What happens when we don't see health as a common endeavor?

How much you believe in a need for universal health care is largely dependent on how much you see health as a common endeavor. The national policy debate we've been having lately and the health economics class I just completed have me giving it some thought.

Respecting people's preferences is an important tenet of economics. So, if you like to spend your leisure time watching football, smoking, drinking beer and eating pizza; we can presume that you know best what makes you happy and you alone suffer the consequences. If however, other people pay the price for your choices, then there is a social cost, and it is reasonable to consider some intervention.

What happens when we don't see health as a common endeavor?

• We suffer the negative effects of exposure to secondhand smoke. 
• We pick up extra work because a colleague is out sick. 
• We accept the risk of catching an infectious disease from the people around us.  
• We loose revenue from tourism in regions that people avoid traveling to because a disease is prevalent like the Zika virus. 
• We share the costs when medical problems lead to home foreclosures--medical problems contributed to half of all home foreclosure filings in 2006
• We share costs when medical problems lead to bankruptcy--medical problems contributed to 62% of all personal bankruptcies filed in 2007
• We share the costs of medical divorces
• We pay higher rates for medical care to make up for the uncompensated care provided in emergency rooms and other settings. 
• We pay higher ticket prices for airline tickets because fuel is required to move weight and more people are obese. 
• We suffer the negative consequences of the opioid crisis.
• We pay the costs of a measles outbreak that occurs because people choose not to vaccinate their children.
• We accept that more children will be raised in poverty and need social support--unplanned pregnancies cost taxpayers $21 billion dollars each year. 

Each of these externalities imposes a social cost in dollars, pain and suffering, and lost opportunity. If we acknowledge this and see health as a common endeavor, then we have an opportunity to address the issues together.

The attitudes of American's are evolving. According to a Pew Research polling data,

Currently, 60% of Americans say the government should be responsible for ensuring health care coverage for all Americans, compared with 38% who say this should not be the government’s responsibility. The share saying it is the government’s responsibility has increased from 51% last year and now stands at its highest point in nearly a decade.

One argument against universal health care is that health insurance does not improve health. The NEJM just published an article by Benjamin Sommers, Atul Gawande, and Katherine Baicker that reviews recent experimental and quasi-experimental studies of the ACA and other expansions of public or private insurance titled Health Insurance Coverage and Health -- What the Recent Evidence Tells Us. 

They conclude that "coverage expansions significantly increase patients' access to care and use of preventive care, primary care, chronic illness treatment, medications, and surgery." There is also abundant evidence that having health insurance improves financial security.

But, do these things improve people's care and not just how it's paid for? Yes, "insurance coverage increases access to care and improves a wide range of health outcomes." It comes at a cost though. You have to cover 239 to 316 adults on Medicaid to save one life. 

I started with a question and I'll end with another. What's a life worth? There are current public policies that address workplace safety and environmental protections that average $7.6 million per life saved. Expanding Medicaid costs $327,000 to $867,000 per life saved. Another perspective on the value of life is Quality-Adjusted Life-Year (QALY). A ratio of $50,000 per QALY gained by a health care intervention has served as a benchmark. These measures are all a little crass, but relevant if we're considering cutting Medicaid to fund tax cuts for wealthy Americans. 

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Ezra Klein explores some of these issues in an interview with Avik Roy. It provides a window into the debate on health care happening within the republican party. It's worth a listen. 

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