Thursday, June 28, 2012

Why We Believe We Are Entitled to Health Care

I learned the Supreme Court voted to uphold Obamacare today while I was in a brainstorming session for a drug that will launch next year. I had the same thought I've had on other occasions when people define the "right" to health care: how can someone have a right to a product that has just been invented, or to a skill that certain individuals study for decades to acquire and perfect? Of course, if we want to be strict with our language, Obamacare doesn't give anyone a right to health care, it creates a new entitlement to health care.

I've always had a problem with the notion of a government entitlement. It implies, to my ears, that the State determines what people need to get by in life, and then sets out to give it to them. And that the people have to be vigilant in making sure that they get what's coming to them. I hear, in my head, a smart but whiny teenager, "If my sister is getting a new car, then I'm entitled to one, too!"

But leave aside my grumpy dislike of the word: should there be an entitlement to health care? And what would we include (and exclude) within that entitlement? A lot of people clearly believe there should be a very broad health care entitlement, including medicines like contraception that stretch that entitlement far beyond life-and-death issues. So, are we entitled to all pharmaceutical products? Even this one? Is every surgery part of that entitlement? Even this one? Suddenly it becomes hard to find the line.

I kept sitting in my meeting, thinking about these issues and (as it happens) eating a wonderful chipwich. My mind went to FDR's Four Freedoms, and specifically the Freedom from Want. That idea is largely defined as implying a right to adequate food, clothing and shelter, and sometimes to the right to a job that pays a living wage. It seems odd, first of all, that we would push for universal healthcare before we would push for universal access to those more basic elements of survival. But it also seems apparent, if we defined a food entitlement as broadly as we define the health care entitlement, that we would be enshrining universal access to chipwiches into law. Of course, people like me would love that, and I'm sure the chipwich people would love that (and clearly, the pharmaceutical industry was bullish on the notion of increasing their potential market with Obamacare), but that doesn't mean it makes economic or practical sense.

Forgive me for going on, but I'm trying to make the argument that we have very muddle-headed thinking about what a health care entitlement should actually do, and what it should (or shouldn't) cover. I'm going to assume that my chipwich analogy has you convinced that we can't give all people access to everything that falls under the header of health care. But why isn't this instantly apparent to people?

Well, I'd like to offer two completely speculative suggestions. The first is that health care consumption is much more passive for most people than is their consumption of food, clothing, shelter and other basic necessities. If you need food, you go out and buy what you think is best and what you can afford. Even if you are on food stamps, the choice of food and the act of getting it is still in your hands. But taking charge of your health in a similar way is almost impossible. You very rarely even know what you need until someone else tells you: if you feel "bad", you go to a doctor who pronounces what you need, and then hands you a piece of paper which you docilely take to a pharmacist, who hands you a bottle of nondescript pills that you assume will do what everyone told you to do. And most of this is paid for by your insurance, so you don't even really know what it costs. Essentially, your health is already basically someone else's problem, so taking the step of saying it is the government's responsibility isn't really that dramatic.

The second possibility is that improving our health through popping pills or invasive surgery is evolutionarily novel. The psychologist Satoshi Kanazawa has developed the theory that intelligence evolved to deal with evolutionarily novel problems, the type of things we wouldn't have to deal with every day. As he puts it:
We know what to do when it comes to mating.  We know what to do when it comes to parenting and learning a language associated with other people. All these things our ancestors did already have ready-made solutions in our brain, but occasionally there are novel problems that required our ancestors to think and that’s how intelligence evolves. Some people who could think and reason and solve these evolutionary novel problems did better occasionally, so my contention is that intelligence evolved to deal with novel problems and as a result more intelligent people are more likely to recognize evolutionarily novel entities and situations.
So, you'd expect that, faced with the proliferation of new treatments, intelligent people would be more comfortable dealing with them and coming up with ways to make them more accessible. But he continues:
The key part of the equation is that intelligence leads individuals to seek novel solutions and as a result they become more likely to adopt novel preferences and values, so intelligence makes people do unnatural things.
I read this to imply that, in the face of evolutionarily novel situations, people are willing to try something different, but we aren't automatically going to pick the right or most workable solution to the problem we face. People generally know what to do to get food, clothing and shelter, but the novelty of accessing health solutions might make us willing to consider "unnatural" alternatives.

To go back to food analogies: we would never say that everyone has the right to prime rib and lobster every day, because we all intuitively understand we'd go broke. But the novelty of health care makes us blind to that simple truth. Of course, eventually economic reality will overwhelm our confusion and the good intentions that have led us to this point.

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