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On Friday, I wrote a response to Ramesh Ponnuru's New York Times op-ed arguing that we don't need universal coverage in health care. Cato's Michael Cannon rose to his defense. Over the weekend, a reader e-mailed a reply that's worth posting in full. What comes next is a quote from Cannon, and then the reader's response:
What Ponnuru proposes is to let Arizonans and Idahoans and everyone else choose what their health plan covers. Imagine that: people rationing medical care according to their preferences, rather than the preferences of employers, interest groups, bureaucrats, health policy wonks...I study applications of game theory and lean towards libertarianism in many policy areas, but in regards to health care have never understood how this could work. You offer what we call in CS a "hand-wavey" (breezy) discussion above, but I feel this issue is pretty fundamental to choice-based arguments on health insurance.Above, you celebrate the idea that people should choose medical care according to their "preferences," as you put it. But doesn't this require an individual to consider expected outcomes, years in advance, regarding actual medical *needs* (rather than "preferences") that an individual's family might face? This seems to require a consumer to enumerate those conditions she was concerned about, and attach a value to each -- is this truly a reasonable burden for a person without medical training?Certainly for hereditary health problems, we have risk assessment models to draw on -- and new personalized screening technologies like 23andMe, that imply that perhaps consumers could be aided in choosing a health plan with questionnaires, computer models, DNA testing, and fancy websites.But for truly unexpected risks, wouldn't this pose an unnecessary burden on your typical consumer?For these unexpected risks, choice based on "preferences" sounds to me like arguing that we should privatize the police, and customers should sign up for protection based on the specific crimes for which they want coverage. Scanning the list of state mandates linked by Klein frightens me away from pure choice-based proposals like yours -- certainly I can rule out "Hair Prostheses," but for treatments like "Chemotherapy" and "Orthoics/Prosthetics" it's much harder for me to rationally decide on a dollar value using just probabilities and quality-of-life calculations.That's my point: in game theory, players must rationally attach values to each outcome for a solution to emerge -- this is a fundamental assumption. But with health issues I feel it's impossible for customers to be rational in calculating these values: certainly everyone wants their family to be as healthy as possible, but if forced to pick-and-choose, certain diseases are simply "scarier" than others! And for those consumers who opt to save by not paying for, say, bone marrow transplants, and then have their child diagnosed with leukemia, what then? I imagine any warm-blooded legislator would be moved to build a safety net for these cases -- or would this be violating the "freedom" you seek?
