Critics have noted many flaws in President Barack Obama's health care overhaul: It's too expensive, too intrusive, too coercive and too complex. But one central defect that accounts for much of the other mischief: the pretense that making us all better off is a miraculous, cost-free bonanza.
The 19th-century French economist Frederic Bastiat foresaw schemes like this when he wrote, "Government is the great fiction, through which everybody endeavors to live at the expense of everybody else." That illusion lies at the heart of the new program.
The president has gone to great lengths not to disguise this element but to celebrate it. He said early in the debate that the additional cost of the program could be paid with taxes on the rich. He vowed to oppose anything "that is primarily funded through taxing middle-class families" -- which he plainly regards as the moral equivalent of drowning puppies.
But why shouldn't middle-class families bear the cost of a largely middle-class entitlement? When a typical family buys a new car, it doesn't expect someone else to make the payments. If health care reform showers so many blessings on ordinary Americans, ordinary Americans ought to be more than willing to pay the bill. If they are unwilling, maybe some rethinking is in order.
The Easter Bunny approach is not unknown among Republicans, either. They too like to hand out tasty treats. House Majority Leader Eric Cantor said in November the GOP would keep some parts of the health care reform, like requiring insurers to take applicants without regard to pre-existing conditions and to let parents keep children on their policies up to age 26. But those provisions are popular partly because their actual cost is invisible.
The general flaw also makes for particular flaws. One of those is the requirement that health insurance companies cover some 45 preventive care services at zero cost to patients -- everything from depression screening to diet counseling.
As Obama has put it, "insurance companies will be required to cover, with no extra charge, routine checkups and preventive care, like mammograms and colonoscopies, because there's no reason we shouldn't be catching diseases like breast cancer and colon cancer before they get worse. That makes sense, it saves money, and it saves lives." In other words, it's the pot of gold at the end of the rainbow.
Sure. And Obama is a leprechaun. Some preventive measures, such as vaccinations, save more in medical expenditures than they cost. But the idea that all preventive care pays for itself is an alluring myth.
Rutgers economist Louise Russell says that as a general matter, it doesn't save dollars. On the contrary, she noted in a 2009 article in the journal Health Affairs, "prevention usually adds to medical spending." Four out of five preventive options, she says, "add more to medical costs than they save."
But Americans have not learned to accept the word "no" when it comes to health care, and the administration has no desire to teach them. Two years ago, a federal panel dropped its recommendation that all women begin regular mammograms at age 40 (based on risks and benefits, leaving aside costs). In deference to the ensuing protests, the health care plan mandates coverage of breast cancer screening at age 40 anyway.
Consider this a harbinger: Under Obama's program, if patients and doctors demand something, the government will make sure they get it.
Many people, of course, put great importance on prevention. They'd rather get inoculated against the flu or shingles to avert a possible spell of sickness. They'd rather get screened for prostate cancer or cervical cancer if there's even a small chance it will save their lives.
But if they value such options so highly, why is it outrageous to ask them to remit something for the privilege? Letting insurers impose a co-payment or a deductible would have the effect of inducing patients not to completely disregard the issue of cost.
One of the chief ills of our health care system is that it encourages excessive consumption of medical services, which drives up total spending and wastes resources. But the preventive-care provision amounts to throwing a drowning man a hose.
If the goal is to restrain spending and make insurance affordable for all, a health care system has to put at least some direct costs on patients. We can't all live at the expense of everyone else. But we can all go broke trying.