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Imagine: What If Health Insurance and Marriage Just Went Away?

by Michael Austin, published

Imagine there's no countries It isn't hard to do Nothing to kill or die for And no religion too Imagine all the people Living life in peace...

--John Lennon, “Imagine” (1971)


John Lennon didn’t have any concrete proposals to offer, just a vision of a different world in which some of the things that we took for granted—like countries, religious divisions, and warfare—did not exist. He didn’t even say we should try to create such a world. He just asked us to imagine it.

I’m going to do the same thing with two issues that have, in my opinion, divided our country more than anything has in a generation: health care and same-sex marriage. Both of these issues are terribly complex, of course, and both of them have produced standoffs between the kinds of entrenched positions that do not allow for much compromise.

But what if it turns out that both controversies stem from our trying to preserve, or substantially modify, institutions that have outlived their usefulness? What if the institutions themselves are the real problems? What if (and remember, we are just imagining here) both health insurance and state-sanctioned marriage simply went away?

Imagine No Insurance

Employer-provided health insurance, at least for non-catastrophic care, has never actually made much sense. Insurance is designed to distribute risk, not to ration consumer goods. Everybody doesn’t die every year, nor do most people’s houses burn to the ground, so it makes sense to use insurance to pool the risk of such things happening to us.

But most people go to the doctor or fill a prescription every year. Basic health care is a consumer good, like food or clothing, and paying for health care through health insurance makes no more sense than paying for food through “hunger insurance” or paying for clothing through “nudity insurance.”

And because we have paid for health care this way since the 1930s or so, we have essentially removed health services from the free market. People who have insurance do not make decisions about their health care based on the cost of various goods and services. We can’t because insurance hides all of these costs. We cannot make rational decisions based on costs that we not only do not incur, but do not even understand.

We make decisions, therefore, based on the cost of the deductibles and co-pays that we actually incur, which drives the real cost of those goods and services far above their actual value to anybody. And it makes it virtually impossible for somebody without insurance to buy any health care at all. It is supremely unfair, I think, to try to invoke free market principles to avoid helping people who cannot afford goods and services that have not been subject to free market pricing for nearly a hundred years.

So imagine: what would happen if we got rid of health insurance altogether—private insurance, employer-provided insurance, government insurance, Medicare, Medicaid, and all the rest—and let health care costs adjust to what people were actually willing and able to pay? What if we stopped spending so much of our energy trying to find ways to keep health care costs unnaturally high? What if we replaced the Affordable Care Act with care that was actually affordable? Imagine all the people, living life in peace. . . .

And No State Marriage Too

The least compelling arguments that I have heard against same-sex marriage are the ones that invoke “the sanctity of marriage” and suggest that something bad will happen to this sanctity if gay people are allowed in the club. It’s not that I don’t believe in the sanctity of marriage. I believe in it deeply—which is why I think that it is a bad idea to let the government determine what is, and what is not, sanctified.

This is not, as some have argued, a tradition as old as humanity itself. Both the cultural and the contractual obligations have changed in thousands of different ways over the course of human history. And they will certainly change some more.

But there is really no reason that the two basic functions of marriage—the contractual and the cultural—have to be combined into a single license or set of practices. In a society where same-sex relationships have become common and unobjectionable, it seems strange that we should try so hard to preserve a government-sanctioned relationship called “marriage,” which creates a contractual relationship between two people (which anyone can have access to) and also adds something called “sanctity" (which applies to some kinds of relationships and not to others).

So, let’s imagine again. What if the government got out of the business of making things sacred--which it is not even very good at--and stuck with certifying contracts between people of any combination of genders who wanted to structure their lives together in clearly defined ways? No gay marriage. No straight marriage. Just civil unions all around. Then, people could take their civil union to the church, mosque, synagogue, temple, NASCAR track, or Richard Dawkins fan club of their choice to have it sanctified according to whatever definition of “sacred” they find meaningful.

Yes, I know that there are all kinds of objections, from across the political spectrum, that could be raised to these proposals. I know that would never be accepted by any legislature likely to exist in my lifetime. I am, in the core of my being, a committed pragmatist.

But, for now, just imagine.

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