Healthcare and the Perils of Marginal Cases

It is no inconsiderable part of wisdom, to know how much of an evil ought to be tolerated.
(Edmund Burke, Thoughts on the Cause of Present Discontents)

Animal rights advocates use the argument from marginal cases to show that the distinctions we draw between human and animal life are baseless: if some animals have greater cognitive ability than some humans, how can we justify privileging the latter over the former? But I think it’s instead an example of what can go wrong in this fallen world when we pay too much attention to marginal cases: by focusing on outliers (humans with severe learning disabilities and genius animals) we can lose sight of the centre (the fundamental differences between humans as a class and all other animals). As Rep. Tim Valentine (D-NC) once said, “You don’t have to tell me that a ’possum’s not a person”.

The utter debacle that is the Affordable Care Act is another example in point. Much of the political impetus for passing the ACA came from the public’s awareness that certain people were being failed by the system: in particular, people with chronic conditions and those too poor to buy health insurance but not poor enough to qualify for Medicaid. Although these concerns were justified, they did not merit or require the complete reorganisation of the American health system to fix: at the lower end, Medicaid could have been extended to cover those unable to pay, and a Medicare-like system implemented to cover medical costs that exceed some percentage of income. This would have cost money, but no more than people have paid indirectly through increased premiums under the ACA, particularly since many would be able to buy health plans that only covered expenses up to the Medicare cap. A few additional tweaks to spur competition, such as mandatory pricing transparency and the disclosure of patient outcomes, and we could have fixed the problems with less cost and less disruption.

But that is not what happened. The Republicans share much of the blame: had they offered any sort of realistic plan to address the failings of the health system, perhaps we could have arrived at a more sensible solution. Instead, the Democrats acting on their own committed the fallacy I have described above: they developed a health system from the outside in, first attempting to solve marginal problems (nearly 83% of people in the US either had adequate health insurance or received healthcare through Medicare or Medicaid) and then applying those solutions to the entire health system.

And they ended up with a mess—a mess that has resulted in thousands of people paying increased premiums, having their insurance cancelled, or having their coverage reduced. The people affected by the failures of the ACA are not the 1%, or even the top 20%, but the working and middle class for whom an extra $10,000 bill is a severe hardship. Formulating a policy on the basis of marginal cases has left those in the centre—the very people the Democrats purport to champion—out in the cold.

This cannot be by design: although the solution from leftist corners is bound to be the single-payer system they wanted all along, I don’t think the Democrats set the ACA up to fail. Instead, the ACA is an example of the utopianism that affects liberal thought, recently under the guise of ‘technocratic government’. There is a strain of liberalism, running from Thomas Paine and Jean-Jacques Rousseau to Karl Marx and Clement Attlee, that believes that the world’s problems can all be solved by sufficiently enlightened policy. When such policies fail, the inevitable cry is for more of the same: more central management, more government, a single-payer health system.

The problem is, the poor will always be with us. This side of Eden, no amount of enlightened planning will ever adequately address all marginal cases. There will be people who slip through the cracks in one way or another. This is intolerable, but it is no excuse to make things worse in misguided attempts at technocratic utopia. The way to deal with marginal cases is to address their individual circumstances directly, not to extrapolate from them to build overarching policies (or philosophies, for that matter). Otherwise, you end up with a well-meaning mess that swaps one set of marginal cases for another.

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