Health care-funding the revolt to freedom

[This is the fourth in a series of articles dealing with the issues involved in the health care debate. For readers who wish to read or review the previous posts, here are the links: 1.) Health care needs a revolt to freedom, not socialism, 2.) Health care- what the revolt to freedom requires, 3.) A health care approach based on responsible individual freedom]

Judging by some of the responses I've received to the previous posts in this health care series, I think it's important to make it clear that the illustrative features I talked about in my last post are not suggested components of some government run health care scheme. I oppose the government takeover of the health sector. It should also be clear from the ideas I've outlined that I oppose perpetuating the third party payer system in any form, whether as a single payer government run approach, or in continuation of the existing private corporate structure. One of the keys to improving the health sector's cost efficiency is to restore the responsible decision-making role of individual payers, so that price signals in the health market once again reflect the aggregate response of buyers to the sufficiency, quality and cost efficiency of the goods and services available to them in the health marketplace.

The ideas presented are also intended to illustrate possible ways of activating another key to cost efficiency, which involves recognizing that those who seek the health sector's ultimate product (health) also play a critical role in producing it. Like production workers in any other economic sector they must accept their responsibility for carefully and efficiently executing their part in the production process. And like other production workers, they need a work environment that offers tangible incentives for them to do so.

Unfortunately the discussion of health care reform has bogged down because of proposals based on outdated nineteenth and twentieth century concepts of economic activity. According to these concepts, the world is divided between workers and owners, managers and resources (including human resources), producers and consumers. By contrast, the paradigm of twenty-first century economic activity has begun to emerge most distinctly on the internet. The very concept of networking outruns the dialecticism of the past. The components of a network are at one and the same time consumers and providers of information. As conduits for its flow, they also modify, redirect and reshape its contents for different purposes, in a way that defies and transcends the distinction between consumption and production. On this account, the very idea of 'ownership' has to acquire new flexibility, so as not to interfere with the flow, modification and exchange of information that creates the network's activities and their economic value.

Social networking internet activities like Facebook are a good illustration of this new reality. The people who turned the Facebook software engine into a profitable enterprise mainly depend on advertising for their revenues. In a sense, such sites are like fairgrounds or expositions. Because they generate a large flow of visitors businesses will pay for the privilege of advertising their goods and services to the passing crowds. However, who produces the shows and other activities that attract the crowd? It's the visitors themselves. They gather in order to show off to one another, with photos, videos, writings, conversation etc. To be sure, just as the performing artists in other media (TV or the theater for example) enjoy what they do, the performers on the social network get pleasure (entertainment value) from their participation. But they also provide the attractions that gather the crowd. They are at one and the same time performers and spectators, producers and consumers, workers who own and manage an enterprise that is, in many respects, identical with themselves.

(At the moment, by the way, the economic model for internet activities takes no proper account of this new reality. But thus far unsuccessful attempts by Facebook and others to impose fees for services that people have hitherto obtained without charge are symptoms that the existing model is facing pressures that will inevitably lead to its modification. The new model will doubtless have to recognize and make use of the fact that charges people resist when they see themselves as consumers become logical and palatable as part of a paradigm that recognizes and remunerates the indispensable contribution they make as performers and producers. As consumers, they may be loath to pay admission to be part of a performance they themselves help make possible (that's like making performers pay for admission to a benefit concert for which they freely provide all the entertainment) But if they share in the profits generated by its existence, they will more cooperatively pay something toward maintenance and operating expenses for the privilege of realizing their share of the advertising revenue that is going at present entirely to someone else.)

The idea of replacing existing insurance policies with individually owned health provident accounts aims to initiate the health sector's move to a twenty-first century paradigm of economic activity. Ironically, though it represents a major change in the administrative structure of health care finance, in other respects the funding structure for those who presently earn employer funded access to health insurance as part of their pay would remain pretty much as it is. Some questions (like portability, for instance) would take care of themselves, since individual ownership of the health provident account means that the relationship between the insurance fund manager and the individual would be unaffected by changes in employment. Employers would pay the insurance fund manager in the name of the employee, just as they do now. But just as someone's employer doesn't decide where they have their checking or savings account, the employer would not decide where the employees establish their health provident fund accounts. This would in no way prevent employers from developing and promoting plans in concert with a particular insurance fund management firm. If the resulting cost and services package was attractive enough, a large number of their employees would sensibly prefer it. But the decision between competing fund management firms would be made by the individuals themselves.

This also opens the way to the creation of contributor pools based on associations and affiliations apart from work. Individuals could form such groups drawing from people in similar circumstances in their church, their service, fraternal or sorority groups, etc. Those who work for small and medium size businesses, for example, would take whatever level of contribution they receive from their employer and go in search of others being funded at a similar level. Once a large enough initial pool has gathered, the sponsoring organization would work out terms with an insurance fund provider, just as larger employers do now. Such groups would doubtless become a permanent feature of the system, identifying themselves with people at different income levels in order to appeal for their participation. So in addition to choosing among competing insurance fund providers, individuals would choose among different contributor group plans to find a package suited to their funding level and needs. Plan groups might be named after a particular employer (the GE plan, the Ford plan, etc.) or after a particular religious denomination, union or service organization (the Southern Baptist Association plan, the AFL-CIO plan, the Kiwanis plan, etc.)

In considering all this, it's important to keep in mind that any ideas I put forward are just for illustrative purposes. The good thing about a structure that empowers people for freedom is that it gives them the opportunity to think out and explore possibilities no one else would see.

A crucial question remains to be considered. How can we make provision for the people who, for economic or other reasons, are in no position to obtain employer funding for a health provident account? There will always be people with characteristics that make them rather like the kids on the playground that nobody wants on their team. Wouldn't the government have to step in to provide the funding and negotiate a group plan on behalf of indigent, infirm or high risk individuals or families? Government funding appears unavoidable, however, only to those who assume that there are no people with surplus resources to invest who would take an interest in helping to provide for the hard cases simply because it's a chance to do some good. The world is full of the foundations and institutes launched and sustained by resources people provided for no other purpose than to do some good. Folks like Gertrude Himmelfarb have done painstaking work suggesting that such good will may be relied upon to meet certain kinds of needs.

Indeed, for centuries, the provision of health services to people in need was a particular focus of well doing in cultures under the influence of Biblical morality. In communities throughout the United States the names of hospitals and medical centers call to mind their Biblical roots (Holy Cross, Shady Grove Adventist, Lutheran Memorial, Methodist Hospital, Mercy Hospital, Good Samaritan, Cedars-Sinai and many others that make an impressive list of saints' names and Biblical places.) The remarkable thing about our time isn't that ten percent of our people may have no assured access to health services, it's that (even by the estimates the socialists use to justify a government takeover) as many as 90% do. A Significant proportion of the system that achieved this result was built and maintained by the faith and goodwill of people in the private sector. Why should we believe that a government takeover is the only way to take care of the people not yet included?

Of course, as a matter of public order, safety and happiness it's natural for the sovereign (in this case the people as a whole) to take an interest in the health facilities of the society. The first care would be to do nothing that unnecessarily constrains or creates impediments for the existence and proper functioning of those facilities. The next would be to assure against malfeasance and abuse, through the civil courts and enforcement of relevant criminal statutes. But just as people have done with respect to education since the earliest years of the republic, so with health care, it makes sense for the government to make sure that, in the exercise of its proper powers and the conduct of its activities, it favors and supports those private activities judged most conducive to the public good.

In one of the famous Federalist papers (no. 36) Alexander Hamilton alludes to the fact that it is a feature of wise tax policy to work in such a way that the surplus of the rich contributes to the activities that address the situation of those in need. He was not suggesting anything like the schemes of confiscatory income taxation the socialists are so fond of. He was discussing the fact that the imposition of excise taxes on the items of more discretionary consumption accessible to those with greater surplus resources "coincides with a proper distribution of the public burdens." Without the need to develop and sustain the costs of an expensive, cumbersome and ineffective government administration, wise tax policy can second the good impulses of private individuals. It can thereby increase and help to sustain their commitment to actions that aid those who might otherwise be neglected. Thus it fulfills the proper hope of those who wield sovereign power, which is to serve, insofar as possible, the good of all the people.

In this regard the first aim of public policy would be to encourage adoption of an approach to health insurance that restores the proper role of individual freedom and responsibility. One way to achieve this would be to exempt from Federal taxation in every respect those who adopted an approach consistent with this objective. This would include both the insurance funds themselves (both as to the individually owned accounts and the investments or other income generating activities related to the general funds) and the transactions involved in their use.

This exemption could include allowing health insurance companies to emit tax-free financial securities (similar to tax-free municipal bonds) with the particular intention of raising capital for use in funding individual accounts for the 'hard cases'. Such bonds could then be marketed with particular attention to charity minded individuals. Instead of scoffing at the idea that needs should be met through charitable giving, this policy would aim to make charity a marketable commodity, that allows good intentions to feed upon themselves in order to nourish and increase the resources available to fulfill them.

As with the desirable features sketched out in the previous article in this series, this suggestion is simply meant to illustrate an approach consistent with individual liberty and responsibility. People with greater knowledge and expertise, encouraged to think along these lines, will doubtless come up with better tailored proposals. Unfortunately, the present focus on socialist concepts doesn't offer such encouragement. Stuck in the rut of archaic nineteenth and twentieth century thinking, the current health care policy debate doesn't encourage the development of decentralized approaches based on individual goodwill and initiative, approaches that would be far more in synch with the opportunities and possibilities that can be empowered by twenty-first century networking and globally targeted niche-marketing techniques.

Aside from being more up-to-date, such twenty-first century ideas would also take account of the timeless moral principles that must be respected when dealing with life and death matters like health care. As we have noted, one of the reasons for mounting opposition to the Obama faction's socialist proposals is the perception that banal bureaucratic calculation would usurp the judgment of concerned and loving individuals when it comes to dealing with the health crises of family members and other loved ones. Though the perception attaches to particular provisions of the Obama proposal, the concern is properly raised with respect to any health care approach that displaces individual freedom and responsibility. Bureaucracies may or may not reliably make decisions that are better informed or more consistent with cost-effectiveness. They will never reliably make decisions with greater love. Love must reflect the voluntary commitment of individuals to the welfare and happiness of other individuals. The works of love transcend rules and calculations, at least in part because the rationale of love takes as its denominator a being perceived to be of infinite worth. The value of an individual's life can therefore never be quantified or measured by any ruler except the loving heart. Beyond the requirements of justice, by respecting individual freedom and responsibility we make it more likely that our approach to health care gives love its due.

A health insurance approach based on responsible individual freedom

As I said in my last posting, for me to offer a health insurance proposal is rather like a weatherman offering to design a jet fighter: though he's familiar with its operating conditions, odds are that his ideas won't fly. That said, I suppose I have at least as much expertise on the subject as, say, leftist politicos like Barack Obama, an observation that emboldens me to share the thought experiment that follows.

I strongly believe that it's often a good idea to start a discussion by clarifying in simple terms exactly what it is we're talking about. Health care becomes an issue of public policy concern mainly with regard to the approach we take to paying for health services. If everyone had as much money as Bill Gates or Donald Trump, I doubt there would be much fodder for political discussion. Still, since money is so much of the issue, it might not hurt to think about how we'd handle things if we did have their resources. We'd have the freedom to do what we thought would most effectively and rationally maximize our health and longevity.

So assume for a moment that you are a person of relatively unlimited resources that you can allocate in any way you choose. Let's also assume that, being a person of good sense and will, you want to take care of your own needs and reasonable desires, while maximizing the surplus that remains to be devoted to some good that you want to achieve. Having a sane regard for you personal comfort and safety, you want to take care of your health. What would be your most reasonable course of action?

Let's say that you are start out in a state of good health. So your first concern is to maintain it. You would budget a certain amount of money for this purpose. It might include an allocation for a fitness regimen; for developing and maintaining a healthy diet; and for regular consultations with health professionals (fitness coach, diet specialist, personal physician) who use appropriate measures to check your overall state of health. Let's call this the health maintenance allocation. Your budget might also include money that you may need in order to deal with emergencies (in the broadest sense) including accidents and occasional bouts of illness. Ideally this allocation would be reserved in the form of some productive investment, so that the money involved, though readily available, would be fruitful and multiply as time passed.

In addition to this basic budget, you might designate an additional amount meant to accrue value over the longer term. This would ideally provide the wherewithal to handle the anticipated inevitable effects of aging, as well as longer term care that might be for chronic, incapacitating illness or during the period of acute decline prior to natural death.

Given your relatively unlimited resources, more extreme and hard to anticipated emergencies would have to be handled by extra budgetary allocations, taken out of the surplus that would normally be devoted to such other good as you are trying to achieve.

Now, most people don't have relatively unlimited resources. Some might be in a position to maintain a reasonable budget for ordinary health related expenses, but many would have trouble dealing with foreseeable health emergencies, much less the more extreme exigencies. Any extra budgetary allocations would probably have to be financed by borrowing. But people with relatively little surplus income beyond what's needed to maintain their everyday life are limited in their ability to service debt, especially in the large amounts that might suddenly be needed to meet a health emergency. At any given moment, however, the risk that any given individual will face such an emergency is relatively small. Spread that risk over a sufficient number of people, and the burden of meeting it in any given case can be met by a fund replenished through small, regular contributions that each of them can afford. Thus the basic concept of emergency health insurance emerges. It's intended to allow people who must live on a wage or other regular but limited income to provide for needed health services that they could otherwise not afford.

Though we call it insurance because of the fund's purpose, we should keep in mind that it is actually much like a special purpose savings bank. Like any such bank, some of its income is properly generated from prudent investment of part of its available resources. Thus its gross income for any given period consists of the total amount of the regular individual contributions plus interest or dividends derived from investment. The total value of the fund at any given time includes, in addition to operational balances, the total value of the invested capital. For any given period, the bank may generate a surplus that consists of the total income for that period minus the sum of its operating costs and any outlays for health emergencies during that period.

Looked at in this way, we immediately notice one difference between the operation of the insurance savings scheme and other kinds of savings banks. At other banks, those who provide the funds the bank uses for lending and other investments receive some interest on their deposits. If they leave them untouched, the value of these deposits increases over time. Depositors therefore have a certain incentive to leave them untouched, in order to maximize their growth. In effect, the bank's profits, in any given period, are divided between the owners of the bank and its depositors, who own the accounts that constitute the bulk of the bank's liquid assets.

The contributors to the insurance fund do not 'own' or derive income from the total amount accounted for by their contributions during any given period. Their premiums pay for the right to borrow from the fund to meet any health emergencies that occur during the period.

In comparison with a savings bank, however, the insuring bank has less control over the amount the bank may be called upon to lend during any given period; they also can't control the relationship between the amount they lend to any given individual and the total amount of the regular contributions they receive from that individual after the emergency has been handled. They can't be sure the loan will be fully repaid (much less any interest that would otherwise accrue.) To compensate for this, they must have a stream of new income from a) new contributors signing on to the fund; b) the bank's investments; c) sale of stock in the company. They must also find ways to manage the overall risk distributed among their contributors so that the fund continues to grow enough to prevent shortfalls on account of any individuals from gradually reducing the fund below the level needed to fulfill its obligation to pay (at any given time) for the needed health services of its contributors.

Assuming however that all this is done competently, (and that unexpectedly adverse conditions do not consume its income producing assets) the insurance savings (or fund management) scheme (what we, somewhat misleadingly, call the insurance provider) could generate a profit over time. As things stand that profit goes entirely to the owners and/or stockholders of the bank. After all, they provide the critically important initial and ongoing capitalization needed to launch and sustain the insurance scheme. But without garnering sufficient contributors to form an adequate risk pool, would the scheme work for very long? Probably not; it would become a rather expensive and short lived form of charitable giving. The money derived from individual contributions, as well as the health and behavior of the individual contributors, form an essential part of its real and ongoing capitalization.

Given this fact, as well as our overall goal of respecting individual liberty (choice and responsibility) in dealing with health matters, does it make sense to leave the whole incentive for managing risk to the banking institution? For better or worse, the individual's behavior contributes to the success or failure of the risk management task. Under present arrangements, some efforts are made to enlist individual cooperation by offering lower contribution requirements (premiums) in exchange for certain behavior modifications. But the accrued value of this incentive is hidden, so that it is psychologically consumed almost at once, and rapidly decreases even further over time. Wouldn't it be more effective (since an ongoing commitment is needed) to offer incentives in a form that persists and grows in perception over time, so that as individuals maintain a state of health that keeps down their withdrawals from the general fund, they see an appreciable increase in the value of the incentive?

Without such an appreciably increasing incentive, as healthy people contribute to the general insurance fund, the perceived value they derive from it decreases in direct proportion to their success in staying healthy. In effect, their good health over any given period subsidizes the outlays made for those who have less successful health maintenance records during that period. The longer their good health lasts, the greater the total amount of this subsidy. In terms of value for money, there is actually an incentive after a certain time, to become more casual about resorting to health services, less prone to reflect much on the real necessity for doing so.

Given this perverse incentive structure, why do we marvel at the present insurance system's tendency to generate higher outlays? How can we alter this incentive structure to reward people who maintain their health, so that the longer they sustain their successful health record, the larger the reward's value to them appears to be? The answer is simple: their good health habits must be seen to contribute to their accrued assets over time so that sustained health translates into increased wealth, thereby encouraging their commitment to healthy behavior.

By combining the wealthy individual's common sense approach to maximizing the surplus available to do other good things, with an insurance fund incentive structure that maximizes individual contributors' commitment to good health habits, we arrive at a health insurance approach that might have features like this:

• Coverage of all aspects of basic health maintenance including the maintenance of good fitness and diet regimens and routine check-ups.
  
• Premiums that, in addition to producing regular operating funds and the money needed to meet the costs of contributors' basic health maintenance services generate the surplus needed in any given period to meet foreseeable health emergencies.
  
• A category of additional premiums going into a separate fund reserved for a) acute emergencies and health situations requiring longer term care; b) the increased costs associated with the inevitable health effects of aging and/or the special care required during the decline toward death.
  
• All regular premiums to be credited to individually denominated, interest bearing checking accounts, associated with an interest free health credit line capped at an appropriately determined quarterly limit. Individuals agree to pay for all health related expenses with funds disbursed from this account. Emergencies requiring disbursements beyond the predetermined credit cap would require a limit increase approved by the insurance fund manager according to a predetermined schedule of step increases, up to the limit set for foreseeable health emergencies. Beyond that limit, disbursements would come from funds obtained out of the acute emergency/longer term care fund.
  
• All acute emergency/longer term care premiums to be credited to individually denominated, interest bearing money market checking accounts, with disbursements according to the model established for the regular premium account, but with a separate schedule of disbursement caps.
  
• Unused balances in the individually denominated accounts, plus interest accrued, would rollover and accumulate from quarter to quarter.
  
• A schedule of discounts would be applied to premiums in one or the other, or both categories, related to an individual's commitment to maintain a fitness and dietary regimen developed and supervised by health professionals and facilities chosen by the contributor, but approved and accredited by the insurance institution. The regimen would include regular evaluations and reports (based on agreed upon measures and areas of evaluation) as to the individuals' active compliance with their regimen's fitness and dietary provisions.
  
• A schedule of interest rates for the interest bearing accounts such that the rate increases in relation to the length of time a) the individual successfully maintains the commitment to an appropriate dietary and fitness regime; and b) maintains a state of health and fitness within predefined age appropriate parameters.
  

This list of features is obviously intended mainly for illustrative purposes. In considering them, it's important to keep in focus the objective at which they aim, which is to eliminate third party administration of the disbursement of health funds, placing choice and responsibility squarely on the shoulders of the individuals who actually experience the provided health services. At the same time, the incentives connected with individual ownership and wealth creation are mobilized to encourage individual behavior that improves health prospects while reducing casually inconsiderate drains on overall health fund reserves. There are probably other and better features with which to achieve these objectives. The advantage of advocating freedom, rather than socialist government control, is that creative individuals and institutions are left free to think through and implement them. The key to defending their freedom, however, is to fund the individually owned accounts the incentive structure requires in a way that respects the power and prerequisites of a free market, while providing effectively for the hard cases that the socialists claim only coercively raised tax dollars can insure. In the next and final installment of this series we'll consider where that key (or at least a serviceable impression of it) may be found.

Health care-what the revolt to freedom requires

Once we shift the focus of the health care discussion from caring for sickness to preserving health, one thing becomes clear immediately. If we wish to remain a free people, health care cannot be the government's business. Though would-be tyrants like Obama want us to forget it, lawful coercion (the force of law) is what ultimately distinguishes government work from other group activities. It makes sense to say that we will force people to be healthy only if our concept of human integrity (healthy human life or existence) includes slavery. But as Americans we long ago rejected this possibility because it is inconsistent with respect for the God ordained unalienable rights that are an essential aspect of human being, i.e., what it means to be what we are. Slaves may or may not have healthy bodies, but slavery cannot be a healthy human condition.

By beginning with this observation, we are led to reflect on the comprehensive meaning of human health- one that goes beyond the material condition of the human body to include the mental and spiritual aspects of human life. Undoubtedly, many diseases appear to be the result of merely material causes. But which merely material cause makes the difference between one person with the will to eat right, resist health impairing habits and keep up a healthy level of physical activity, and another who lacks the will? What merely material cause makes the difference between one person doggedly determined to battle cancer or infection for the sake of life, and another who confronts the same physical threats with despairing lassitude, or peaceful acceptance?

Sickness may be a material condition but health is also a state of mind. As such it is susceptible to material, mental and spiritual influences. These days it's not uncommon for people to pay lip-service to this fact. But when we consider the main preoccupations of the so-called health care proposals being debated at the moment, do any of them take it seriously in a positive way?

To do so requires that we respect the role that human will, conscience and spirit have to play in the critical decisions that influence a person's state of health. It requires that we accept individual choice and responsibility as the first premise of any health care approach. Though many opponents of the Obama faction's proposed socialist takeover decry its implications in this regard, how many of them are honest enough to admit that the third-party payer system it would replace just as surely eviscerates the exercise of responsible individual choice in any meaningful sense?

Responsible choices take account of both the benefits derived from a decision, and the costs it involves. But the third party payer system puts individuals in no position to do so. Sure, they choose an insurance plan. But at the point of delivery, they lack both the information and the incentive to react effectively to the relationship between the service they receive and the price set for it. This deficiency has at least two bad effects: a) Providers have little incentive to respect the power of individual clients; b) individuals have little incentive to resent or appreciate the price paid for the quality of service they receive.

Since it breaks the price/perceived quality ratio, the third party payer insurance system abandons a vital prerequisite of any free market system. It breaks the cost governing mechanism that generally allows the market to achieve equilibrium at a point of price efficiency that reflects informed, responsive decisions by the individuals whose activities make up its existence. These individuals are replaced by corporate (or government) bureaucracies driven by control/management and profit/budgetary preoccupations that have, at best, only a coincidental relationship to the actual price/quality ratio of any particular service transaction. How can it be anything but coincidental when it excludes from reckoning the perceived experience of the particular individuals involved.

As the result of what we might call this coincidental price structure, system resources are distributed with little or no regard for perceived cost-effectiveness. It's like running a restaurant based on aggregate decisions (how much of what kind of food to buy, how big a wait staff to hire and at what wage, how much to charge for each different menu item, etc.) that take little or no account of how individual patrons react to the service or the taste of the food. Meanwhile, individuals pay a flat fee to eat at the restaurant, choosing from menus with no prices on them. (The bill is sent to a company that insures access to restaurant services. Doubtless it began as a provider of starvation insurance for the cooking impaired.)

All these reflections point to what ought to be the first set of goals for a health focused approach to health care:

• It must respect the mental and spiritual as well as material aspects of health, beginning with the human right to liberty i.e., responsible individual choice.
  
• It must therefore be based upon a resource collection and distribution system that respects the requirements of liberty i.e., responsible individual choice.
  
• As things stand in America today, this means a) rejecting any socialist, single payer, government administered system; b) establishing a health insurance system that respects the prerequisites of a true marketplace; c) abandoning the third party payer approach in favor of one that recognizes individuals the as owners of the dollars expended for the health care services they receive, with full responsibility for the disbursement of those dollars at the point of service. This requires that individuals perceive themselves as directly gaining or losing value from all such dollars as they are expended.

In my next posting, I'll discuss some of the features that might be part of an approach to health care that reflects these goals. Be advised, though, that I won't be offering "my" health care proposal. The notion that people like me, whose main vocation has to do with the responsibilities of citizenship (the proper definition of politics) should be the source of remedies for health care is a symptom of how far the totalitarian socialist mentality has corrupted our common sense. However, because considerations of justice are relevant to all human affairs, I can try to make a useful contribution to thinking about how the possible features of a health care approach relate to the principles of justice that inform our identity as Americans. Stay tuned.

Health care needs a revolt to freedom, not socialist 'sickness care' reform

For years I have made the point that the key problem with discussing our so-called health care system is that we don't have one. The system focuses mainly on taking care of people when they get sick. It's a sickness care system. This system ends up producing two things: more sickness and ever-increasing costs. This makes sense, since the people who own and work the system mainly derive their income from sick people.

Think of the old Maytag commercials, featuring a Maytag repairman with too much time on his hands, because Maytag washers rarely break down. The manufacturers could afford to make a joke of his idleness. Demand for their products didn't depend, in the first instance, on mechanical breakdowns, but on the endless supply of dirty clothes. But the sickness care sector is rather like the repairman. Its income depends on the possibility and frequency of breakdowns.

Unlike the demand for washing machines, however, the demand for a properly functioning human body doesn't rise in relation to some other product. The body has an intrinsic value, like the human being whose existence in this world depends upon it. But just as they take existence for granted until it's threatened, people generally tend to take the body for granted until it's ailing. Then they seek the services of someone who can restore its proper functioning. This obviously complicates the incentives of the person who has the necessary expertise. Though he gets paid to make people well, they are by and large only inclined to seek his services when they get sick. In which does he have the greater interest, their sickness or their health?

Considered simply as a matter of selfish calculation, the medical expert is likely to profit most from a situation in which people who are prone to get sick see him as the source of a sure and effective remedy for what ails them. As Socrates points out from time to time in the Platonic dialogues, this leads to a dangerously ironic situation for his potential clients. The medical expert has the knowledge to cure them, but he may also have a strong motive to use that knowledge to make sure they don't stay healthy. Oddly enough, the result would correspond to the one we've been getting from our sickness care system- people clamoring for what they perceive as effective care while overall becoming more and more susceptible to disease. Meanwhile, budgets are strained as more and more money flows toward the sickness care sector.

Of course in ancient times this result was not as pronounced as it is today because medical experts weren't so good at dealing with sickness. Once someone got sick, the experts soon reached the limits of their ability to do more than palliate his suffering. The techniques of modern science have produced breakthroughs in sickness care that allow contemporary experts to do a better job of treatment in many areas, particularly those susceptible to surgical intervention or the use of antibiotic drugs. But this success has produced another less desirable result: medical expertise that focuses on sickness. Because ancient experts were less successful at dealing with sickness, they put greater emphasis on keeping people healthy. They focused more attention on understanding the dietary and exercise regimens that increased health and vigor. Though pain relief and sickness cures certainly played a role in their livelihood, the best advertisement for their wisdom was the strength and health of the people who followed their advice, not the excited praise of those they cured of disease.

More limited knowledge led to greater humility. They ascribed miracles cures rather to divine power than their own sophistication, which gave their profession a tinge of something more akin to religion than what we today would call science. Medical experts were seen as followers of a divine path or way, with a mystical component that also addressed the issue of trust implied by the double-edged quality of their motivation. They were oath bound not to follow the promptings of cynical calculation, and therefore to place the good of their patient above their own selfish advantage. These days we still assume the existence of this moral framework. Given the elite embrace of moral relativism, and its quiet contempt for religious truth, God knows why we do.

Be that as it may, these reflections help us to understand the fatal flaw in the present debate over the future of the medical services sector: it takes a deceptive rubric of analysis as the basis for discussion. This is due in part to the deceptive language characteristic of the discussion. We talk about access to health care, when sickness care is the real product. Terrified by the economic implications of its rising costs, we tacitly accept the deadly necessity for rationing, now going so far as to propose targeting the elderly and infirm to bear the burden of budgetary constraints. Suspecting the profit motives of those who own and work in the sickness care sector, we are also increasingly tempted by socialist proposals that would enslave them to our needs, allowing us to keep costs down by dictating the terms of their remuneration. Meanwhile, we neglect even to discuss the true source of the cost push- which is the rising tide of sickliness (preoccupation with disease), that increases the demand for sickness care despite the much touted breakthroughs of medical science.

I have long argued that we won't arrive at, or even conceive of, approaches that turn the situation around until we reject the assumption that sickness care is an acceptable product for the health services sector. The rubric and aim of health services should be health. The measure of success in the health sector must cease to be the amount, distribution and financing of treatment for sickness. Instead, we should focus on what keeps more people healthier for longer periods of time; what strengthens them in mind and body; what feeds and encourages their will to live, and their understanding and implementation of the discipline needed to serve that will effectively.

This amounts to a Copernican shift in the way we conceive of and analyze the health sector challenge. Tomorrow I'll outline a number of relatively simple and straightforward goals that come into focus as a result of this shift, goals that provide a basis for a true revolution in the meaning of, and provision for, our society's health concerns. The key to that revolution is responsible, individual freedom, not a socialist takeover.