Julian offers a thought experiment designed to sharpen progressives’ thnking about health care. He writes:
For the purposes of our example, suppose that the correct conception [of justice in our hypothetical society] seeks to neutralize to some extent the effects of bad luck, so that someone who is burdened with health problems, either congential or as a result of accident, may be entitled to a greater share of social resources by way of compensation. Also suppose that, unlike most social democracies, this market egalitarian society does not generally go in for direct government provision of goods, but instead, having ensured that everyone has their fair share of all-purpose resources—in other words, wealth and income—allows adults to secure these goods for themselves. Imagine that this is a generally affluent society, and in it there lives a Mr. Rich, who is as well off as anyone else—and perhaps, if this is compatible with your preferred conception of economic justice, economically better off than most. As he gets on in years, he is diagnosed with a serious condition that will shorten his life—though appropriate medical care can affect how much it is shortened. If necessary, according to your preferred conception and the specific facts of the case, his share of social wealth may be augmented through redistribution to compensate for this stroke of bad fortune.
Though he could expend some of his share on the appropriate medical treatments and be left with enough to maintain a perfectly decent quality of life, Mr Rich decides to use his resources in service of other projects: Perhaps he decides to travel to parts of the world he’d always wanted to see, or endow a library, or in other ways enhance the quality of his remaining years. As a result of this, suppose he reaches a point where he is no longer able to afford the medical treatments that would extend his life. Can he still claim a right against society to be provided with care? Or are his rights exhausted by his consumption of what, by stipulation, is his fair share of aggregate social resources? Can society fairly say: “We’ve given you what you had a right to already, and you opted against using it for health care”?
Julian is trained as a philosopher, and philosophers construct thought experiments like this as a way of simplifying and hopefully clarifying thorny moral issues. The problem, I think, is that his simplifying assumptions are doing an awful lot of the heavy lifting here. In particular, I don’t think a progressive should concede that it’s reasonable for Mr Rich’s income can easily be “augmented through redistribution to compensate for this stroke of bad fortune.”
To see the problem, let’s make the scenario a little more specific. Let’s say Mr. Rich’s doctor has discovered that he has a tumor. After further analysis, the doctor thinks there’s a 90 percent chance that the tumor is benign, and a 10 percent chance that it’s a rare and deadly form of cancer. The recommended treatment for the deadly form of cancer costs $1 million and is extremely unpleasant for the patient. So unpleasant, in fact, that Mr. Rich likely would opt against receiving it even if it cost him nothing—the 90 percent chance of unnecessarily reduced quality of life outweigh the 10 percent chance of saving one’s life.
In Julian’s hypothetical society, things look different. The doctor isn’t sure if the tumor is malignant or not, but he does know that if he says it’s malignant his patient gets a million dollars. So as long as he can make a plausible case that the tumor might be malignant, he signs the paperwork saying so and the patient gets his million dollars. And once word gets out that an adverse diagnosis gets you a fat check, there’s going to be a cottage industry in . (much as we’ve seen with Social Security disability payments)
To avoid being robbed blind, the government would have to develop an elaborate bureaucracy for independently reviewing doctors’ diagnoses. Indeed, given the stronger incentives patients would face to game the system—a negative diagnosis gets them cash rather than unnecessary medical treatments—the required bureaucracy would probably be greater than the present-day Medicare bureaucracy, and probably even greater than the bureaucracy you’d need to administer a full-blown single-payer system.
Even if this perverse incentive problem could be solved, I think there’s a deeper philosophical problem with the concept of writing people checks to compensate them ex ante for their medical misfortunes. Let’s say Mr. Rich gets his million dollars and spends it on treatments that wind up not working. This is another stroke of bad luck. Does it entitle him to another check from the government? Do we say that he only gets a check if he complied with the government’s recommended treatment regimen? Or do we take a harder line and say that he already got his ex ante share of the medical resources, and he’s now out of luck.
All of which is to say that assuming the government can figure out how much health care money each citizen is entitled to is assuming away most of what’s hard about health care policy. The egalitarianism-vs-paternalism tension Julian is hinting at is an interesting and important one in a number of different policy contexts. But I’m not convinced it’s especially important to the health care debate.