Peters for Iowa Senate District 15

This is a special post, which I am primarily writing to myself, and from which I will likely draw no definite conclusions. Given this, it may not be of interest to many, but for those that are interested, and have ideas, please feel free to share.

I was walking around yesterday and today, asking people to sign my petition to place my name on the ballot for the November election. I met a fellow physician this evening who happens to be a pediatric medical subspecialist. She works at the University of Iowa, which serves a large proportion of children and adults who receive Medicaid benefits. We discussed the inequity of physician reimbursements between those who do procedures (like I do) and those who don’t. Her primary concern, however, which is obviously laudable, is how her young patients can receive necessary care if their parents are unable to provide for that care (whether out-of-pocket or through their own insurance).

The dilemma I face, given our unsustainable spending and burgeoning debt, is that we simply cannot afford all of our current welfare spending. Also, libertarianism, in fundamental principle, opposes the idea that one party should be forced (through taxation, with threat of fine or imprisonment for failure to pay said taxes) to pay for the needs of another. Libertarians value the fundamental rights of life, liberty and property, which would necessarily denounce most forms of taxation. There is certainly some degree of difference of opinion here, even among libertarians, but the general principle is a consistent line of thought. Libertarians believe that the primary role of government is to ensure that each individual’s inalienable rights are preserved. A secondary role of government may be to provide those goods and services which would otherwise not be provided by the free market, or through charity. Traditional examples of these are lighthouses, roads and bridges, and commonly also emergency services (although these are increasingly provided in the private sector).

One obvious answer is to eliminate that welfare spending which could be considered unnecessary, but who is to make that judgement? My father, for example, receives Medicare, Tricare, and  Social Security benefits, but honestly doesn’t need them (sorry, Dad, for using you as an example). Should he pass along these benefits to a needy child? Personally, I think that would be the moral thing to do. But, problems arise in defining who is most needy, who might willing give up their “entitlements” (incidentally, there are few words I despise more than “entitlement”), and whether or not to force an unwilling participant to give to a more needy recipient.

These dilemmas are why most libertarians emphasize the value of charity. Americans have a remarkable history of charitable giving. Even apart from what is “given” in the form of taxation, Americans are exceptionally generous. Looking only at foreign aid (I should place foreign aid in parentheses when speaking of federal giving, but that is another matter), private charity by Americans historically averages 2-3 times that spent by the Federal Government. But, is it enough to rely on charitable giving for the care of our most defenseless and dependent citizens, our children?

In honesty, I suspect that charitable giving would likely provide more than adequate care for the young patients of this pediatric subspecialist. In fact, I suspect that with proper organization, a charity designed to provide for such children would do a vastly better job of providing care, and more adequately reimburse their providers, than our current Federal/State Medicaid system. Still, what if I am wrong? My stop-gap measure is to imagine that some form of government subsidization might be worthwhile, even though it would necessarily involve the coercive action of government. One problem inherent in such a plan, as is well exemplified by the gradual growth of our Medicare/Medicaid system over the past 45 years, is what is known in the military as “mission-creep”. We could initially define the limits of such care to only patients under 18 years of age who live below the “poverty line”, who have certain ailments, and who have no insurance. But, it would only be a matter of time before the age restriction changes, the “poverty line” definition is altered, other medical conditions are added, etc. If such a measure were pursued in any manner, I would prefer to see it done entirely at the state or community level, which I expect would offer greater accountability and transparency, and less temptation to corrupting influences. Medicaid is a combined State/Federal program already; it would not be too much of a stretch to imagine it becoming an entirely state-run program.

Again, I do not have definitive answers here. Clearly, the status quo is unsustainable, and is therefore not an option. Also, as the libertarian writer David Bergland has stated, Utopia is not an option, either. I suspect that in a truly free society with limited government, charitable giving would fill such needs as I have outlined above. Still, as a physician who understands these issues well, I can imagine that a state-sponsored program to serve our most vulnerable might be worthwhile, and possibly necessary, recognizing the inherent “slippery-slope” risks, and realizing that I am not being entirely faithful to my libertarian principles for saying so.

Healthcare, by the way is an enormously difficult subject. I have promised to import my previous blog on the subject to this site, and will do so in the immediate future…