President Trump and many “conservative” Members of Congress believe that it is the duty of the federal government to see to it that every American receives healthcare, regardless of cost. Anyone opposing the healthcare entitlement must be willing, or even happy, to see people die in the streets…

at-the-doctor-s-1900There is much noise coming from Washington about the revival of plans to “repeal and replace” Obamacare. After House Speaker Paul Ryan’s high-handed tinkering with the existing system fell flat, it was withdrawn from consideration; this despite some vocal support from Donald Trump. Now we hear that even the conservative “freedom caucus” is leaning toward support for a somewhat modified version of “Ryancare.” This new legislation would reduce the requirements imposed on insurers under Obamacare, seeking to increase consumer choice and lower premiums, while at the same time maintaining the essential elements of socialized medicine—namely federal guarantees of health coverage for those seeking new coverage for pre-existing conditions.

Readers may recall that the Ryan plan failed to garner sufficient support to make it worth risking a vote on the House floor because significant numbers of both conservative and liberal (a.k.a. “moderate”) Republicans found too little to their liking in the bill. Liberals decried cuts in subsidies and guarantees. Conservatives argued that Ryancare amounted to “Obamacare Lite” on account of its retaining all the essential infrastructures of subsidies, mandates, and bureaucratic rules that make Obamacare the disastrous boondoggle it is. Yet it appears that even conservative Republicans (as that word is used within the confines of our Imperial City, Washington, D.C.) now are willing to accept the fundamental character of Obamacare as a permanent fixture of our new form of government. This is unfortunate.

Whatever fancy administrative footwork may be involved, keeping the guarantee that everyone will receive services in private, non-charitable hospitals, even if they previously chose to forego insurance is part of an overall view that healthcare is now an “entitlement.” President Trump and even many Members of Congress who call themselves conservatives are now willing to declare that it is the duty of the federal government to see to it that every American receives healthcare, regardless of cost or previous conduct. Added to now long-held “entitlements” to federally guaranteed old-age pensions, unemployment insurance, and various forms of ”welfare,” this new entitlement completes the transformation of America’s free society, rooted in free markets, local associations, and charitable institutions, into a social democracy under the tutelage of the national state.

None of this is terribly surprising, of course. The Obama Administration worked ceaselessly to impose the capstone of social democracy, bending legislative rules beyond the breaking point and ignoring the clear economic illogic of Obamacare. They did all this secure in the knowledge that, once established, the entitlement would be defended through whatever means necessary, including open nationalization. Ryancare would have provided a brief rest on the road to nationalization, trimming some fat and increasing a few incentives. The latest roadmap for healthcare seems aimed at adding more incentives for savings and lessening some of the more onerous bureaucratic rules. Both continue Obamacare’s essential character as an entitlement and, like other entitlements, rest fundamentally on the power of the national state.

The typical response to such arguments is that anyone opposing the healthcare entitlement must be willing, or even happy, to see people die in the streets for want of government guarantees. It is worth noting, then, that the logical conclusion of Obamacare, Ryancare, or even Trumpcare, so long as it retains the assumption of federal guarantees, is nationalization. The logic of a national guarantee is risk-sharing. And risk-sharing always means redistributing from those with more to those with less. With income guarantees this means redistributing wealth directly. With health care guarantees it means taking from those who do not need the care to those who need it. So far, this may sound charitable and decent—after all, we already tax the young and healthy to pay for the old and sick through Social Security. The problem is that, with health care in particular, we are not dealing with merely a problem of health—that is, of the absence of specific, catastrophic illnesses or injuries—but also with demand for preventive care and the like. That is, we are dealing with regular, routine services that cost money. Moreover, most people tend to want more healthcare services than they actually need; we go to the doctor when we are not actually sick, seek procedures that make us look or feel better but are not necessary for survival, and so forth. In other words, it is extremely difficult to control costs for health care without resorting to some form of rationing. This is why so much money is wasted in insurance schemes that emphasize savings through oversight and various limitations on patient (and even doctor) choice. Indeed, once the “right” to healthcare or any other positive right is established, nationalization actually appears more efficient than the Rube Goldberg machinations common within the American administrative state. Both in the end result in draconian rules, distorted incentives, and ultimate systemic failure.

What social democrats, in whatever party, fail to recognize is that various “positive rights” to things like welfare, healthcare, and education, merely grant power to the government, to the extent it wishes, to take over portions of society, substituting its will for the decisions of various persons and associations throughout society. Americans, having a deep-seated aversion to federal power, have allowed national aggrandizement only incrementally and under the guise of various regulations and guarantees. The result retains the appearance of freedom and the reality of chaos. It also retains a consistent tendency toward further federal power, and toward further erosion of freedom. After all, one can provide a good everyone wants for free (or highly reduced cost) only by rationing its distribution, substituting force for voluntary transactions.

None of this is to say that people do not, as persons possessed of human dignity, have a kind of right to health care. It is up to all of us to support charitable causes and institutions that provide health care, as well as food, clothing, shelter, and education, to those who cannot afford them. This is why it is such a tragedy that federal policies have all but eliminated charitable hospitals and forced to the sidelines much of Americans’ habitual charity.

The claim always is that people fall through the cracks of more voluntary and local systems, and that the nation must not allow that. The argument ignores basic, well-known facts. People—especially the poor and vulnerable—fall through bureaucratic cracks all the time. The horrors of the Veterans’ Administration and its criminally reckless treatment of veterans’ health needs should have shown us that. The real question with health care as with so many “positive rights” concerns who ought to take responsibility for reaching out to those in need: neighbors, local institutions and perhaps states, or a distant, uniform national administration.

Our supposed betters in Washington, like too many of our own neighbors, think that the nation’s guarantees are worth the price. Sadly, they are wrong, for they overlook problems of government corruption and self-aggrandizement, as well as the inevitable failure of central planning to predict human behavior. Through entitlements, the nation-state inevitably ends up imposing new requirements, lowering benefits, increasing taxes, and further regulating people’s behavior to provide infinite goods within a brittle, corrupt system with limited means. Lest we forget, the “entitlement” to Social Security payments has been modified repeatedly, with new taxes imposed, the retirement age raised, and penalties for working made increasingly more onerous. What the nation-state gives it may modify or even take away, entitlement or no.

One might wish, here, that the proposals of more “libertarian”-minded legislators who want to do away with Obamacare altogether might gain more traction. Alas, this looks not to be the case. We are told, then, that some solution is necessary to prevent disaster. It remains an open question, however, whether this is true, or whether it would be better to allow Obamacare to complete its inevitable self-destruction. As insurers continue fleeing its faux markets, they may force Congress to rethink the role of the state in controlling health care, or perhaps throw all of us back on ourselves to reconstruct a system more in keeping with the nature and requirements of a free and virtuous people. Bad times are in the offing for the simple reason that we have been making selfish, foolish choices in health care, as in much else, on the selfish, foolish assumption that we are entitled to help from a nation-state that is, in the end, less capable and more dangerous than we would like to believe.

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