The two sides are already squaring off. The nationalization of the American health-care system is once again an issue in the forthcoming Presidential election. The pro-nationalization side has rolled out arguments rooted in "social justice;" the anti-side has settled upon cost considerations plus debunking of the pro-side’s statistics. Both sides have missed an important, if indirect, consequence of nationalizing the health-care system. In order to see what this blind spot is, it’s necessary to consider folkways that don’t appear much in antiseptic news studios or seminar rooms.
Before introducing it, allow me to tell a tale about a government-owned health care system of long standing. This system exacts no fees, although an informal rationing system does take place. In order to show up to a hospital, patients have to be sent there; they can’t just check in on their own. In the olden days, the treatment was brusque and subject to tighter rationing. Few complaints were made about the treatment level: every potential patient understood that the system had relatively few resources directed its way, and was subject to huge demand from time to time. The work ethic, as well as the working hours, of the attending physicians and surgeons made it clear that limited resources were the cause. In addition, the system was deliberately optimized for efficiency and speed. Anyone who objected to the downside was set straight, through a reminder that there were lots of others who needed the same services. Hogs tended to be discouraged.
As the past gets closer to today, a noticeable increase in the level of care is evident. Many more resources have been poured into the system. Some facilities have top-notch care, which may even be better than the finest available to Americans who can pay top dollar. Surprisingly, for a system that had attracted dark jokes and subtle complaints, there have been little to no outright complaints about the overall cost or effectiveness of it. Granted that the care is still somewhat spartan in many smaller outposts, but its drawbacks are nothing compared to the system extant about forty years ago. Any complaints have been confined to abuses in parallel branches of this system, not the system itself.
This system is well-known to many Americans, but relatively few Americans have experienced it as patients. It happens to be the medical system of the United States military, for soldiers.
The long-existing tie between "free" medical care and the military points to another side of the debate — one far removed from the "Hangnail Problem," or the moral hazard of a "free"-on-demand health care system. These analyses and criticism block out another, grittier, cost-benefit analysis. To put it bluntly, on-demand health care encourages physical aggressiveness.
Wounds gotten from fighting, as well as injuries from physical recklessness, are real. The ones that doctors examine tend to be severe, as a tough who enjoys fisticuffs is not likely to show up for a hangnail. In fact, such a tough may think of himself as a good citizen, well worthy of government-paid health care, because his pain threshold tends to be high. The same tough-guy ethic that mocks someone for crying, or running away, will heap scorn on anyone who shows up at the hospital for a minor cut, bruise, creakiness or pain. On the surface, a nation of toughs doesn’t look all that cost-bloating for a tax-paid health care system.
Look below the surface, however, and it becomes plain that tough guys can be squanderers of government-paid health care systems. Their injuries are largely volitional…and may even be seen as goods, not bads, in the hard-core fighting circuit. "Scars of honor," to put it one way. This custom is, of course, consistent with the conceit that a "real man" of this sort is jolly well entitled to full and free health care.
Consequently, government-provided health care contains a completely different moral hazard than the hangnail problem: the "bruiser" problem.
Naturally, the State can find real use for this type. A brawling bully fits quite neatly into the "spoiled and undisciplined" category beloved in recruiting stations.
Even if the State has no need of war at the time, the secondary growth of the State still continues as a result of State-controlled health care. There is already some recognition of this consequence in the area of health maintenance, which has given new encouragement to the usual prohibitionist factions. At the more basal level described above, though, new State encroachments on individual liberties are already manifest. More, and more aggressive, police forces; more government supervision of the public square; more laws and regulations (ironically) to avert initiations of physical force; more government intrusions upon previously State-free zones.
The end result is a kind of minor, low-level civil war — and the accompanying fears that such a state of un-nature calls forth. This fear, as Robert Higgs’ Crisis and Leviathan documents, is one that State agents are expert at turning to advantage. To sum it up in a slogan: "Government health care today means government monitor cameras tomorrow."