Floors and Ceilings In Health Care

When Rick Santorum said during the campaign that inequality is a good thing, a lot of people were surprised. Santorum was attacking a straw man—he was arguing that everyone shouldn't have precisely the same income, while no one actually believes that they should—but it was revealing. One of the questions that we've neglected to ask in our health care debate is just how much inequality we are willing to tolerate—or in the case of conservatives, want desperately to maintain—in this particular arena.

Conservatives like Santorum have an ideological commitment to inequality, the idea that some people simply deserve to have more than others. While conservatives used to believe that the identity of those who get more should be determined by birth (inherited membership in a favored class), these days they say that it should be determined by merit, which they tend to define tautologically as the state of being wealthy. Wealth is determined by merit, so if you're wealthy, it's because you're a better person—smarter, more industrious, and more virtuous. Liberals counter that the system doesn't just reward the virtuous. For instance, Mitt Romney is indeed smart and hard-working, but if he had been born to a poor single mother and not to a corporate CEO who became governor of Michigan, his chances of earning hundreds of millions of dollars would have been rather smaller.

So to return to health care: What kind of inequality should our health care system incorporate? This is basically a question of the floor and the ceiling. Other systems have answered this question in different ways. For instance, in Canada, where there are no private insurance companies, the floor and the ceiling are basically the same. Everyone has coverage, and you can't buy better coverage than other people. Conservatives find this system vulgar to the point of obscenity. The idea that a rich person can't buy superior care to a poor person is just appalling to them.

Now in our system, there is no ceiling. A rich person can buy all the care they can afford, with the most expensive drugs and the fanciest tests and the most elaborate therapies. But unlike in every other advanced country, there is almost no floor. We have over 50 million people with no health coverage, and though they can go to the emergency room if they must, they have no regular access to health care. Conservatives have fought against every single effort to raise this floor, to get people at least basic coverage. And they have always done so, oddly enough, by arguing that the ceiling would be threatened, that if we give everyone some coverage then we'll find ourselves in a socialized system where we are all forced to accept the same coverage. For them, the lack of a floor is a reasonable price to pay for there being no ceiling.

Of course, they and the people they represent aren't affected by the absence of a floor. They've got coverage, so who cares about those millions who don't? They're probably all Democrats anyway, and they've proven their lack of virtue by not being rich.

What I've never understood is why we can't seem to wrap our heads around the idea that we can accommodate both the liberal desire for a reasonably high floor and the conservative desire for an infinitely high ceiling. We can make health care a right, while still incorporating privileges. As I've said before, the best model for this is the system they have in France, where there is a single-payer system that includes everyone and provides adequate coverage, and then on top of that most people buy supplemental insurance that gives them as many fancy additions to that coverage as they want or can afford. We never seriously discussed instituting such a system here, but if we did I'm pretty sure conservatives would oppose it vehemently. And this is what is so puzzling. It's one thing to fight to maintain privilege. It's something else to fight, tooth and nail, every effort to grant suffering people some relief and security.

See Jonathan Chait for more on this.

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