健保不是權利雜談(20131008)

這是我與一位印度朋友與一位美國朋友討論關於該主題的想法。大體上與我先前〈〈健保不是權利〉雜談〉的觀點差不多。茲置於此作為紀錄。
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I think we all agree that human lives are precious and worthwhile to fight for. On that side, I of course welcome a society providing a compulsory health insurance. (I come from Taiwan, which has public health insurance for almost twenty years.) But I disagree using the "Health Care is a Right" (HCR) argument to realize that goal.

By using the HCR argument, we try to argue that "health" is so important that we should see it as a fundamental and basic value which the whole political community has to use all of its power to protect it. In addition, we see the fulfillment of this goal is so prior to almost everything that even people built a state just for those kinds of reason. In this case, we then have the position to make the HCR argument.

Yes. Health is very important for a citizen living in a political community. But, is the status of "being healthy" so hard to maintain for an individual citizen so that he has no choice but to cooperate with other citizens and therefore made the social contract and built the state in the first place?

If the answer of this question is a "Yes," then I will admit the HCR argument. But, as you all know, I eventually do not stand for the HCR argument at all.

While saying HCR, what is really on our mind is nothing about "insurance" but the "quality of life." However, the idea of "health" is eventually ambivalent. "Having a health care plan" per se unnecessarily guarantees us a healthy life. What insurance can do is nothing but to dilute or transfer our risk about life to someone else.

As a matter of fact, having a good health plan (no matter we pay it by ourselves or the whole society pays it) has nothing to do with being healthy at all.

We, not the government or anyone else, are eventually responsible for ourselves' health. We are the one who decided living unhealthily.

If we insist that we all had made that kind of social contract about HCR and what we actually want is to upgrade our life quality, then we are virtually saying that the state has the obligation to make all citizens healthy.

In other words, the law should prohibit any "unhealthy" life style (eating fast-food, drinking intemperately, staying up, doing no exercise, ...) in order to make all citizens healthy rather than just provide an affordable public health care plan for poor people.

In that case, we will have a comprehensive or even a ubiquitous government (U-Government). The idea of "having a ubiquitous government" itself is nothing wrong, especially when that kind of government is controlled by a group of knowledgable, deliberate, mature, and experienced wise gentle(wo)men. What might go wrong is the part about "how to make it happen."

Like health, almost everyone welcomes high-quality education, clean air, tranquil life pace, and warm and attentive solicitude from the community. But the problem is always "how to bring us such goods." Moving it further, the problem in front of us is always "how much the cost we would like to pay for."

If a government has infinite resources, we of course can expect an omnipotent state to fulfill all of our needs, and even desires. But unfortunately, no state has inexhaustible resources. Therefore, we only need the state collectively provide something valuable but we cannot individually afford, e.g. the national security or the national or inter-state infrastructures. In other words, we will not expect the state to step in the field we are supposed to handle it well by ourselves, because sustaining the state itself costs us a lot.

If people need to be covered from the risk of being ill, they need to buy an insurance policy. The HCR argument is so salient due to the fact that the basic health care policy in the US. is too expensive for normal people (especially for those who have no stable job at all) to afford. However, the problem here is the "expensiveness" of the basic health care policy.

If there does exist the market mechanism, then the price of a health policy reflects the cost of providing this service. That is, the HCR argument cannot cut the cost of providing the same service, but just transfer the cost to the whole political community. In other words, all citizens have to pay more taxes to provide this kind of service.

This arises two questions:

(a) Did this clause (about the political community should fulfill citizens' basic health need) be codified in the social contract we theoretically made when people got together and built this political community in the first place? If it did exist in the social contract, why can we not see it in the constitution, just like the constitutional freedoms protected by the First and the Second Amendments? If it did not, why can we insist the HCR argument?

(b) If the whole political community needs to fulfill the urge of HCR proponents, why should it not fulfill other people's different urge? For example, if a White woman insists that she deserves the right and the freedom from the fear of being bothered by pariahs or pagans, or if a conservative "good" Christian urges to live in a neighborhood without "filthy" homosexual people, why can we insist that the state or the government should not fulfill all these urges?

We do not permit these requests because they violate other people's fundamental civil rights. Likewise, we cannot allow the state to raise the tax in order to provide something we had never put into the social contract in the first place.

Indeed, some HCR proponents would invoke the Universal Declaration of Human Rights (UDHR), and it seemingly sounds plausible. But it actually does not.

No matter how much we value it, the UDHR is eventually an international pact, which at best has the same legal priority as laws rather than the constitution. A state can always shred an international pact whenever it wants. Sometimes a state can do that just by the executive's will, while sometimes it needs the popular approval to be done. In either way, a state can withdraw its approval about an international pact, much easier than amending any constitutional clause.

In this meaning, everything in the UDHR could hardly be a real "right," no matter how much we appreciate them, as long as we have not put these values into our constitution. We of course can pass laws to protect or fulfill all of these values in the UDHR. But we cannot call them "rights," at least the right based on the social contract theory.

My position is clear: We should never see something as a (constitutional) right casually, until the whole political community reaches a consensus about that idea, including how much cost we need to bear in order to protect this value as a right and what the theoretical consequences once we put this value as a right would influence other existing constitutional rights.

I really think we still can work out a legal solution or a policy to help poor people fix their "uncoveredness" without urging the HCR argument. Though I admit that the HCR argument provides us a theoretical sovereign priority while arguing, the HCR argument rigidifies our policy elasticity as well.

For example, it is quite common for people to see the national security as a basic right. However, even needing the national security, we might have different perspectives about how to realize the national security. At the level of international relation (IR), some of us might support a belligerent superpower, while others might expect a moderate peacekeeper or even an isolationist.

Of course, citizens pay differently according to the foreign policy position we choose; that makes all our citizens and politicians keep considering about the policy performance / cost, the short- or long-term interest, and the image of all our nationals. In other words, we, citizens or policy-makers, need the policy elasticity to fulfill our different needs in different ways.

The Second Amendment demonstrates an interesting case for us while discussing the HCR argument. While Funding Fathers urged the right of being armed and protecting ourselves, they never thought of the problem of violence we are facing today. In fact, the Federal government Funding Fathers once considered was rather a necessary buy small one, which had no sufficient resource and power to protect all citizens directly. Today, due to the comprehensive protection provided by the powerful Federal government, firearms have become the problem itself rather than the solution. However, we can hardly fix this dilemma since the Second Amendment sees "keeping and bearing firearms" as a fundament right.

Another example happens in Taiwan. We Taiwanese have a compulsory public health insurance system, which is codified by the Constitutional Amendment. However, the government in fact can barely sustain the whole public health system. As a result, our public health system heavily exploits doctors and nurses. Our doctors’ average income falls and their working hours increases dramatically, comparing to their antecessors thirty years ago. In addition, our government needs to issue debts every year to fill the regular budgetary deficit caused by the public health insurance. Since our public health insurance is guaranteed by the Constitutional Amendment, our parties and politicians have no choice but to keep issuing more debts to cover it. It is as if a dangerous game of "passing the inflating balloon," all everyone expects is the balloon not blows in his hand.

People's needs change all the time. What we consider imminent today might not be seen as necessary tomorrow. Therefore, we should use our democratic process to converge the contemporary consensus and make relevant laws, rather than prioritize some of our preferences to the level of "right" casually.

I am not saying that we should never add some values as fundament "rights." Of course we can do that. But we must be very careful while doing so. Naming something "rights" arbitrarily will not only narrow down out policy flexibility but also result in a catastrophic theoretical consequence which weakens people's trust and the authority of the whole system.

A value, such as the social justice, can never sustain without the general support from the whole political community. We can rely on our democratic process to deal with it. But we should not presume a sovereign policy position to eliminate the policy space for debating and compromising by each generation.

All in all, I support a compulsory public health system. But I see no need to treat it as a (constitutional) right.