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In yesterday’s New York Times Book Review Sarah Bakewell deftly explains“trolleyology:”
You are walking near a trolley-car track when you notice five people tied to it in a row. The next instant, you see a trolley hurtling toward them, out of control. A signal lever is within your reach; if you pull it, you can divert the runaway trolley down a side track, saving the five — but killing another person, who is tied to that spur. What do you do? Most people say they would pull the lever: Better that one person should die instead of five.
Now, a different scenario. You are on a footbridge overlooking the track, where five people are tied down and the trolley is rushing toward them. There is no spur this time, but near you on the bridge is a chubby man. If you heave him over the side, he will fall on the track and his bulk will stop the trolley. He will die in the process. What do you do? (We presume your own body is too svelte to stop the trolley, should you be considering noble self-sacrifice.)
In numerical terms, the two situations are identical. A strict utilitarian, concerned only with the greatest happiness of the greatest number, would see no difference: In each case, one person dies to save five. Yet people seem to feel differently about the “Fat Man” case. The thought of seizing a random bystander, ignoring his screams, wrestling him to the railing and tumbling him over is too much. Surveys suggest that up to 90 percent of us would throw the lever in “Spur,” while a similar percentage think the Fat Man should not be thrown off the bridge. Yet, if asked, people find it hard to give logical reasons for this choice. Assaulting the Fat Man just feels wrong; our instincts cry out against it.
Count me among the 90% who would find sacrificing one Fat Man to save five morally abhorrent. And yet this is precisely what Obamacare will do in its own way. The principle raison d’etre of this misguided law is to provide coverage for the uninsured. Admittedly, the number who eventually will secure coverage has shrunk each time the Congressional Budget Office has calculated it. Nevertheless, according to the most recent estimate last May, 25 million uninsured Americans eventually are projected to obtain coverage.
Let’s set aside a pointless debate about whether the law–unraveling as we speak–will actually provide coverage to 14 million uninsured in 2014 as CBO projects. I realize there are plenty of true believers convinced that all the rollout “glitches” will soon disappear and that the law will cease to become a nightly punching bag for late-night talk show hosts.
Let’s focus instead on the 3.8 million Americans that the RAND Corporationestimates will become newly uninsured as a result of this law. 2.5 million of these currently have employer-based coverage and another 1.3 million have non-group coverage. While there arguably are tens of millions of other losers created by this ill-conceived law, these 3.8 million arguably are its biggest losers. These are the “Fat Men” Obamacare would sacrifice in the service of expanded coverage.
What should be obvious and is doubly tragic is that we never needed to sacrifice these 3.8 million victims in the first place. As just one example, the conservative alternative to Obamacare recently proposed by Ramesh Ponnuru and Yuval Levin would provide universal catastrophic coverage to every American. The Obamacare prescription insists on “thick” (dare we say fat?) coverage so expensive that it leaves 31 million uninsured Americans behind despite hundreds of billions of dollars in taxpayer subsidies. Indeed, it is the unaffordability of this thick coverage that creates 3.8 million newly uninsured from the ranks of people who previously were able and willing to afford their own coverage. The conservative alternative instead proposes lean coverage that would protect everyone without adding fuel to the very fire that has encouraged so much excess use (one third or more of health care spending is avoidable) and the highest prices on the planet. And while this particular proposal is the newest kid on the block, it is far from the only one. Even Obamacare architect Jonathan Gruber nearly two decades ago helped Martin Feldstein develop a similar market-oriented plan that would have ensured universal catastrophic coverage for all guaranteeing that no American ever spent more than 10 percent of family income on health care.
But we need not argue whether lean coverage for all is superior to thick coverage that leaves behind 31 million Americans. Instead just focus your attention on the 3.8 million “Fat Men” of Obamacare. Are proponents of this law really prepared to say their sacrifice is both necessary and worthwhile for the “greater good”?
There’s a better way. We can either watch helplessly as this out-of-control trolley plows through 3.8 million victims on its way to delivering coverage to others. Or we can find a way to derail it before it claims any more victims and figure out a better way to help every American.
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