To the more hardcore libertarians in the audience ( @oktavia-von-gwwcendorff, @voximperatoris ):
How should doctors and hospitals act with regards to emergency care, assuming an inability to tell for sure whether or not someone has insurance at the time treatment is given and an inability to shop around for hospitals during an emergency? What should happen when I call 911 as a patient? What about as a bystander?
It seems to me that you essentially have to choose between (A) inventing a more-or-less foolproof system of verifying that people have insurance, then letting everyone else die in the gutter (B) refusing emergency treatment to a lot of people who do have insurance but can’t prove it because they’re having a stroke © some sort of class profiling being rampant, with all the negative effects and bad incentives that brings, or (D) treating everybody regardless of ability to pay. If we choose (D), then that seems to lead almost inevitably to state-subsidized or funded preventative care, unless we want to deal with hospitals and state budgets going bankrupt.
Until EMTALA in 1986 we got along without hospitals being forced to provide emergency care for everyone and somehow society was able to function, but that requirement is to a significant degree responsible for the massive rise in health care costs since then, and the failed attempt to force everyone onto insurance that was Obamacare was essentially a way of attempting to deal with the severe negative consequences of EMTALA, which has forced many hospitals to stop providing any emergency services whatsoever.
The libertarian thing to do would be to go back to how it was before Congress intervened in 1986, and let hospitals decide for themselves how to provide care and to whom, as is their right. Then if your top priority is making it so that poor people are treated regardless of ability to pay, organize a charity and pay for them yourself, don’t push it onto hospitals as an unfunded mandate that messes up the entire health care system.
So before EMALTA, how was it determined whether someone would be treated? Did hospitals turn people away if they didn’t have insurance cards? If they did, would the ambulance keep on going from hospital to hospital until they found someone who would treat the patient? How often were people with insurance accidentally turned down? If the passage of EMALTA caused prices to rise as much as you say it did. Then obviously there had to have been a lot of people who used to be turned away but now are not. What do the profiles of these marginal people look like?
Hospitals did turn people away if they thought they wouldn’t be able to get them to pay for care, yeah, but I think that’s rational and defensible. Insured people accidentally getting turned down didn’t seem to be a significant problem - if you have insurance you’ll probably always have your insurance card or at least an ID with you out in public, and if you’re having an emergency at home you’ll probably get brought in by someone who knows who you are. And I think hospitals were more focused on denying care to people they were already certain wouldn’t pay than unidentified unconscious people in urgent need.
A lot of the people who would have been turned down before EMTALA are people with non-life-threatening conditions who go to the emergency room knowing they can’t be turned down for treatment and then disappear without paying. I used to date a girl whose job it was to try to bill those people for the care they received at her hospital - less than half of emergency care in the US now actually gets paid for, they wind up just having to write most of it off and the rest of us pay for it through higher insurance premiums, ultimately. It’s a significant component of why health insurance has become so unaffordable.
Her hospital at least worked with charities to try to make sure the true charity cases got paid for, and some people who had the means but refused to pay were sued or referred to collections agencies so ultimately the hospital would receive pennies on the dollar. Poor US citizens are covered by Medicaid. This was in California, so the real problem was illegal immigrants - they couldn’t get insurance but they couldn’t be made to pay for anything either, so hospitals are just forced to give them unlimited free care and they jam up emergency wards with non-urgent problems because they have no other place to go. It’s not their fault, really, but the inefficiency of this system is mind-boggling, the waste of medical resources is immense, and it generates a lot of animosity against illegal immigrants. California passed a ballot initiative in the 1990s that would have allowed hospitals to deny emergency care to anyone in the country illegally but it was struck down as going against federal law.
In Libertopia there’d be no such issues with citizenship status preventing people from getting insurance or simply paying for care on a fee-for-service basis, which would likely be much more common without the tax incentive for employer-provided health insurance, one of the other big problems ruining US health care. Costs would drop massively and I think it’d bring guaranteed life-saving emergency care (within reason) for almost everyone within the range of things that could easily be accomplished through voluntary charity in a developed country.
It’s the discrimination problem once again; if you make decisions on the hospital level you can turn away the people who are obviously Not Going To Pay without causing more than a few highly-visible false positives (and even there making it possible to create better commitments like “I know my situation looks sketchy but if I skip paying you’ll just contact my Dia group and they’ll pay you okay” would make it easier to discriminate accurately), but if you’re trying to make sweeping policy-level decisions you inevitably have to discard massive amounts of information, rendering the bureaucracy necessarily stupid. Then economic incentives lead to people capitalizing on that enforced information asymmetry.
Additionally, you can use modern technologies to create robust reputational systems that reward hospitals that deliver care for true emergency cases (= actual unanticipated emergencies, not “this known but untreated condition has gotten worse over time and it was inevitable that it would cause an Expensive Crisis at some point”) regardless of immediate ability to pay. If customers prefer hospitals that do provide such care, that’s effectively an indirect subsidy for privately socialized emergency care.
As a patient I’d prefer to have some more specialized number than 911 for contacting my own emergency health provider. Additionally I’d probably be totally fine with an rfid chip linked to a blockchain identity smart-contracted to my insurance subscription (= subscription and payment status verifiable by anybody with internet access) assuming I had actual control over it and could wipe+reprogram it at will whenever I want to use a different identity for whatever purpose.
I mean, the advantage of 911 is that it’s a universally known “OH SHIT FUCK HELP” button that even a five year old can understand how to use. Complicated setups with rfid chips make that harder. Same problem with private solutions to policing, really. People need simple, universal, easy to understand panic buttons that will put them at least somewhere close to the right track. Like, police aren’t ideal, but I feel like there has to be SOME kind of publicly run organization that handles emergencies or things-that-vaguely-seem-like-they-might-turn-out-to-be emergencies, and unless that organization asks for upfront payment on a per-call basis it’s gonna be a public good. (Yes we need to make the cops not be the default responders, but I’m not convinced that this necessarily involves getting rid of 911).
I don’t know what you were expecting. Privatizing everything based on assuming the rationality of economic actors is kinda the ‘thing’ of the ideological group you reached out to.
Some answer where some regulations are loosened while others are strengthened is not what you’re going to get. And if you’re going to have generic emergency responders in America that aren’t cops, then they’ll need guns.
But here, let me throw in an oddball solution. Have multiple competing police agencies - but under the government, contracted at the municipal level.
Edit: Actually, let me throw a more serious one out here. People are bloody irrational, so I don’t care if they want to spend it on something else: tax everyone and give them an $X,000 healthcare voucher which can either be spent on insurance, or a health savings account. Take money out of it for unpaid emergency care at some rate over time. Maybe allow the HSA to be inherited.
