The False Promise of the Greater Good

What is the role of the state in promoting "health?"

In debating how to finance healthcare, Medicaid specifically, I favor giving people a government-funded HSA for routine care, eliminating the insurance middleman. There’s no reason to use insurance for something as inexpensive and predictable as primary care.

This idea often draws fire from critics who claim that any out-of-pocket cost burden will cause people to forgo needed care.

But that argument rests on the assumption that more care equals better health. Yet The Oregon Medicaid experiment and the RAND health insurance study both show that when patients pay less, they consume more healthcare, but their health outcomes don’t improve.

The truth is: more healthcare isn’t always better. Health outcomes depend far more on lifestyle factors (diet, exercise, family structure, driving habits, tobacco and alcohol use) than on anything that happens in the exam room. Yet policy discussions keep assuming that if we just make healthcare free, people will be healthier.

Preventive care is often cited as a silver bullet. Mandating preventative care coverage was a key pillar for the Affordable Care Act. But we have shifting guidelines, contested evidence, and mixed results. Yes, keeping blood pressure and blood sugar under control prevents complications. But the evidence also shows that zero-dollar copays don’t always improve that control.

There’s a deeper problem with the pushback to DPC and cash-pay models: the assumption that we already know what’s best for everyone. That preventive care is always cost-saving, that early intervention is always better, and that a centralized payment system is the only way to ensure access.

But public payer models don’t just fund care. They define it. They must decide what counts as “essential,” which screenings are worthwhile, and which treatments deserve reimbursement. Should cancer screenings be free? Which ones, how often, and using what methods? Should we cover coronary calcium scores? Whole-body PET scans? Genetic testing?

Answering these questions requires a level of certainty we simply don’t have.

Preventive care science is evolving. Screening thresholds shift. Long-term outcome data is murky. When we embed today’s best guesses into rigid payment structures, we risk turning evolving science into permanent policy and coercing everyone to follow it in the name of the greater good.

We’re constantly told that public health policies, from Medicaid financing to COVID mitigation, must balance individual freedom with the so-called “greater good.” But COVID revealed what happens when that balance vanishes entirely.

We don’t just live in a society. We live under a state. And when the state invokes the greater good, it’s rarely to empower individuals. It’s to control them.

Jean-Jacques Rousseau argued that people must sometimes be “forced to be free,” and that individual liberty could be overridden in service of the collective will. This kind of collectivist thinking has always made me uneasy. After COVID, it terrifies me.

Policies that began with reasonable goals (flatten the curve, protect hospital capacity) quickly mutated into sweeping mandates, lockdowns, surveillance, and social coercion. Public health experts, unaccountable to voters, dictated personal behavior with the backing of the state. And the justification was always the same: the greater good.

But there was no limiting principle. No off-ramp. Once the government claimed authority over the individual in the name of health, the burden shifted, not to the state to justify its restrictions, but to the citizen to prove they deserved autonomy.

We were told it was paternalistic but necessary. Like a cop pulling you over to say your headlights are off. But the government wasn’t pointing out hazards. It was deciding which roads you could drive.

This experience clarified something for me: I don’t believe in collectivist public policy. I believe in individual responsibility.

Which leads to my skepticism of the entire framing of healthcare “overutilization” versus “underutilization.” These terms imply there’s a correct, measurable level of care that can be centrally calibrated to achieve the “greatest good.” But who decides that? Primary care doctors argue for more primary care. Trauma surgeons want more trauma centers. Spine surgeons advocate for more spine surgery. Each sees value through their lens. So who’s right?

Healthcare is not suitable to central planning. Like economies in general, healthcare is a decentralized landscape of personal trade-offs, risk tolerance, and values. Some people will skip care. Others will overuse. That’s not a flaw in the system. That’s a feature of freedom.

The idea that citizens can’t control their own healthcare spending because they might make the “wrong” choice is, frankly, paternalistic. Yes, poor decisions have consequences. But so does treating adults like children. A functional society does not require perfect behavior. It requires respect for agency. And if we insist on rigid, centrally defined Medicaid funding systems, forcing taxpayers to pay for “essential” care in the name of the greater good, how far do we carry that logic? Should we also begin regulating the behaviors that most strongly influence health outcomes: smoking, alcohol, processed foods, sedentary lifestyles?

That may sound extreme. But if we justify centralized payment models on the grounds that individuals might misuse their freedom, then it’s not illogical to begin restricting more than just spending.

The belief that people must be compelled to make healthy or efficient choices, by nudges or force, leads inevitably to a state that sees people not as citizens, but as liabilities.

People are autonomous. And nobody cares more about their own health than themselves. Our role as medical professionals is to advise, to guide, and to recommend what we believe to be the most effective path toward health.

Every patient is different. Every decision requires nuance, context, and individual judgment. Admittedly, if patients and physicians are given the freedom to act, then there will be mistakes. Someone will prioritize a frivolous purchase over a doctor visit. But as FA Hayek reminds us, the dispersed knowledge of millions of people making decentralized decisions will always yield better outcomes than the rigid dictates of a central planner managing blood pressure targets from afar.

Government should support a safety net. It should catch people when they fall, not strap a harness to everyone “just in case” someone trips.

A society built on personal responsibility may see some individuals harmed in ways we collectively lament. “We could have prevented that,” we say. But trying to control every aspect of people’s lives to prevent every possible harm ends up being even more harmful in the end.

Autonomy isn’t a luxury. It’s the foundation of dignity. And when we preserve freedom, we preserve that dignity.