Sometimes, libertarian ideology and the reality of modern technology come into conflict--we saw that at the Republican presidential debate in Tampa on Monday night. The issue then was healthcare, but the issue, in the future, could be many other things as well.
It was a lot easier, for example, to practice laissez-faire live-and-let-live in the era before modernity gave each individual, and each country, the capacity to generate significant amounts of pollution or maybe even weapons of mass destruction (like a genetically engineered smallpox bioweapon).
Today, on the other hand, libertarian political principal and public health imperatives often come into conflict; disease, for example, can cross borders and continents with the speed of an airline flight.And yet a quarantine--and the bureaucracy to impose a quarantine--are essentially un-libertarian things. But in the minds of most Americans, the practical need to contain a potentially deadly epidemic overrides political theory. And the same holds true for border- and homeland security. America learned a bitter lesson about trans-national terrorism a decade ago; we may have to learn similar lessons about the trans-national dangers to public health in the years to come.
In Monday's Republican presidential debate, Rep. Ron Paul was asked by CNN's Wolf Blitzer what he would do about a hypothetical case of a healthy young man who chose not to have insurance, and yet ended up with a serious medical condition--"a coma, for example." Blitzer's question to Paul was direct: "Who pays for that?" And Paul's answer was equally direct; he offered a forthright and principled articulation of libertarian belief. In a society that accepts "welfarism and socialism," Paul said, this hypothetical man naturally "expects the government to take care of him." But that's not the libertarian view. Instead, the Texas Congressman continued: "Freedom is all about taking your own risks."
Blitzer pressed: "But Congressman, are you saying that society should just let him die?"
Paul answered: "No. I practiced medicine before we had Medicaid, in the early 1960s, when I got out of medical school. I practiced at Santa Rosa Hospital in San Antonio, and the churches took care of them. We never turned anybody away from the hospitals." At this point, Paul was interrupted by loud applause from the tea-partyish audience, and he continued, "And we've given up on this whole concept that we might take care of ourselves and assume responsibility for ourselves. Our neighbors, our friends, our churches would do it."
Well, maybe. In tight-knit communities, it's possible to imagine that charity will save the day. But in cities full of strangers and transients--including illegal immigrants--it's easier to imagine people falling through the cracks without some sort of non-libertarian intervention. One such intervention would come from the media; the reality of dense-packed populations is that anyone's problem has a way of becoming known--and thus everyone's problem.
Indeed, the right to get treatment at an emergency room for any ailment--no matter how trivial, and without regard to ability to pay--has been the law of the land for decades. It was signed into statute, in fact, by President Ronald Reagan in 1986; EMTALA, the Emergency Medical Treatment and Active Labor Act, has been a boon to uninsured patients-- and a bane to hospitals--ever since. Indeed, the "anti-dumping law," as it is sometimes known, has resulted in hospital closures and a general crisis of hospital finance, as facilities all too often seek to "cost shift" their "uncompensated care" to other deep-pocketed sources. According to the American Medical Association, 55 percent of ER bills are now unpaid, and according to FamiliesUSA, a liberal advocacy group, the overall cost to hospitals for 2008 came to $42.7 billion. The cost-shifting needed to recapture these huge sums is no doubt the backstory for many of the excessive hospital bills that make the headlines--the notorious $10 aspirin tablet, for instance.
Indeed, it was exactly this "emergency room" argument that proved to be a powerful talking point for the Affordable Care Act. As President Obama said in a 2009 speech to a joint session of Congress, "If . . . people still don't sign up for health insurance, it means we pay for these people's expensive emergency room visits." Yet as we have seen in Massachusetts, for example, guaranteed health insurance has not reduced ER visits; guaranteed health insurance seems to have increased such visits in the Bay State.
So what to do? Two Washington DC think-tankers, James C. Capretta and Tom Miller, have suggested an alternative to mandated health insurance. They advocate a national "high risk pool" for the uninsured, modeled on the pools that some 35 states have already established; they estimate that this system could be brought into existence for $15-20 billion. Such a solution might deal with the ER-visit concerns raised by Obama--but without, of course, the Obamacare bureaucracy. Still, it's not clear that Ron Paul and his purist libertarian allies would support the Capretta/Miller approach, either.
To be sure, Ron Paul is not going to be the next president. But at the same time, libertarian thinking, both on the left and the right, has hampered our collective ability to deal with public health issues. And so we come to the real concern: All issues of compassion aside, it is actually in our collective self-interest to see that people get at least some medical attention in this country.
Why? The reason is public health. In recent years, we have seen new strains of contagion reaching our shores: tuberculosis, malaria, West Nile virus, and dengue fever. These diseases don't just pose a threat to a few; they pose a threat to the many. And the fact that most of these maladies are coming from overseas--from places with considerably weaker public health infrastructures--is a reminder that American-style big government has managed to do a few things right in its time, such as improve public health to a point that these maladies are not home-grown. If Uncle Sam is failing at those tasks today, that's an argument for bolstering his capacity, not for giving up and allowing the unmonitored importation of health crises from around the world.
And looming over all is the possibility of a truly serious epidemic, as imagined, for example, in the new movie "Contagion" http://en.wikipedia.org/wiki/Contagion_(film). The film is fiction, of course, but epidemiological history shows that it could happen here.
To be blunt about it, an open-borders world, as well as a world in which everyone has privacy, is the enemy of good public health. American government was organized around the securing of certain public goods, including insuring domestic tranquility, providing for the common defense, and yes, promoting the general welfare.
That was a good idea in the 18th century, and, suitably updated, it's still a good idea in the 21st century.