How Conservatives Can Begin Thinking About a Public Health Option

Someone mentioned recently that conservatives ought not cast so many stones in the health care debate when none of them are coming up with any viable alternatives. I figured I’d use that as my cue to finally jump in and explain some of the principled ways that a conservative ought to think about health care.

Insurance: “You keep using that word. I do not think it means what you think it means.”

The first problem that keeps us from intelligently discussing health care is the vocabulary. Health “insurance” is not really insurance. Insurance is how we pay for something in case some contingency in a pre-defined class of contingencies occurs. Health “insurance,” instead, means something more like pre-paid health service, or a fixed-rate health plan. The point is, regular doctor visits, properly speaking, are not part of health insurance any more than oil changes are part of auto insurance. Of course, we know what insurance is supposed to mean. Most of us have car insurance. Many of us have home insurance, or renter’s insurance. We might even have insurance on the flat screen we bought at Best Buy. So why do we insist on speaking as if our annual checkups should be included in our health insurance? To be productive with talk about public alternatives to health insurance, we need to remember what insurance means.

The Dateline Effect

The next thing to think about is what exactly we are trying to accomplish with public health care. Noting the difference between “insurance” and something more like a fixed-rate health plan, it should be pretty clear that what we are not particularly interested in making sure everyone is able to get cheap doctor visits whenever they get a sniffle. My co-pay is just $10. Had I more time and less aversion to doctor visits, I would never opt not to see the doctor. I am not interested in the least in paying more taxes so that everyone can have such whimsical access to chat with the doc. The "least among us" are not known by whether they have ready access to a Wellbutrin prescription.

Instead, what we are after is eliminating the “Dateline effect”—gut-wrenching in-depth news-show stories about families just like yours and mine having financial ruin heaped on top of emotional ruin resulting from little Billy’s bout with terminal cancer, made all the worse by the plucky lad’s resolve to push on beyond all doctors’ predictions and cost estimates before finally reaching the end. That’s what the clamor for the public option is all about. People will still break their limbs and split their heads open and accidentally shoot their thumbs off, requiring the occasional trip to the emergency room. And if they don’t have insurance, they’ll grumble about how to pay for the services they received. But it's not going to break anybody—and, more importantly, it’s not going to make Dateline. The stories of indigents struggling to pay off a few grand in emergency room bills are not the ones that are galvanizing the move toward public health coverage. If you can’t imagine a story about it on your favorite TV news journal, it shouldn’t be covered by the public option.

The Agony of Having No One to Blame

The other benchmark driving the push for a public option is fault, or rather the lack of it. When we hear about tragic health stories, the first thing anyone does is try to place blame. It’s the natural human response. If we can identify the cause—i.e., smoked too much, drank too much, carried on so fat, visited that dubious third world country, was negligent, etc.—the whole thing becomes much less terrifyingly arbitrary. Humans are stupid and silly and repugnant, to be sure, but at least they’re predictably so. And a surprising amount of satisfaction and all-around peace with the universe can be derived through comeuppance. At any rate, once we find the loathsome culprit, we can direct our fist-shaking accordingly. And then we can forget about the whole thing and get back to Dancing with the Stars.

But things like cancer leave us feeling so unresolved, at odds with the universe. Without someone to blame, we have no way to turn the grief into indignation. After a while, that dull sense of guilt that starts to really eat at us. It’s an entirely irrational guilt, of course. But guilt, like the rest of our emotions, does not shrink at name-calling. So after shaking our fists at the sky yields no results, we turn to the next most powerful and arbitrary force known to us: government.

So long as we insist on waging this war on guilt by devising a public health care option, let’s at least limit the scope of that war to those things that are actually causing the guilt—to those ailments that are not properly attributable to the fault of some individual. The test could be quite simple:

“When you discovered your ailment, what was your response?
A. ‘D’oh!’
B. ‘That bastard!’
C. ‘Goddammit.’”

The public option only covers C; both A and B indicate there's already someone to blame—yourself or someone else—and thus the rest of us are quite capable of activating our grief-to-indignation conversion mechanisms without footing your bill.

That is the key to the whole thing, after all. This is a war on guilt, and whatever the cheapest way of beating our guilt is the way we ought to go. The best way, incidentally, is to just tell our collective guilt to go suck an egg. But since it seems we’re unwilling to do that, we should examine any public health option in terms of how well it assuages the guilt. I submit that only those ailments that are, by all accounts, arbitrary and owing to the fault of no one, should be covered by a public option.

[Cross-posted (and with lots of discussion) at League of Ordinary Gentlemen.]