…At the same time, as a matter of economics and mathematics, we also know at the back of our minds that we simply cannot give it to all – because these breakthroughs involve huge investment, highly trained experts, and inherently expensive technology. And as the options for health grow, we are forced to make choices that were previously out of our grasp, and those choices make us, in some way, gods. We collectively decide who can live for how long and who can die – because for the first time in human history we really have that choice. In fact, we have no escape from that choice. Healthcare is no longer triage, where sickness and death is the norm; it is an open-ended, blurry range of positive choices, where wellness is the expectation….
…Only the ACA is really trying to deliver more efficiency; the Ryan plan simply shifts the responsibility for someone’s health after a given point from government to individuals.
Both proposals therefore make some sense to me. But Obama’s is both more humane and less ambitious in its attempt to solve the basic dilemma. My fear is that the ACA’s admirable experiments in cost control, even if they work, simply will not save enough money to alter the basic reality. And so we can either tackle the widening discrepancy between our expectations and our means politically through a government appointed rationing board or economically through the market. The market feels more manageable and at the same time more callous to me – because to make these choices consciously through the political process turns politics into a citizenry’s version of Sophie’s Choice. Yes: at some point, if you really wanted to hyperbolize and demonize such proposals, you could call these decisions “death panels” for those without great wealth. But the alternative is really hidden death panels, where the market makes the cut, and not the government.
My fiscally conservative mind sees some variation of the Ryan option as the only long-term viable one. You just, at some point, choke off the supply and force human beings to go without. And that’s where my Christian-informed conscience rears its benign head. As a human being, I find it extremely hard to deny another human being the ability and means to cure their sickness, if it is available. Health, one recognizes, is not like other goods; it is the precondition for all such goods. Going without chemotherapy is not like going without an iPad 2, or a car. There is, in other words, an inherent tragedy here. Accepting that tragedy is the first step to trying to ameliorate it. Because we can ony ameliorate this dilemma; we cannot resolve it.
I think Mr. Sullivan is delving too existentially. I think it’s far simpler. Health is always an individual choice; it always has been and always will be. Until it’s not and you need expensive care. Expensive medical care is inevitable for almost everyone. Let’s assume “everyone” in this instance is the average healthy American. This average American will eventually be eligible for government provided health care.
Over the course of your life, whether under the ACA, Ryan’s health grants, or a socialist medical delivery system, you need to take care of yourself, or have a high probability of facing unpleasant medical issues. Smoking will almost certainly lower your quality of life, drinking too much will do the same. Eating processed corn products made in giant vats of deep fried corn syrup and topping that tasty meal off with some form of corn syrup-infused cupcake will make you obese and/or give you diabetes. There are lots of incentives not to partake in these activities. So what do you do?
You avoid all of these things, exercise twice a day, and get 8 hours of sleep a night. This is what I do, yet I know I will need expensive medical procedures some day, and I know I won’t be able to pay for them myself, because very very few people can.
There will come a time, unless you die prematurely in some freak accident or hidden medical issue, that your body will age, be exposed to enough pollution, or it’ll just be “one of those things”, and you’ll require expensive medical care. However, if implemented, the procedure or treatment will allow you to continue to lead a quality life.
It may be emergency surgery, chemotherapy, whatever, but how many people do you know personally who have had such an operation and fully recover? (Just because you’re old and fully recover to still being old isn’t reason to start thinking of limiting government-funded care.) I can name several dozen family friends and loved ones who did; most of them qualified for Medicare.
Then, it’s not your choice. Once you need a doctor to save your life, you’ve done all you can. Now you have to rely on the systems you helped maintain through taxes and votes. Now hopefully I’ll still be employed and have private insurance (*see the next paragraph), but what if I lose my job and I’m on Medicaid, or this happens when I’m old?
*Tangent: The government is even helping my private insurance, if I’m not retired by the time I need such expensive medical care. Even if you use employer-provided insurance, the government still made that insurance cheaper for them. Tax Subsidies for Health Insurancepdf.
Medicare and Medicaid aren’t facing future cost overruns because they’re giving out unneeded freebies, it’s because there are a lot more old people, the inflation of medical services is skyrocketing, and we insist on demanding tax cuts from every president that comes into office. So I’ll be damned if some idiotic Republican proposal effectively makes that procedure too expensive to have, or bankrupts me or my family in the process of saving my life. Either way my loved ones are left worse off – or worst – they paid for my procedure, bearing more under Ryan’s grant plan, and I died anyway.
The problem with Ryan’s grant program is that it will leave every participant at the mercy of scrapping together enough savings for inevitably high medical costs. It is designed to price sick people out of health. Since an expensive procedure is extremely likely to happen to everyone, it makes no moral or fiscal sense to turn government medical care into grants that are purposefully designed to not pay as well for medical services as the status quo.
To me, there’s no fiscal dilemma here. Ryan’s plan is bad at the household level, worse than we have now under ACA.
Andrew Sullivan shouldn’t confuse fiscal prudence with free-market theology.
And maybe those grants would be bigger and actually keep medical procedures affordable if Ryan’s plan didn’t have tremendous tax cuts for the richest Americans in it.