"Have you ever seen a working class old person?" is not a devastating rejoinder to my previous posts. (The answer, by the way, is yes, lots; my roots are decidedly proletarian.) Nor is "My sister, the starving artist, has cancer." If the working class old people cannot afford to pay for their own health care without assistance--which is by no means proven; the working class runs from McDonalds fry cooks to members of the UAW--then this might be an argument for giving money to working class old people. Or to the subset of the working class who cannot cover their health care. Or to your dying sister. It is not an argument for giving money to every single person who happens to be old and/or sick, whether or not they can afford to pay for their health care, which is what happens under single payer.
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Okay, one more bad argument in favor of single payer
24 Aug 2007 01:49 pm
Comments (86)
As long as you insist on evaluating distribution of health care based on economic analyses, you are not going to get anywhere with me.
That's all I've got to say about that.
t is not an argument for giving money to every single person who happens to be old and/or sick, whether or not they can afford to pay for their health care, which is what happens under single payer.
But, as has been demonstrated again and again by a lot of very intelligent people, the system doesn't work if you can opt out. So you force people in, just like government forces people into doing a lot of things they might not like.
As for the appeal to emotion thing-- sure, you're right, someone's argument isn't improved by discussing something emotionally fraught, simply because of the emotion involved. You've got no argument from me there. But I caution you, first, that you can't allow that to mean that anyone who mentions something emotionally powerful is cut out of the argument. It seems to me that some of the people here who have talked about their sick friends and loved ones are making very sound arguments, that also happen to contain emotional content. Appeals for universal health care are appeals to a particular moral vision. That sort of thing invites emotionalism. Emotion doesn't disqualify an argument, just as it doesn't improve it.
Also, I think it's important for people to tell there personal stories as an antidote to your own attempts to move to discussion as far away from actual human suffering as possible. It's no more logically sound to attempt to divorce the discussion from the human costs, to make it a dry discussion about bureaucracy and wealth transfer, than it is to make it about someone's dying mother. As I've said before, you have an almost pathological tendency to trivialize the human costs of your arguments. Gordon Geckos like yourself could use a little reminder of the consequences of, say, treating 47 million uninsured people like some insignificant minority.
*their personal stories
That's not a moral argument; that's an efficiency argument. I'm getting to those next week.
It's actually pretty simple. Single payer is the only way to insure the uninsurable. If the healthy and the sick are in separate pools, then no actuary in their right mind would endorse a policy to insure the riskiest. The argument that single payer would stiffle innovation is bunk because of the efficiency gains that could be realized through innovation. Take AIDS. It was the needs of the patients in the developing world that spurred research on single dose pills. Innovations in preventive medicine would make the costs of health care go down for everyone in a single payer system--those gains are not translated to lower premiums in the current system. Long lines for organ transplants is also bunk for the same reasons. A single payer plan doesn't mean that doctors couldn't compete for patients. It just changes the way we pay for health care. Finally, insuring the population and making it easier for people to see their doctors regularly, like requiring immunizations and checkups for children before school starts for example, makes it easier to catch problems sooner. The most expensive procedures are those that have to account for complications (like organ transplants). The moral arguments are also apt. The externalities of a system that lets its poor languish are never internalized in private systems.
Poorly rephrasing arguments you don't like doesn't count as responding to them.
You're selfish, and don't want to care about other people. That's the gist of your argument. You're worried about your money being taken and given to someone actually in need. Nevermind how you've benefited from the society those old people contributed to, you need that money to put an HD flatscreen in your bathroom, or to buy that fourth prada bag.
I honestly hope you get a bad, but non-life threatening, chronic illness. You need a clue, desperately, you selfish, horrible person.
I was just about to give up on Megan altogether, or at least to refer to her forever more as Ms. McCardle, but this--along with her earlier post on international law--gives me some hope.
There is very good reason to offer those who cannot afford basic medical care a subsidy, but there is little reason to compel everyone to participate in a government controlled scheme. I guess it is fashionable to use the euphamism "single-payer system" for what is, in truth, socialized medicine. Regardless of what you call it, it is a poor way to help the indigent.
Wherever you have government control of medicine you also get rationing, shortages and reduced quality. Moreover, socialized medicine invariably stifles innovation, which means fewer drugs and medical devices for all of us in the future.
What do we do for people who cannot afford food? We do not take over the agriculture and grocery industries, we offer food stamps. So why should medical care be any different? Offer health care vouchers to the needy, and let the rest of us attend to our own health care.
It's just silly to say that rich people like Bill Gates--or, for that matter, John Edwards--ought to be getting subsidized medical care for the sake of "equity" or "social justice" or whatever.
I'm curious to find out if libertarians of the type who read this blog object to a health care system of the type used in Singapore, the Netherlands, Germany, etc. In this type of system most people obtain medical insurance through their employers. If the employers don't provide it, they pay a tax to the government, so much for each uninsured employee, that goes into a health fund. Money from income or payroll taxes also goes into this fund, and individuals who do not receive medical benefits from their employers can buy subsidized private insurance, with the subsidies coming from the health fund. When Mitt Romney was governor of Massachusetts, he helped enact a plan of this type. Arnold Schwarznegger is pushing a similar plan in California.
If the people reading this post object to a subsidized insurance plan of the type I described, I'd be interested in hearing why.
Okay, let's get to it. Attacking the "bad" arguments for universal health care (from a moral view) is not that difficult. Here are the "good" arguments in favor of universal health care:
1) People are not rational actors, and have less than optimal forethought. (Yes, the argument for universal health care is in part paternalistic).
2) The moral arguments are intertwined with the efficiency argumetns. That is, the types of efficiencies that universal health care provides serve important moral goals. Seperating the two arguments is like overrelying on Kalder-Hicks, because 1) you can't practically create a more efficient system anyway (yes, I know you'll get to that next week), and 2) the winners won't willingly and can't practically be forced to compensate the losers, even if they had the capacity.
How would you pay for vouchers? If I pay taxes to fund a voucher system, am I not after a fashion participating in a mandatory health care system. I suppose I could object and tell my rep to vote against a bill that would create it, so to that extent it's voluntary. The moral argument is whether the government should take care of the needy. The economic argument is how the government should take care of the needy--we all need access to healthcare even when we are young. Don't believe me? Go break you ankle and comfort yourself with the abstract notion that at least no one made you join a single payer system. Xrays catscans medical research student loans for med students the government is already well-esconsed in the political economy of medicine. We ought not pretend otherwise. Instead we should be talking about how best to provide health care for everyone. Is a voucher system more efficient than a single payer system. And to mix morality with economics, does a voucher system require the poor to make more or less sacrifices that advantage the rich than a single payer system. People beat the drum along the parade of horrors that will result from a single payer system--longer lines at the transplant desk--but a system that has left a serious minority of this country uninsured is not an ideal we should be aspiring to. There are countless things in this nation that we pay for but never derive a benefit from--roads we never drive, reports we never read, salaries for white house staff--objecting to single-payer and blinking at everything else strikes me as inconsistent.
I wish I could post links without getting flagged, Ezra Klein and others have written extensively about how a system that can be opted out of won't work for anyone, when it comes to health care. I personally probably wouldn't do their arguments justice.
This is a puzzle, to me, though. As JC suggests, wouldn't this "pay for the people who need it" approach also be a wealth transfer? Shouldn't MM and the commenters from before oppose that kind of wealth transfer, too? Or am I missing something?
I think Megan's point would be better made if it emphasized the strength of a health care voucher system (for example) instead of a single payer system. You can argue that vouchers would be able to take advantage of a competitive environment while providing the disadvantaged with what they need.
Justin's point #1 is still important, in that safety nets can be considered partenalistic, and not everyone considers that a bad thing. And with catasrophic illnesses being, well catastrophic, penalizing an old sick person for the activities that got them to that point can be tantamount to a death sentence, in that they won't have the funds to save themselves. We may choose to be the type of society that demands that level of personal responsibility from its members. This is where some people would expect charity to step in, but usually charitable organizations cannot serve everyone that they would like to serve.
From a moral perspective, a good thought experiment is to consider what you think a society should force its collective members to pay for health care if all diseases and medical issues of individuals were known in advance. With genetic testing growing more powerful as time goes on, its not an entirely irrelevant question, and it gets at what people think an individual member of a society owes and deserves to receive.
First of all, I'm not quite sure what you mean by "single payer". What you appear to be talking about is mandatory health insurance (everyone is included) with community rating (everyone pays the same premium (possibly with subsidies for the poor) regardless of their current need). While such a system appears to subsidize one generation (the old and sick)at the expense of another (the young and healthy), its intended purpose is to force the younger generation to save: to pay more than they need to now because the true cost of health insurance becomes prohibitive as they get older. Why does savings need to be enforced? MORAL Hazard - if people were not obliged to save when they are young, they will plead poverty and ask for assistance from society when confronted with high expenses when they get older. Any system that tries to prevent moral hazard will have the same apparent intergenerational transfer. For example, I could be required to pay into a personal health savings account so that I can afford private health insurance when I am older
Great point JC! For the sake of consistency we should force everyone into a single/socialist health care plan!
Woohoo!
Any other inconsistencies you care to illustrate so we can make everyone's life better?
Guaranteeing health care only to people who are so sick or poor that they can't afford it creates a pretty serious moral hazard problem.
In fact a lot of people would view this sort of means-tested system as unfair and immoral, just as people saw the old welfare system as immoral. They would have a decent argument.
Morality is in the eye of the beholder, I guess...
I think that the point is for better or for worse we already are in a single payer system. One way or another we pay for the failure to provide people with access to health care--either in higher crime rates and their concomitant effects of property values, chaos at the ER, or the ever declining bargaining power of individuals vs. their insurers--don't agree? try to find an insurers that will cover you when you are already pregnant. We can pretend, if we want, that we don't live in society, and holler when wake up to find out that we do, or we can face the problem and figure out a way to insure the uninsured. Only states have the ability to fund the riskiest (either those who are diagnosed with a disease or those who in the future have a genetic test which reveals that they will get MS), because only states at the end of the day won't make that determination on purely economic grounds. Any private insurer, even with the deepest reinsurance pockets in the world, would go out of business if they had to pay for the medical bills of those who are 100% likely to get very sick. We can pretend like vouchers aren't just another form of wealth redistribution, we can pretend like wealth redistribution doesn't happen every single day in the U.S. in ways that definitely benefit even those seemed to be opposed to it in principle--hey, you Ivy League grads, even your tuition is subsidized, imagine if Harvard had to pay property taxes? Or we can wake up to reality and admit that leaving people uninsured has enormous costs and doing so on the argument that the market will fix it has a heavy burden of proof given its track record so far.
shorter isocrates:
"SOCIALISM! BOOGEDY BOOGEDY!"
that dog dont hunt so well anymore.
Freddie wrote: This is a puzzle, to me, though. As JC suggests, wouldn't this "pay for the people who need it" approach also be a wealth transfer? Shouldn't MM and the commenters from before oppose that kind of wealth transfer, too? Or am I missing something?
Every type of tax is a wealth transfer, but that doesn't mean all wealth transfers are bad. Is Medicaid bad? I wouldn't say so, although there are very good arguments to be made that Medicaid is badly structured. However, wealth transfers can be very bad when they are used indiscretionately, transferring large amounts of money to persons who don't all need it at the expense of less wealthy persons, or when wealth transfers are premised on population dynamics that can shift in ways which are outside of the transfer system's control.
Which is precisely what tends to happen under Social Security, universal healthcare, and a number of other well-meaning schemes when they are made available to everyone or nearly everyone without respect for means testing, and without suitable mechanisms to limit moral hazard.
"How would you pay for vouchers? If I pay taxes to fund a voucher system, am I not after a fashion participating in a mandatory health care system."
It's funny, not long ago people were accusing me of being a fascist; now some seem to think me an anarchist. But I am neither.
I accept the need for a government that preserves order, ensures our national security, builds roads and bridges, etc... Oh yes, and it ought to offer a social safety net for those who have fallen on hard times. I don't think there is anything inconsistent about supporting some kind of basic assistance for the needy and also opposing socialism, and evidently neither did great libertarian economists like Hayek and Friedman, for this was also their view.
But like Hayek and Friedman I am always reluctant to grant government greater control of the economy, so I want a system that protects the poor while interfering with our liberty as little as possible. Yes, we'll have to pay taxes to fund vouchers, but the taxes would probably be much less than now go to pay for our massive and poorly targeted Medicare entitlement and certainly less than needed to pay for socialized medicine.
liberalrob wrote: As long as you insist on evaluating distribution of health care based on economic analyses, you are not going to get anywhere with me.
It's time for you to depart childhood and start thinking like an adult, Rob. In the adult world, nobody gets anything, anyhow, without costs attached; and those who refuse to acknowledge this fact and factor it into their decision making live lives of miserably slavery to debt.
Or, in simpler terms: When you make expensive demands and refuse to hear a reasoned economic analysis of what it will take to achieve them, YOU ARE DEMANDING THE POLICY EQUIVALENT OF SANTA CLAUS.
I too am confused by what Megan's shorthand of "Single Payer" stands for.
First, consider a system in which all health care is paid for by the government out of general tax revenues. In this system, at least the collection of funds is fairly progressive.
Second, consider the same system, but funded by something like the payroll tax. This arrangement seems to fit the premise of Megan's arguments much more than the first.
Single payer describes a way a system distributes services, not how it funds them.
Yes, we'll have to pay taxes to fund vouchers, but the taxes would probably be much less than now go to pay for our massive and poorly targeted Medicare entitlement and certainly less than needed to pay for socialized medicine.
What if the amount you paid in taxes wound up being less than the amount you pay to every private business that offers health insurance to its workers? We already indirectly subsidize each other's health care, so in a way a single payer system is really just replacing a private sector middle man with a government one.
Also, since the US has the most expensive health care and the least efficient and the one with the highest amount of privatization, I don't see how anyone can argue that a government run system would automatically be more expensive or less efficient than the one we already have.
So if we were agree that some (obligatory) wealth transfer were necessary to pay for health care, then the argument turns to how that wealth transfer should structured. Universal health care, health care that is accessible to every person without condition, will have to account for those who are currently uninsured and those who are currently uninsurable. One way to pay for the uninsurable is to grow the pool of healthy participants--through programs that emphasize preventative care, or programs that improved safety standards (e.g. seatbelts), or programs that foster good nutrition (like better school lunches and neonatal care), or discourage threats to public health (binge drinking, cigarettes). The fact is that the all the poor are poor, but not all the poor are sick, and all the sick are sick, but not all the sick are poor. So adding poor healthy people to the rolls can grow the pool of people who are healthy (and with health care stay healthy) and makes it more affordable to provide care for those who are not. Never mind the peace of mind of knowing that your baby will have access to the best health care in the world, or that you will be able to afford to help your parents age with dignity, or the increased productivity that reduced stress can promote. So it comes down to whether "taxes would probably be much less than now go to pay for our massive and poorly targeted Medicare entitlement and certainly less than needed to pay for socialized medicine" is actually true. Absolutely, the ideal system would aim to have low operating/transaction costs, and the highest efficacy--these are limits towards which the system should continually and constantly approach. The question is how this might best be achieved without leaving anyone behind.
"...we'll have to pay taxes to fund vouchers, but the taxes would probably be much less than now go to pay for our massive and poorly targeted Medicare entitlement and certainly less than needed to pay for socialized medicine."
Got any data (citations, objective evidence) to back up those broad strokes, iso?
Or, in simpler terms: When you make expensive demands and refuse to hear a reasoned economic analysis of what it will take to achieve them, YOU ARE DEMANDING THE POLICY EQUIVALENT OF SANTA CLAUS.
Posted by anony-mouse | August 24, 2007 4:07 PM
Coal in your stocking for sure this year.
Something like these premises seem to me to capture the heart of whatever "moral argument" exists for single-payer. I don't know enough to say whether 2 is true, but I think 1 and 3 are.
1. We should ensure that sick people have access to good medical care whether or not they can afford it.
2. Single-payer is the fairest way to provide good medical care to sick people whether or not they can afford it, and single-payer wouldn't have any really bad consequences.
3. If we should achieve G and P is the fairest policy that will get us G (or reasonably close to G), we should have P as our policy, provided P wouldn't have any really bad consequences.
Maybe you think all of them are false, but I'd be curious to know.
brad, how about responding to the actual arguments, instead of your strawman caricatures of conservatives and libertarians?
"You're worried about your money being taken and given to someone actually in need."
The disputed point which you have failed to address is whether anyone sick is ipso facto "in need". Bill Gates can easily afford to pay for any conceivable medical treatment, with or without insurance.
"I honestly hope you get a bad, but non-life threatening, chronic illness. You need a clue, desperately, you selfish, horrible person."
This must be that liberal compassion I keep hearing about.
"Got any data (citations, objective evidence) to back up those broad strokes, iso?"-FF
I think it should be fairly obvious that covering the medical expenses of a small portion of the populace (say 10% for argument's sake) would be less costly than paying for everyone's medical expenses, which is the socialist solution.
Moreover, right now, more than 40% of all medical expenses are paid by the government. My plan would certainly mean the government would pay a much lower percentage of total medical costs. So it would be less expensive for the government than the current system.
*Note that I am not arguing that total expenditures on medical care in a market system with a small government subsidy would be lower than in a socialist system, just that government spending on medical care would be lower. The socialist system would very likely use price controls to keep overall expenditures low (the price controls have some very bad side effects, but I'll address that another time).
Well Brian, I happen to think a touch of Crohn's Disease might just teach Meghan a thing or two. I did specify non-life threatening.
As for your non-sequitur of a response, huh?
Meghan is not making any deep points. She's saying "I don't wanna pay for helping other people". She's entitled to argue that, but it's selfish and shortsighted. I'm not going to be drawn into this "accept my def of term A so we can argue over term B" type squabble.
All of Meghan's terms are wrong.
Excellent choice brad. As a Crohn's sufferer, I heartily agree that first hand knowledge would change a lot of people's minds. Particularly if you don't have medical insurance. Or even better -- if you do have medical insurance but don't get your prescriptions or doctor's bills covered because of a pre-existing condition clause. Big fun.
I think my problem with the why should healthy people be forced to pay for sick people is the fact that they already are, that they will have to no matter what--either in lost opportunity costs, negative externalities, or direct subsidies through charity/taxes. The question is whether denying the existence of social costs and depending on the market is the best way to go--the market after all is yet another social institution so even there you would have to back track and consider the subsidies they get through tax breaks and write-offs (not that those are inherently bad, only that they already exist)--or whether it is better to admit on some level that the government has to be involved on some level with health care and take it from their. From both a moral and efficiency point of view the uninsurable--those with a pre-existing condition--must be covered someway somehow and the market on its own will not do that. The government is the best insurer of the uninsurable because where people are not necessarily policy holders they are citizens and have rights as such. Insurance companies may be able to deny them coverage, but the government cannot. In a way the uninsurable are the quintessential minority--not large enough to force change on the market or in politics but still entitled (as citizens or as human beings depending on how you look at it) to access to health care. Just as the government protects property owners (another minority) from takings without just compensation, so too should the government step in to play a role in protecting the interests of the uninsured. Again the question is how much of a role and how that role should be structured. Conservatives are absolutely right to look for efficiency gains in the current system, but sacrificing the uninsurable is not an efficiency gain. (I am not suggesting that anyone is saying this, only trying to lay a threshold of what should be the sine qua non of universal health care.)
If they pay taxes, they're paying for their healthcare...RENDERING YOUR ENTIRE ARGUMENT MOOT.
Most people aho advocate a single payer (aka socialist) system pretend that their only opponents are Social Darwinists who say "Let the poor and sick be damned." But Herbert Spencer is dead and his philosophy died with him. No serious person now denies the importance of government subsidies for those who cannot afford their own basic medical care or insurance.
What I object to, like many others, is government subsidies for those who can afford to pay for themselves. There are many affluent people who are getting heavy subsidies from Medicare in this country and the NHS in Britain. I would much rather see any health care subsidy targeted at those who need it.
Except that as in Britain, France, etc., you get better results for less money when everyone is subsidized.
Now, you're the one making the illogical moral argument - that it's better to introduce massive inefficiencies into a system so that a particular class can draw no benefit from it than it is to have a more efficient system that all can draw benefit from.
How does that make any sense?
Hmmmm. First off, as far as I can see Megan is pretty much correct in her analysis. Single payer would transfer money from the young and healthy to the old and sick. And, by her quite reasonable criteria, there is no moral basis for this. In fact, on face value such a transfer appears to be immoral.
My only problem with this argument is that this moral distinction is somewhat sensitive to one's choice of classes. For example, single payer healthcare would also transfer money from those who are genetically-predisposed to to some common set of illnesses with a believed genetic component (heart disease, some cancers etc.). Let us assume that such a genetic predisposition can be measured and that we use it to partition society into two distinct sets: those in the upper 50% percentile of genetic predisposition, and those in the lower.
Assuming that there is a net transfer of money from the latter class to the former, we can now run the McArdle analysis:
1- Need. Here we gain little. There is no reason to suspect that the genetics of health are strongly (or, in fact, at all) correlated to relative wealth. Still, neutrality of need is better than we were doing with the old and sick vs the young and healthy, so let's not give up yet.
2- Fairness. Well, all other things being equal (and assuming the absence of karmic reincarnation), this one's a winner. Clearly it is relatively unfair to be predisposed to ill-health by virtue of your DNA.
3- Responsibility. Once again, neutral. Actually, I might be being unfair here, so let us examine more carefully. Clearly there is no reason to expect that those who have some responsibility for their ill-health should be unequally distributed between my chosen classes. But is this sufficient to ignore responsibility? After all, as Megan points, out it only takes a few folk who caused their own misfortune to doom the entire class. Well, given that we all stipulate that, for example, smokers shouldn't take money from the rest of us, then it is clearly unfair to have non-smokers pay for their healthcare. However, if smokers are equally distributed between the two classes (and, by construction, so are the non-smokers) this is a wash - both classes are equal contributors and leeches.
So, we find that with this particular choice of classes single-payer healthcare is moral. Hooray.
Of course, in the spirit of intellectual honesty, I should point out that I cheated. Need, fairness and responsibilty are (almost) orthogonal to one one another. Accordingly any 50-50 division of society based on one of these(i.e. using simply a fairness, need or responsibilty index - such indices don't exist but there are good proxies: wealth and genetics being the obvious ones) is bound to give the conclusion I drew. This doesn't mean single-payer systems are moral. It just means that this particular kind of morality is tautological. What's more, as Megan demonstrated, there exist perfectly valid choices of classes that lead one to the opposite conclusion. So what should we conclude? I have no idea, but broadly I think that one cannot use this particular subset of morality arguments to advocate for or against single payer healthcare. Luckily, there are lots of other reasons we can debate.
PS Since I'm not a philosophy student, this could all be nonsense. Apologies if that's the case.
What I object to, like many others, is government subsidies for those who can afford to pay for themselves.
Exactly. The willful misunderstanding of this point is impressive. The left constantly opposes non-targeted tax cuts as "handouts to the wealthy", yet when we have *actual* handouts to the wealthy it's suddenly vital to national solidarity or something.
Except that as in Britain, France, etc., you get better results for less money when everyone is subsidized.
That's far from clear. Check out cancer survival rates, for example.
Look. Insurance companies are in business to make money. A person with a terminal chronic condition is not a profitable enterprise--if this was pick-up basketball they would never get picked. Which is why insurance companies don't insure against pre-existing conditions, why they limit the scope of their malpractice insurance, why they raise their rates on bad drivers. It is just business. But health and welfare are not about business, having a family is not about making a profit, taking care of a sick parent does not pay dividends. If there was a private market for health insurance no one, absolutely no one would invest in people with expensive chronic medical conditions. Charity would be the only recourse. At the same time insurance companies do expect the government to back them up when someone doesn't pay up. They do expect to avail themselves of bankruptcy court if one of the companies they have plowed their premium payments into goes belly up. They do expect someone to keep the lights on and the lines open so they can solicit customers. They do expect accreditation of law schools and public financing of judicial payrolls to hear their cases in court. They do market freely to people who are good risks--life insurance for the young, better rates for better drivers. In other words while they reap the benefits of government, they will only insure the uninsurable if the government makes them. The young and healthy may decry the immorality of having their money line the pockets of the old and wealthy but such complaints miss the mark. If the rich and old can afford it anyway then they will but it will be the uninsurable who suffer the consequences as rich and young opt out leaving only the sick and indigent behind for government to clean up after. If the solution was for government to intervene only after people could not find insurance elsewhere then we would have a system defined by desperation (if you have ever been deathly ill is not a cheery prospect). Imagine dialing 911 and being asked for a credit card number. The result will be a lot of very sick and very scared people, and for what? For the benefit of being able to say "better dead than red;" hey, "we may be sick but at least we aren't socialists." It's patently absurd. Hayek & co. never acknowledged the social underpinnings of markets, the participants in their abstractions are all shadows without families values preferences it's a fantasy world for those who cannot accept that not everything in life is an economic exchange. I just don't think anyone who has lost a child or a sister or an old working class relative to a preventable or at least treatable disease (to give a shout out to the sophmoric post that started this whole thread--a blog on cooking and ground zero, really??) could credibly argue that a system that impoverishes the poor for the benefit of the young and healthy can claim the moral (or economic) high ground on the topic of health care.
The left constantly opposes non-targeted tax cuts as "handouts to the wealthy", yet when we have *actual* handouts to the wealthy it's suddenly vital to national solidarity or something.
Do we then deny all benefits of the government to the wealthy? Do we force them to buy private armies, private trash pickup, private roads? Do we ask them to set up a private legal system?
The reason that "the left" opposes non-targeted tax cuts to the wealthy is because the net effect of them is to put a lot more money in the pockets of the rich for little or no gain. In the case of single-payer health care, everyone derives the same benefit, regardless of income level, which is something that Megan and her followers seem to purposefully obscure. It isn't a transfer from the poor to the wealthy, because the poor get the exact same coverage.
By the way, check the world health rankings. You know, for information and all that.
Let's review some basics.
Insurance: risk sharing, used in situations where everyone is subject to random risks.
Wealth transfer: used to ameliorate the excesses of capitalism.
I hope this remedial lesson will assist you in further blogging.
First off, as far as I can see Megan is pretty much correct in her analysis. Single payer would transfer money from the young and healthy to the old and sick. And, by her quite reasonable criteria, there is no moral basis for this. In fact, on face value such a transfer appears to be immoral.
Forgive me for singling you out Nav since many before and after you have put forth similarly sophomoric arguments, but have you ever been forced to choose between paying your rent or buying needed prescriptions that your insurance didn't cover?
I'm of the opinion that you have not, and that the overriding factor guiding your perspective that these "wealth transfers" are "immoral" is that you're unfamiliar on a first hand basis with the very real choices that tens of millions of Americans have to face on a daily basis. I mean, really, make the choice between whether you can personally afford paying your rent or buying your prescription that will keep you healthy and then come back to me with what types of wealth transfers are moral or not. K?
Old people already have universal coverage, and have had since the sixties, so aren't they kind of irrelevant to the present discussion?
The criteria used by the world health rankings are very poor. "fairness of financial contribution," and "distribution of health in the population" are silly things to use in what purports to be an objective ranking of overall health care. Clearly the people who made the rankings prefer a socialist system and used criteria that ensured the socialist systems would come out on top. But even they couldn't hide the fact that the US had the best "responsiveness" which includes:
"respect for persons (including dignity, confidentiality and autonomy of individuals and families to decide about their own health); and (b) client orientation (including prompt attention, access to social support networks during care, quality of basic amenities and choice of provider."
So even according to the WHO the US medical system treats individuals with the greatest respect, offers them the most freedom, and gives them the highest quality of basic amenities. Sounds pretty good to me.
And as Brian pointed out above, the US also has the best survival for cancer patients. That makes me glad I'm here.
Your roots are proleterian?
Megan McArdle was born and raised on Manhattan's Upper West Side. She graduated from the University of Pennsylvania in 1994 with a degree in English Literature, and worked for several technology startups before getting an MBA from the University of Chicago. After graduating in 2001, she worked for a time at the World Trade Center disaster recovery site, where she started blogging at Asymmetrical Information. Megan currently works as an economics journalist for the website of The Economist.
I don't know you personally, but someone who casually read that biographical sketch of you would think you were completely full of s***. But I'll let you defend your claim, although at this point you'll need to present some evidence you weren't just trying to sneak a fast one by your readers.
a) My parents did not spring, full grown from the head of Zeus, into being on the Upper West Side of Manhattan. I have relatives elsewhere
b) There are a surprising number of working class old people on Manhattan's Upper West Side.
Justin, Justin. I know. I thought the same. But then I realized someone of Megan's stature, hired by the Atlantic and all, would never post such a easily disproval fiction, if it was such. I think she must have been raised by someone's maid, under the stairs as it were. Perhaps her father was the butler/driver, handyman type. Then, the kindly employers helped with the college fees, providing the young Megan with first hand experience of the charity she mentions re: Katrina.
Because, after all, McCardle's humble beginnings must be known to many of those she grew up curtsying too, and they'll vouch for her, I'm sure. Well, mainly sure.
Justin, Justin. I know. I thought the same. But then I realized someone of Megan's stature, hired by the Atlantic and all, would never post such a easily disproval fiction, if it was such. I think she must have been raised by someone's maid, under the stairs as it were. Perhaps her father was the butler/driver, handyman type. Then, the kindly employers helped with the college fees, providing the young Megan with first hand experience of the charity she mentions re: Katrina.
Because, after all, McCardle's humble beginnings must be known to many of those she grew up curtsying too, and they'll vouch for her, I'm sure. Well, mainly sure.
Now I'm really baffled. Ms McCardle likes bulleted lists. OK:
A)My parents did not spring, full grown from the head of Zeus, into being on the Upper West Side of Manhattan. I have relatives elsewhere
B)Megan McArdle was born and raised on Manhattan's Upper West Side.
Is it A or B, or A-B, B-A, or sort of a quantum fluctuation?
I'm interested in hearing from anyone who's posted on this thread that has actually navigated through the public welfare system. C'mon dispassionate libertarians. Tell me how you personally tried to get your crushing medical bills paid by the state but were denied because, after the Clinton era welfare reform, you made more than minimum wage at 20 hours a week. That's why I was denied. Oh wait, I'm making an anecdotal argument. I can be easily dismissed. By all means, dismiss me.
It seems that Schrödinger's Cat has got McCardle's tongue.
It seems that Schrödinger's Cat has got McCardle's tongue.
gorillagogo, my apologies, I should have been more precise in my initial paragraph. I am not offering an opinion about the morality of single-payer healthcare. I was merely pointing out that given the (reasonable) axioms Megan postulated for morality and the way she chose to make the analysis, her argument is consistent.
What I was trying to do with the rest of the post was illustrate that despite the consistency the argument is problematic because the framework used lends itself to multiple conclusions. Ergo, we shouldn't use it.
As it happens I am hugely in favor of universal healthcare and I think single-payer systems offer the best way to achieve this. Furthermore I believe that we do have a moral obligation to provide healthcare for all - though I would make such a moral argument in abstract terms (in much the same way as one would make an argument for equality in the eyes of the law) and, moreover, I think moral arguments should not form the genesis of the case for socialized medicine.
However, my personal views aside, this is not the argument Megan was countering(at least as far as I could tell). There are many ways to argue about moral value. I believe hers is perfectly reasonable in principle, it just happens to be the case, though, that I can sick with her axioms, use her precepts and come to a different conclusion. Which suggests that this particular line of reasoning may be futile for everyone - both those in favor of single-payers systems and those against.
Hope that clarifies things. Apologies once more for my initial inelegant phrasing.
Isocrates, it's much easier to be responsive to your patients when a truly significant number of them are so uninsured or underinsured that their first point of contact with the healthcare system is the emergency room.
Re: cancer survival rates. You know what countries have almost the same survival rate? Iceland and Sweden. They have single-payer systems that cost forty to fifty percent of the per capita cost of America's system.
Whatever problems they have, the American system is uniquely wasteful - we spend nearly twice as much as any other country on healthcare to insure far less of our population for, at best, slightly better results.
If that makes you comfortable, you have a bizarre idea of comfort.
Forty-one countries have higher life expectancies than ours, forty have lower infant mortality rates, and thirty-six outrank us in the World Health Organization's study of national health systems. Deaths due to violent incidents, sometimes cited as the cause of our low life expectancy, are an insignificant fraction of our annual mortality rate. Infant mortality is strongly correlated with low income in New York City, but not in London, Paris, Tokyo, and US military bases, all of which provide adequate prenatal care and counseling. We have an infant mortality rate greater than Cuba's and a life expectancy lower than Jordan's. How people can claim we have the best health system in the world is beyond me. What planet are they talking about?
"Whatever problems they have, the American system is uniquely wasteful"-starscream
I agree. There are many reasons American medical costs are so high. Part of it is access to expensive technologies and treatments unavailiable in other countries (becuase the government won't pay for them). But a big part of it is waste, I agree.
The best way to address the spiraling costs would be to reduce third party payment. The tax deduction for employer provided insurance is a big part of the problem, as is the expansion of Medicare. Both of these have contributed to the waste. We could address these problems and bring costs down without moving to socialism.
We have an infant mortality rate greater than Cuba's and a life expectancy lower than Jordan's. How people can claim we have the best health system in the world is beyond me. What planet are they talking about?"-stan
Many things affect life expectancy other than health care quality. For example the higher rate of obesity here than in, say, Sweden, could be a significant cause of the differences in life-span. But if you insist on using life-span as the acid test, I notice that Hong kong is at the top of the list (2nd sctually) with an average life-span of 82.2.
I have for a long time believed that we should move more in the direction of Hong Kong--which has long had the freest markets in the world. Low taxes, light regulation, free trade and minimal government spending seem to be good for our health, as I'm sure you'll agree.
The best way to address the spiraling costs would be to reduce third party payment. The tax deduction for employer provided insurance is a big part of the problem, as is the expansion of Medicare.
Was there some part of my economics classes I missed where communally pooled risk over a large population was more expensive than distributed risk for each person within the same population?
Do you just really, really like bankruptcies, or are they just sort of a cherry on the ice-cream sundae of sickness you're serving up?
The surest way to drive up medical costs is to move towards an HSA system, if for no other reason than that healthcare isn't a market commodity that can be shopped around like a TV or groceries, for a large variety of reasons. Getting rid of the deduction for employer provided system would happen under a single-payer system, and the expansion of Medicare to all people would, long term, drive down costs, just as similar systems do all over the world.
And if you want to move towards the Hong Kong model, say goodbye to intellectual property development.
Megan,
I'm sorry, but that *was* a pretty pathetic defense. Not everyone who can't trace their roots to the Mayflower can claim "proloteriat roots." And unless you're a Kennedy, everyone has "some" poor roots.
Your claim is that YOUR roots are DECIDEDLY proloteriat. Which at this point is pretty clearly a lie. If you're willing to lie about something so inocuous and provable, how can the Atlantic trust you? It's only time before you say something untrue that's going to affect THEIR credibility.
Ooops, that should say "some poor relatives" not roots.
"And if you want to move towards the Hong Kong model, say goodbye to intellectual property development."-starscream
You seem to think that a socialist system would do more to spur innovation than a capitalist one. Serious consideration of the history of the Soviet Union or India should disabuse you of that notion. Socialism stifles innovation. You make much of the ability of socialist systems to hold down costs. They do so through price controls, which certainly reduce the incentives to innovate.
If you want innovation, you should support a market system with adequate patent protections.
Starscream wrote:
"Except that as in Britain, France, etc., you get better results for less money when everyone is subsidized."
I am blind in my right eye because of British health "care" I received while on vacation. Had I been in the US, my sight would have been saved.
And should you get prostate cancer, why don't you move to Canada or France or the UK? Hint: Don't bother buying a return ticket.
You don't have the slightest clue as to what you are talking about.
Something Megan seems never to have encountered is the germ theory of disease. Once comprehended, the idea that diseases are caused by microbes that spread from person to person explains a great deal about health care. I fail to see how anyone's life is improved by living amongst people who do not have access to health care when they have an infectious condition. Just because she is old and sick is no reason to tax the young and healthy to diagnose and treat Typhoid Mary (a real person). Just let her go about her daily routine as best she can.
The problem here is that Typhoid Mary infected quite a few people, many of whom died from typhus. So, young and healthy were saved from paying for the old and sick at the price of their lives. Is this a worthwhile trade off? I doubt it.
IMHO it is in the rational self interest of young and healthy people to pay for the diagnosis and treatment of all infectious diseases. Like TB, HIV, typhus, diptheria etc. Because the young and healthy are also at risk of contracting these diseases.
Our current system allows someone with untreated, undiagnosed hepatitis to work in a restaurant. And infect diners with this condition, as has happened a number of times. Why should the young and healthy want to play roulette with their lives? Universal health care, financed by taxes, protects the young and healthy from disease. Just as universal santitary sewers and universal safe water do.
The surest way to drive up medical costs is to move towards an HSA system, if for no other reason than that healthcare isn't a market commodity that can be shopped around like a TV or groceries, for a large variety of reasons. - Starscream
This point cannot be stressed enough. Market incentives work differently in health care than in any other good. People who refuse to address the complexity of how demand actually works in the health care market are either ignorant or, like McArdle, self-consciously and deliberately naive.
Chester, I'm sorry you lost the sight in your eye. But the statistics show that British health care is as good as American health care for the overwhelming majority of people. I live in an expatriate community in Vietnam, and encounter comparisons between international health care all the time -- people fly back to Europe and North America for various kinds of care (giving birth, etc.), as well as to Thailand and Singapore. My British friends have no complaints. I'm sure many people lose their eyesight because of poor medical care in the US as well.
It is through reading the thoughts of Megan McArdle that I have begun finally to understand that Libertarianism is really just a compassionless Conservatism with no sense of morality. The entire reasoning of the libertarian seems designed to hide their inhumanity. Libertarianism is a vile and worthless ideology whose adherents deserve our contempt.
If Megan is a libertarian, hers is the least intelligient I have ever seen. Looks like some leftist found the worst libertarian going and gave her space to make the philosophy look bad. She comes out and presents her 'class' based analysis of health care without any clear statistics or understanding of the cycle of illness. Views that compare the interests of 'classes' are in my view Marxist not Libertarian.
On health care, a Libertarian would first ask: what is my rational self interest in this situation. Clearly it is to protect myself from disease and illness so I can live as long and as healthy as possible. Then I would look into how health works. Along the way I learn something that Megan seems never to have heard of: the germ theory of disease. Dr. Pasteur discovered that tiny microbes pass from person to person and attack their new host.
So, rationally I want to avoid catching a germ because it would make my life less pleasurable. There seem to be two solutions to this situation. One is to live like Howard Hughs, isolated from the world. But I can't do that, I have to work in the world.
Which tells me right up front that the health of others has a direct bearing on me. I need to be concerned that they will not pass something on to me. As we learned in the AIDS epidemic, what protects people and saves their lives is Universal Practices rigourously enforced. Always wear a condom. Have clean safe water available to everyone. Especially heated water so they can bath. Wash your hands every time you use the toilet.
A society where the people who handle your food don't have access to health care endangers those who do. A kitchen guy who is not feeling well should see a doctor. Under our system he will go to work, handle food and pass along hepatitis. Or typhoid. Megan sees these instances as 'anecdotes'. I see them as specific evidence of why everyone should have access to health care.
Not to provide beneficence to others, but to protect our very own selves. Universal health care is in my rational self interest.
Interestingly enough, one cancer (Kaposi's Sarcoma) is now shown to be clearly caused by a virus. Other cancers are showing a viral involvement. Same situation here.
I find it disgracefull to see an alleged Libertarian present Marxist 'class' analysis as Libertarian thought.
Justin, the question was whether I knew any working class old people. The answer was, yes I do; they are members of my family in Western New York State, who work(ed) in such exciting industries as farming, manual labour, and the post office.
As it happens, many of those family members are descended from the Mayflower, which unfortunately conveys no immunity from being poor. The Boston Irish half of my family is decidedly more solidly middle class.
My parents, both the first generation in their families to go to college, are not very proletarian at all. But I was using "roots" in a pretty commonly accepted way . . . no one blinks if a politician describes his "irish roots" even if he wasn't, himself, born in Ireland.
Could somebody kindly explain to me why so many people on this thread support putting George Bush in charge of their healthcare?
That is what single payer, nationalized healthcare requires.
The problem that drives a lot of the concern over healthcare is those people who can't get health insurance because of financial difficulty or pre- existing conditions.
Note this number is smaller then the total number of uninsured because some people have enough money to afford health insurance but elect to spend it on other things.
So could someone explain to me the burning desire to destroy the existing US healthcare system and force everyone into a new, centrally planned and managed government system?
It would not make sense to attack homelessness by bulldozing all of the existing housing and then force everyone into government housing.
It does not make sense to attack lack of health insurance by bulldozing the existing system and forcing everyone into a government run healthcare system.
TJIT, there are many ways to identify the problem, one of which is cost. Looking solely at that issue, the real money to be saved is overhead, administrative costs. Insurance companies inflict huge overhead, both their own, and the costs we have to pay because medical professionals have huge administrative departments to try to collect. Single payer solves that problem.
Of course no one wants George Bush or any Republican in charge of any government program, but that is because they and their cronies want to destroy government, not make it work, not because we think the government is automatically a failure.
FWIW, the McArdle approach isn't one of the standard forms of argument. She seems to think that the problem is inter-generational wealth transfer, but most people realize that this is a barren framework.
Megan:
It seems that you touch upon, but do not fully explore, the issue of single-payor healthcare's inability to decrease the overall cost of health care without either dramatically decreasing the payment for health care services (running the risk of decreasing the quality of the services provided) or dramatically reducing access to health care services (which is the reason that more than 80% of citizens of the UK have supplemental private insurance, to "jump the queue"). A single-payer system in the U.S. will be incapable of addressing the issue of buyer demand, the demand for services from buyers (patients) insulated from the cost of those services. It is also incapable of addressing the issue of provider demand, defensive medicine that prompts physicians to order more and more care in an attempt to insulate them from the risk of a lawsuit. Perhaps this is one of the things you are planning to address soon?
Unlimited demand equals infinite cost. A single payer system can only address the two demand forces (patient and provider) by limiting top line expense on a global basis and/or limiting access to services. I'm interested in your thoughts.
I am blind in my right eye because of British health "care" I received while on vacation. Had I been in the US, my sight would have been saved.
My grandfather spent a significant portion of his later years suffering the debilitating effects of an internal infection missed by American healthcare on his private American health insurance, because the test was considered "experimental".
I was sent to collections for an unpaid bill from a surgery - the procedure itself was covered, but the anaesthesia was not. It was over $1,000.
An ex-girlfriend had to drop out of college in order to pay for an emergency room visit - a visit that, because she was taken to an out-of-network hospital where several members of her family works, cost over $9,000.
Have I succeeded in invalidating the American system of medicine yet, you short-sighted fop?
In writing my last line, I intended no offense towards your ailment - I was referring to your condemnation of the British system of medicine for a single bad result, and overlooked your initial description of what happened to you.
My deepest apologies for any offense caused because of that poor choice of words. I in no way intended to mock your condition, and am deeply regretful that I unintentionally did so.
Insurance companies inflict huge overhead, both their own, and the costs we have to pay because medical professionals have huge administrative departments to try to collect. Single payer solves that problem.
And we all know about those lean, operationally efficient organizations like the post office and DMV. We should make sure that medical care runs more like those august institutions.
And we all know about those lean, operationally efficient organizations like the post office and DMV.
Well, the comparison would actually be if FedEx was the dominant mail carrier in the United States for all but a couple of selected groups of citizens, and the primary focus of their administration was on delivering as few pieces of mail as possible.
Although, yes, let's do less regulation - an industry which has the best profits when it collects the most premiums and pays out the least benefits will do a killer job of providing quality health insurance and care to our citizens.
Emphasis on killer.
Starscream,
I'm going to try to make this very easy for you to understand. masaccio argued that single payer will somehow magically offset the increase in costs due to the absence of price rationing with savings in administrative costs imposed by the insurance industry. Now, maybe you missed this, but my comment demonstrated the relative operational efficiency of the public and private sector. Maybe you think that, under socialized medicine, the government wouldn't impose any expenditure controls or adminsitration whatsoever. Fine. I'd be the first to open the Dalasio "Clinic". Olympic-sized pool. Gourmet meals. In-room jacuzis. Beautiful beachside location. Open bar. Only $10K per day. But, hey, it's a "medical treatment" paid for by socialized medicine. Somehow, I suspect I'll have more "patients" than I'd know what to do with.
Bill,
This post could profitably be expanded to cover the more general case, e.g. "Moral bullying as a substitute for argument (inadequacy of)."
Posted by Paul Zrimsek | August 24, 2007 1:59 PM