most recent post, here’s my thoughts on health care. First, any reform should have three main ideals:

1. As much universality as possible. Health care should be a right, not a privilege. An individual’s standing in the class hierarchy should have as little effect as possible (ideally, none) on the quality of the health care s/he receives.
2. As little centralization as possible. A single bureaucracy must not be allowed to run the whole show. Imagine what would happen if a competent fascist (as opposed to an incompetent one like Trump) got control of such a bureaucracy, and used denial of health care as a tool to oppress people.
3. Be achievable soon. It should not require any grand revolutionary transformation of society. As desirable as I personally happen to think that is, I also realize that it will take time. There’s people suffering from lack of access to health care who need it now, not at some vague point in a distant future.

The first two goals conflict somewhat, of course. The simplest way to decouple access from place in the class hierarchy is to have a centralized bureaucracy ensure that all get the same access. And the simplest way to decentralize is to let health care policy be market-driven. Welcome to the real world, where good solutions are never simple or easy.

That said, there are things one can do. Single payer, whatever my misgivings about the centralization it involves, actually is a measure in this direction. It centralizes health insurance, while leaving health care decentralized.

Doctors and clinics in Canada are private businesses, who if they choose can buck the system by giving care (at their own expense) to those whom the government would deny insurance. This is imperfect, of course, but it beats the pants off any system where doctors could simply be summarily dismissed by the centralized government bureaucracy that employs them.

But there’s no reason for insurance to be centralized for there to be universal coverage. It’s a false dichotomy to insist that the only two options for health insurance are capitalist competition or government centralization. Private, nonprofit, noncapitalist organizations already exist. There is no fundamental reason why health insurance could not be provided by multiple private nonprofit organizations.

In fact, this is already partially being done in Switzerland. Health insurance companies there are still for-profit capitalist concerns, but only partially. On the basic, universal insurance that the government subsidizes, they are forbidden from making profits (and required by law to offer such coverage). Universal access has been achieved with one more level of insulation between the State and its awesome power and those who furnish health care.

Critics point to how Switzerland is not as good at controlling costs as most other countries with universal health care. That is in fact the case, but it is also the case that the Swiss system is much better at controlling costs than the one in the USA, and does so while ensuring a basic level of access for all.

Moreover, the Swiss seem to actually get something for all the money they spend. Theirs is a high-quality system as well as a high-cost one; Switzerland ranks near the top of European countries when it comes to life expectancy. Importantly, they are also getting decentralization and the resultant resistance to tyranny. Securing liberty is certainly worth paying for as well.

It’s not a perfect system, of course. It’s greatest failing is that it’s a strongly two-tier system; the universal insurance is fairly basic. But there’s no reason a decentralized system could not be accompanied by a more generous level of universal care.

There is also, to reiterate, no reason for private insurance schemes to be for-profit, capitalist ones. One should take it one step further and require or strongly encourage insurance firms to be non-profit. For bonus points, encourage them to be governed by those whom they cover: have insurance cooperatives.

The State’s role would be largely limited to distributing vouchers for coverage to everyone. Vouchers have something of a bad name in the USA, due to their use by opponents of universal education. The problem here is not the vouchers themselves, but that schools are allowed to charge tuitions above and beyond the voucher amount. Therefore vouchers end up serving merely as discount coupons for the wealthy to purchase privilege for their children. One can eliminate this problem by banning the institutions accepting the vouchers from charging anything extra.

Also, there must be a promotion of civil society. Health care workers must be encouraged to unionize, and health care consumers should be encouraged to form watchdog groups. There need to be multiple, intersecting, non-government organizations in place to promote the interests of all involved, and if needed to resist the efforts of any tyranny from above to undermine the right to universal health care.

None of this will guarantee a positive outcome, of course. No plan will. Even plans modeled on successful programs elsewhere might fail if tried in the USA. Countries are not the same; what works in one place might not work in another, and in the real world success is never guaranteed.

This is a quick and incomplete sketch. I haven’t even begun to address things like the need to keep coverage reasonably well-standardized, and to collect and disseminate impartial statistics on how well various insurers and providers do, so that people can make well-informed decisions, instead of being compelled to swim in a sea of policies with twisty little mazes of fine print, all different.

When it gets to where health care is now, where the USA is paying more and more for it and getting less and less to show for it, it should be possible to replicate pieces of what have been done nearly everyplace else to achieve better outcomes. The “better, cheaper, faster” trichotomy only is valid if one is at an optima point, and evidence strongly indicates that the USA has drifted well away from any of those.