Thursday, July 23, 2009

Health care decisions: public vs. private

Yesterday I mentioned a court case in British Columbia that will determine whether the provincial government has to pay for prostate cancer screening as part of the state run health care, with the plaintiffs alleging that to not do so would constitute gender discrimination given that women are given pap exams and mammograms at public expense. This is, as I noted, a form of rationing. But it also illustrates something else.

In most instances when there is a product or service that you wish to obtain you simply approach a seller and decide whether their offerings are worth the price. If the service or product is deemed inadequate or is at too high of a price you move along. Not so with the public sector.

In the public sector such decisions are made collectively. You don't haggle individually with the government, agreeing to pay a certain amount of tax in exchange for certain levels of public services such as police, education, roads, etc. (User fees for things like toll roads and public parks being an exception) Rather the same system is applied to all of us, and if you don't like it, tough -- wait for the next election and try to get your guys voted into power.

This is, of course, why elections -- especially on the national level -- are contested so fiercely. With so much at stake it is no surprise that people become so emotionally invested in the outcome. It also illustrates another danger of government-provided health care and the public option.

With such a public option it will be one size fits all. If you don't like the services provided, well, that's the way the cookie crumbles. To get what you want to you will have to either wait until those who share your ideas are voted into power or -- like the Canadians -- go through the courts. This is fine for items such as national defense, where no clear alternative exists. For an individual interaction like health care this strikes me as less than optimal.

One possible objection to this line of thought is that a public option is just that, an option. If you don't like it go somewhere else.

In response I would make two points. First, for most people health care is linked to employment. It's really not your call if your employer switches to the public option or not -- and believe me, plenty of businesses will switch to the public option (this isn't a vote of confidence in government provided services, but rather a recognition that the public plan will not compete on a level playing field, with politicians unwilling to risk a situation where few people sign up for the government option).

Second, even if an individual wanted to go elsewhere and had the money to purchase extra insurance, there are indications that one goal of current health care legislation is a diminished role for private insurance. It's not at all clear how much longer that will be a realistic course of action.

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