You get what you pay for

Americans complain a lot about taxes being too high, which implies that lower taxes are always better. We speak as if the money we pay in taxes is just wasting our hard-earned dollars, and ideally we should keep all we earn and spend it entirely on things of our own choosing. When pressed, I suppose most of us will admit that the government actually uses those tax revenues to do things like maintain armed forces, which most of us will admit are necessary. Leaving aside the question of waste for the moment, what things we are willing to give our government money to accomplish?

This is the first in a series of posts about the role of government. What is government for, and what should we expect of it? In American schools, we learn about the structure of our own government, and from the polls I’ve seen, most of us promptly forget it all. But it is not until specialized college level courses that more general questions about the purpose of government are brought up.

The first broad area of government activity can be called Security. Quite likely it is this function that first led to the creation of government. We can divide Security into a few aspects: External, Internal, and Border Control.

External Security generally takes the form of military organizations. Almost every nation in the history of our planet has had some kind of military force, and very few citizens of any nation would argue that it is not needed (Costa Rica is an interesting counter-example, having abolished its army in 1949, as is Liechtenstein, army-less since 1868). Of course, the size and organization of the military are subject to a wide variety of possibilities. Some countries spend as much as 10% of their GDP on their military forces, some less than 0.1% – the US comes in around 4%, though some military programs are difficult to quantify, so this could be slightly higher. (Information from the Stockholm International Peace Research Institute.)

Most countries with coastlines maintain some kind of coast guard, which may or may not be considered military. They provide a wide variety of services, such as search and rescue, that are outside the scope of defense, as well as border control and law enforcement. For example, the UK’s Coastguard is a civilian agency, while the Icelandic Coast Guard is a law enforcement agency. The American Coast Guard is a branch of the military which has some non-military functions.

Which leads us to law enforcement or Internal Security. This is another area that virtually all nations have, and organization and duties vary widely. In the US, most law enforcement is organized at levels other than federal, such as state, county, city, or whatever, though we do have the FBI and a few other national entities. For the purposes of this discussion, I’ll include courts and prisons in this category of government activities.

Border Control is another aspect of Security that governments engage in, and another function that few citizens would protest. Even countries with the most liberal immigration policies want some control over who enters, and most countries are interested in stopping the entry of certain items, like illegal drugs, dangerous materials, weapons, disease-carrying people, animals or plants, and so on.

That’s my broad overview of one of the least controversial functions of government. Check back next week when we move into areas that more people take issue with. While we may argue about the details of enforcement, budgeting, and so on, virtually all of us agree that our government should perform these duties.

Is health care a service or a right?

John Mackey, co-founder and CEO of Whole Foods, caused quite a stir recently with this post on the Wall Street Journal web site. Sensational exaggerations and knee-jerk boycotts aside, while his statements may seem to make sense, there is a fatal flaw in his reasoning that I've not seen anyone call him on, at least not in a reasoned way. The core of his argument comes down to this:

Many promoters of health-care reform believe that people have an intrinsic ethical right to health care—to equal access to doctors, medicines and hospitals. While all of us empathize with those who are sick, how can we say that all people have more of an intrinsic right to health care than they have to food or shelter?

Health care is a service that we all need, but just like food and shelter it is best provided through voluntary and mutually beneficial market exchanges. A careful reading of both the Declaration of Independence and the Constitution will not reveal any intrinsic right to health care, food or shelter. That's because there isn't any. This "right" has never existed in America.

So is health care really a service, not a right? If a bleeding car crash victim staggers into an emergency room, can they be turned away? There is nothing wrong with denying service, right? A restaurant can refuse to serve a shirtless or shoeless person. But even the most hard-line conservative is not going to advocate denying emergency room service to a person in need. I would argue that a service that cannot be denied is a right.

Obviously, we have no trouble denying some medical services to the uninsured, which turns American emergency rooms into their primary source of care. If a problem is not serious enough to drive someone to an emergency room, they do without care. And if the problem becomes more serious, that's exactly where they go, even if it's something that could have been prevented easily with earlier treatment. This is one of the primary reasons American health care is in such trouble. Even aside from the cost in suffering and unnecessary deaths, it would be far cheaper to provide the service of early treatment to the uninsured than to treat them only when they are in serious need.

Another problem with Mackey's point is this: even if health care is a right, that does not mean "equal access to doctors, medicines and hospitals," which sounds like some kind of communist system. Virtually every other developed nation in the world has designed systems based on the idea of health care as a right, and nowhere is there any pretense of "equal access." People who have enough money can always get extra care and have more choices, being able to afford travel to the doctor or hospital they want. The right of freedom of speech does not mean equal access to mass media; the right to keep and bear arms does not mean everyone gets a gun for free; the right to work does not mean we can all do whatever job we choose.

Mackey mentions that there are no rights to food or shelter either. I would like to point him to the International Covenant on Economic, Social and Cultural Rights, which the US has signed but never ratified. Of course, that Covenant also mentions health care as a right, along with other things that many Americans do not consider human rights, but "desirable goals." Which puts the US in the odd position of claiming to be one of the world's foremost proponents of human rights while simultaneously being one of the nations with the narrowest definition of human rights. Our view is that it would be nice if everyone had enough to eat, but there is no intrinsic right to avoid starving to death. So not only is it acceptable to not help starving people, but it is also acceptable to deny people food if they don't meet some standard of merit. After all, this is not a human right, but a service that can be denied.

Am I reducing Mackey's argument to the point of absurdity? Maybe, but I think his argument is at its core flawed and even of questionable morality. He says health is not a right, and I don't know where he draws the line.

He uses the Declaration of Independence and the US Constitution as the only definitions of human rights. Well, a lot has changed in 200 years, and maybe those are not the only documents that should be used. I've mentioned the International Covenant on Economic, Social and Cultural Rights, and there's also the Universal Declaration of Human Rights, widely regarded (outside the US, I suppose) as the Gold Standard of rights documents.

Mackey also goes on to raise the specter of horrendous waiting lists for medical care in Canada and the UK. This is a false argument and misdirection of attention. Which is better, 830,000 Canadians on waiting lists for care, or millions of Americans who get no care at all? But that's really a different topic for another day.