The Ethics of Health Reform

Who should pay for my health insurance?

I’m not raising this as a legal or contractual issue.  This is an “ought” question.

As a moral and ethical issue, who should pay for my health insurance?

If you spend all your time around health policy wonks, I’m probably the only person you know who even thinks this is an interesting question.  I’ve never heard it raised at any health conference.  But then most of the ones I attend are in Washington, D.C. – where no one ever talks about the ethics of anything unless he is skewering an opponent.

Anyway, let’s start with Warren  Buffett.  He can certainly afford it.  But why Buffett?  Why not John Templeton down in the Bahamas?  Or the Queen of England?  Or anyone else on Forbes’ list of international billionaires?

You might think that since Buffett and I live in the same country, we must have some sort of moral bond that I don’t have with non-American rich people.  If you’re thinking that way you need to wise up about the world of international finance.  Most wealthy Americans hold international portfolios, and there is probably no foreign billionaire in the world who isn’t partly invested in the U.S.  Plus, the companies these folks invest in are themselves invested all over the world.  So it’s hard to argue that a rich American gets more benefits from the U.S. economy than rich people elsewhere in the world.

Okay, so let’s entertain the idea that I have a moral claim against rich people everywhere.  How would we collect?  The same way we collect from Buffett.  Use the coercive power of government to seize their assets.

But (and this is an ethical question as well), is it really in my self-interest to seize rich people’s assets?  From what I know about Buffett, his consumption is quite modest.  All his wealth is invested.  If we seize a dollar from Buffett, his lifestyle won’t change one whit.  But wages won’t be paid, equipment won’t be purchased, taxes won’t be collected – once that dollar leaves the capital market.  Other people’s lifestyles will change.   

Now if it’s just me, the effects will be small.  But since we’re talking ethics here, Kantian universalizeability applies.  So we have to include millions of others just like me.  Bottom line: standing behind a Rawlsian veil of ignorance, I definitely wouldn’t choose to live in a world where health insurance was paid for by taxes on capital.  (Let Hillary and Obama and Edwards go there at their peril.)

But why are we only talking about billionaires?  If my need is a claim, doesn’t it also apply to people who are mere millionaires? More generally, is my need a claim against anyone who has more than I have?  What if we started out at the same place in life, but they worked harder or saved more?  Or what if we didn’t start out at the same place?  Should that matter?

And let’s not overlook people who have less than I have.  In a few years I will be eligible for Medicare. (I know I don’t look that old, but it’s really true.)  Then every poor laborer in America – even those earning the minimum wage – will be contributing to my health insurance.  Is that fair?

Try as I might (and be assured I am motivated), I am unable to think of a way to parlay my needs into a claim against other peoples’ assets, incomes or productive capacities – be they rich or poor.

But if need were a claim, surely greater needs give rise to greater claims.  And surely these claims are not a function of geography or distance or citizenship.  The billion or so people in the world who live on $1 a day surely have the most compelling case of all.

This must be how Bill Gates is thinking.  Whether out of obligation or a desire to do good, he’s giving his charity health dollars to Africans, not to uninsured Americans.  Shouldn’t the rest of us follow his example?

Oh, and as to the original question:  who should pay for my health insurance?

I should.

Have a good day.


This is must read for all Democratic primary voters.

Comments (9)

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  1. Libby Wright says:

    John, I always like to argue that no matter what, we do and always will pay for our health care. The question should be: who will make the decision on what my health care plan will look like?

    If it is government run, taxpayers pay for it but politicians and bureaucrats decide on what it looks like — what it will cover and more than likely, what it wont cover.

    If we keep the current system, we are essentially paying for our health plan. Instead of a higher salary, we get a benefit. (based on the history of employer sponsored health care) But employers make the decisions on what it looks like.

    But if we change the tax code and incentives so we can make the decisions on the health plan we want, that is the better route to follow.

    Libby Wright
    Citizens Against Govt Waste

  2. Roger Beauchamp says:

    Me too and I do!! Some may think I am anti-insurance because I am pro free choice. I have carried and paid for insurance my whole life. What I am against is coercive insurance, wasteful insurance, mandated insurance, overpriced insurance etc. Need I go on?

  3. Your Gates point is interesting and to a great extent true; we rescue elephants in South East Asia while people die in our hospital emergency rooms.Need is indeed a claim and until we can work together to correct the economic and political conditions which create the Katrina after-math, the campaign finance debacle, the fact that medicare and social security were created to serve a need based population and not retired officials with millions in the bank and million dollar pensions who feel entiled to collect because they contribute, need should continue to be a test.

  4. Sean Khozin, MD, MPH says:

    It is estimated that 30% of our healthcare dollars go to administrative costs related to insurer restrictions imposed on physicians. The health insurance industry has made it very difficult for physicians to deliver appropriate care. I agree that each individual should be responsible for paying for their own health insurance but we must come up with a way to change the wasteful ways of the system. Insurance companies should just sell insurance and allow physicians to manage the care of their patients.

    Many physicians have realized the need to be directly involved in the next wave of healthcare reform. I’d like to bring your attention to an ambitious physician-led campaign currently underway to raise public awareness on the reasons behind our broken healthcare system.

  5. Regina Herzlinger says:

    So what about the 80/20 eg the top 1% spend over $35k a year and some of that is repetitive.

  6. Stephen Moses says:

    This post tickled me even more than most of your always-excellent, thought-provoking pieces. I reckon there are several of us out there who think “who should pay?” is an interesting question. But I’ll bet there aren’t many who understand “Kantian universalizability” or the Rawlsian veil of ignorance.” You go, guy. Hit’em where it hurts: in the principles.

  7. Chris Ewin says:

    You know my thoughts on primary care. Just because you have health insurance doesn’t mean you have access to primary care. You should pay your primary care physician directly and avoid all the middlemen.

  8. Lucy says:

    Beautifully put, John!

  9. I just had to jump in here and offer my 2 cents.

    Yes, I should pay for my own health care. Unfortunately, I not only do that, but I also pay for a lot of other people’s healthcare as well.

    I don’t smoke and I’m not obese. Even work out 2 or more times a week. So, I may not need to claim my insurance benefits real soon. Others in my risk pool who are rooting for cardiac arrest and at the same time poking down another pizza are primed for action.

    My thinking is that sooner or later the fats and smokers will find themselves in their own risk pool. Then the State will have to step in becuase that risk pool dies off. Of course when the State steps in (be it local state or federal) I’m back to paying again.

    Bill Gates has it right methinks. He is putting his charity cash where it will be used for the most good because there is no welfare state, no net, no reassigning of income or benefit.