We talked about the problem of setting up a hypothetical insurance scheme like the one Dworkin describes.
We also discussed three broadly different approaches to deciding how much to spend on health care that I labeled the individualistic (economic), democratic (political), and objective (philosophical). We came up with an impressive list of advantages and disadvantages for each.
I see what Dworkin is trying to do. I find it appealing, even. He wants us to look at our lives as a whole and decide how much to spend on health care in the light of what it would cost us in other areas of our lives.
That is a perspective that is usually lacking when one is faced with an immediate health problem.
But it’s not at all easy to identify a psychologically determinate perspective on your life as a whole. We could pick a particular moment in life and imagine what choices you would make if you were highly informed about health care but quite ignorant of your particular needs. But no particular point in life is the same as a view of your life as a whole.
On the one hand, as Jennifer pointed out, those who are older know more about how life works. What really was a good decision and what was a mistake? But they have the least reason to economize as all of the decisions about their lives have been made. Health care is the last major thing they need.
On the other hand, the young do have their whole lives ahead of them. But they have little knowledge of or imaginative access to what they will want when they are older. So why think their decisions should govern when to cut off care for their older selves?
What if we asked for a judgment from a timeless perspective, cut free from any particular point in the life? The problem here is that it’s hard to see how we could get an answer about what insurance someone would buy from such a perspective. I don’t know what the psychology of a timeless person is like, so I can’t hazard a guess about what kind of insurance such a person would buy.
Why not a real market? Give people the resources that they should have (by whatever lights you think appropriate) and let ‘em buy the insurance they want. Why have a hypothetical anything? No need to guess, after all, and the results would genuinely be tailored to individual preferences.
Well, health care markets don’t develop well given the inherent uncertainties. Arrow taught us that.
But if so, why not have experts pick the level of insurance that we need? That is, why not turn the decisions over to doctors who are informed about the lifestyle preferences of people in various socio-economic groups? That would be much more realistic than trying to imagine what levels of health insurance lay people would choose for themselves if they had as much information as doctors do.