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Monday, January 26, 2009

Universal health care-a religion or a bureaucracy

There are a number of conscientious, well meaning physicians who strongly believe that the problems of the current U.S. health care system can be solved by having a universal payer (aka the government) or at a minimum that such a system would improve things significantly. There are other conscientious, well meaning physicians who have also spend much time thinking and writing about the alternatives who believe exactly the opposite. Those in the second camp might think those in the former group are members of the church of universal health advocacy, a view expressed in this posting from Cato's blog.

I have quoted Thomas Sowell before. In this entry I wrote about his exposition of two very different visions and the explanatory power of that formulation.

Sowell's "Visions" are world views- or simply put- the way folks see how things work and how things are largely because people are the way they are. Sowell speaks of two such views-the constrained or Tragic view versus the unconstrained or Utopian view.

The Cato blogger would seem to fit into the first category and at least some of the advocates of a single governmental health care payer into the second.

For those who view the world through the Tragic view lenses, humans are basically limited creatures with those limitations involving their knowledge, virtue and wisdom and therefore social arrangements must take these inherent limitations in mind. The Utopians think differently believing that these limitations are due to the flaws of society and its arrangements and they can be overcome and that they should be overcome by better plans and putting better people in charge,often the same people who advocate for those putatively beneficial changes.

In the Utopian view, social inequalities such poverty,uninsured patients,drug addiction, not owing a home, racial or gender imbalances are seen as resulting from faults in society and therefore demand that social targets be developed and plans be made to rectify the social problems. The tragic Visionist would be concerned with the self interested motives of the people who are tasked with carrying out the programs and also with the unforeseen and unintended consequences that such projects seem to routinely bring about. The self interest and unintended consequences have been amply discussed and documented by the Public Choice school of thought authors. Utopian view physicians would celebrate the introduction and insertion of the concept of social justice into the new medical professionalism.

In the Tragic view, man is constrained by his moral limitations and his egocentricity. The social challenge is how to work with those limitations rather than engage in energy wasting and ultimately futile efforts to change human nature.In this view, one deals with trade-offs and not solutions. Benefits to society derive from actions largely unintended but emerging from market actions which derive from the pressures of the incentives for individual gain which include the monetary and the psychic.

If the tragic vision folks might see the Utopians as being faith based in their advocacy of a single payer I wonder if the reverse is also true. That is, do the utopians view the tragic world view's advocacy of individual freedom and market solutions also as a faith based initiative.

As Sowell has suggested advocates of both views typically frame their arguments by cherry picking facts that seem to conform with their vision and and the two camps rarely actually discuss or debate issue but rather talk past each other and cannot often even agree on what the terms of the discourse really are.


Cindy Marsch said...

I appreciate your blog, Dr. Gaulte, and this post, especially, is a clarifying one. Thanks!

One of the Tragic View camp

Roy M. Poses MD said...

This is an really interesting post. I do wonder, however, why many who seem to have professed to the "tragic" view seem to have been so "utopian" about how the (unregulated) market would lead to the best health care decisions. A real "tragic" or maybe "realistic" viewpoint would suggest that giving huge incentives to people to make short-term profits in health care, unconstrained by any ethical concerns about what might be done to achieve such profits, would lead to abuses.

james gaulte said...

Your point is well taken.Doubtlessly there are folks who profess to be tragic view folks who have unrealistic expectations for what "the market" can do.Many aspects of the medical scene has been more regulated than unregulated. But even with a veneer of regulations, people seem to find ways to game the system and circumvent the spirit of regulations some examples of which come to mind in the recent financial mess.In some instances the incentive for short term gains killed the goose or at least wounded it badly.