The Poor Will Be Worse Off

Published October 11, 2017

National Review Online

EDITOR’S NOTE: Pascal-Emmanuel Gobry, a conservative writer and fellow at the Ethics and Public Policy Center, is writing a series of columns on uncomfortable truths about health care in America. Some will make conservatives more uncomfortable, others will make progressives more uncomfortable, but most should make everyone uncomfortable.

“The poor you will always have with you,” says the Good Book. Jesus might as well have been speaking at a health-policy seminar.

We don’t, mostly, speak about health-care policy in the cold language of efficiency, productivity, and resource allocation. We also use a moral language about fairness, justice, and righteousness. And rightly so! Health affects us in a profound and immediate way so that health services have a different moral valence than most other goods and services. The rain falls on the just as well as the unjust, and while conservatives are stubbornly opposed to government-provided help for those who can help themselves, when it comes to health, the calculus is different.

Conservatives believe that a free-market system would abound with so much innovation that everyone would receive much better care, and with such price competition that even the poor would find the best treatments affordable, and I agree. Progressives, meanwhile, view as a profound moral outrage the idea that two different people might receive a different standard of care simply because they have different economic resources, and I agree.

But the uncomfortable truth is that under any conceivable system, the poor will always have worse health outcomes than the rich.

The first reason for this is that health is not only determined by the health care one receives but also by one’s environment, and that pretty much every unhealthy thing you can think of correlates with poverty. Obesity? Check. Alcohol abuse? Check. Substance abuse? Check. Smoking? Check. Over the past decades, a growing body of research has accumulated to show that other “softer” variables linked with poverty have a negative impact on health, such as personal behavior, job stress, the psychological environment of work, and social networks and social support. What’s more, the research suggests that all of these negative inputs not only accumulate over the course of life, but even that they can be passed on across generations by parents to their children.

All of that means that, however your health-care system works, poor people will be worse off simply because they’re going to be in worse health over the course of their lives. In a sense, this is almost tautological: Poverty is not just material deprivation, it is exposure to all those negative things that are associated with material deprivation, which necessarily have an impact on our health. This is the reason why poverty is bad and why we should seek solutions to alleviate it.

All right, fine, you might say, maybe poor people start off at a disadvantage, but perhaps there’s a way to design a health-care system that ensures they get an equal level of care. And the answer there is still, no, sorry. The reason for that is that resources are limited. Medical innovations, whether they are drugs, devices, or processes, do not spring fully formed from the thigh of Jupiter in every hospital and doctor’s office. Imagine a world where every bureaucratic and market constraint is suspended. It will still be the case that an experimental drug’s effects will only be partly understood at first, so that it will have to be tested on some number of people before it can become widely available. It will still be the case that the earliest version of a new magical medical device will be imperfect and only the third or fourth version can be rolled out widely. It will still be the case that not every doctor can always stay abreast of the latest medical research so that at least some doctors will, without gross negligence, apply outdated procedures and remedies.

Take the most egalitarian of all rich-world health-care systems, which is Britain’s National Health Service. Unlike most “single payer” systems where the health system is at least privately run, with the government acting as funder and regulator, Britain’s NHS is centrally run as a government body, like the Veterans Administration. Conservative critiques focus on the dramatic inefficiency of such state-run systems, and rightly so. But here’s my point: Not every cardiologist in Britain is as good as every other cardiologist; not every trauma surgeon in Britain is as good as every other trauma surgeon. Even if the NHS were run by perfectly well-intentioned and omniscient bureaucrats, it would still be the case that some NHS hospitals would be better than others — which is why the private sector publishes rankings of these public hospitals – so that some people will get a lower standard of care than others. Even if money doesn’t matter, getting care in the best hospital will depend on having inside information and, perhaps, inside pull — which correlates really well with socioeconomic status.

Even if your primary objective was egalitarianism, and even if you could implement policies perfectly, you just could not have an egalitarian health-care system.

Indeed, the NHS example is analogous to an old conservative talking point against Communism, which is that Communist societies, on top of everything else, are extremely inegalitarian since a coterie of apparatchiks enjoys a de facto plutocrat lifestyle while everyone else trudges along in deprivation. Socialists would have us believe this happens in capitalist, not socialist, societies, but experience has shown otherwise. So even if your only concern is economic inequality, you still should be a capitalist rather than a socialist. On top of everything else that’s horrible about it, Communist North Korea is also the most economically unequal society on Earth.

But by the same token, while the poor are undoubtedly better off under a free-enterprise system than under a truly socialist system, it is still the case that any system will have poverty. What is true about political economy in general is true about health care.

All of this might sound like quibbling: Of course, we can’t have perfect equality, but it’s still true that some systems are better for the poor than others, and surely that’s got to count for something. And I completely agree! The problem is that this is a big taboo in American politics. We want the rising tide to lift all boats. The idea that one person might get a lifesaving treatment and another not through no fault of their own is intolerable to us, and quite rightly so. Conservatives say that if you let the market work its magic, everyone will have the health-care equivalent of a BMW. Progressives want the government to buy everyone a BMW. In reality, whatever we do, most people will get a Honda, and only some will get a BMW. This is tragic, but that this is tragic should not make us willing to delude ourselves that it can be otherwise.

— Pascal-Emmanuel Gobry is a fellow at the Ethics and Public Policy Center.

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