Health Care

Health Care Is the Opposite of a Right

Sen. Bernie Sanders on Capitol Hill (Joshua Roberts/Reuters)
Bernie Sanders, like many American progressives, is almost completely parochial.

Senator Bernie Sanders, gamely making the case for socialism on CNN, offers a familiar argument: that access to health care and other goods like it should be understood as a “right.”

Properly understood, that claim is literally nonsensical, having the grammatical form of a sentence but no meaningful content, inasmuch as it is logically meaningless to declare a right in a scarce good. (I am using scarce here in its economic sense rather than in its common conversational sense.) For example: If you have twelve children and six cupcakes, the possibilities of division remain the same even if you declare that every child has the “right” to an entire cupcake of his own. Goods are physical, while rights are metaphysical, and the actual facts of the real world are not transformed by our deciding to talk about them in a different way. Other declarations in the same form — “Health care is quintessentially axiomatic,” “Health care is candy-apple gray,” “Health care is a spastically cloistered bottle of courageous smoke,” etc. — would be equally meaningless as sentences.

“Health care is a right” is a sentence that fools some people into thinking that it means something because the synthetic impression of moral urgency that accompanies the declaration of “a right” overwhelms the ordinary logical faculty, which in many people is less developed than the emotional endowment, that widespread condition being the principal defect in democracy. When a politician declares a “right” in a scarce good, it indicates either that he is a simpleton or that he believes you to be, and one’s as good as the other, that being another defect in democracy.

(Another defect in democracy is its apparently inability to learn, hence the Democratic embrace of socialism in 2019 in spite of socialism’s unbroken track record of failure and brutality.)

Senator Sanders points to the Scandinavian model as an example of what it means to have health care as a right. Senator Sanders has traveled widely in his life — he found much to praise in the Soviet Union while honeymooning there, and said so — but he is, like many American progressives, almost completely parochial. As is the case with the United Kingdom and much of Europe, Sweden, Norway, and Denmark are in the 21st century markedly different from the countries they were in the 1970s, when Senator Sanders’s awareness of the world seems to have congealed into the impenetrable clot of ignorance on such ghastly display in his current political career. A generation of reform — including tax cuts and reductions in the scope of the public sector — have left the Scandinavian countries with lower public-sector spending than such European standard-bearers as France and Belgium. In the Heritage Foundation’s economic-liberty rankings, the Scandinavian countries come in right alongside the United States — and behind such market-oriented leaders as Switzerland, Australia, New Zealand, and Singapore. On many scores, the Scandinavian countries offer more robust free-market systems than does the United States.

Another thing the Scandinavian countries have in common: Their politicians may talk about health care as a right sometimes, too, but in none of those countries is health care free.

There isn’t a single “Scandinavian” model of health care, but there are some features common in the set. One of them is that consumers pay out of pocket for health care, starting with copays but also extending to many specialist services, prescription drugs, dental care, and the like. In fact, as the Commonwealth Fund runs the numbers, private out-of-pocket spending on health care is proportionally higher in Sweden (about 16 percent of all health-care spending) than in the United States (about 11 percent). Out-of-pocket spending as a share of health-care costs is higher in Denmark (12 percent) and Norway (14 percent), too. (Statistical note: There is a small difference between private spending and out-of-pocket spending, but it is trivial in the Scandinavian cases cited here, with out-of-pocket spending accounting for 98 percent or so of private spending. Also, those figures are complicated by the fact that spending levels are different from country to country, and that the United States is an outlier; the Swedes spend more out-of-pocket as a share of a lower spending total, meaning that their out-of-pocket expenses are higher than U.S. rates as a share of medical costs but lower in absolute terms.) In other countries with widely admired health-care systems, out-of-pocket spending is even higher as a share of health-care costs: around 19 percent in Switzerland and 60 percent in Singapore.

Those numbers in some ways say both more and less than it may seem, in that the U.S. employer-based health-insurance system plays a role similar to the social-insurance programs some other countries (it does not perform that role especially well), and a dollar taken out of your paycheck for health-care coverage is a dollar gone whether we call it a tax or an insurance premium. It is a peculiarity of the American system that we attempt to deputize employers to administer what is in many other countries part of the welfare state. As it stands, the U.S. system retains much of what people dislike about private care while incorporating much of what’s undesirable about state-dominated systems: insecurity and relatively high costs plus sclerotic bureaucracy and cumbrous regulation — hooray for us.

The numbers may not be quite what American progressives expect, but what is interesting about them is not so much what they tell us about economic incentives as what they tell us about health-care attitudes. In an interview with James Pethokoukis, Swedish economist Tino Sanandaji links the social organizing principle behind the Scandinavian welfare states to what the Swedes refer to as duktig — loosely translated, “competence.” Citizens are understood not as baby birds with open beaks being fed by the state, but as having primary responsibility for themselves. “It has the connotation that you have the social obligation to be competent,” Sanandaji says.

Not a right, but a duty.

As a matter of national rhetoric, this is strongly emphasized in countries such as Switzerland and Singapore. That is one reason why the individual mandate to carry health insurance is uncontroversial in Switzerland. “We consider the health insurance mandate to be a form of socially responsible civic conduct,” former Swiss health minister Thomas Zeltner told Health Affairs. “In Switzerland, ‘individual freedom’ does not mean that you should be free to live irresponsibly and freeload from others.” In the United States, the individual mandate has been effectively repealed, but even before that, the Supreme Court was obliged to participate in a silly charade that the mandate was an exercise of Congress’s taxing authority in order for the law to even partly withstand a constitutional challenge.

Adopting a rhetoric of rights is not going to simplify that. Fundamentally, health care is not a moral question but an economic one. That much can be demonstrated by the fact that even if every American agreed with Senator Sanders about health care as a moral question, we’d still be obliged to approach it as an economic one — the moral consensus, even if it were not mistaken, would solve precisely nothing. Medical care costs something, and we have a social commitment to seeing to it that those costs don’t come down on vulnerable people in an unnecessarily burdensome way, part of what F. A. Hayek described as “providing for those common hazards of life against which few can make adequate provision.” Contra Senator Sanders et al., this is not a project that require socialism in any degree.

What it does require is responsibility — including responsible citizenship — and a clear-eyed understanding of the nature of the problem. What does it mean to be a responsible citizen? In the United States, we have a poor and diminished notion of citizenship, that citizens are only “taxpayers” and “voters.” Good citizens, in the inescapable contemporary formulation, are those who “play by the rules and pay their taxes.” That’s the real individual mandate: Pay and obey. The progressive proposition is that, in exchange for this obedience, childlike citizens are to be provided for by government in loco parentis, and that their role in this is almost entirely passive: submit to taxation, follow the regulations, receive the benefits. Hence the rhetoric of health care as a right.

A fuller and more mature notion of citizenship would be one that holds, as ours once did, that among the first duties of the citizen is to provide for himself and look after his family so as not to burden his neighbors unnecessarily. The rhetoric of benefits as rights cultivates just the opposite attitude, one of learned helplessness, not in response to extraordinary challenges but in the face of the ordinary business of life. That attitude of helplessness is of great benefit to a certain stripe of politician. It is not good for people or countries.

And it isn’t really characteristic of the Scandinavian societies that Senator Sanders thinks he admires.

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