As most of you know (or can guess) I'm not content to accept received opinions about things like health insurance reform. I've been researching it and working it out for myself for a couple of years now. Most of the discussion online has been tribalist bullshit and not particularly useful, but I've managed to define a few things that make the whole issue of health insurance a lot harder to deal with than otherwise might be. What surprises me the most is that these issues almost never come up.
The first of these, in fact, I had to coin a name for: Higgsism, from the clueless protagonst of Samuel Butler's wicked little gem, Erewhon. If you recall, while Higgs is jailed in Erewhon, he befriends his keeper's daughter, Yram. Higgs watches, astonished, as people who fall into bad health are convicted of a criminal offense, yet people who have been caught embezzling are treated as though they were suffering from a headcold. When Higgs himself gets a headcold, Yram scolds him severely, and only at that point does he put two and two together. As poor Higgs puts it: "I never remember to have lost a cold so rapidly."
It's a great book; a sort of steampunk Gulliver's Travels, and bears close reading. In a nutshell, what I call Higgsism is this: the belief that we have complete (or almost complete) control over our health, and that when we get sick, it's because we have done something wrong, making illness our own damned fault. Just as the lucky prefer to ascribe their success to hard work, the healthy generally ascribe their health to pure clean livin'.
Alas, the more we look, the more evidence we see that health is more luck than skill. Matt Ridley's 2004 book The Agile Gene describes the emergent nature of the human body, and how we're at the mercy of not only our genes but also poorly understood environmental stressors of gene expression that come into play starting at the moment of conception. Beyond avoiding a handful of obvious hazards like smoking, recreational drugs, and promiscuity, there's not a whole lot we can do. Eat moderately, walk a little, and get your sleep--but hell, if body weight is almost 80% heritable, health may be a steep climb indeed.
I've lived long enough to see a fair number of people die for no known reason. A healthy, trim, athletic nonsmoking man like Harry Helms with no family history of colon cancer dies of it. What did he do wrong? Carol's late Aunt Berenice lived a modest life and never held a lit cigarette, yet she died of lung cancer. What did she do wrong? The truth is that they did nothing wrong at all. Yet these days, when somebody gets cancer, everybody starts thinking back to try and identify what the poor slob's sin was.
The truth is grim: We control little of our own health, and what little we do control is often misunderstood (like carbohydrate metabolism) and not always universally applicable across the human species. (Milk is great for you--if you can digest it.)
The health insurance industry can only get away with medical underwriting because of the implied moral culpability of the unhealthy: If you'd just lived a cleaner, healthier life you wouldn't have cancer or diabetes or ALS or whatever, so you're a poor risk and deserve to go bankrupt and die. This widespread belief is why high-deductable catastrophic health insurance is unpopular: People see it as money going out of their pockets directly into the pockets of heedless reprobates who can't or won't adopt a healthy lifestyle, whateverthehell that is, while those who practice clean livin' still have to pay for their own broken ankles and flu shots.
As long as we continue to believe that, we'll be unwilling to face the truth: Health insurance is a sort of luck tax. The lucky pay the money while getting little back in terms of benefits. The unlucky get their lives saved through expensive treatments that they could never afford out-of-pocket. The moral dimension of health is almost entirely an illusion.
What's the solution? I didn't say I knew of one; in fact, I've often wondered if universal health insurance as we understand it is even possible. Yet even if it is possible, as long as we embrace Higgsism, I guarantee you we're not going to get anywhere with it. You might as well give antibiotics to embezzlers.
There's another part to this, which I'll try to get to in coming days.