Jonathan Cohn — one of the best-informed voices on healthcare in American journalism — has a new article in The New Republic about the reductions in provider networks that insurers are imposing, due to constraints in the Affordable Care Act. Except, as he points out,
Even before Obamacare, employers and insurers were already moving in the direction of limiting networks and penalizing costly hospitals like Cedars. Kominski notes that his employer, the University of California system, aggressively restricted its provider network two years ago. The change affected thousands of employees—and was one of many such decisions employers made around the country. But it didn’t generate a national controversy. The city of Los Angeles just took Cedars off the network for one large plan in order to keep premiums for city employees low. And while it’s possible Obamacare accelerated a trend toward limited networks for direct consumers, it’s also possible that insurers would have made that switch anyway—and that they’re introducing these changes now, in one big wave, because Obamacare gives them a convenient excuse.
This is a genuine bias, particularly in American democracy, toward leaving problems unaddressed, because as soon as you start trying to deal with the problem, voters will hold you responsible for any remaining defects.
I remarked on this shortly after I came to the UK, that it seemed to me that the British underrate the NHS, because any health problem that occurs anywhere in the country, whether it’s unhygienic conditions in a hospital, or GP surgeries not being open at sufficiently convenient hours, is blamed on “the NHS”. That is a strength, but it’s also a temptation for politicians to offload the responsibility onto “the market”. The political culture hasn’t gone that far in this country, but that’s why there’s a major US political party whose political philosophy is, conveniently, essentially “There’s nothing we can do”.
(Physicist David Deutsch has written a book-length quantum-utopian manifesto whose main lesson seems to be that the fundamental criterion for the progress potential of a political system is the extent to which it makes it clear, when things go wrong, who is to blame.)
This is a well-known problem in torts law — a public danger that has never been touched is nobody’s responsibility. If you try to make it safer, but cannot eliminate the danger entirely, suddenly it has become your responsibility if someone is injured. I first encountered this many years ago, when The Economist published a somewhat surprising plea for a planetwide defence against rogue asteroids. Like (I think) most people, on the rare occasions when I do think about asteroid strikes, I generally do not consider the legal implications. The article pointed out, though, that while an unmolested asteroid that obliterates London is an Act of God, as soon as some government tries to divert it, it becomes a legal liability.
This is an issue that I’ve never seen raised in the famous trolley problems that moral philosophers love to natter about. If you’re the trolley driver then you have a real moral dilemma. If you’re a bystander who happens to see a switch that could be thrown, you’d best call your lawyer first. She’ll tell you, under no circumstances should you touch anything. If 5 people die, that’s not your fault. If you save the 5 but kill one — if you even hurt the one’s finger — his family will sue you.