Chris Bertram reminds me that Ronald Dworkin’s view of justice in health care is actually quite similar to the “distributive-justice-plus-paternalism” account that I’ve argued is a more coherent progressive position than a nebulous “right to health care.” On this view, what society should do is, in effect, buy for each person the sort of insurance coverage that it believes people would buy for themselves at the start of their lives under conditions of full information, rationality, the absence of extreme present bias, and so forth, assuming each had a fair allocation of resources with which to purchase that coverage. And what he concludes, I think correctly, is that there are many types of coverage rational and informed people might not choose to cover, though they might be able to afford it. (I have some serious doubts about the meaningfulness of an attempt to divine what a hypothetical market would look like under a system of baseline government provision, but the core inuiition here seems sound enough.)
Contrast Megan’s approach, which seems to ask what people would want after they know that they’ll get sick in such-and-such a way. Now, if I have no other extremely attractive uses for my money, it might well seem worth spending what I have remaining on a very low probability of extending my life by a month, which from that point of view will no doubt seem extremely valuable. It will almost certainly seem worthwhile to ask my insurer, whether public or private, to pay. But that doesn’t mean I would’ve chosen to cover that eventuality even with a perfectly clear understanding of how much I’d want it if and when it arose. Now, Megan is surely right that in the real world people don’t have this kind of clarity of understanding. Ex ante, we tend to underweight how highly we’ll value additional time late in life, but also to overweight the detrimental effect various kinds of disability would have on our happiness. But time bias cuts both ways. Someone who consumed a lot of resources or took on debt in early life will naturally wish they had more resources and less debt—and may well discount too heavily the now-distant past benefits they enjoyed. We have, I think, an unjustified tendency to regard inconsistency between earlier and later assessments of a tradeoff as evidence that the early assessment was colored by temporal bias, while the later one is more fully informed and so more objective. I’m pretty sure that’s a mistake; time bias can take the from of irrational regret as easily as prospective imprudence. Though I should caveat that I’m not sure the use of “irrational” works here, as I’m not sure there’s some objective “view from nowhere” way of aggregating inconsistent judgments across time that would count as the benchmark of rationality.