When the COVID-19 virus invaded the United States, it found an ill-prepared and complacent foe. As such, the impact is likely to prove devastating on the personal and national level. While the pandemic has yet to run its course, it is wise to start considering some of the lessons that can be learned at this point. One clear lesson is that the aggressively for-profit health care system is a clear weak point in our national defense against disease. I will make my case with the obvious analogy between health care and military defense.
Imagine, if you will, that the United States military operated like our health care system operates. Our current health care system is analogous to having a mercenary military, albeit one with a professional code of ethics and some loyalty to the nation. During normal times, the health care system is almost purely mercenary: it fights battles in order to make a profit. This is not to disparage medical professionals, but the profit model chosen by those who control health care. Because the main goal is profit, the health care system is operated to minimize costs and maximize income. This means operating like a mercenary force: employing the minimum personnel needed to do the job, maintaining only the needed resources for normal operations, focusing on the highest paying customers, and only taking on profitable contracts. This is certainly a rational way for a mercenary unit to operate. But is it a good way for a national military to run? That is, would it make sense for the United States to switch from a public military to a mercenary military?
Laying aside the problems of loyalty and dependability presented by mercenaries, relying on the mercenary (for-profit) military model would be rather problematic for the United States. One obvious problem is that the United States needs a large force that is ready to engage in prolonged conflicts that we might not get to select. After all, national security need not match up with what would be the most profitable military operations and typically requires keeping resources available, such as the reserves, that no for-profit military would sensibly maintain. If the United States relied on a mercenary military for its defense, it would face various challenges in times of crisis: rapidly ramping up to meet the challenge, making the operations in the national interest profitable enough to motivate the mercenary forces (such as paying them enough to protect everybody). These are, in fact, all reasons advanced as to why a country should have a public, national military rather than relying on for-profit contractors/mercenaries. After all, the United States needs a military that is ready to face whatever threat arises and not a force limited by the need to make a profit. It is thus no surprise that our mercenary health care system runs into analogous problems.
Being focused on profits, the health care system operates with minimum resources and personnel. Maintaining a reserve of medical professionals and the resources needed for a crisis would cut deeply into profits. The government, it should be noted, does keep some medical resources in reserve—but this is obviously the public sector in operation. Because of this razor thin operation that maximizes profits, the health care system is like a mercenary unit: ill-prepared when the battle turns into a full-scale war requiring large reserves and resources. The health care system normally deals with the problem of resources by allocating them based on profit—like a wise mercenary commander who accepts the most lucrative contract to fight easier opponents. In the case of health care, the wealthy get the best health care money can buy, while the poor get whatever is left over. But in the case of a national crisis, the response must be large scale—it is an invasion under the public eye and not just the usual battles. Those who are not well off face the same problem, be it in a battle fought by mercenaries or health care provided by mercenaries: they need to be able to pay in order to get protection.
One principled reason we have a national public military rather than using mercenary forces is that we accept that the military should protect all the citizens from enemies foreign and domestic because they are citizens and not because they can afford to pay mercenary forces. The same principle should apply to health care: having a mercenary medical system means that a citizen’s survival depends heavily on what they can pay, and this should not be acceptable. If we believe that the state should protect all citizens equally from the likes of ISIS and North Korea, then we should accept that the state should protect all citizens equally from the likes of COVID-19 and H1N1.
It could be sensibly argued that the military model fits in the case of pandemics and while health care should be modified to address the threat of pandemics, the for-profit model should remain for more everyday medical matters. So, for example, everyone should have access to testing and treatment for COVID-19, but we should still be on our own when it comes to the flu, hepatitis or automobile accidents.
One reply is to argue that the state has obligations in the everyday medical care of the citizens. To use another analogy, if handling pandemics is like fighting a war, lesser threats are analogous to small-scale conflicts or police operations. We do not, for example, expect Americans to pay to get police services to address crimes against them, just because the crime is against them and not a pandemic of crime.
This is not to say that the state must pay for everything—I am sure that someone is thinking about the state being forced to pay for elective surgery like breast implants or tummy tucks. But expecting the state to pay for these would be like expecting the state to pay the bill because a citizen wanted to see a fancy military parade on their street. As such, only the medically necessary should be covered—just as we limit the obligations of the national military and local police, the obligations of health care can also be limited.
It could be objected that people bring on their own health issues by bad choices and we should not pay for that. But the same argument would apply to the police and military. For example, if the police thought that you did not take enough precautions to protect your car, they could refuse to do anything about it being stolen. Or, as another example, if you get attacked and injured, they could refuse to help you because you failed to take enough karate or perhaps your lifestyle choices caused the fight.
If we continue to rely on mercenary health care as part of our national defense, we can expect things to play out in a manner analogous to relying on mercenary forces for our national defense: no matter how brave or dedicated the individual soldiers are, a mercenary system is simply not up to fully facing the challenge.