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Tuesday, April 13, 2010  

It's Important for People to Suffer

A lot of people seem to have trouble thinking and speaking clearly about the causes and consequences of the new health care law. Here's Congressman and Senate candidate Roy Blunt (R-Mo.):

"Access for kids who have pre-existing conditions, who would be against that?" Blunt asked a group of health care professionals in Springfield, MO.

Well, for starters, Congressman Roy Blunt would be against it. He voted against access for kids with pre-existing conditions as provided for in the new law. Blunt also voted against expanding SCHIP in 2007 and 2009, in an attempt to keep 8-10 million otherwise uninsured (and often uninsurable) children off the insurance rolls. It's never a good sign when you are the answer to your own rhetorical question.

But then he takes up the issue of adults:

"But access for adults who've done nothing to take care of themselves, who actually will have as I just described every incentive not to get insurance until the day that you know that you're going to have medical expenses--that's a very different kind of story."

OK, so there's a ghost of a point here that I'll get to in a moment. But I really, really dislike the right-wing habit of looking for a failure of personal virtue behind every misfortune in life. Even to the extent that such an exercise yields actionable judgments, it's just a mean and sore-headed way of looking at the world. Who would say of his own child that he is morally obligated to go without insurance because he smoked or ate too much? It's monstrous.

And it's not even a remotely useful heuristic for the problem of health insurance. Some pre-existing conditions are genetic entirely (like the cancer gene that devastated my father's family), some are due to bad luck or accidents, and sometimes these factors combine with ordinary human short-sightedness to create or amplify health problems for which you can be excluded from insurance. The previous status quo did not protect the righteous nor punish the wicked as Mr. Blunt would have it.

Under the old status quo (and current law for a while longer), if you lost your insurance due to a pre-existing condition, you could do a few different things. You could try to get into your state's high-risk pool. These are pretty strained nowadays, however. You could try to qualify for a public aid program. You could find a hospital to treat you as a charity case. Or you could just die. Now options 1-3 all impose costs on society, either in the form of taxes or higher provider fees. Option 4 has the virtue of making the unlucky/unworthy person who gets sick pay the full cost of her bad luck or bad morals, but it's such a distasteful option that conservatives take great pains to pretend that it does not happen and to insist that they do not wish it to happen.

So back to the ghost of a point. How do we encourage healthy living in the context of guaranteed-issue insurance? For one thing, Blunt is ignoring the matter of the individual mandate. The penalty for being uninsured is meant to make sure people are contributing to the system somehow, either through premiums or through fees that will help pay someone else's premiums. If Mr. Blunt thinks the penalty is too light to have this effect (as many people do), he should argue for stiffening it. As for the problem of "adults who've done nothing to take care of themselves," I think we need to look seriously at excise taxes on unhealthy stuff. We already enshrine this principle with tobacco taxes, but those are apparently nearing the point where a black market will emerge if they're taxed any further. I don't see any reason not to do it with sweeteners, alcohol, trans fats, maybe even sodium content. You keep these funds distinct from general revenues and dedicate them entirely to the premium subsidies so that the benefits stay within the system (this should also be done, I'd argue, with the "Cadillac" tax, the fees for going uninsured, and the employer free-rider provision). Then if I choose to eat a healthier diet, I am getting my guaranteed health coverage at a lower effective cost than someone who eats badly. And if I eat badly but have genes that give me some protection against my habits, I pay into the system the same as someone who eats the same diet but has less favorable genes. This is not only fairer, it makes the system more rational. If taking good care of myself day by day right now will only yield a moderately increased chance of keeping my insurance ten or twenty years down the road, I'm going to need other incentives to do it. Cutting my weekly grocery bill seems like a pretty good one.

What my idea does not do is make sure that someone, somewhere is being dramatically punished for doing things Roy Blunt disapproves of. Actual pragmatic difficulties can be overcome. A yearning for the suffering of the wicked--which I see evident in a whole lot of opposition to the new law--cannot be overcome. I hope people who listen to Roy Blunt spare a thought for which kind of objection is motivating them.

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posted by Benjamin Dueholm | 10:42 AM
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