Putting the Horse Before the Cart

As each presidential candidate has unveiled his or her plan for reforming health care, one practice seems safe: emergency medical care. Congress may wrangle over the specifics of expanding medical insurance for children, but no one seriously talks about repealing the 1986 law that requires emergency rooms to treat the uninsured.

In July, President Bush blithely reminded parents of this important recourse, telling them to “just go to the emergency room” if their child becomes deathly ill. Never mind that the typical emergency room visit costs several times more than a typical visit for preventive care, and hospitals that must swallow unpaid bills pass them along to paying customers. The President must have known this when early last month he vetoed an expansion of federal insurance for children.

So what’s at the bottom of this? Why would Bush and some Republicans, who in some areas might champion efficiency, opt for a status quo that only increases costs for everyone else? Well, their fear is that if we provide basic primary care to the nation’s children, we are one step closer to “socialized” medicine and the land of Lenin. This may sound like dubious logic, but there’s an element of truth to it.

Conservatives are (clumsily) making a moral argument: “socialized” medicine by rationing care restricts choice. Individuals must then rely on the state for medical access, rather than their own willingness to pay. The extra costs associated with the government picking up emergency room visits is worth it to thwart the slide into single-payer healthcare.

Liberals, rather than questioning the moral tenability of such a position—whether choice for some and nothing for others is acceptable—often make an argument based on efficiency. New York Times columnist Paul Krugman, for one, suggests governments are necessary to correct for market failure. Those who need care the most, the chronically sick or diseased, are denied insurance. As a result, their conditions worsen, debt accumulates, and the public must eventually pick up the tab.

Many liberals claim that covering the 47 million uninsured with public funds if necessary or by restricting insurance companies' ability to exclude patients and thus opening the door to preventative care will reduce emergency care visits, and possibly health spending overall. But that’s the problem: some conservatives, it seems, are quite content with inefficiencies.

Witness the taboo that is single-payer health care, something which no Democratic candidate short of Dennis Kucinich is publicly supporting. Self-described progressives can’t understand those who brush off their inexorable logic. European countries, they point out, spend a fraction of what we do on health care but have healthier populations. Thus, a single-payer system is obviously the solution.

Yet economic reasoning is hardly motivating, even among the famously pragmatic American electorate. Trumpeting efficiency rarely panned out in other countries: Britain’s National Health Service, created by a Labour government in 1947, was in large part a response to the collective hardships suffered during World War II, not to statistic-laden arguments from economists.

The war has been waged on different battlegrounds: conservatives feverishly positioning themselves on the moral one, and liberals wonkishly blustering around the economic one.

And liberals’ attempts to capture the moral high ground have thus far been weak or incoherent, especially in their moral case for single-payer health care. Such a system, by funneling most health care spending into the public sector, eliminates the private sector, and thus inequity. Millionaires, they beam, have to wait in the same lines for surgery as janitors. It is egalitarian. And therein lies its problem.

Rather than making sure that the uninsured have a sufficient amount of choice, a single-payer system often forces everyone to have the same choice, which has an insidious flipside. In Canada this meant that no one could sacrifice more to obtain better or more prompt treatment. It was only in 2005 that the Canadian Supreme court struck down a Quebec law forbidding private insurance for medically necessary operations, claiming that it violated the defendant’s right to person.

Conservatives can sound reasonable when comparing a system that allows private money to flood in to one that bans it entirely. If a heiress wants to spend her millions on an untested cancer treatment, this should not be prohibited for equality’s sake.

Advocates for universal health care must make a moral argument to counter conservative inertia, but they must make the right one. Otherwise, the public will suspect that they are motivated by a vindictive egalitarianism, rather than a genuine desire to help the medically needy. The leading Democratic candidates—Clinton, Edwards, and Obama—are taking the step in the right direction by stressing the moral case for a sufficient amount of coverage for everyone.

Universal coverage is a moral imperative, but numbers and charts must follow rather than precede its implementation. It should be reassuring that imperatives of efficiency cannot raise public ire. It is a sign that means-end rationality has not completely dominated public discourse. Hopefully, it also means that soon the emergency room will no longer be the first and last resort for America’s uninsured.

Will E. Johnston ’08, a Crimson editorial editor, is a social studies concentrator in Adams House.