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The Creeping Takeover of Medical Care, Part 1


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President Clinton favors barring health-insurance companies from using genetic testing to determine whom they will insure. If that position is enacted into law, it will be one more step toward what he has been aiming at since he came into office: a government takeover of medical care.

Why shouldn’t health underwriters use the results of genetic testing in making decisions about whom to insure? Medical insurance is a hedge against financial hardship due to health problems. Insurers, who are in business to make a profit (and who can’t stay in business without it), will naturally want to charge premiums according to the risk presented by their customers. If they cannot do that, they will go bankrupt. To assess that risk properly, insurers need information. In recent years the science of genetics has made new information available about people’s risk of disease. To pass a law prohibiting insurers from using that information undermines the very function of insurance. Can it really be wise to mandate ignorance?

The president says people with risky genetic profiles will not be able to buy insurance. More likely, they will be charged higher premiums than those without such profiles. But that is how insurance is supposed to work. When Ben Franklin opened the first fire insurance company, he charged higher premiums for wooden homes than for stone ones. Was he discriminating? Of course, and in a highly rational fashion, because it was based on objective risk.

Ever since Mr. Clinton’s (and the First Lady’s) bid to nationalize health care met with resounding defeat, he and his congressional allies have been moving step by step toward the same objective. By tampering with the insurance rules, they make it nearly inevitable that the federal government will take over the health insurance industry, if not outright, then through comprehensive regulation. A facade of private enterprise may remain, but in fact it will be a government operation.

Here’s how it will work. By forcing insurance companies to guarantee portability when a worker takes a new job, by requiring full coverage for existing medical conditions, by mandating that mental health benefits equal regular medical benefits, and by doing all sorts of other nice-sounding things, the government makes health insurance more expensive than otherwise. If employers are to continue to provide it, they will have to reduce cash wages. If they can’t do that, they may stop providing insurance (or lay people off or hire fewer in the future). Meanwhile, young healthy people will forgo insurance because they would rather have the cash. (If existing ailments must be covered, they have no incentive to buy insurance when they are healthy anyway.) But that would leave the insurance pool with few low-risk people who don’t draw benefits. That’s bad for the remaining higher-risk people.

Thus, as the health insurance industry becomes more precarious, the government will have a strong pretext to intervene even more. Insurance might be made mandatory in order to force low-risk people to stay in the pool. The government might define a package of basic benefits, a process that will be subject to intense lobbying by people who do hair weaves and the like. Premiums might be capped under political pressure, creating shortages. Insurers might be forced, in the name of antidiscrimination, to charge high-risk and low-risk people identical premiums. All this could drive companies out of the marketplace, further hiking premiums and leaving big gaps in the marketplace.

There is no way around this. If the government regulates medical insurance, it will encourage insurers and low-risk people to leave the market. Those left behind will suffer. The private sector will be declared a failure. The final step might be the nationalization of health insurance. That has been the goal of Sen. Edward M. Kennedy and others for years.

This is not conspiracy. It is logic.

It is an old story. Government regulations cause problems. Then people point to those problems as reasons for more regulations. The spiral to comprehensive control requires no stretch of the imagination.

The only alternative is to repeal the earlier regulations that caused the trouble in the first place. Politically, this is difficult. It requires understanding and courage. For example, one must grasp the difference between insurance and welfare. If insurance companies must cover people regardless of their risk of ill health at premiums unrelated to that risk, that is welfare, not insurance. Facing that fact honestly would be a start on the road to medical freedom and better health.

Something else is required as well: a commitment to liberty. When it comes to health care, that commitment is weak indeed. People seem to believe they have a right to medical services either at very low cost or no cost at all. They think the government should be the provider of last resort.

The idea of a right to medical care is so casually asserted that most people never take time to see the monumental consequences that result from it. This is a classic pseudo-right. A pseudo-right is any claim expressed as a right that would expand the power of the state at the expense of genuine rights. The “right to medical care” is alluring. People not used to dissecting political discourse will think of the benefits of having medical services provided “free” or at a guaranteed low price. More sophisticated people may see the proposal as a giant insurance system and feel that there can be no danger in it. If all citizens pay and all have access to care when they need it, what could be wrong?

Much could be wrong. First, for a right to be real, it has to be capable of being exercised without anyone’s affirmative cooperation. The full exercise of my right of self-ownership requires you to do nothing except refrain from killing, assaulting, or otherwise physically harming me. The full exercise of my property rights requires you to do nothing except refrain from taking what is mine. You have no positive, enforceable obligations to me, apart from any you accept through contract.

That principle of nonobligation is an excellent test to which we can submit any proffered right. How does the right to medical care hold up? Leaving out self-treatment, it is difficult to see how there can be such a right. Medical care, unlike air, is not superabundant. It is produced by someone who spent resources to acquire expertise and education. It requires the use of instruments and drugs, which have to be manufactured by someone. A right to those products and services implies the right to compel others to provide them. But that would make slaves of those so compelled. What about their rights?

Since the “right to medical care” requires an affirmative obligation, it fails the rights test. Put simply, that “right” cannot coexist with the right to be left alone.

In today’s welfare state, doctors, nurses, and manufacturers of medical instruments and pharmaceuticals are not typically forced to provide their services at gunpoint. So this critique may not seem germane. But although providers are not compelled, the taxpayers are. Taxation is somewhat less egregious than conscription, but it is still compulsion. Taking people’s earnings is tantamount to taking their time and labor. Since the compulsion of taxation is spread across large numbers of people, it is less noticeable than the conscription of medical personnel. But it doesn’t fundamentally change what’s going on. Someone is being forced to provide something to someone else without there being a freely accepted contractual obligation to provide it. The fact that those who are taxed at times also are beneficiaries of coercively financed services does not alter the picture.

Thus, the “right to medical care” fails on at least one rather important count: it cannot be a right because it must negate the rights of others. The purpose of rights is to enable human beings to live like the potentially rational beings they are. To live that way, conflict over the use of resources must be averted. People need to know what they may and amay not do with respect to physical objects. A distinctly human life is impossible in a Hobbesian war of all against all. Since life is the fundamental value, making all others possible, and lives come in units known as individuals, rights are a moral concept intended to enable individuals to live and flourish.

Rather than being a humane consideration, the alleged right to medical care negates rights. But that’s not all it does.

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    Sheldon Richman is former vice president and editor at The Future of Freedom Foundation and editor of FFF's monthly journal, Future of Freedom. For 15 years he was editor of The Freeman, published by the Foundation for Economic Education in Irvington, New York. He is the author of FFF's award-winning book Separating School & State: How to Liberate America's Families; Your Money or Your Life: Why We Must Abolish the Income Tax; and Tethered Citizens: Time to Repeal the Welfare State. Calling for the abolition, not the reform, of public schooling. Separating School & State has become a landmark book in both libertarian and educational circles. In his column in the Financial Times, Michael Prowse wrote: "I recommend a subversive tract, Separating School & State by Sheldon Richman of the Cato Institute, a Washington think tank... . I also think that Mr. Richman is right to fear that state education undermines personal responsibility..." Sheldon's articles on economic policy, education, civil liberties, American history, foreign policy, and the Middle East have appeared in the Washington Post, Wall Street Journal, American Scholar, Chicago Tribune, USA Today, Washington Times, The American Conservative, Insight, Cato Policy Report, Journal of Economic Development, The Freeman, The World & I, Reason, Washington Report on Middle East Affairs, Middle East Policy, Liberty magazine, and other publications. He is a contributor to the The Concise Encyclopedia of Economics. A former newspaper reporter and senior editor at the Cato Institute and the Institute for Humane Studies, Sheldon is a graduate of Temple University in Philadelphia. He blogs at Free Association. Send him e-mail.