On the first of this month, health care exchanges facilitated by the Affordable Care Act (ACA) were brought online. How might changes from ACA, a.k.a. Obamacare, affect the way we view the health of our fellow citizens?
Matt Sowada: I predict the ACA is here to stay and we will find ourselves more involved in each other’s health decisions. We already have a moral obligation to strive towards health, because our community might justly call upon us to provide bodily service (sandbagging in a flood for example) and it is our duty to be prepared. Obamacare will deepen that moral obligation due to the financial effects our actions will have on health costs for the rest of society. Vik, do you feel we have a moral obligation to strive for health and will the ACA affect it?
Vikram Patel: Yes, we have a moral responsibility to try to be healthy, but the real question is: Should the moral aspects of health also carry legal weight? An apt analogy comes from how our society handles lying. Lying always has a moral dimension, but rarely does it carry legal consequences. When it does, the legal consequences fall into two categories: significant harm to another individual (e.g. fraud) and harm to the public (e.g. perjury). I can’t see the harm done to another individual by our health decisions rising to a level necessitating legal intervention (even with the ACA). However, I can envision new legislation intended to incentivise better health decisions justified by the financial burden that poor health decisions can place upon society. These inducements to avoid poor behavior would correspondingly take a financial form—taxes and subsidies. I think this is reasonable, within limits.
Matt: Well, I think that this is a tricky sort of problem: a real, serious concern with (ever-growing) externalities that does not avail itself of a just and effective governmental response. Whether it’s the negative incentives that taxes offer or the positive incentives of subsidies, I don’t see what more the federal government can really do. When, exactly, should the government use its power to part me from my money?
One approach would be to encourage people to make wise daily decisions. The problem here is that there are a million different healthy lifestyles. Just looking around my kitchen I can see that most of the food that I consume falls into the category of “part of a healthy diet, in moderation.” A couple of glasses of red wine per night is good for the body and soul, but nine glasses of wine a night will kill you. A little butter to sauté some vegetables is great, but half a stick is horrendous. How is the government supposed to walk that tightrope? How do the health benefits of a banana compare, in dollars, to those of a head of kale? Furthermore, how much money will you give me for jogging an hour? For swimming 30 laps? These questions are absurd, but even if they weren’t I wouldn’t trust the feds to answer them. It’s too complicated to govern; You have to trust the individual.
The alternative would be for the government to apply financial pressure to outcomes, but all men are not created equal. Vik, you and I are blessed in that we are able-bodied young men with the finances to make wise health decisions pretty easily. Someone born with a serious disability will have a much more difficult path to health than I do; they don’t deserve to be financially punished. Again, it seems that we must trust and expect individuals to do the very best they can.
Vikram: Well, if we had to implement incentives in the ways that you outlined, the process would be absurd. However, there are other, more successful injunctions we can seek to model. Smoking and excessive drinking are such unhealthy behaviors that we tax those products to discourage their regular use. Many states require motorcycle riders to have a minimum level of health insurance if they decide that they aren’t going to wear a helmet. We know that regularly eating fast food or microwave dinners is unhealthy, so why not tax them? In a more benefits-based approach we have the Women, Infants and Children (WIC) program which subsides some generally accepted healthy foods for new mothers who have a low income. The public would likely benefit from this program’s expansion. Preventative care is important to maintaining one’s health, so why not subsidize annual medical exams? The federal government could balance the public good against individual choice using fairly straightforward (if creative) incentives.
Matt Sowada and Vikram Patel, former hosts of American Reason, bring monthly political, social and ethical musing to Little Village.