The philosophy paper that I attribute to my original interest in philosophy was one by my professor, Helga Varden, called Rawls vs Nozick vs Kant on Domestic Economic Justice. Helga's argument blew open the standstill between the ideology of the two political parties in America. Rawls represents the Democratic side, in a literal sense the Clinton's both said they were moved by Rawls's A Theory of Justice. Nozick's libertarian stance represents the more restrained approach to government that the Republican ideology leans on. In America, the debates around issues such as abortion, gun rights, taxation, and many more revolve around the core issue of what is a reasonable level of government force on the people.
No where else is this felt in the debates around healthcare. Unlike Germany, with figures like Bismarck and Kant who might have more norms to appeal to for something like universal healthcare, America does not. Healthcare started out as a private matter. During WWII when wages were frozen, so the story goes, health insurance was a benefit used instead of cash for acqusition of workers. This health insurance was modeled after earlier forms of Worker's Compensation laws.
Universal healthcare never got off the ground in America, although every generation has a renewed push for it, from the era of FDR to the Clintons to Bernie Sanders. I don't think there is one theoretical correct answer here, there actually might be many correct answers that depend more on the execution and optimizing for increasing for the right variables and decreasing the wrong ones.
What is pretty much agreed upon is that the current system is not working. Healthcare costs are almost 20% of GDP, American health outcomes relative to spending is abysmal relative to other similar countries. There may be people who benefit and highlight the pros of our system compared to other countries, whether its access to specialists or reduced wait time for many surgeries and routine care. But when thinking about it from a system perspective and a policy perspective, the current state of things everyone can agree is pretty bad. We don't need to go far to see evidence of this, whether research or anecdotal.
I just finished the chapter that deals with the fall of healthcare in the United States in The Rise and Fall of American Growth by Robert Gordon. Gordon does not have much to highlight, since through the lens of quality of life improvements, productivity, and value not captured by the GDP, measures that Gordon highlights throughout, healthcare is performing extremely poorly.
There are a few things he gives credit for however. One is that there are indeed some inventions and processes that, for dollar inputs, have greatly improved health outcomes. There have also been successful campaigns to reduce smoking. Gordon also notes that, through no fault of anyone's, once you have solved for major infectious diseases and infant mortality, you have the problem of diminishing returns in that, a smaller percentage of the population is at risk of trickier diseases to cure and prevent. Sure, there might be some inefficiencies in the way we are researching the fight against cancer, but arguably cancer is a much trickier problem to solve than something like antibiotics. It was much easier to go to the moon than it is to make a reusable rocketship like SpaceX is attempting to do.
So let's go over some of the reasons Gordon outlines that healthcare is flailing in the United States and I will try and reflect a little bit about the age old question of if universal healthcare or single payer healthcare is a good approach.
Gordon highlights one of the reasons for loss of trust in the healthcare system is the rise of specialists and loss of the primary care physician. Gordon gives many reasons for why this happened, but the general idea is that because of the way insurance is structured or the appeal of becoming a specialist and earning a lot of money, the old family doctor that took care of you and your family for decades is not as prevalent. The idea is that, building a relation with a single doctor who knows you and your family is more trustworthy but also they have more intimate and historical knowledge of you and your family's health. This means that they can try and help with preventative care and treat you when you need it and only send you to a specialist when absolutely necessary. This keeps costs down while keeping you healthy and also trusting a real human face you know and respect. But now, it is more normal to "bounce" from specilast to specialist without any central coordinating doctor between them. Gordon cites that fewer than 30% of doctors today are generalists, whereas most other advanced countries have at least 50%.
There are two parts to this problem. One is that doctors will overuse expensive testing such as CT Scans and MRIs. By overusing these, they are still being billed to the insurance carrier which affects the cost of healthcare overall. The second is the duplication and lack of optimization of these machines. For example, Gordon cites a statistic that in Indian in 1978, there was 1 CT scanner per 100,000 people, but in Canada is was 1 per 1 million and in Britain 1 per 2 million, with "no apparent advantage in outcomes." Another inefficiency is the inequality of access to hospitals. There are areas where poorer people barely have access to a hospital and medical care whereas others, wealthier areas more likely to have great insurance, have an overabundance of access to care. One might argue that this is optimal from an individual perspective, but when one looks at it from a lens of managing a finite amount of resources AND that we are all more or less in the same boat when it comes to healthcare in the United States, this is not optimal. Gordon cites a story where in 2018, an 18 year old named Dmian Turner was shot just blocks away from UChicago's Medical Center, but because they closed their major trauma center in 1988, he had to be taken to a hospital eight miles away, where he died.
Much of the research in speculative areas such as genomics and stem cell therapy has not yet proven to be widespread effective. At the very least, it is not as quick, effective, and widespread such that it is going to significantly grow the US economy as other inventions and innovations like electricity, the combustion engine, or even clean water via sewer systems. Another is that R&D industry for drug development is not as valuable or revolutionary as earlier drugs that were invented. This is part of his thesis that there was once in a lifetime inventions in the years of 1870-1970 (with some inventions occuring before 1870 but only seeing widespread adoption after 1870) that were the causes of the massive growth of the US economy. Gordon also cites the widespread intuition that most drug development is either not statistically significant at all despite being labeled as new drugs.
Another cause is the amount of red tape. Some might say they are all useful and justifiable. This is probably conflating useful with explanable. For example, Gordon cites Jan Vijg that regulatory hurdles signfifcantly dampen the possibility for innovation, and that with today's rules "innovations such as kidney dialysis and antibiotics might never have come to fruition." In addition to drug development, there are more hurdles doctors face that, albeit less controversial such as the
One of the simplest arguments for single payer healthcare is that, even if we change nothing but the fact that there is just one way of paying for healthcare to one entity, we could save potentially hundreds of billions of dollars, i.e. the famous Sander's campaign idea that universal health care would pay for itself. This idea comes from research, cited here by Gordon, that a significant amount of expenses are from administration overhead, to be precise, the estimate is that 39% of excess spending is due to this alone.
Medicaid, Medicare, and the Affordable Care Act (ACA) all brought in more people under insurance who previously would not have received it. This is where Nozick and Rawls come in on fairness and legality, but it is too late to debate these as they both are here to stay. However, moral merits aside, they did substantially increase the cost of healthcare. Gordon praises Medicaid and Medicare more than the ACA for the execution and simplicity of the programs, but does not dismiss both on the moral merits. Gordon sees real value in this and does not want to undo the intention or roll it back, rather, he gestures towards a better solution. But it is a simple fact that covering more folks, especially the elderly, the poor, the disabled, and those with pre-existing conditions will raise the cost of healthcare oevrall. There are those who make enough or a lot of money and are ok with this from a moral perspective, but this is part of the squeeze post-"Obamacare" that many Americans felt in that, those on the cusp of lower and middle class saw more and more of their income go to healthcare, and sometimes for potentially worse healthcare experience and outcomes. None of this Gordon leaves out, validating many Americans' feelings.
The goal of health insurance originally was that you would buy into it, similarly for life insurance, because you did not know when or how something could happen. Like unemployment insurance, it was a way to force money to be saved such that you could rely on it in unexpected circumstances. The idea also works when, with advanced statistics to structure rates and claims well, the insurance will not go under. You can structure life insurance more predictably, outside of wars and plagues, because you can predict normal amounts of deaths and when they happen based on a few indicators. However, healthcare worked out quite differently. Whereas in some insurances, the costs can go down, such as long term disability or life insurance, healthcare costs only ever seem to rise.
Just as hospital insurance removed individual anxieties about paying large hospital bills, it removed considerations of cost constraints from hospital billings. Hospitals could pass increased costs on to insureres, who could pass them on again to millions of subscribers, sick and well, in small increases in hospital insurance premiums. The potential of a third-party system unleashed an unprecedented demand for hospital services. It was a demand that could be stimulated by the suppliers, that is, by the doctors and hospitals themselves. Hospital expenditures and reimbursement meachnisms drove each other, in an expansionary spiral.It is not that healthcare somehow does not follow the logic of supply and demand, it is that the logic is quite different and there seems to be escape valve to cover _any_ problem in healthcare, it is to just increase the cost of premiums. People can't _not_ have healthcare, although some younger people are opting out of it, betting that they will not need it. Businesses _not_ offering healthcare for employees is almost a non-starter when it comes to being competitive. But there is not enough friction in the right ways to control the cost of healthcare, let alone move in the direction towards better health outcomes. This is why, although inventions like new drugs, genomics, stem cell therapy, GLP-1s, psychiatric medications, cancer drugs, IVF or adding more people under the health insurance through Medicare, Medicaid, and the ACA are all good, we added good intentions to a system that had incredibly shaky foundations. You add all these things together, and you get folks with health insurance premiums that are more than the cost of their housing and food, increasing number of those who even after insurance still have extreme amounts of medical debt, and the worst dollar-in dollar-out invement on healthcare among the major developed economies.
Gordon cites ways in which people have tried to rein in healthcare costs, such as HMOs or PPOs. There are also additional options on the table such as HSAs and FSAs. Technology is slow in this area, but it is coming. There is an influx of startups in the "consumer healthcare space". But nothing is stopping the rise of healthcare costs still, and the problem feels too big to solve in a bottom-up way. There is also no easy scapegoat to fix the problem here. You cannot just tax the rich and subsidize your way out, you also cannot just add work constraints to healthcare or reduce the number of people covered. It is also not certain that single payer healthcare would fix it all. If the foundation of healthcare is not sound, the way insurance is structured, research, hospitals, doctors, and even the ways consumers use and expect their ability to consume healthcare works, I don't necessarily see universal healthcare or single payer as fixing all of these issues or even just the fundamental problem of essentially unlimited demand and consumption of healthcare. It could be that it actually exacerbates the problem, despite good intentions, like the other good intentions of Medicaid, Medicare, and the ACA. Cover everyone, have one payer, one set of rules, maybe there is not a long enough runway to reshape the system until it would work. It is like inheriting a company with really poor financials, like Intel maybe. The CEO is trying, but he had to give up part of his company to Trump, all the competitors seem largely outpacing them. The best options for Intel look like the options for other companies in similar situations, get bought or torn apart for pieces and sell them off individually. John Gall in his The Systems Bible writes that the best way to fix a system is essesntially make a new one if it diverges from its original purpose too much. This is a little tongue in cheek, how can one just make a new healthcare system, the only option is to change and reform it. But what do you do if incremental improvements are not enough quick enough? What if improvements make the system worse and not improving anything make the system worse? Will the system self-correct at some boiling point? What happens if the system fails, like GM or the Banks, but it is too big to fail?
To end with Kant, on American healthcare weirdly enough, Kant's idea is that, in fact, the private right of individuals, the "ideology" or moral justification for the limits of government, in fact are only made possible by a more original public right of the state. At the end of the day, private rights are only made possible and guaranteed by a state that is willing to enforce them and protect them. Kant, and Varden, and her original teacher Arthur Ripstein, argue for this in pretty much an airtight way I would still say.
This original public right of the state makes one see that, the state does have a right to use coercion when it comes to protecting the right of individuals, but it also has the right to make use of coercion when it is line with what we might call the "public good". This comes in the most banal but important way in public roads. If there were no public roads, it is entirely possible and likely that I could be coerced by arbitrary private individuals in not being able to go from point A to point B. This arbitrary restriction on my freedom comes about through the coercion by other people, even if that coercion is not coordinated between these people.
Thus, in America, we have always already had a more original justification of the right of the state when it concerns the public good. Universal healthcare would fall under this mandate as well. But it is not a matter of right here, this is a matter of what is the best way to achieve an ambiguous idea of a public good, i.e. having a healthy and productive population that will in turn guarantee the perpetuity of the state itself. If a private market with no centralized, coercive authority was the best way to achieve this, then maybe. There are many instances where modeling finite resource management is best done through a free market mechanism, but there are plenty of examples where something genuinely good and more optimal came about from the government as a centralized authority, with coercive power, and no need to worry about stock prices or a bottom line, essentially as an investor in the common good and the perpetuity of the state for decades and centuries to come.