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Monday, September 2, 2013

What does Universal Health Care Mean? Let's create UWBI

In the Annals of Internal Medicine a commentary was published titled as above(Pubmed link). It was written by  representatives of  the Health Section of UNICEF. It's focus hinges upon a basic question which the development community wrestles with; investment in health care vs. development. I call into question making this distinction whatsoever.

Perhaps we need to reframe the issue and make a new designation. Let's call it UWBI standing for Universal well-being insurance. I can justify this on the basis of health being linked to resources, environment, and culture. We will never get to the point where there is equity in health care until EVERYONE has control over sufficient resources to control their own destinies. Scarcity always matters to some degree and what better vehicle can we envision to address the scarcity issue than to insure everyone on the planet against scarcity using some sort of government issued insurance policy. While we are at it why don't we simply pass laws to guarantee than everyone will live to 1000 years of age without pain or deprivation. I don't want to hear from those nay-Sayers now. Let's keep the discussion positive.  Problem solved. The only thing left is to convince a do nothing Congress and Tea Party to get off their butts and pass the laws. 

I cannot help but harken back to the von Mises quote regarding common goals but different means which separate even most disparate political foes.
But each party is intent upon proving by ratiocination and by referring to historical experience that only the system it recommends will make the citizens prosperous and satisfied. They tell the people that realization of their program will raise the standard of living to a higher level than realization of any other party’s program. They insist upon the expediency of their plans and upon their utility. It is obvious that they do not differ from one another with regard to ends but only as to means. They all pretend to aim at the highest material welfare for the majority of citizens.
The question becomes how do we move toward a world where more human needs and wants are met?
The temptation is to make a distinction between health care goods and services and all other goods and services which enhance human lives. I am not entirely sure where this comes from. The article by the UNICEF group underscores the futility of this exercise. Individual and population health outcomes are perhaps more related to delivery of goods and services viewed outside of the health care arena. Do populations have ready  access to clean water, electricity, transportation, high quality and inexpensive food, shelter from the elements, safe work places, and modern waste disposal systems? All of those things require coordinated human action and resources. 

In a world where there are lots of possibilities of outcomes, without the right rules and incentives, there are more likely bad outcomes than good outcomes. For most of human history humans lived brutish and  short lives because everything needed to make human lives longer and better were either non-existent or in short supply. Even now people in much of the world live such lives.Looking back and using metrics we seem to value presently, there might be aspects of earlier times which we seem to want to replicate in the present. When everything was scarce there was less inequity among humans. Everyone was essentially dirt poor but there was little disparity.

Only when specific people and groups began to make significant inroads into mass production did humans first observe resource inequities. How one views such snapshot inequities, as being the product of desirable innovation or unfair fates of one group vs. another, should hinge on taking a long term perspective. Should we view equity as being so important as to advocate against disruptive innovation which might ultimately make some better off than others although in the longer term everyone will be better off than they started?

The concept of Universal Health Care is essentially meaningless. None entity can define the goods or services which would fall under this designation at any given point in time or place and there is no mechanisms for defining this in any sort of dynamic way which would be required to make it a useful within any legal entitlement framework. The words sound good and have the potential to make us feel good. Beyond that, they are at best neutral in their impact and more likely terribly destructive. We ultimately move toward the concept of UWBI and in doing so unleash the moral hazards associated with the use of insurance.

People have needs and wants and through time these are constantly changing. These needs and wants exist in a world where the the resources to meet the needs and wants are not unlimited and expansion of the pools of goods and services to meet human needs are accomplished by human action. Set the incentives correctly and one inspires people to act to create more resources and interact in win-win transactions. Set the incentives wrong and you increasingly engage people in win-lose or lose-lose, resources consuming actions. This results in a race to the bottom.   These basic rules work in all human endeavors. To suggest they do not operate in health care requires that one then be able to define how health care activities are different from other human endeavors. That cannot be done. 

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