Ken’s Take on the World

Healthcare: Privilege or Right?

As Republicans struggle to obtain enough votes in the US Senate to pass their version of a bill (Better Care Reconciliation Act) that was originally brought forward to repeal, and replace, the Affordable Care Act (ACA) much focus has been placed upon the economic costs and the personal costs to those who would be affected should this legislation become enacted into law.  As one who has paid attention to the debate over healthcare access for the past three decades, I have been thinking of a much deeper question that we should be asking of ourselves as it would, perhaps, better drive the debate over this legislation.  The question that each of us should ask is this:  Should healthcare be considered a privilege, a commodity, that should be available only to those who can afford such care or, should it be considered a necessary right for every person that must be protected, and assured by government?


When I have posed this question to those who express opposition to the ACA, the most common response that I receive is that healthcare should be treated as any other service that a person would seek out.  The most common support offered for this position is that every person receiving services should be required to pay for such services.  To bolster this claim, these critics argue that it is not fair to expect others to pay for services that they receive.  On its face this appears to be a reasonable argument that must be considered.  After all, you wouldn’t take your car to a mechanic and not be expected to pay for repairs or maintenance on your vehicle.  You don’t take your family to a restaurant and expect to receive free food, do you?  You wouldn’t call an air conditioning repair person and expect to not receive a bill for the parts and services provided, would you?  These criticisms appear to suggest that healthcare services and products are no different than whether or not your vehicle or your heating and cooling systems at home are functional.  This is a false and illogical argument.


When one dines out at a restaurant, one knows what they can afford and if they are unable to afford to dine at a certain establishment they simply eat dinner at home or at a less expensive restaurant.  When your air conditioner is on the fritz, if you do not have the money available for repairs, you will need to open your windows, use fans, or other methods of staying cool.  For those with underlying health conditions in which extreme heat is dangerous, communities provide cooling centers, or family and friends are often able to step in to provide temporary shelter until the air conditioning is repaired.  Even if a new central air system must be installed, the cost is almost always going to be less than $5,000 USD.  Many heating and cooling companies will also finance this amount to keep costs manageable.  Similarly, if you need repairs on your automobile, you can determine what are the most crucial and pay for those and defer other repairs until later.  Or, your community may have decent public transportation available.  Or, you may be able to car-pool to work or use a ride-sharing service.


Healthcare, unlike these other services, is not a commodity that can simply be delayed in many cases.  I have frequently likened the provision of healthcare as an essential service that must be available to every single person.  Similar to a community that provides fire departments and trained personnel to operate this life-saving equipment.  Or, law enforcement agencies that respond to safety or criminal complaints.  Or, military agencies like the Coast Guard who respond to emergencies on our nation’s waterways.  We don’t bat an eye when we are asked to fund these critical services.  As a society, we have come to realize these are critical pieces of infrastructure that exist for the benefit of each of us even if we never need to directly use these services.  Why, then, do we look at healthcare differently?

When I have attempted to discern how so-called conservatives continue to maintain the position that healthcare is a commodity, and not a right, in addition to the arguments about paying for services and the burdens of having to pay for those who cannot afford these services, they remind me that healthcare services are already provided to people in the nation’s Emergency Departments (ED) regardless of one’s ability to pay for such care.  This, then, implies there is, in fact, some existential right to healthcare.  When I point out this inconsistency in logic, one person actually mentioned that fewer (uninsured) people seek medical care as if this implies lower costs to taxpayers.  The problem with this (il)logic is that while uninsured individuals are far less likely to present to a primary care physician in the community setting, they are far more likely to present to an ED for treatment of conditions that can be much more effectively, and economically, managed in a community setting by a primary care physician.  This translates into significantly increased healthcare costs for all of us.  The average cost of an ED visit in the United States is nearly $2,200 based on a study described in “The Atlantic.”  Compare this to the average cost to a primary care provider (PCP) in the US which is only $100 based on an Agency for Healthcare Research and Quality (ARHQ) study by the Department of Health and Human Services (HHS).


A review of multiple studies has demonstrated that access to health insurance is correlated with significantly improved health outcomes.  The review, published recently in the “New England Journal of Medicine” (NEJM), documents that improved healthcare outcomes are especially notable among pediatric patients.  Further, this review notes that not only are healthcare outcomes improved, but other measures of quality of life, including educational achievement, are improved with access to health insurance.  Other studies have demonstrated the significant economic consequences associated with illness.  I am not only speaking of the direct costs associated with providing medically-necessary care, but the impacts that illness and preventable injury have on individual and societal economic stability and growth.


I believe we must frame the debate over access to health insurance as one of a necessary right that must be protected by government actions.  Only then, will we be able to determine the most effective means of financing healthcare in the United States.


An Ethical Basis for Use of Military Force in Syria

In light of the increasing evidence that chemical weapons were used against civilian targets in Syria, there has been great debate about what role the United States, if any, should play in addressing this serious transgression.  Popular sentiment has been against any military intervention in what is widely believed to be a civil war.  It is difficult to fathom that such a weighty decision as to the use of force would be achieved using purely emotional means.  However, the use of pure logic is also flawed in this instance because of the complexity of using military force is itself fraught with many potential complications.  Limiting this discussion to the events currently unfolding in Syria, we should look at the use, or non-use of military force using an ethical approach.


Ethical decision-making requires us to identify and weigh applicable values and attempt to reach a moral conclusion.  It requires that we seek to recognize right and wrong and act appropriately.  Values that must be assessed using this approach include: autonomy, power, paternalism, protection, liberty, technology, safety, justice, economy, efficiency, integrity, diplomacy, humanity, and security.


As a nation, we are committed to the belief that every nation has an inherent right to determine its own future among nations.  Americans would not tolerate a foreign entity interfering in our course of affairs.  Likewise, the community of nations does not take kindly to one nation, or nations, attempting to determine the future course of another.  This is the principle of autonomy—each nation determines its own destiny.


The United States has the most technologically-advanced and committed military force in the world.  It has been an all-volunteer force for decades which provides for a level of commitment not seen with forced conscription.  Advanced weapons platforms and systems that can deliver the might of a nation are attached to a tremendous responsibility to use restraint in the use of such weapons.  America has the capabilities of striking targets using a broader variety of weapons than any other nation.  As a result, the responsibility for judicious use of its military forces is greater than for other nations.  The simple idea that because you have power that it can be used without restraint or consequences, good or bad, is irresponsible and dangerous.  The use of force should only be undertaken after careful and serious deliberation. Power is also held by the President and by Congress.  Both have authority over military action granted by the US Constitution as will be discussed later.


There are those who suggest that the United States, as the most powerful Superpower state, has an obligation to use its military forces for the good of the world.  I will admit, that, as a Veteran, I do believe that our nation’s armed forces are well-equipped and well-prepared to handle most challenges that face the interests of America, and indeed, the world.  However, I, along with a majority of people, do not like the idea of the United States serving in the role of international police officer.  I do believe the US has an obligation to stand up for the oppressed and that there are numerous occasions in which we, as a nation, have failed to do so.  Or, we acted too slowly to avert human catastrophe.  The United States is uniquely qualified to intervene anywhere there is violent oppression of a people to prevent genocide.  This does not mean that we, as a nation, should commit military force to every conflict that involves the death of civilians at the hands of a brutal regime.  Having the ability to do so does not provide a moral obligation to do so.  It could be argued that there are some actions that are so heinous that they require a swift and devastating response in order to deter future atrocities, protect others, or to punish the perpetrators.


Our American sense of values cherishes the concept and the promotion of individual liberty.  Personal freedom is, quite possibly, the single-most important value that we hold to be true.  Our sensibilities cannot accept when any person is oppressed whether they be American or foreign.  Liberty differs from Rights in that Rights require another person to acquiesce in order for the Right to be upheld.  Liberty, or freedom, does not require another person to sacrifice anything for the enjoyment of another.  In the United States, for example, we have a limited right to free speech.  On the other hand, you are free to inhale as much air as you desire. Of course, this is very simplistic, but you get the idea.  Liberty is, in essence, a more compelling argument both in favor of, and in opposition to, the use of military force.  We believe that citizens should have the right to select their own leaders in an orderly fashion even though this is not the primary form of government in each nation.  We frown on Heads of State using force to brutally suppress protest.  We believe that they are denying Rights that most Americans take for granted.  Because the Rights afforded under each nation’s laws may vary, it is difficult for citizens of one nation to comprehend how another nation could not establish certain things as Rights.  Our American sense of justness requires that the victims of crimes against humanity must be afforded redress and that perpetrators of such atrocities must be punished for their actions


Any intervention, diplomatic or military, comes with an economic cost.  A frank discussion should occur that will lay out the economic factors helped, or hindered, under various scenarios.  This discussion cannot look only at the immediate economic costs associated with intervention or non-intervention.  We must recognize that the United States is part of a global economy and that our economic interests in the nations that neighbor Syria will be impacted by actions, or inactions, the US participates in.  Economists can drill down and identify the actual economic costs of any given plan of action.  It is more difficult to estimate the economic costs associated with taking no action or over a longer time.  For example, we know the cost of an aircraft or a missile today if it was used as part of a strike on targets.  If such action is not taken today, there is an immediate savings, however, if such a strike is ordered in a year or two, would it become more expensive or less expensive?  There are many other economic factors to consider including loss of economic output from targets like factories that could be destroyed, loss of productivity of workers, cost of medical care to injured personnel and civilians, re-construction costs, etc.


Any conversation that contemplates the use of military force must be conducted with integrity, honesty and transparency.  The United States was founded as a Constitutional Republic in which the people elect representatives to serve our individual and communal interests.  These elected leaders must have the opportunity to review all available materials prior to making a decision on such a momentous action.  Our Senators and Representatives in the House have an obligation to thoroughly vet this information before they make a decision.  There are many who may disagree, but it is not as important for the average American to have access to all information, however, no elected official should be denied access to any information.  It is not the job of the Executive or Senior Leaders in Congress to determine what information is relevant or not regarding deploying military forces.  Our elected legislators have a duty to not compromise sensitive information, but to honestly and thoroughly assess information, and to communicate their rationale with the voters to provide sufficient transparency to the American people when they wish to support sending our troops into harm’s way.  Polling of the public should have limited impact on elected officials decision-making on this most-serious of considerations.  Congress, in their deliberations on Authorization of the Use of Military Force (AUMF) in Syria must make the following determinations based on evidence: a) Chemical weapons were very likely used against civilian targets in Syria; b) The use of such weapons were very likely ordered, supplied, or deployed by Syrian government forces or supporters of the Syrian government in order to have an ethical justification for the use of military action.  The use of chemical munitions is a violation of international law in which the United States is a signatory.  If Congress determines that chemical weapons were used against civilian targets but cannot determine if the Syrian government authorized, or furnished such munitions for use, there is a much weaker ethical justification for military action.


Efficiency must be considered as a broader discussion regarding economy and efficacy of undertaking a particular course of action.  The United States, as strong and powerful as the nation is, still possesses finite resources.  When there is consideration of military force, it is important to consider that the man or woman wearing a uniform of the Armed Forces is the most valuable asset that the nation possesses.  While missiles, tanks and other weaponry may be more expensive, there is no value that can be placed on the life of a soldier, sailor, Marine, or airman lost in combat actions.  Economists can model this cost, but the emotional toll on loved ones left behind is impossible to figure.  In order for an action to be considered efficient, it must be determined to be cost-effective, time-constrained, and goal-oriented.  Goals must be measurable.


As a nation, the use of diplomacy has always been a mainstay of our international relations.  It is generally considered that great diplomacy is backed by a sufficiently strong military force.  The carrot and the stick approach to difficult topics that arise between nations.  Diplomacy can, and should be, used to address regional crisis.  In many cases, conversations with individuals who possess sufficient authority to implement change can lead to successful outcomes.  This approach serves to protect American servicemen and women and is, therefore, a more cost-effective approach in dealing with irresponsible or despotic leaders.  Diplomacy does require the active participation of all members to the conversation.  Without active engagement, diplomacy cannot be successful.  Diplomacy can be complimented with the use of economic sanctions.


 Security is a paramount concern for every person.  We task our nation’s leaders with establishing a military force capable of addressing any threat to our national interests.  This task has been quite adeptly met with our supremely qualified military forces.  Defining our national interests is more of a challenge.  Much of the current debate includes references to the Congressional authority, established in Article I, Section 8 of the US Constitution to declare War and to the President’s authority under Article II, Section 2 as Commander-in-Chief of US Armed Forces.  Lost in the current dialogue is another provision under Section 8 that grants authority to Congress, “to define and punish…Offenses against the Law of Nations.”  Both Sections explicitly, and as interpreted by the Courts, have relevance and implications in the current discourse regarding Syria.  Throughout our nation’s history, the terms national interests, vital interests, and security interests have been tied together or interpreted more loosely to justify the use of military force mostly as a matter of political convenience.  While legislators in Congress have tended to seek a compelling national security interest prior to authorizing the use of Armed Forces, President’s have often been satisfied with claiming a general national interest when initiating the use of military action.  There has not been a formal Declaration of War made by Congress since 1941.  Eighteen times since then Congress has provided an authorization for the President to use military action.  President Obama has approached Congress a seeking its 19th Authorization of Use of Military Force.  History shows that Congress has been consistent in its approval of an AUMF.  This should not imply that Senators and Representatives simply defer to the President on such crucial decisions, but it is incumbent on both the Congress and President to act responsibly in order to ensure that this process is carried out with integrity and scrutiny.


I believe that the use of chemical weapons is an outrage that cannot be tolerated.  The use of such weapons against civilian populations is an abomination that demands action.  Multiple factors must be considered.


1.  Were chemical weapons, in fact, used?

2.  Were chemical weapons authorized, and/or used, by Syrian government forces?

3.  Has diplomatic action been attempted?

4.  Is diplomatic action likely to be unsuccessful?

5.  Is a multi-lateral military action feasible?

6.  Is there a threat against national security interests?

7.  Is there a threat against national economic interests?

8.  Is there a threat against regional allied nations or neutral nations?

9.  Is it less likely that further use of chemical weapons will occur without a military response?

10.  Is it less likely that further use of chemical weapons will occur with a military response?

11.  Are future US diplomatic efforts undermined with a military response?

12.  Are future US diplomatic efforts supported with a military response?

13.  Are regional nations at greater risk if the US conducts a military action?

14.  Are regional nations at greater risk if the US does not conduct a military action?

15.  Is there a risk of chemical weapons falling into the hands of non-governmental forces?

16.  What are the tactical goals of military action?

17.  What are the strategic goals of military action?


If the President is able to present sufficient proof to Congress that the Syrian government employed chemical weapons against civilian targets, this information should force consideration that if the government would target its own citizens, there is no rational basis for thinking the government would not be willing to use similar weapons against outside targets.  If, it is likely chemical weapons were obtained and used by rebel forces, it is critical for the United States to determine the origin of such weapons.  This would indicate a far-deeper problem than the Assad government using chemical munitions.


Diplomatic intervention has already been attempted and proven to be unsuccessful.  Economic sanctions are ineffective because Syria’s strongest regional allies in the region are Russia and Iran with whom the United States has strained or non-existent diplomatic relations.  The use of chemical weapons violates International Law which falls under the purview of Congress.  I do not believe it is less likely that a failure of the United States to take action, in light of documented proof of the use of chemical weapons by the Syrian regime, the Assad regime, or other nations, would hesitate to use weapons of mass destruction in the future.


I believe a failure to act on the part of the United States would serve to embolden other pariah nations who have been kept in check by the ever-present threat of a US response to conduct that threatens international norms.  If the evidence proves the use of chemical weapons AND if the evidence proves that it was the Syrian government who ordered or deployed these weapons, the United States has no ethical option but to act.