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January 24, 2005

What would the Founders say about Medicare? And who cares? Medicine is something the Founders knew only from experience from a weak and unimportant version of its modern-day self. The political choices the Framers embodied in the constitution and in a generation of behavior hardly matter now that the choices we face are so vastly different. Asking how James Madison or Alexander Hamilton might have designed a federal agency (or not) to intervene in healthcare is an interesting academic question, but not a fit subject for political debate. Madison and Hamilton won't decide about the government's role in health provision; we will.

Sebastian Mallaby, Washington Post op-ed writer, discusses the Bush administration's decision to use a certain treatment for a cardiovascular disorder. The details are comparatively unimportant, except to note that the intervention is apparently proven and cost-effective. The larger question is whether the government should continue to expand the level of health care spending it provides, given that the money to pay for that spending must come from somewhere. At the moment, for instance, my future earnings are paying for senior citizens' prescription drugs.

Most people, if they give the matter some thought, will conclude that the government should provide some minimal level of health care to its citizenry; how they reach that conclusion is less important than that they do reach it, because democracy does not ask for a justification for voters' reasoning. Faced with that tendency, then, we have to realize that the "minimal" level of health care will constantly increase, and probably continue to increase much faster than inflation. What was minimal a hundred years ago would be in violation of the Geneva Conventions today, and even the best practices of twenty-five years ago would be grossly inadequate today.

How to design institutions to cope with these new demands? It is probably useless in the short or medium terms to hope that the middle class will demand less medical coverage; only in the very long term is such a radical shift possible. In the meantime, we would do well to remember that incentives matter, and policies that are workable in a static analysis run a high risk of failing in the long run. If, for instance, access to treatment for problems that are undeniably the result of lifestyle choices depended on whether people had made the right choices in the past or were at least willing to make better ones in the future, one suspects there would be fewer adult-onset diabetes cases. We expect welfare mothers to work for their benefits; middle-class citizens should be held to the same standard.

Posted by Paul Musgrave at January 24, 2005 05:09 AM

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