In Practical Anarchy, Stephan Molyneux discusses how health care is provided under the current statist system and how it might be provided through the purely voluntary interactions of people in a stateless, anarchic society.
Anarchism recognizes the empirical reality of human corruption in a way that statism simply does not. Anarchists recognize that power corrupts, while statists forever believe that power is the cure for corruption. Anarchists understand that the only valid and proven way to oppose human corruption is through voluntarism and competition – statists believe that the only way to oppose human corruption is to create a monopoly of violent power.
Fundamentally, anarchists believe that virtue results from a marketplace of voluntary interactions – statists believe that virtue is a dictatorial compulsion, created and maintained at the point of a gun.
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In statist health care systems, the doctor is paid per patient visit, not for a successful cure. Thus doctors do not make their money from curing patients, but rather from seeing patients – thus they have every economic incentive to keep consultations as short as possible, and to outsource any complicated “cures.”
Furthermore, in socialized medical systems in particular, it is actually illegal to collect and publish information about the quality and success rates of doctors. If I find out that I have prostate cancer, I cannot possibly find out which doctor has the greatest or best success rate in curing it. (More importantly, if I have a family history of prostate cancer, I cannot find out which doctor has been most successful in preventing it from occurring.)
When you sit back and really think about it, this is staggering – absolutely staggering!
It is illegal to sell a food item without publishing the nutritional information. It is illegal to run a public company without publishing your financial information. It is illegal to sell a car without publishing its fuel efficiency. Hell, it is illegal to sell an item of clothing without publishing where it was made.
Every stupid and irrelevant piece of information is required by law – but the success rates of doctors are not only not required, but you will actually go to jail for collecting and publishing this information!
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Imagine if I suggested the following as the solution to the problem of how to deliver healthcare in a stateless society:
The way that I see it working is this: one DRO [dispute resolution organization] should amass enough weaponry to violently drive all other medical DROs out of business. This DRO should then take about twenty percent of people’s income – and kidnap or shoot them if they do not give up their money – and then provide health care as it sees fit. This same DRO should also have complete control over how many doctors there are, and how a doctor should be trained, and how a doctor should be paid. Again, if anyone attempts to become a doctor without following the detailed and lengthy rules of this DRO, they can be kidnapped and/or shot. This DRO should pay doctors per patient visit, to ensure that doctors would see as many patients as possible in any given day – and it should make sure that doctors are neither paid for successful treatments, nor penalized for any unsuccessful treatments. Doctors should not make any money whatsoever by preventing illness, but rather should get paid for treating as many illnesses as possible, as quickly as possible.
Furthermore, this DRO monopoly should be able to shoot or kidnap anyone who dares to collect and publicize any information about the success rates of its doctors.
In order to ensure that citizen feedback is available to this DRO, every couple of years, citizens should be able to appoint a representative of their choice to the Board of Directors. Whoever they choose should be paid by the existing doctors that the DRO controls, or by the pharmaceutical companies…
We could continue with this example, but I think that you can see the ridiculousness of this “solution.” If I put this forward as my answer, I would receive an unbelievable tsunami of incredulous and contemptuous e-mails, wondering just what particular drugs I had been on when I described this as the best possible solution to the problem of providing health care.
Inevitably – and again, ludicrously – these same people will also deluge me with incredulous and contemptuous e-mails when I suggest privatizing the provision of health care.
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Ever since Blaise Pascal discovered the laws of probability, a singular human institution has arisen to help people deal with unpredictable risk – insurance.
Insurance is simply a way of playing the law of averages in order to create predictability. If one out of a hundred people is going to be randomly hit with a ten thousand dollar bill, it makes sense for everyone to have the option of paying a fixed amount of money in order to be insured against such a bill.
(Please note that in this section, I am talking about the free market insurance companies of the future, not the mercantilist semi-statist monsters of the present.)
The wonderful thing about insurance is that the interests of consumers are almost exactly aligned with the interests of providers, since both are directly motivated by the desire to decrease risk.
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(This is an enormous topic, but I would briefly like to mention that any discussion of free-market health-care provision – and insurance companies in particular – will doubtless draw comparisons to the existing system within the United States. This “system” has very little to do with the free market, in that more than fifty cents of every health care dollar is spent by the government, which violently protects a monopolistic doctor’s union called the American Medical Association, and also hyper-regulates the medical field with literally hundreds of thousands of laws, rules, directives and requirements. The incentive of private profit, combined with the corrupt largesse of a public purse, is technically called “fascism,” rather than freedom.)
In terms of health care, then, we can be sure that your insurance company wants to keep you as healthy as possible. The farmer who sells cows is interested in their long-term health, in a way that the butcher who disassembles them is not.
Due to this motivation, private insurance companies will be reasonably proactive in attempting to prevent health problems from developing, rather than merely curing them after they have occurred. They will be sure to pay doctors first for prevention, and then for successful cures, rather than for merely cycling as many patients through their offices as humanly possible.
In any situation where lifestyle choices can ameliorate health problems, those will be chosen in preference to endless medication. It does not cost the insurance company any money if you go for a walk or do some sit-ups; it does if you have to be on insulin for the rest of your life.
Conversely, medication is in general cheaper than surgery, all other things being equal, and so effective medications will be researched, developed and prescribed more often than invasive and dangerous surgery.
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Spending money on a pricey doctor is probably about the most cost-effective investment you will ever make. The most effective doctors are those who cure the most efficiently – and for sure, most customers of health care insurance would also purchase life insurance from the same company, so that any disastrously failed “cures” would cost the company an enormous amount of money.
In this way, returning a customer to health not only guarantees future health care payments, but it also postpones the payment of death benefits. In this way, the self-interest of the insurance company is directly aligned with the self-interest of the customer, who doubtless does not prefer to be either sick, or dead. If the doctor is also paid to prevent, cure and keep alive, then all three parties have the same goal, which is the polar opposite of any statist system.
Thus whenever anyone starts evaluating which health care insurance company to go with, each company would be tripping over themselves to provide independently verified statistics about the long-term health of their customers – the number of ailments prevented, identified and cured; the average life expectancy, successful pregnancies and births and so on. These companies would be selling health to you, rather than inflicting repetitive treatments on you, which is the case with socialized medicine.
Thus, Molyneux makes an outstanding case that, rather than increase government involvement in health care (as the Democrats and their mostly well-intentioned supporters are calling for), we should get government OUT of health care entirely, ideally (though no time soon, I’m afraid) as part of the complete dissolution of the state in favor of a free, stateless society.
Of course, many of the aforementioned well-intentioned supporters of increased statism in health care recognize the essential truth of this line of reasoning, but are overwhelmed by their desire for the poor to not be left out. Of course, a stateless society would be so much wealthier that there would be a tiny fraction of truly poor individuals, and the competitive and pro-consumer health care system that would emerge under anarchy would produce quality health care for far better prices. But nevertheless, Molyneux addresses this particular concern:
We certainly want to help the unfortunate, but we do not wish to enable and subsidize bad decisions – this is only part of the complexity involved in helping others – which a statist society cannot distinguish or deal with at all.
If society gave everything that a poor person could possibly require in order to live comfortably, that would scarcely reduce the numbers of poor people, but would rather increase them considerably. On the other hand, the children of poor people are scarcely responsible for any bad decisions their parents may have made – however, if charities give a lot of money to poor people with children, more poor people will tend to have more children, which will only increase poverty.
This balancing act is one of the enormous and complex challenges of true charity – and yet another reason why a violent monopoly will never end up helping the poor in any substantive or permanent manner.
When it comes to health care, there is no doubt whatsoever that the majority of people care about the provision of health care for those who cannot afford it. At a hospital I visited recently, I saw a placard on the wall thanking the five thousand volunteers who helped run the place.
Doctors as a whole will always treat someone who comes with an immediate injury, whether they can pay or not. If we assume that medical treatments for the genuinely deserving and needy poor would consume about ten percent of general health care spending, then we can be completely certain that this amount of money would be donated by concerned individuals, either in time or money. We can be certain of this because we know of a large number of religious organizations that require ten percent of people’s total income – twenty percent in fact, since this is pretax income – and people are quite happy to pay that.
Thus the medical needs of the poor would be entirely taken care of in a free society through charity and pro bono work. Charities would also compete to provide the most effective care for the poor, in order to gain the most donations. I would certainly prefer to give my money to an organization that was best able to create and provide sustainable health practices and medical treatments for the poor.
In this way, not only would the self-interest of doctors, insurance companies and customers be aligned – but also the self-interest of donators, charities and the poor they serve.
In a stateless society, the poor will be genuinely served by a far better system, composed of those whose self-interest is directly aligned with the health of the poor.
As has been shown over and over again, throughout history and across the world, benevolent self-interest, enhanced by free association and voluntary competition, is the only way to create sustainable compassion within society.
I am aware that I have not answered all possible objections to the question of how health care is provided in a free society. I am also aware that the possibility always exists that people can “fall through the cracks,” or that charities could conceivably make mistakes, and either fund the wrong people, or fail to fund the right people.
Once more, this possibility of corruption and/or error is often considered to be an airtight argument against anarchy, when in fact it is an airtight argument for anarchy, and against statism.
Competition and voluntarism are the only known methodologies for repairing and opposing the inevitable errors and corruptions that constantly creep into human relations. The fact that human beings can make mistakes – and are always susceptible to corruption – is exactly why they should never be given a monopoly power of violence over others.
When an entrepreneur – whether charitable or for-profit – makes a mistake by failing to provide value – others will immediately rush in to provide the missing benefit. It is this constant process of challenge and competition that allows the best solutions to be consistently discovered and reinvented in an ever-changing world.
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