Wednesday, November 14, 2007

The fallacy of health insurance as a "right"

At some point in the past 30 years, there was a transition - or series of transitions - that brought the collective mindset of the American public to the conclusion that health insurance (or health care) is a "right." We hear it all the time from the halls of government, from political pulpits and political pundits, from news "anchors" who amaze us with their ability to read words from a teleprompter spun by some invisible, high-tech Cyrano de Bergerac. Eventually, we hear it around the proverbial water cooler from those that ejaculate moral certitudes with the righteous indignance endemic to those that lack the will to go beyond the prima facie. How did we come to that point? And is that belief flawed?

The first things that must be defined in order to be able to balance this equation of logic are:

  1. What is "health insurance".
  2. What is a "right" for anyone to have and expect?

The first item seems to be relatively simple at first glance, but, as is often the case, we need to think between the lines. The common mistake that is made by people - be they spigot or sponge - is to confuse the notion of "health" with that of "health insurance". Even the difference between "health" and "health care" causes similar stumbles amongst people, and yet that is a significant crux of the entire issue.

Health, lest we diverge in our understanding, is defined formally as:

  1. the general condition of the body or mind with reference to soundness and vigor: good health; poor health.
  2. soundness of body or mind; freedom from disease or ailment: to have one's health; to lose one's health.

(There are two other definitions that are not relevant here.)

In either case, it is obvious that "health" is specific to the organism - i.e. the person. So, without the clutter of the "care" or "insurance", let us deal with "health" by itself for the moment.

Do people have a "right to health"? The premise that would have to be in place for that statement to be true is that our health should not be taken from us. We should always be in a state of healthiness unless someone came to deprive us of it. While certainly a person could deprive us of health due to some action, that isn't the only way that our health could leave us. Mother Nature does an admirable job of depriving us of health. Allergies, gravity and even the occasional wild animal can do damage to us in spite of our alleged "right." I can't imagine trying to reason with the shark or tiger that may want to maul us by explaining that we have a "right" to not have our limbs removed from our person. In fact, our own bodies are often instrumental in the reduction of our own physical well-being. If my thyroid or pancreas or heart go on the blink, there is no authority to which I can appeal to say that I have been wronged. There is no entity that is responsible for the deprivation of my health. I simply do not have a "right" to continue to be healthy. I can't live as long as I claim the right to live.

We do have the right to care for our health. If we are injured, we can tend those wounds. If we are sick, we can try to fix what ails us. We even have the right to seek assistance from others, if we so desire. This is the point where the argument comes.

Out there in our society are people who have chosen medicine (or some sister-discipline of it) as a profession. They have chosen to expend and invest their energy, their time, usually their money (which is simply a representative symbol of their energy or time), and hopefully their talent in the education and training that is necessary to become a medical professional. Let me repeat something - they chose to do this. Free will is still in effect at this point.

So... here we are sick and miserable and, having realized that we have not spent the energy necessary to acquire the skills to heal ourselves, we are choosing to search for someone else to help us out. And over there is someone who has chosen the training and route and they are hoping to practice their craft on someone in need.

After meeting this doctor, we may very well decide that they are capable enough for our needs. After meeting us, this doctor may very well have decided that they are capable enough for our needs.

At this point, both parties have decided that something could take place. The doctor could treat us and make us better. We both know that. So what is the final step that must take place? The only thing that is lacking is the human volition to actually begin the process. We have to agree to be treated, certainly... but no less important is the fact that the doctor has to choose to agree to treat us. It doesn't matter how badly we want his services if he doesn't consent... which is no different than if we were refusing our end of the deal by saying that (for whatever reason) we don't choose to allow the doctor to treat us. There are only 4 outcomes here:

  1. The choices are both in agreement for action - treatment happens.
  2. The choices are both in agreement for no action - no treatment happens.
  3. The choices are in disagreement on action - no treatment happens.
  4. The choices are in disagreement on action - but one person or the other is forced to do something against their will.

Taken out of the medical field, this contrast is more obvious. If the medical service was replaced with physical labor, the scenario is still familiar. "Will you build that deck for me?" "Will I hire you to build my deck?" "OK?" "OK." Everything looks fine... except for number 4. "I don't care what you say, you are building my deck whether you agree to my proposal or not." That looks strikingly like forced labor - which is a euphemism for slavery.

If you apply the statement made in #4 above to most any situation, the result is negative. In labor, it is slavery. In payment, it is robbery. In sex, it is rape. The entire premise is based on the idea that no one has the right to demand something from someone else when they are not in agreement with the terms of that exchange. Put another way, no one has the right to something someone else has.

We don't have the right to receive medical services from that doctor unless he agrees to whatever terms I am offering. While we may have the right to seek someone to take care of our ailments and we may have the right to propose terms under which we would like to be treated, we don't have the right to those services whether or not the person agrees to our proposal. We do not have the right to health care.

The addition of insurance brings in a new factor. Insurance is a gamble. A wager. We choose to purchase insurance because we believe something negative will happen to us. If something did happen to us, we would like someone else to carry the burden of it.

Insurers, on the other hand, choose to insure someone because they are wagering that something won't happen to us. Of course, eventually it is likely that eventually something will happen - but they are gambling that it won't be as often or as soon as you think it will be.

Regardless, the exchange is similar to what we have already covered. Both parties have to come to an agreement on the terms or else there is no insurance contract. In the end, they both have to choose to go through with it. So, again, we do not have the right to insist that the gambler insurer choose to take that wager about our health on our terms - or at all. We do not have the right to health insurance.

Going back up to my 2 points at the top, I have defined both health care and insurance. The casual reader will have noticed by this point that the word "choose" and its variants are sprinkled liberally throughout. But what is choice?

Choice is about volition. Freedom. Options amongst which we can discern our preference. We have a right to make choices... until and unless those choices involve someone else's rights as well. I can choose to like food. I can choose to eat food. However, I can not choose to eat someone else's food. At that point, it is countered by a reciprocal choice that the owner of the food faces - do they choose to share their food with me?

Rights are the same way. I have the right to want food. I have the right to eat food. However, I do not have the right to eat someone else's food - unless they have made the corresponding choice to exercise their right to give me their food if they so desire.

"Rights" can be a complex issue at times - but there is always one underlying tenet that has a way of simplifying the process. An individual right should never (or at least rarely) trump another individual's right. If there seems to be a contradiction between two rights, there is likely an error in the underlying premise of one or the other.

For example, if I claim I have the right to yell loudly when you are sleeping, you may claim that I am violating your right to sleep (therefore claiming that I do NOT have the right to yell loudly). Of course, I can tell you that your choice to sleep is violating my right to yell loudly. There is a seeming contradiction. So what is the issue? Well, while you certainly have the right to sleep where and when you want, you do not have the right to do so without interruption. Your alleged "right to sleep" without my yelling is not really a right after all. You can choose to go elsewhere if my yelling bothers you. (Not that the above doesn't make me look like a real ass.)

So, while I may have the right to seek my own health, I cannot do it at the expense of someone else's right - for example the doctor's right to choose who to treat and who not to. While I may have the right to seek to insure myself against the possibility of tragedy, I cannot do it at the expense of someone else's right - for example the insurer's right to choose to cover me or not.

One question that I cannot answer here is...

Where did this very basic concept go astray?
And why does so few people even realize the fallacy?

(I will leave for another day the argument about how federalized health insurance/care is actually violating the rights of those that pay for the well-being of those that are treated. That is a far larger subject covering more than just socialized medical care.)


The Happy Hospitalist said...

Loved it. Great job.

A few points to remember. When a patient choses to pay for insurance, it is a contract for a prearranged price for the right to discounted services by a physician/ hospital etc. It doesn't guarantee that the provider must see you. A patient is certainly able to pay cash for services rendered if an agreement on price is made.

Take for example Medicare. Just because a doctor accepts Medicare patients, doesn't mean they HAVE to accept you as a Medicare patient. There is no requirement to see all Medicare patients.

What will happen soon, as insurance becomes "wortheless" to doctors, is patients who have insurance, but no providers willing to see them under the provisions of the discounted insurance rates.

Cash will always be accepted, as it should be.

I believe everyone has a right to purchase health insurance. I believe, in those who are unable to afford it, that government assistance is not inappropriate, and infact should be one role of government.

But understand, insurance doesn't equate access. All parties involved must still agree to the terms of the contract, which brings me back to my original thought that insurance doesn't guarantee access. The terms of payement must still be agreeable to all parties. And right now, Medicaid,Medicare and many private insurance policies have priced themselves out of many doctors agreeable terms of service.

The walk out is upon us just ast baby boomers graduate to "old age"

DDx:dx said...

Over the years I have come to believe insurance MIGHT be evil. It distributes risk. And we learn from taking risks. Does it inhibit learning? I think it does for some. Thus the Moral Hazard...
Still, I would want help paying for 3 weeks in ICU after my MVA...And we are left with market driven insurers looking for the healthy to put in their pool to improve their pooled risk...And docs are left making contracts with no real info...
And Medicare is the 800 pounder we all can chose to contract with or not...
I appreciate your essay. I don't get a sense of direction from it.

Critical Thinker said...

Insurance isn't evil as long as the person setting the premium is allowed to do so based on his own estimate of what the risk is worth to him. In cases where the government has stepped in and said "you can't raise premiums" or "you must take this high-risk person" then there is a problem since he is now being forced to make a deal that he may not choose (there's that word again) to do.

Thanks for your comment. I agree that I didn't present a "sense of direction". That was not my intent - I was just addressing the erroneous claim that health insurance/care is a right. Since the action step of educating the masses on the philosophy of individual rights is probably out of my scope, there's not much I can do.

Again, thanks for stopping by!