I’m currently enrolled at the University of Wisconsin’s Leadership in Population Health Improvement Certification program. The program is fully online, so participation on a forum is a major component of the course. There’s an argument for more government involvement in healthcare that seems to be tacitly pervasive in the worldview of the type of people attracted to this sort of program.
The argument is best summarized by one of my fellow students after I made the point that people respond to incentives, and cost sharing measures by insurers will cause patients to take a more active role in their own health decision making. This isn’t an exact quote, but I promise I’m not trying to make him sound worse than he really sounded:
Many people struggle with misinformation when making financial and health decisions. For example many people still think that fried okra is healthy. If people can’t get this basic information right or are worried about paying the bills, they aren’t thinking about this sort of overarching, higher-order effect.
That’s right, I shit you not: my classmate in a public health class thinks that people are too stupid to take care of themselves, don’t respond to economic incentives, and therefore can’t be trusted to take care of themselves and their own healthcare. This individual phrased this argument in a particularly condescending way (both to me and patients), but the core of argument is very prevalent in today’s political discussion.
Dissecting the Argument
Let’s break this down a little bit. This argument was posed as a reason for having universal, comprehensive coverage with no cost sharing. So according to my classmate, the reason copays and coinsurance are bad is three-fold:
- Patients don’t understand the basics of health, like diet and exercise, so therefore they can’t be expected to understand the more complicated relationship between screenings for early detection and long term health outcomes.
- Patients don’t respond to economic incentives because they don’t understand the actual risks and costs involved.
- If we remove the financial cost of medical services, patients will follow their physician’s’ advice, at least with regard to getting the care they need, even if they don’t change their lifestyle choices.
My frustration with this argument is also three-fold:
- Each step is logically and empirically false, though there are enough data out there to cherry pick to make a fairly convincing story, and possibly persuade the casual reader.
- It’s extremely short-sighted, by only looking at how people behave right now, and not thinking about how people change their behavior in response to incentives.
- It’s extremely paternalistic and implies that most patients are unable to make medical decisions for themselves
When I was originally writing this post, I went on a long, tortuous diatribe about the nuances of rational ignorance, rational avoidance of screening tests due to the bus stop paradox and false positive paradox, and how economic incentives through coinsurance mitigate this and lower costs through price transparency and competition. I might come back to that line of reasoning in a future post, and I’ve written about economic incentives as a game changer elsewhere, so for now, I want to focus on my more emotional response to my classmate’s worldview: my disdain for paternalism.
In this regard, I have two questions for myself. First, why does paternalism like this make me so angry? Second, why do so many public health students practice this paternalism?
My Disdain for Paternalism
That the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others. His own good, either physical or moral, is not a sufficient warrant. He cannot rightfully be compelled to do or forbear because it will be better for him to do so, because it will make him happier, because, in the opinions of others, to do so would be wise, or even right. These are good reasons for remonstrating with him, or reasoning with him, or persuading him, or entreating him, but not for compelling him, or visiting him with any evil in case he do otherwise.
John Stuart Mill, On Liberty, Chapter 1
In the tradition of the Classical Liberal Economic thinkers, I am very averse to coercion. Furthermore, my fierce INTP independence and skepticism leads me to question others’ goals and I don’t take well to being told what to do (just ask my mother). I’m repulsed by the idea of someone legislating something a certain way because they believe I’m incapable of doing what’s in my own best interest. If they want to incentivize or encourage me towards my own best interest (e.g. a health insurance company giving discounts or reimbursements for gym membership and usage), I’m perfectly happy with that. But only if they start with the premise that I want to do the right thing and they’re just making it easier.
The notion of paternalism implies a lesser and a greater. In a Rawlsian Veil of Ignorance sort of way, I would never want to be the lesser, coerced by the greater: the intellectually inferior whom the greater believes cannot take care of myself. If I am in error, whether by behavior or by belief, Mill is right to encourage others to correct me and me to be corrected, but when the others view me as a lost cause and would try to push me in line with their vision, that’s where the theoretical version of me “behind the Veil” draws the line and pushes back.
Assuming an examined life, people know their needs and values better than anyone else. Assuming rationality, at least insofar as people never say “Hey, I’m going to do this thing that I know will make me net worse off” and then do that thing, people will attempt to live the best life they can, according to their definition and values. Therefore, it is hubris to believe that I know how you should live your life better than you do, but this is what paternalistic thinking embodies and acts on. Now, if I discover a logical flaw in how you are living your life (e.g. drinking energy drinks for energy instead of eating an apple), I may point out the error in your reasoning (the example is an admitted error in my own life), but persuasion must be my only tool to convince you; not coercion, and my reason for attempting to convince you can only be the belief that you don’t adequately understand the facts, not that you are incapable of understanding the facts. Any deviation from these guidelines deviates into paternalism, which by construction and implementation, even if not by definition, inevitably leads to coercion.
In the case of my classmate’s argument against cost sharing, his rationale was that people are incapable of following their own self-interest. If that’s the case, a physician is unlikely to convince them to not eat fried okra, and reducing cost sharing would make no difference. In that scenario, would my classmate take the next step and ban certain foods? The answer, as I found in a subsequent discussion, is apparently yes. Paternalism, with all the best intentions, removes freedom. By creating the mechanism to remove freedom, you create a mechanism that can be used with less-than-ideal intentions to remove freedom for the good of the leader, not the good of the governed.
The Draw of Paternalism
Besides not being paranoid like me, why would someone be drawn to Paternalism? The short answer, I believe, is that it’s expedient. Coming up with an effective “nudge” campaign of paternalistic libertarianism is hard and not always successful. It’s much easier to just be a benevolent dictator (at least it seems that way when you’re not actually a dictator). And it when a certain truth seems obvious to you, it’s easy to think that people who don’t see the obviousness of that truth are incompetent and in need of your correction.
You know why people don’t like Liberals? Because they lose. If Liberals are so fucking smart, how come they lose so goddamn always?
“Will McAvoy,” Newsroom
In the modern Liberal worldview (i.e. the Political Left in America; not economic liberalism) in general and the public health sphere specifically, the solution often seems like a tautology (minimum wage increases earnings and banning smoking makes people live longer), so anyone who disagrees or votes against this agenda must be voting against their own self-interest or not understand their own interests.
Furthermore, public health graduate students, and the Democratic party in general, are better educated than the majority of the population, and it seems like a very reasonable conclusion that someone with a graduate degree understands the interests of the high school drop-out better than the latter individual does herself. And in an objective sense, the more educated person is right. I, with my econ degree, understand the economics of minimum wage–its pros and cons–better than most of the minimum wage workers campaigning in favor of a minimum wage hike.
So why shouldn’t I tell them how it is, and if they don’t listen to reason, just push them in the right direction? I have to admit, it’s tempting.
To answer Aaron Sorkin’s question through news anchor Will McAvoy in Newsroom, “Why do liberals lose [all the time]?” I think a big part of the answer is that Liberals are presumptuous. They presume to know what people’s best interest is, how to get there, and often leave the individuals themselves out of the equation. This is certainly an issue in Public Health, where the community is almost always involved in the health needs assessments, sometimes involved in the prioritization, and rarely involved in the implementation (at least historically, this is changing slightly for the better). Even if Liberals are right from an objective, empirical standpoint about what policies are effective in improving the lives of individuals, the fact that the individuals themselves feel ignored or powerless in this equation goes a long way to explaining both ineffectual policies (feelings of powerlessness have a huge impact on health outcomes) and why Liberals lose “so goddamn always.”
Government action, including coercion, is justified and necessary to prevent individuals from harming others–directly or through externalities. Any other coercion, for an individual’s own good as perceived by the government actors (including lobbyists) is paternalism. In general, paternalism, however well-intentioned, is both immoral (at least from my view) and ineffective. I should note that I’m only talking about able-minded adults here, children and the intellectually disabled are a different discussion.
It’s immoral because it’s arrogant, easily blinded, and lazy. Instead of taking the time to convince mentally competent adults of the truth or falsehood of a belief, the paternalist treats that adult as a child, thereby demeaning her.
It’s ineffective because benevolent dictators like Marcus Aurelius are still mortal, and Commodus still looms in the background. If you push too hard, the populists will revolt (Trump 2016) and/or someone worse will take the reigns of power and undo all that the paternalists have done, including whatever good may, in the short run, have come from their expedient solution.
Where are we to go then?
Paternalistic coercion is such a commonly used option because, unfortunately, it’s not always possible to persuade people of the truth, through rational arguments or otherwise.
Should we in public health keep trying, hope against hope, to convince people what their best interest really is? Do we leave them to their own means?
My Sisyphusian inclination is that the ethical option is to keep trying to persuade people through clever data visualizations and logical argument, but ethical is damn slow.