Healthcare and the slippery slope of state growth: lessons from the past

All over Europe, the provision of healthcare services is widely considered a primary duty of the government. Universal access to medical care can be considered a basic ingredient of the so-called "European social model." But if universal access to medical care is seldom questioned, European governments-faced with expanding costs caused by an increasing demand driven by an aging population and technology-driven improvements-are contemplating the possibility of "rationing" (1) treatments, or the possibility of allowing a greater role for private suppliers. If a "multi-tier" healthcare system has long been anathema to the European leadership, guaranteeing a uniform access to state-of-the-art care seems to be well beyond the means of states suffering from persisting debt crisis. Was the failure of state-controlled "adequate" healthcare totally unpredictable? Far-sighted criticisms had been offered by two eminent thinkers in the classical liberal tradition, Herbert Spencer (1820-1903) and Friedrich A. von Hayek (1899-1992). Neither author is usually recognized as a forerunner of contemporary critics of the welfare state, and both investigated the issue of the state financing and providing health services well before (Spencer) or right after (Hayek) the establishment of national health services. With the benefit of hindsight, reading Spencer and Hayek helps us to understand how the crisis of state-supplied healthcare is not rooted in the mere progress of clinical technology, but is rather the logical consequence of the theoretical basis of the model itself. Whereas modern theorists of the welfare state tend to offer theories that are impervious to a critical appraisal of their unintended consequences-insofar as they are framed in a language of "rights"-both Hayek and Spencer understood that human systems are complex, and that unwanted effects of public policy should be taken into account. Although Spencer emphasized the moral hazards accruing from the paternalism involved in governmental provision of health services, Hayek explained how modern healthcare systems differ from real, private insurance designed to offer proper coverage against risks. These authors appreciated that the politicization of healthcare was bound to result in both standardization of care and disregard for the responsibility that comes with personal freedom. These two "diagnoses before the illness" can help us in defining the challenges and the potential solutions that healthcare systems face today. Understanding the fatal conceits inherent in the very architecture of national health services can be the first step toward healing our healthcare systems.