Mr. Madison on Universal Healthcare

Oscar Madison, who I recently had the pleasure to address as Professor Madison, muses about Universal Health Care. He observes that

When it's your own health that's involved, it's hard not to take that far more personally than, say, lousy service at your auto mechanic. Still, bad customer care is not always the same as bad health care.

I think that's quite right, but I disagree with where he goes from there:

My guess is that, when push comes to shove, the main popular resistance to universal health care (opposition in public opinion, as to opposed to opposition from the private health insurance lobby) boils down to inegalitarianism. Sure, there's a lot of rhetoric about being able to choose your own doctor, and avoiding bureaucracy in getting treatment, but the predominance of "managed care" in our current system is making those aspirations a thing of the past even in the absence of a universal health care policy. The real underlying objection is the strong belief that people with more money deserve better health care.

While I agree that managed care is the epitome of the bureaucratic gridlock bogeyman that universal care opponents try to draw from every closet, I think the real problem is that people actually prefer the bogeyman they know to the bogeyman they don't. Here, the rhetoric is the reality.

People have been persuaded that "Canadian-style" health care will result in six month waits for a routine checkup or the government selecting doctors for patients (as if HMO's don't do that now). I think it's fundamental that most people support at least the general idea that we should take care of the sick. Where there is any economic motivation, it's generally couched in terms of the cost to taxpayers of providing care. That's a pretty easy sell when the middle class is drawing its health care from its employers and from payroll deduction; "why should I have to pay more in taxes, when I already pay for my insurance out of pocket?"

However, I think the logical consequence of the Republican policies to erode even the limited employer-sponsored system we now "enjoy" is a setting of the stage for long term defeat on the issue. As more and more employers drop coverage or raise premiums in the face of the "ownership society" policies that encourage private purchase of high-deductible insurance and tax free savings, the economic rationale is flipped precisely on its head.

I think it's fairly obvious that the point of Health Savings Accounts and high deductible insurance is to shift the burden of rising health costs from employers to consumers and the government. Once people have to write an actual check every month and they are told how much HSA's cost the government every year, not to mention paying the high deductible the first time(s) they see a doctor, a low-cost single payer system might start to look really attractive.

Maybe I am just sappily optimistic about my fellow human beings, but I prefer not to believe that people really believe that a rich cancer patient deserves to live more than a poor cancer patient.

Much excellent prose follows, and the Perfesser concludes:

Our current system is probably like a commercial jet liner: first class for the rich, coach for the middle class insured, and the poor just can't afford to fly. Universal health care will be, at best, an early 20th century ocean liner: 1st class, 2d class and steerage.

Maybe so, but I know which one I'd pick. Health Care is a veil of ignorance problem. If I had to cross the ocean, I'd rather have a seat in steerage than be watching the plane take off from my backyard.