Health Care—What Matters Is the Direction We Push the System

Often public policy issues focus on, well, issues. Issues tend to be the states of affairs we would like to have, and there is nothing wrong with that. But a limited focus on issues is dangerously thoughtless in setting public policy, particularly when we thoughtless assume it should be a political issue reduced on to the question of how to design government to address the problem. Of course we have wants, goals, ends, outcomes for our societal good but in centering our attention exclusively on ends, we hide the more fundamental differences among the means to be used, the design if you will of a system that is implied in a position on an issue.

The means are more important since they are the operating rules of the system and they determine what can be produced; they are the dynamics of the method of production as opposed to the statics, the descriptions of the state of affairs we want as outcomes and goals or that are actually being produced by the current system. To ask how we get to a desired end raises difficult intellectual challenges since it requires us to pull out the structure of the system inherent in a design that we will think we could use to organize the production of the end. It is intellectually much more challenging that a limited focus on ends or states; it requires what psychologists call a “reflective abstraction” in which we pull out of our thinking the relationships that are implied in our thoughts.

Perhaps the lowest level of thoughtless public policy is to simply focus on the appealing aspect of ends and goals since it is done without the conceptually difficult work of figuring out and explaining how the desirable ends could actually be produced. Educated people seem particularly susceptible to expressing good intentions as if they are good political policy. “Everyone should have the right to affordable health care,” one psychology professor wrote in an opinion piece. That goal would be nice of course, but when we ask for details on exactly how such a “right” (more properly he is referring to an entitlement) is not obviously unrealistic.

Think of all the nice sound bites that express goals most of us want: control of rising costs, better access by poor people, affordable drugs for senior citizens, curbs on excess profits by drug companies, better availability of organs, lower infant mortality rate, and so on. More thoughtful people can agree with the desirability of the goals but reject the goals as unrealistic and unwise as a basis for policies because they know the ends cannot justify the means.

This thoughtless focus by a professor on goals happens in other areas of public policy, not just health care. Public education is always an issue and it too is dominated by this kind of thoughtless kind of advocacy and focus on ends. In education the ends focus mostly some form of high test scores with some reference to holding someone accountable but without a corresponding expression of any valid understanding of the means by which human intellectual growth is produced, testing and accountability can’t describe any methods for actually delivering the ends. They remain hopes, good intentions, desirable states of affairs we all can easily agree would be nice to have.

The difficult challenge in shifting the focus in health care discussions to the means is that it involves a new focus on relationships. Relationships shift the focus away from goals and outcomes; they are more complex, more abstract, and less observable as content of thought. To pull out the relationships involves requires an investigation and conceptuation of third party systems of government programs and intervention and compare these to the direct, two-way relationships of free systems of consumers directly pay and benefiting from producers. The content of this kind of thinking is that of the difference in the relationships of these two kinds of health care systems; it is no long about the concrete descriptions, facts, outcomes, goals, desired ends that are easily debated.

Since underlying our policy discussions is the policy choice between whether to move the health care system toward more government planning, control, and funding or toward more direct consumer/provide relationships, we cannot consider the wisdom or morality of such proposals merely by looking at how various government programs would work to produce some desired outcomes. We have to also understand and compare these government methods with methods of free systems of health care that are controlled by the self-regulation inherent in voluntary, mutually beneficial exchanges between consumers and providers. Until we understand both, we cannot thoughtfully reject one or the other.

All thoughtful public policy involves this kind of abstract thinking because at heart, all public policy involves the question of the direction we want to push a system. As to the means of any public policy, do we want to design the means that would put more of the human activities of our society under government control or do we want to design a policy that would promote the free constructive problem solving activities of citizens. It may be true, and it does some evident from survey data, that most citizens cannot think at such a level of abstraction. But if that is so, then that incapacity calls into question the very idea of democracy as the means for organizing our society. It would suggest that rather than democratically getting together to decide what to do about health care, we should instead examine why and how our design of government tends to make so many issues into political ones. If government is prevented from controlling, spending, and intervening in an area then we have no public policy issue since we would have society solving the problem and producing public benefits without government.

Opposite to the authoritarianism of dictators is not democracy, it is a free system. Control of citizens’ activities is as authoritarian when imposed by a majority of the ruling, voting group as it is by a dictator. Both produce oppressive government. The opposite this oppression by government either imposed democratically or by a dictator is a society that protects the free activity of citizens. To pretend the democracy of imposed government control is better than a society that protects the free activity of citizens from government requires an assumption that free activity doesn’t work or is somehow destructive of the public good, not its source.

The scope of history shows conclusively that free societies promote the societal good to an astonishing degree while government controlled societies impoverish citizens. Much of the public good is produced by society without government planning, controls, and spending. The solution to public policy issues is not more democracy. More democracy implies ‘governmentalzing’ a problem so that we have more government and the imposition of more restrictions on citizens’ activities. More democracy in this sense is a cause of problems since it is the inappropriate expansion and use of government power that creates even more problems and political issues such as it has done in health care.

The inescapable policy question underlying the health care issue is whether we want to increase the use of the force of government to mandate and control citizen activities or do we want to push the system toward solving problems with less centralized control. Already our health care system is fundamentally controlled and distorted by government funding and involvement. It is a matter of which direction to push the current reather dysfunctional and inefficient system—toward more government which caused most of the problem in the first place or towards more direct, voluntary choice and opportunities between consumers and providers. The wisdom of our choice always comes down to the third party problem. The benefits and costs are separated by third party government programs, and there is no known economic solution to the problems that causes. Such systems are inherently unstable and inherently tend to move toward increasing costs, restrictions of supply, and decreasing or fixed levels of quality.

To thoughtfully choose such a system would necessarily mean to have developed and demonstrated some new design. The new design would have to show that it avoids the problems of third party programs that are caused in systems imposed and protected by government force. Since it has never been done and appears economically to be undoable, without this clear demonstration of how a new, workable design solves the third party problems of government control, such systems must be assumed to be defective. If it cannot be shown how it will solve the problems, then it must be considered to be harmful to society. The benefits and justification of free systems need no longer be proven; the imposition of government systems must be. With history, experimental results, and theory clearly established, we no longer have to prove that free markets work. However, if we are to push society toward more government that imposes third party programs by force, we do have to somehow come up with a theory of government that demonstrates these government designs can work. It has not yet been done. Without this clear showing of benefit in promoting the public good, it must be considered immoral to use government force to impose controls on citizens’ activities against their will and their choices.