We Can’t Have a World Free of Opportunity Costs
The political and philosophical debate surrounding healthcare & other universal programs should begin by acknowledging there will be trade-offs
Persuading ourselves that our preferred alternative has no downside is the greatest delusion of all. Coming in a close second is the conviction that the costs of our favored choice will be far lower than they are.
These are common mistakes in political and policy debates. Progressives do their cause no favors when they indulge in them.
Medicare for All (or for all who want it) is a case in point. For its supporters in the US, the argument in favor has seemingly been reduced to some version of ‘single-payer can be all things to all people.’ However, this is not a view that reflects the inherent nuances of healthcare policy, single-payer or otherwise — and I say this as a supporter of the single-payer model.
Opportunity costs are defined as the sacrifices we make upon selecting a course of action. There are no choices in life that come without these costs, even if they are often small. For example, as children, we may have sacrificed the option of watching a favorite television show in favor of playing outside with friends or lost the privilege of eating dessert by refusing to eat our vegetables. That to us these losses may have seemed trivial, perhaps even so much so that they went unnoticed, doesn’t mean there were no opportunity costs associated with our choices at all.
When we scale up to the level of national policy, we aren’t talking about missing a favorite television program or forgoing dessert: we’re talking about decisions with potentially life-altering consequences involving billions of dollars. We’re also playing with often cherished human values. That policy A is quantifiably better than policy B on average doesn’t necessarily justify policy A if society believes the [frequently intangible] opportunity costs associated with it are just too high. For instance, a society that values individualism far more highly than it does equality will find it difficult to justify mandates and outcomes imposed on everyone, no matter how equitably distributed or cost-effective they may be.
Canada’s healthcare system is one of the main reasons my wife and I decided to move to Canada nearly ten years ago. We believed then, as we do now, that Canada’s single-payer model is both more equitable and more affordable than the United States’ predominately private for-profit system. At the personal level, the reduction in stress associated with living in a society where our employment decisions and other life choices didn’t require us to put our health insurance coverage at risk was worth the financial and other costs associated with starting a new life in another country.
But Canada’s healthcare system isn’t perfect. No country has a “perfect” healthcare system. One big difference between the United States and all the other nations with universal healthcare coverage of one sort or another is that other countries generally acknowledge their system’s imperfections and aspire to correct them. Uncle Sam, on the other hand, wastes his time insisting over and over again that he already has the best healthcare system in the world and minimizing the need for improvement, though these claims are becoming harder and harder for his citizens to believe.
While I appreciate the efforts of Senator Sanders and others to advance reform, I can’t help feeling they may be putting the policy cart before the values horse. Before Canada or any of the other developed nations universalized their healthcare system, they engaged in a meaningful if often informal national discussion regarding their moral priorities.
Canada’s current single-payer system is the product of decades of what many progressives in the states are currently criticizing as incrementalism. It started with hospitalization coverage in one province followed by a few more provinces. Expansion to all provinces and the inclusion of visits to the doctor came later. So did efforts to control drug costs. Vision and dental coverage are still provided only through private supplemental insurance.
I’m not suggesting a similar kind of transformation will take decades to achieve in the United States. That said, having the patience to discuss the purpose and limits of meaningful change within a society requires the courage to honestly confront both the benefits and the costs of the actions being considered, including the speed with which they are implemented. Figuring out exactly what your cultural values are and how they inform the choices under consideration is a central part of that process. Moving too quickly when dealing with complex systems that are vital to the wellbeing of tens of millions of people can have serious and detrimental unanticipated consequences. A little patience and humility are called for. So far, I’m not seeing that kind of commitment in the US either from advocates of change or their critics.
Does the United States value equality over privilege? If equality in the delivery of healthcare services is something Americans value, do they value it enough to wait a bit longer for certain medical treatments in non-life threatening cases so that everyone needing immediate medical attention can get it quickly? How do Americans balance individual desires against the good of the whole? Whether explicitly or implicitly, these questions need to be addressed before anything like consensus on Medicare for All can be achieved.
Unfortunately, politicians aren’t being entirely truthful with the American people when they claim that Medicare for All, or other proposals intended to expand coverage, will deliver the kind of healthcare that at least some privileged patients with excellent insurance are already used to. As most Americans correctly suspect, they won’t. This failure is only adding to the cynicism already poisoning American politics.
I don’t entirely blame the politicians for this state of affairs. I also blame an American electorate with a deeply ingrained attachment to the anti-intellectualism that has rendered it resistant to any sort of nuanced debate for most of the country’s history. It’s a stance that has left too many voters paralyzed by doubt and mistrust even when confronted with overwhelming evidence. Under these circumstances, any politician daring to publicly indulge in a deliberative and nuanced discussion is likely to be severely punished at the ballot box.
The US and Canada have almost the same number of doctors per capita. The difference between the two nations is in how they ration healthcare services, not in their respective system’s capacity. Changing the US system to something like the Canadian model will likely produce similar outcomes. That’s not a bad thing in my view, but it will have consequences I’m not convinced Americans are prepared to accept any time soon.
Currently, the US can deliver quick treatment of even minor conditions to the wealthy and/or well insured because it’s rationing those treatments, along with far more urgent ones, by denying or delaying them in cases where people can’t afford to pay for them. Rationing in Canada is based on medical necessity, not the ability to pay. As a result, greater waiting times for many less urgent treatments are a burden shared more or less equally by every Canadian citizen regardless of income.
The point is, both countries must ration healthcare to some degree to deliver it. However, how they each choose to ration this care reflects a significant difference in their respective priorities. Canadians have developed an understanding of the trade-offs involved in the implementation of universal coverage through decades of experience. They’re more or less comfortable with the idea that triage becomes more necessary, not less if everyone is to have the best chance of receiving the best care possible when they need it most. This reflects a commitment to the value of equality that I don’t think my fellow Americans share to nearly the same degree as my Canadian neighbors do.
To be honest, I’m not fully convinced most American liberals are willing to accept longer wait times in certain cases to improve both overall average outcomes and reduce overall average costs.
A Canadian co-worker of mine has an American girlfriend who recently had her hip replaced in the states. He shared with me his girlfriend’s impatience to have the surgery and her inability to understand how Canadians could put up with delays of even a few weeks for the same procedure. Though my co-worker naturally has no desire to see his girlfriend suffer, he was nonetheless a bit surprised and disappointed by her impatience given his girlfriend is a Democrat who loathes Trump and loves both Senators Sanders and Warren. Though her Canadian boyfriend understands the trade-offs of the universal healthcare system intuitively, he still couldn’t make her see these are costs universal coverage inevitably entails. Like most Americans, his girlfriend wants it all and she wants it now. That this unrealistic desire has left many of her fellow citizens receiving little to nothing seems lost on her.
America has consistently missed the mark on healthcare reform not because the proposals being offered are inherently terrible but because the public hasn’t first bothered to honestly confront the necessary moral questions that would eventually lead to meaningful reform. The American healthcare system has developed, like so many of the country’s other social systems, in an ad hoc fashion. It is the product of a peculiar and near-perfect philosophical vacuum in which extreme individualism and national exceptionalism are the only two relatively consistent premises upon which any national debate is being built. In this intellectual climate, such as it is, being reactive rather than proactive is the norm.
Before America can achieve true universal healthcare coverage or otherwise liberate itself from inequality, it must proactively attempt to prioritize its values. How much longer can the US afford to put off that debate by defaulting to the simplistic adulation of the market and paeans to individual choice? Avoidance is, after all, a decision that comes with steep opportunity costs of its own.