I have an article out in the current First Things magazine in which I try to differentiate between what could be called “medical” health care and “consumerist.” From “Careless Consumerism” (subscription required):
When the Supreme Court upheld the Affordable Care Act, relieved supporters happily looked forward to implementing the law over the next several years, while infuriated opponents vowed to repeal the law, even as some states refuse to implement its Medicaid and other provisions. Whatever happens to the ACA, the need to contain the costs of health care will not disappear, and indeed will almost certainly grow more pressing. The conflicting policy goals of ensuring that all Americans have access to “basic health care” while containing the system’s costs will roil bioethical and public-policy debates for many years to come.
And therein lies the rub. “Basic health care” as envisioned by the medical intelligentsia, government technocrats, and their media cheerleaders is neither basic nor necessarily health care. To an increasing degree, “basic” coverage often includes what I call “consumerist” procedures that, though delivered in medicinal or clinical contexts, are not actually medical in nature.
What do I mean by these terms?
By “medical services” I mean the prevention, diagnosis, treatment, or palliation of injuries or illnesses. The term “consumerist” identifies procedures that use the traditional methods and tools of medicine—surgery, drugs, technology—not to treat actual maladies but to fulfill patients’ personal desires, enhance their chosen lifestyles, and assist them in attaining goals unrelated to their physical health.
I give examples of consumerist, e.g., cosmetic surgery, elective abortion, etc. And I describe how the UK’s NHS–seen by many Obamacarians as a model for the US–has gone whole hog into paying for consumerist procedures:
Recently, what is effectively the United Kingdom’s health-rationing board, the National Institute for Health and Clinical Excellence (NICE), recommended that the National Health Service (NHS), one of the U.K.’s publicly funded health care systems, pay for sophisticated artificial insemination procedures for lesbians and for IVF treatments for all women up to forty-two years old who have been unable to conceive.
Should society pay for artificial insemination when, because it lacks funds, it must ration some life-extending cancer treatments to the terminally ill, as sometimes happens in the U.K.? (Even if the society wants to promote homosexual equality by ensuring that lesbians can bear children without sexual intercourse, this is not precisely a medical concern.) Should the collective be financially responsible for expensive IVF procedures for women unable to conceive because they are at the end of their normal childbearing years when NHS hospitals and nursing homes are in the midst of a severe medical-resource crisis?
The same process has started here under Obamacare, for example, with the Free Birth Control Rule:
That is just the first of what will likely become many consumerist coverage mandates. Does anyone doubt that the current leadership of the Department of Health and Human Services hopes to order health-insurance policies to cover elective abortion? Or that most IVF procedures will eventually be considered basic health care, as is already the case in the United Kingdom and Quebec?
And it won’t stop there. The city of San Francisco already covers sex change surgeries for its transsexual employees. Oregon’s Medicaid pays for physician-assisted suicide while explicitly rationing some life-extending medical interventions for its most seriously ill recipients.
To be sure, it isn’t always easy to distinguish the medical from the consumerist, and there will be times when consumerist coverage–such as restorative surgery after serious burns–should be considered basic health care. I conclude:
But here’s the bottom line: Regardless of the ultimate fate of the ACA, as a society, we appear to have decided that guaranteeing access to basic health care is a collective obligation. If that accommodation is to have any chance of being affordable, we will have to draw proper boundaries between the basics that insurance should provide and the extras that people should pay for themselves, either through insurance riders or by paying the full price.
A good starting point in that difficult and complicated process would be to exclude obvious consumerist services—starting with those we’ve discussed here—from the definition of basic health care. That would better preserve our collective resources for the most pressing and serious medical needs.
No, that isn’t health care rationing. But that is a discussion for another day.