Among the issues most commonly discussed are individuality, the rights of the individual, the limits of legitimate government, morality, history, economics, government policy, science, business, education, health care, energy, and man-made global warming evaluations. My posts are aimed at intelligent and rational individuals, whose comments are very welcome.

"No matter how vast your knowledge or how modest, it is your own mind that has to acquire it." Ayn Rand

"Observe that the 'haves' are those who have freedom, and that it is freedom that the 'have-nots' have not." Ayn Rand

"The virtue involved in helping those one loves is not 'selflessness' or 'sacrifice', but integrity." Ayn Rand

For "a human being, the question 'to be or not to be,' is the question 'to think or not to think.'" Ayn Rand

25 November 2007

The Misunderstood 47 Million Uninsured

Over and over again, we are told that there are 47 million uninsured Americans. My own simple-minded Senator, Ben Cardin of Maryland, just wrote me an e-mail note attempting to justify the Children's Health Insurance Program with the opening sentence of "Currently, more than 47 million Americans lack insurance coverage and approximately 9 million of the uninsured are children." Then he and many others claim that health care is too expensive for Americans. We are to uncritically assume, and it appears that most of us do, that the 47 million uninsured Americans are uninsured because they cannot afford adequate or even inadequate health insurance. But, worst of all, this is a play upon our good nature and our concern for the welfare of other Americans, which is supposed to imply that if we wish to be a good person, we must be willing to consent to a partial enslavement of all of us and an extensive enslavement of health care professionals so that 47 million desperately poor Americans will have health care.

Charles, you say, it is outrageous that you equate proposed government-provider systems that would tax us all and then spread the health care benefits over all or some favored sub-group of Americans with partial enslavement of us all. And then you even say that the government regulation of the resulting health care system extensively enslaves American health care professionals. Just because we are going to force everyone to participate in this universal, one provider plan does not make it slavery. After all, we simply want to take care of those who cannot take care of themselves. To which I reply, when you do not allow people to manage their own lives, you have enslaved them. When you will not allow them to own their own life, the liberty to make their own choices, and to pursue their own idea of happiness, you have enslaved them. That you claim to be motivated by paternalism does not even differentiate yourself from the plantation owner of the antebellum South who often claimed he was taking care of those who could not care for themselves.

If there were 47 million Americans without health insurance and they could not afford it, then we would simply be in the situation of earlier times or of much of the rest of the world. But because we have had some respect for individual rights in America and we often claim that we believe in the right to life, liberty, and the pursuit of happiness, Americans have enjoyed a widespread prosperity which has greatly improved the lives of every income strata among Americans and has specifically delivered them the best health care system in the world. We provide a very disproportionate share of the medical innovation and win most of the Nobel prizes in Medicine, as well as those in the sciences, which often also support medical innovations. We develop a disproportionate share of the new drugs. Our medical professionals provide timely care for life-threatening medical problems which puts all of the basic care only and highly rationed higher end care provided by national medical systems in other otherwise advanced countries to shame. Canadians must come to the U. S. for many live-saving operations that Canada will schedule them for only after they are dead. This makes for an interesting approach to reducing the demand for operations which the state system would have to provide manpower and care for. Canada exports much of its medical expense to the U.S.

However, the 47 million Americans without health care insurance is a fraudulent figure. Of this 47 million, 10.2 million are not U. S. citizens. Of course, many of them are Americans, but only in the sense that they are citizens of countries elsewhere in the Americas! But this is not what most people are thinking when this figure is given. So, fewer than 37 million U. S. citizens are without health insurance.

The next important point is that many American citizens who have the means to buy insurance, choose not to do so. 8.5 % of those with household incomes greater than $75,000/year do not have health insurance. Of course, some fraction of these people have so much money that they are fully justified in regarding themselves as self-insured and there is simply no reason to pay a middleman. Bill Gates, Warren Buffet, and even The Donald have no need for health insurance. But, apparently a great many other people making good money do not need it either, although some of them do not have it simply because they are in the midst of changing jobs. There are 9.3 million of these well-off people. Then there are the rest of those who make more than the national average for a household and yet do not have health insurance. Of those households with incomes between $50,000 and $74,999 a year, 14.4% do not have insurance. This is another 8.5 million people. So, 17.8 million people can afford health insurance, but choose not to buy it. Again, many of this group are only briefly without insurance as they change jobs. A large fraction also goes without insurance because they regard themselves as too healthy to want to buy insurance to subsidize the health care of those who are less healthy! This is a manifestation of their pursuit of happiness. I have a nephew who has made this choice.

At this point, we are left with only 19.0 million Americans without health insurance. Of these, once again many are without health insurance only briefly as they change jobs. Some also are eligible for government health programs, but do not apply. John Stossel found that about a third of those eligible did not apply. Americans without health insurance make frequent use of hospital emergency rooms, which are required to provide them with medical care. They also use Medicaid in many instances. So, it is simply not the case that many millions of Americans cannot get medical care. Any implication that this is the case is fraudulent.

There are serious problems with our medical care system, but they will not be improved by making it a national system, if the problems rampant in Medicare and Medicaid can teach us any lessons at all. Or, if we can learn anything by examining the national health care systems of Canada or the United Kingdom. Our problem is that 86% of all American health care purchases are handled by third parties. This means that the patient has little to no incentive to demand cost-effective health care. The result is that little attention is paid to being cost-effective. My mother has a habit of asking medical care givers to justify the high costs of her and my Dad’s medical care and they very commonly are indignant that she cares. They say that she should have no interest in the matter, since she is not paying for it.

Another problem with our system is that it is so geared to the avoidance of legal suits, that one cannot get a straight answer from most doctors about almost any medical question. The profession has decided that certain procedures are to be considered acceptable practice and that if one stays strictly within those practices, then there should be no legal problems. This causes a different set of problems. For one thing, people are highly unique and what is statistically the most likely procedure to be successful, may well be the wrong procedure for a given non-conforming individual. Yet the doctor is unwilling to devise a procedure for the non-conformer, since to attempt to do so means he will have to leave the comfort zone of the accepted common procedure that protects him from law suits. In fact, I have heard of cases in which doctors gave advice they knew was wrong for a given patient, simply so they would remain consistent with convention. There are also cases in which the doctor believes that the chances for failure of a treatment are high and will not provide it even if that treatment is the only life-saving option for the patient. This is because to fail is to be open to a lawsuit.

So, if you actually do care about your fellow man, instead of making fraudulent claims about 47 million uninsured, do something to allow doctors and other medical professionals to really provide medical care without being totally paralyzed by fear of lawsuits. If you really care, let us change the tax code so that Americans will buy their own healthcare plans, be the guardians of their own costs, and be able to choose from many more treatment options which will be made available to them in a timely way.