One more stab at the apple

An exchange with a blogger who is apparently a philosophy student at the University of Virginia leads me to believe that many people are still misunderstanding my point about the morality of single payer healthcare. Many people responded to my first post by saying, "But we have a duty to care for the sick!" Trying to make myself very clear, I wrote 2,000 words explaining that even assuming, arguendo, that we have a duty to make sure people don't die from lack of health care, this is not a good moral argument for single payer. At which point I got more posts, including from said philosophy student, saying "But we have a duty to care for the sick!" Length having failed, let me try brevity:

1) Single payer transfers money from anyone who is young and healthy to anyone who is old and sick, regardless of their need for the money.

2) For this to be moral, the entire enormous class of people who are old and sick must have some justified claim on the money of the young and healthy.

3) The large class of old and sick people do not need the money; as a group, they are wealthier than the young, healthy people from whom we are transferring the money.

4) Therefore, we must look for another legitimate claim on society's resources.

5) Another such claim might be a fairness claim: the old and sick have been terribly unlucky, so we should pay for their health care even though they don't need the money.

6) This is not a good argument. Most of the old and sick are sick because they are old. Getting old may suck, but it is not unfair; it is inevitable. All of us will become old and sick, unless something even worse happens to us to make us dead. Some of the old and sick are just sick, and have never been healthy. But to calculate the relative deservingness of the whole group, we have to weigh the bad luck of those people against the bad luck of the currently young and healthy people who will, in the future, die young. As a group, there's no reason to think that the (currently) old and sick have had worse luck than the (currently) young and healthy, although obviously some members of each group are unluckier than others.

7) A third argument we might make is that the young and healthy should pay for the care of the old and sick because they have more responsibility for the problems than do the old and sick people themselves. This is self-evidently stupid. If even 100 people who are currently old and sick smoked and dranked themselves into early debility, while all the other old and sick people in America had absolutely no causal role in their own illness, this tiny aggregate responsibility for a few cases of lung cancer and cirrhosis would, to a near certainty, be larger than the responsibility the young and healthy bear for other peoples' ill health¹.

8) Thefore, as a group, the old and sick have no moral claim to massive transfer payments from the young and healthy. This tells us nothing about any moral claims individual members may have. For example, veterans could be entitled to care, regardless of need, because they incurred some part of their current illness on behalf on the nation.

9) Arguments that we shouldn't let the worst off members of society die are not valid moral arguments for single payer. They are arguments in favor of giving health care to those who cannot afford it, a much more limited project.

¹ What about car accidents, flu shots, and the like? For this to be compelling, we'd have to have some evidence that the relevant failures are unequally distributed between the groups. But the elderly are worse drivers than teenagers, they're more likely to have inflicted secondary smoke on the young than the reverse, and so forth. Even if we could do the utilitarian calculus, it seems unlikely to run in favour of the old and sick.

Comments

Single payer transfers money from anyone who is young and healthy to anyone who is old and sick, regardless of their need for the money.

I'm new to the argument so forgive me for not already commenting, but don't we already do this? Why does the argument focus on this, but not on the millions of younger Americans (children included) who lack health care?

If your goal is solely to discuss national health care in the phenomenon of wealth transferral from the young to the old, then I don't see how that is of much use to the overall debate.

Again I haven't read the earlier posts, so perhaps it's simply that the argument has been boiled down to irrelevance.

Posted by Xanthippas | August 24, 2007 11:44 AM

"1) Single payer transfers money from anyone who is young and healthy to anyone who is old and sick, regardless of their need for the money.

2) For this to be moral, the entire enormous class of people who are old and sick must have some justified claim on the money of the young and healthy."

This is where your argument gets silly and you lose your commenters - right from the start. Although your first statement happens to be false as a matter of fact (by the use of the word "anyone"), its also false as a description of the NATURE of universal health care. It's (once again, to the degree its true) an EFFECT of universal health care, but neither its purpose or its PRIMARY effect.

Because of that, there are OTHER justifications for its morality. By immediately jumping to the wealth-transfer effect, ignoring the far more important effects (including, to a large degree, wealth CREATING effects, although those are occasionally empirically challenged, if poorly so), you're simply talking past your commenters into a false world where single payer is simply a guy with a gun with a list of people who are "young and healthy", steals their money, then writes checks to the "sick and old."

So even if one could justify point 2 (and its not completely unjustifiable), there's no reason 2, because point 2 is based on a FALSE PREMISE.

Posted by Justin | August 24, 2007 12:00 PM

PS - I have absolutely no explanation for shorthanding "to" as a number in the above post.

Posted by Justin | August 24, 2007 12:01 PM

1) This is a bad thing? Explain.

2) The young and healthy can work to make money. The old and sick cannot.

3) This is an unfounded assumption, and contradicts real-world evidence.

4) Falls because 1), 2) and 3) are false or unproven.

5) The problem with this is?...

6) Really? Are not some of the old and sick sick because they got bit by an infected mosquito? Could not the young and healthy be made sick in the same manner? (That's just one example.) And as a group, there is also no reason to assume that the old and sick have had BETTER luck than the young and healthy; getting sick or being healthy is not only a matter of luck, and in any case we should not base our decisions on distributing resources on the basis of luck, should we?

7) You just called the thousands-of-years-old civilizations and traditions of the Chinese "stupid." Nice. Would it be such a bad thing for the young to feel that responsibility? Note, not responsibility as in making the old sick (although they certainly can be argued to be doing that, though increased pollution if nothing else), but responsibility as in feeling a duty to take care of their elders who are less able to take care of themselves, or who they simply love and respect?

8) That's a very facile conclusion. It requires a morality that is based on purely economic determinations of value and utility. In other words, cold and unfeeling. The morality of a computer and an Excel spreadsheet.

9) We ARE "giving health care to those who cannot afford it"; it's called "Medicaid." We also decided we could afford to give some health care to those who were old and needed more; we call it "Medicare." Both programs are "single payer," and are fairly successful at delivering care (not perfect!).

You're not going to get anywhere with this line of argument. The argument in FAVOR of single-payer is that it eliminates the health insurance industry, which are a bunch of emotionless, heartless lampreys attached to our healthcare system. The insurance industry exists because we decided to make health care a commodity rather than a right; the market took care of the rest, driving up prices ever higher, coverage and service ever smaller, and making outcomes less important than profits.

The United States health care system is not even in the top 10 in the world as far as outcomes; and the British single-payer system, for all of its faults, delivers significantly better outcome performance at 40% less cost. Bob Somerby at The Daily Howler has all the cites.

My #1 moral argument for single-payer is this: economics should not be used to quantify the value of a human life. Health care should not be a market commodity. It is one of the "inalienable rights," part of "life" and "the pursuit of happiness." To the extent that it can be provided to its citizens, government has a duty to provide it.

Posted by liberalrob | August 24, 2007 12:10 PM

Megan: Your new explanation isn't going to be any more satisfying than your last (very clear) explanation. Your interlocutors simply don't distinguish between "voluntary" and "involuntary." Astonishing, but true.

Posted by David Cohen | August 24, 2007 12:11 PM

Actually, you've done a pretty good job of explaining your position on this. I suspect that your philosophy student is one of those people who believes in single-payer as more or less an article of faith, almost as if it were a religious belief. Such people are immune to logic.

Of course, no part of the political spectrum has a monopoly on this sort of thinking. You can find plenty of examples of faith-based thinking among conservatives and libertarians. It's just that we notice it more when it comes from people with whom we disagree.

And by the way, what do you do when a BA in philosophy shows up at your door? You pay him for the pizza.

Posted by Jim Nelson | August 24, 2007 12:13 PM

Justin-

How is describing single payer as wealth transfer from the young and healthy to the old and sick (or old and healthy to the young and sick if you prefer, tho I would say the overwhelming majority of transfers would occur between the y&h to the o&s) false as a matter of fact?

The problem with health insurance, as many people point out, is that often the young and healthy will simply not pay in, meaning that prices for the old and sick increase because there is no pooling of risk. In a single payer, the risk is forcibly pooled, and with it the financial resources of those who were not previously in the system. That forced pooling reduces the average cost of someone in the system, thus making it a wealth transfer from those young & healthy persons who previously had held that money for their own use to the old & sick who are saving their own money by using the new money in the system to reduce their own costs.

So where is the falsity of wealth transfer in a single payer system?

Posted by Karl | August 24, 2007 12:13 PM

McArdle's analysis is flawed because you can apply it to insurance as well. When I enter an insurance pool, everyone in that pool is agreeing to transfer wealth from the "young and healthy" to the "old and sick". David Cohen is technically right in that insurance is voluntary...but when one basically has no choice to get insurance if they want any hope of affording medical care, I question how "voluntary" it really is.

Since there is no real difference between insurance and single payer on the "wealth transfer" front, which seems to be the crux of McArdle's arguement, we can now turn to the question of efficacy: which system more justly transfers wealth in this way? It is here that single payer wins hands down.

Posted by Musa | August 24, 2007 12:17 PM

Sooner or later the young and healthy will be old and sick. Under single payer, they are then covered by the next generation of Y+H, recovering their earlier input into the system. It's not a one-for-one proposition, but it's also not quite as simple as paying in for no personal benefit. The first generation of O+S get a big freebie, but after that the input is cycled back to the payer after a few decades, at least on average.

The above doesn't address the issue of effectiveness or coercion, but it does mean that the simple wealth transfer calculus is wrong, or at least grossly incomplete.

Posted by togolosh | August 24, 2007 12:25 PM

That's not what she said, what she said is that it transfers from "anyone" who is y+h to "anyone" who is o+s. That's not true. An 18 year old person who gets into a serios car accident will be a transferee, not a transferor. The only way to make Megan McArdle's absolutist statement true is to define "healthy" and "sick" in TERMS of recepients of health care. But if that's the case, then "old" and "young" are completely redundant.

But that wasn't even my primary point. The problem wasn't that it was false, but that it was only a description of an effect of health care, not the primary effect, and certainly not the purpose or nature.

Posted by Justin | August 24, 2007 12:25 PM

Musa,

The difference is that insurance is voluntary and single payer is not. When I buy insurance I am voluntarily paying my money. With single payer, the government is taking my money.

Relative to fairness, should a healthy couple just beginning their lives together be forced to subsidize health care for a 65 yr old millionaire?

Posted by jbb | August 24, 2007 12:28 PM

BTW, I don't think the problem is your commenters not understanding you. I think you have this assumption that if you just speak clearly enough, people will agree with you. They understand you. They think you're wrong.

Posted by Justin | August 24, 2007 12:29 PM

I think the post should lead off with point 9, which gets the crux of the issue.

If we take the view that government funding is rationalizable for the worst off, that still leaves the question of how to run the non single-payer system for everyone else. And there I think there are still some very non-libertarian conclusions forced by circumstances.

For example -- should we force people to buy health insurance? We force them to buy auto insurance (which btw means that this voluntary/involuntary distinction is not clear cut).

Do we require that everyone be charged the same rate for health insurance?

Or is the model that everyone is supposed to have enough lifetime income to self-insure?

And what do to about the likely worsening of adverse selection problems as genetic information gives people more information about their disease susceptilities?

Posted by P O'Neill | August 24, 2007 12:29 PM

Someone explain to me why "wealth transfer" to make sure everyone gets health care is any worse than "wealth transfer" to buy lots of tanks and planes.

Megan, please please please give up the Randian analysis. It heartless, cold, and unfeeling. Like Rand herself was.

Posted by liberalrob | August 24, 2007 12:31 PM

And what do to about the likely worsening of adverse selection problems as genetic information gives people more information about their disease susceptilities?

Posted by P O'Neill | August 24, 2007 12:29 PM

If you don't know what he's talking about, go rent "Gattaca." Imagine your job opportunities, lifestyle, even marriage prospects being determined by your DNA.

Posted by liberalrob | August 24, 2007 12:36 PM

liberalrob says:

My #1 moral argument for single-payer is this: economics should not be used to quantify the value of a human life. Health care should not be a market commodity. It is one of the "inalienable rights," part of "life" and "the pursuit of happiness." To the extent that it can be provided to its citizens, government has a duty to provide it.

If not economics, how do you quantify the value of a life? I'm more ok with market driven valuation as part of a voluntary transaction than arbitrary limits imposed by a bureaucrat or politician.

When did the government get into the funding of "the pursuit of happiness."? If that's what they're funding now, I've got a list...

Posted by Kevin | August 24, 2007 12:38 PM

2) For this to be moral, the entire enormous class of people who are old and sick must have some justified claim on the money of the young and healthy.

You're ignoring the fact that the young and healthy will not always be young and healthy. I think a more honest assessment is that the young and healthy subsidize the old and sick, the same way future generations of young & healthy will subsidize today's young & healthy once they become old & sick.

Additionally, you frame the question so that it pits the interests of one group vs another, leaving aside the question of whether society as a whole will be better off.

Posted by gorillagogo | August 24, 2007 12:53 PM

The difference is that insurance is voluntary and single payer is not. When I buy insurance I am voluntarily paying my money. With single payer, the government is taking my money.

Not all insurance is voluntary. What about auto insurance? In my state, at least, it's mandatory. So is mandatory auto insurance wrong because safe drivers subsidize unsafe ones? I would argue not at all, since we're all better off if everyone's insured.

Posted by gorillagogo | August 24, 2007 12:57 PM

I'm sorry, but the British system providing better outcomes for 40% less cost doesn't even pass the laugh test. My biggest problem with giving the government control of the health industry is that the government will screw it up. Right now, the insurance industry and the medical industry are both regulated by the government. Before going to a government run system, I'd rather try reducing the current levels of regulation.

Ultimately, single-payer where the payer is the government will be the same as government controlled as the government will put so many restrictions on what it will be paying for that it essentially be running things.

Posted by Earnest Iconoclast | August 24, 2007 1:03 PM

Liberalrob-

The difference between funding tanks and planes and funding healthcare is that society is in agreement that providing for national defense is one of the primary functions of government, whereas that consensus has not been reached with regard to providing healthcare.

And I see nothing wrong with cold calculated analysis in deciding spending and policy preferences. Empathy and sympathy are indeed virtues that we should cultivate, but they should never drive policy. Just look at the Schiavo debate.

Posted by Karl | August 24, 2007 1:05 PM

I think my issue with Megan’s post is that I don't think that people are actually making a moral argument for single payer. I believe people are making a moral argument for reform and that the majority is taking the position that single payer is the only alternative available.

To put it simply, I believe that as a society we think that money shouldn’t matter where your life is on the line. Hence the emergency room, our dysfunctional attempt at a social safety net. In the current system we are transferring money from the insured to the uninsured. Not exactly a big improvement on young and healthy to old and sick. For myself, I’m leaning more towards a national catastrophic insurance plan. Basically, if it’ll kill, cripple, or maim you you’re covered but please shop for anything else you need.

Posted by Mike Garfein | August 24, 2007 1:12 PM

wow, you are incredibly irritating and insensitive.

http://www.sadlyno.com/archives/6929.html

Posted by rageahol | August 24, 2007 1:20 PM

Gorillagogo,

There are two differences between health care and auto insurance

1) I can choose not to drive because the cost of auto insurance is so high. Many people in urban areas do this and many people moving their residences look at auto insurance costs as one variable in their decision.

2) I can shop for auto insurance, thus using market forces to give me options.

As far as I understand, this would not be possible in a single payer health care system

Posted by jbb | August 24, 2007 1:22 PM

I agree with Mike Garien.

Posted by jbb | August 24, 2007 1:26 PM

Okay, folks. There are a couple of things that really muddy the waters here. Let me take a stab at clearing this up:

- Megan, if you're going to reduce the entire populace into two simple categories, you would do much better to simply say "sick" and "healthy". Age has nothing to do with it and, honestly, makes you sound like a whining child. While I believe in health care reform, your points might not inspire such frustatration if they weren't couched in such dumb and kind of offensive language.

- Even if you divide the entire populace into "healthy" and "sick", you have the situation we ALREADY have. I.E., if I am healthy and purchase insurance, I am paying to support someone who is sick. Period. My premiums are paying for 21-year olds with colon cancer and 85-year olds who break their leg on the dance floor. I'm also "insuring" (the big hint is in the name) that, if something bad should befall me, that I can receive services without bankrupting myself. That I can choose my provider is an added benefit. But the situation you describe and treat as being so undesirable is the situation we are all already in.

- The moral issue, as I see, is not so much that it's immoral for people not to have health insurance. It's immoral (and I agree with this) that health insurance be so expensive that many, many people (and, though I don't have figures on it, I'd guess that the primary beneficiaries will be the young and poor) have to choose between being covered and putting food on their table (or getting a better job or having a child, etc.). Especially when the government could alleviate that burden without doing mucn. That's the moral argument. You're very, very busy building strawmen to attack here.

- Much of this system ALEADY exists. The majority of people advocating health care reform are advocating that we expand the programs that exist to cover everyone. Again, the prime beneficiaries of this will be the young, working poor whose jobs don't provide health insurance or a large enough wage to pay for it out of their own pocket.

- Many other commenters on this thread and the other health care threads, in spite of having it pointed out a number of times, insist on conflating single-payer health care and socialized medicine. No one even near the mainstream of American politics (or even on any of these threads) has come close to advocating socialized health care. As I understand the programs currently being talked about, private insuranc would still be available, the "government" would not be running the hospitals.

Posted by J. | August 24, 2007 1:29 PM

Jesus,

What a bunch of ridiculous wanking. The arguement for single payer healthcare is that the other western democracies have been implementing variations of single payer for decades with significantly better health outcomes at a significantly lower cost. If conservatives (and I guess libertarians) were really the clear-eyed pragmatists they pretend to be, they would be clamoring for a similar system. Instead, they are so in thrall to ideology that they write painfully silly blog posts like the one above.

I can't say how disappointed I am that the Atlantic has hired such a weak writer/thinker. James Fallows must be thrilled.

Posted by feral1 | August 24, 2007 1:29 PM

Hey Meghan,

Have you ever talked with an over-65 working class person?

Ever?

Posted by Jon H | August 24, 2007 1:30 PM

Megan, there are three critical problems with your analysis.

First, it makes factual claims with which some people disagree. This: The large class of old and sick people do not need the money for example is an issue of fact that many people believe is simply wrong.

Second, you fail to explore the entire universe of reasons for making transfer payments before making this really incredible claim: Thefore, as a group, the old and sick have no moral claim to massive transfer payments from the young and healthy

As an example, you do not address the temporal claim that the young will become the old. Nor do you address any of the other societal temporal transfers. For example, it can be argued at any one slice in time the young have no moral claim to massive transfer payments from their elders to pay for public education. Is there a moral argument for public education or is it purely an efficiency argument?

Third, you are grossly internally inconsistent in your argumentation. Any system of universal health care necessarily involves temporal transfer payments. So this: Arguments that we shouldn't let the worst off members of society die are not valid moral arguments for single payer. They are arguments in favor of giving health care to those who cannot afford it, a much more limited project simply makes no sense. Giving health to those who cannot afford it by definition means taxing those who have income (the healthy employed) and giving money to those who do not (the non-working elderly).

Since you seem consumed by the idea that grandma is getting hip replacement surgery without having to sell the family heirlooms, it would be nice to see a little intellectual honesty by having you support a wealth tax. And since taxing wealth is very difficult to do except at death of the asset holder, I anticipate seeing a long list of posts supporting the return of the estate tax.

To be blunt, your assumption that your readers are your intellectual inferiors is unsupported. Instead of just reading comments, try understanding them.

Posted by Francis | August 24, 2007 1:31 PM

I disagree with your first point jbb. Clearly, for some people choosing to not drive is an option but what about everyone else.

As for item 2, the fact that you can shop around for auto insurance just means that you can minimize the amount that you're required to pay, not eliminate it entirely. To take this example further, would single payer magically become moral if citizens were required to have some kind of coverage but were allowed to opt into one of several different plans and were taxed accordingly? I don't think you'd agree with that.

Posted by gorillagogo | August 24, 2007 1:35 PM

liberalrob wrote: My #1 moral argument for single-payer is this: economics should not be used to quantify the value of a human life. Health care should not be a market commodity. It is one of the "inalienable rights," part of "life" and "the pursuit of happiness." To the extent that it can be provided to its citizens, government has a duty to provide it.

Hold the phone -- what do they teach in Civics classes these days?

The "inalienable rights" you refer to are part of the Declaration of Independence, not the US Constitution, and were given as part of the cause for breaking ties with Britain. The revolutionaries declared that governments were to "secure" these things, which one can quickly discern -- both from the word's own meaning, and from the structure of the US Constitution that followed later -- is not the same thing as "provide".

It was only after about 70 years of US existence that a formal federal income tax was instated (to fund the civil war), and it was only after another 70 or so years that a president discovered the ability to use taxes to meddle in social services (with notably non-uniform results).

And now, after another 70-ish years, we have people mutilating the Declaration of Independence to claim that it is every citizen's right to have health care equality via enormous wealth transfers? A.F. Tytler's cynical maxim about the inevitable failure of democracy is looking wiser with each passing day.

Posted by anony-mouse | August 24, 2007 1:36 PM

WHO Rankings of the world's health systems (2000):
18. United Kingdom
37. United States of America
Source
Press Release

"The U. S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report finds. The United Kingdom, which spends just six percent of gross domestic product (GDP) on health services, ranks 18th."

Paul Krugman was the one who said, in an editorial behind the NY Times' "select" barrier (but quoted by Somerby), that:

"Meanwhile, every available indicator says that in terms of quality, access to needed care and health outcomes, the U.S. health care system does worse, not better, than other advanced countries—even Britain, which spends only about 40 percent as much per person as we do."

Quibble with Krugman if you want, but I trust his numbers.

Here's an SFGate.com article that talks about how we spend far more on health care as a percentage of GDP than many other countries, but still rank lower:

"Still, the United States spends a higher percentage of its gross domestic product on health than any other country -- more than 16 percent compared to France's 10.7 percent. The United States spends $6,102 per person in public and private funds compared with $3,159 per capita spending in France."

So much for the "laugh test."

Posted by liberalrob | August 24, 2007 1:39 PM

Francis, will you join me in supporting a 100% estate tax, with no exempted amount, until all Medicare benefits are recovered? Or are we to prefer the desires of a 55 year old eyeing an inheritance over the desires of the 20 year old working at Wal-Mart?

Posted by Will Allen | August 24, 2007 1:43 PM

The "inalienable rights" you refer to are part of the Declaration of Independence, not the US Constitution
Posted by anony-mouse | August 24, 2007 1:36 PM

Did I say it was in the Constitution? No. I got an "A" in Civics thank you very much.

The Declaration of Independence is a declaration of principles. The Constitution is a document organizing a government to secure those principles. They both are important to our national identity.

Posted by liberalrob | August 24, 2007 1:45 PM

My response to "Earnest Iconoclast," with links to supporting information, is held up in moderation.

Posted by liberalrob | August 24, 2007 1:46 PM

There's much to say, but I'll just limit myself to this: it is incredibly weasely, and intellectually bankrupt, to claim that people who disagree with you simply don't understand you. We do understand, and we think you're wrong. By playing that card, you're simply wiping the table clean of argument, rather than engaging in argument. I mean you've been at the Atlantic what, a week? And already I've seen post after post about how misunderstood and unfairly treated you are. That's not argument; it's an argument surrogate, a way to inoculate yourself from criticism without actually improving your position. It's amazing to me that someone who has had a blog for years is this unprepared to actually take part in the marketplace of ideas. Have the guts to confront the fact that people disagree with your arguments, or get out of the arena, please.

Posted by Freddie | August 24, 2007 1:47 PM

liberalrob is an advocate of slavery, and that isn't hyperbole. He actually thinks that he has an inalienable right to the labor of people who provide health care to him. Alas, this is what the term "liberal" has come to.

Posted by Will Allen | August 24, 2007 1:48 PM

What a bunch of ridiculous wanking. The arguement for single payer healthcare is that the other western democracies have been implementing variations of single payer for decades with significantly better health outcomes at a significantly lower cost.

...and the arguments against the inherent superiority of the other western democracies are that the ones which have tried to provide everything for nothing up front have encountered serious rationing problems and limited the overall access to the local healthcare market (Canada, Britain), and the others are dealing with smaller and frequently more homogenous populations (continental Europe, Japan). Long term, many of them are finding themselves to have serious cost problems in spite of everything (Canada, Britain, France), and peripheral markets are seeing shortages of professionals willing to work under the national healthcare terms (dentistry in the UK).

And in any case, pretty much all of these systems have found it necessary to cap pharmaceutical prices, with the consequence that drug companies are primarily conducting research in the wealthy, and as-yet uncapped, American market.

Meaning, it's a complex question in which one answer is not automatically right, and citing "it's worked elsewhere under limited contexts and for limited timeframes" is not a valid answer given that even the definition of "worked" is subject to a lot of contextual limitations.

If conservatives (and I guess libertarians) were really the clear-eyed pragmatists they pretend to be, they would be clamoring for a similar system.

"If everyone thought exactly like me, none would disagree, and what a wonderful world it would be. Wheeeee!"

Instead, they are so in thrall to ideology that they write painfully silly blog posts like the one above....I can't say how disappointed I am that the Atlantic has hired such a weak writer/thinker.

Wow, this must be really embarrassing for you.

Posted by anony-mouse | August 24, 2007 1:52 PM

(keeping the thread going here instead of in later posts)

Megan, you are turning increasingly to strawman argumentation. How many people are making the claim "single payer is moral" and how many people are making the claim "universal health care is moral"? And of the people making the first claim, how many of them are simply combing the moral argument -- universal health care -- with the efficiency argument -- single payer is the way to get there?

Here, for everyone to take potshots at, is a basic moral claim:

As a matter of morality, every US citizen, without regard to income, should have access to quality healthcare, including preventive care, emergency care, surgery, pharmaceuticals, mental health care, dentistry, vision and hospice.

Note that the moral claim says nothing about how to pay for it. It's the economists like Megan who raise issues about free riders and unstable insurance pools that lead to the consequence that the only way to achieve the moral goal is through some kind of single payer plan.

Posted by Francis | August 24, 2007 1:54 PM

I thought universal health care was for everyone and by everyone.

If we all pay in and all are eligible to receive benefits, how is that unfair?

Posted by Walter | August 24, 2007 1:54 PM

And Will Allen is an absolute fascist. He actually thinks people's entire existence and utility should be determined by the state, and when no longer useful, they no longer matter. Sadly, this is what the term "conservative" has come to. (And apparently, "libertarian" as well.)

Was that fun for you too?

Posted by liberalrob | August 24, 2007 1:57 PM

Gorillagogo,

I would be much more inclined to agree to mandatory insurance with a choice of insurance carriers. I, and everyone on this thread- libertarians and lefties-, all know there is a problem. It gets ugly when any disagreement is based on the morality or immorality of whichever side you happen to be on. It's almost like being on the wrong side of a religious discussion.

If mandatory insurance- multiple insurer plans get more people covered more efficiently yet still provides some element of choice for the individual, it sounds good.

Posted by jbb | August 24, 2007 1:59 PM

liberalrob wrote: Did I say it was in the Constitution? No. I got an "A" in Civics thank you very much.

Well then, that confirms my suspicions about what they're actually teaching in Civics classes these days. I guess they're only using NEA-vetted texts now.

The Declaration of Independence is a declaration of principles. The Constitution is a document organizing a government to secure those principles. They both are important to our national identity.

Then maybe you would like to spend some time responding to the charge that there is an evidential inconsistency between the original expression of those principles, and your efforts to employ them to ends the writers and a good portion of US history never espoused.

Posted by anony-mouse | August 24, 2007 2:01 PM

Will: It seems to me that the post-retirement social safety net needs to balance our desire to limit elder poverty with the universal obligation to pay into a universal system.

So, I think it would be fair for people over 65 who fail to make their annual health care payment to have that amount accrue against their estate.

But I haven't thought about it much, to be honest, so I'm open to being persuaded either way.

Posted by Francis | August 24, 2007 2:03 PM

And, one other point: the bulk of the uninsured in this country (according the CDC) are between the ages of 18-34. The "young and healthy". Who are, actually already paying to support the "old and sick" (particularly the poor, via Medicaid, but also, should they have insurance, via premiums). That separation has no bearing on reality.

Posted by J. | August 24, 2007 2:09 PM

As a matter of morality, every US citizen, without regard to income, should have access to quality healthcare, including preventive care, emergency care, surgery, pharmaceuticals, mental health care, dentistry, vision and hospice.

Serious Question: why? What moral calculus dictates that people are entitled to things that man did not have from time immemorial, invented only recently, and which can cost up to very large amounts of money to administer?

Please note that a valid answer can not be lightly re-arranged to claim, with equal facility, that all are entitled to a Ferrari; or that all persons are entitled to an identical ideal physical constitution, because the natural world will just laugh at you.

Note that the moral claim says nothing about how to pay for it.

...and therein is a recipe for disaster. Good ideas can be shared all day long without ever having a realistic grounding for application, and then when somebody does try to apply them, the law of unintended consequences kicks in.

Posted by anony-mouse | August 24, 2007 2:11 PM

liberalrob, look, don't get all uppity when it is accurately asserted that a person who states that he has an inalienable right to that which is provided by the labor of others is, in fact, a supporter of slavery. If you don't like a logically inescapable and wholly accurate description of your beliefs, then change your beliefs.

Also, don't lie about what others have written, simply out a chidish fit of anger at having your beliefs accurately described. I really would prefer that the state have much less influence on people's existence, and I have never thought about whether a person "matters" or not, since my default position is that everyone does.

Now, dear liberal, if you want to explain how you can have an inalienable right to that which is provided by others' labor, without others becoming your slave, feel free.

Posted by Will Allen | August 24, 2007 2:12 PM

I assume the case for single-payer is similar to the case against means-testing for Social Security benefits: Sure, means-testing would make the system more distributionally moral, but it wouldn't be supported by the politically powerful group of mid- and upper-class old people necessary to ensure the program's continued existence.

Under basic public choice theory, Megan's preferred alternative--government provided healthcare for those who can't afford it--is not a politically viable option. You either have a program that caters to the politically powerful, or no program at all.

Posted by J | August 24, 2007 2:14 PM

So Meaghan - Your first 8 bullett points would seem to argue in favor of never providing free medical care for the elderly. Would you favor the repeal of Medicare and the requirement that hopsitals treat the indigent? After all, that's a transfer of resources.

What if a 75 year old indigent person comes into a hospital with an infection that could be treated with antibiotics but would otherwise kill him. Should society ensure treatment takes place? What if the 75 year old indigent person was somehow blameworthy for the infection, does that change your calculus per your #5.

The government does all sorts of things with disparate impacts because they benefit society as a whole (everything from roads to parks to libraries to museums to social services). If single payer would benefit the country as a whole by providing better health care and lower cost, then it is worth doing even if members of society realize a greater benefit when they are older. It has a moral component if single payer advocates are correct that it will lead to better health outcomes.

Posted by Chuck | August 24, 2007 2:17 PM

Chuck,

What if the same 75 year old indigent comnes in needing a $1,000,000 heart transplant? Should society insure that takes place. What if he needs a drug that will cost 100k/yr? I think at some point any system will have to say no at some point and each choice requires trade-offs.

Don't you think a single payer system will also require the system saying "no" to some people some times.

Posted by jbb | August 24, 2007 2:21 PM

Single payer is blantantly redistributionist, but that's not a bug, it's a feature. An economy simply works better when Labors medical costs are socialised. You get better outcomes.

Posted by Northern Observer | August 24, 2007 2:22 PM

No, chuck, the point is that the elderly as a class are far wealthier, and are getting wealth transferred to them from people much poorer as a class, and some of those poor saps aren't even going to see old age, after forgoing the chance to enjoy the dough they coughed up to the rich geezers.

"Liberalism" in today's venacular, when it isn't the pure thuggery advocated by the likes of liberalrob, often is nothing more than the advancement of a gerontocracy, wherein the old lord over the young. I ain't young anymore (sigh), but screw that.

Posted by Will Allen | August 24, 2007 2:26 PM

More wanking...

[...and the arguments against the inherent superiority of the other western democracies are that the ones which have tried to provide everything for nothing up front have encountered serious rationing problems and limited the overall access to the local healthcare market (Canada, Britain)]

Serious rationing compared to the US? Nope. They cover a much larger % of their population (100%) with better health outcomes for significantly lower per capita cost. The US system has led to greater rationing at a higher cost.

[and the others are dealing with smaller and frequently more homogenous populations (continental Europe, Japan).]

No country is the demographic doppleganger of the US. This, of course, does not mean we cannot learn from their example.

[Long term, many of them are finding themselves to have serious cost problems in spite of everything (Canada, Britain, France)]

Yet they are still providing universal healthcare at a lower per capita cost than the US. So they would be in a worse position if they adopted a US style system.

[And in any case, pretty much all of these systems have found it necessary to cap pharmaceutical prices, with the consequence that drug companies are primarily conducting research in the wealthy, and as-yet uncapped, American market.]

Somehow we manage to do enormous amount of R&D to get hugely expensive and complex high tech weapons systems through a single payer system. I imagine pharmaceutical R&D will do alright under single payer health care.

[Meaning, it's a complex question in which one answer is not automatically right, and citing "it's worked elsewhere under limited contexts and for limited timeframes" is not a valid answer given that even the definition of "worked" is subject to a lot of contextual limitations.]

Particularly vigorous wanking. Has anything anywhere ever "worked" under unlimited contexts and unlimited time frames? I've provided my definiton of "working"- providing better health outcomes for the general population at a lower per capita cost.

Posted by feral1 | August 24, 2007 2:29 PM

Then maybe you would like to spend some time responding to the charge that there is an evidential inconsistency between the original expression of those principles, and your efforts to employ them to ends the writers and a good portion of US history never espoused.

Posted by anony-mouse | August 24, 2007 2:01 PM

Would it make any difference if I did?

Sigh. The Founders were brilliant men but not omniscient. Their words expressed truth as they understood it. Others removed in time and space might understand them differently. Their intent is unknowable except in the context of their times and what is revealed in their own writings; our interpretation of their meanings is not dependent on that intent and will inevitably reflect the context of OUR times. Maybe it never occurred to them that health care, which in their time consisted of scanty anatomical knowledge and theories we laugh at today in their backwardness, would become so advanced that the average lifespan today would be nearly double that of their era. Maybe they never considered health care something that might be vital to life and the pursuit of happiness, or that access to health care regardless of cost and ability to pay would be one of the "blessings of liberty." That doesn't prevent me from believing that today, nor does it invalidate the Declaration or the Constitution.

Posted by liberalrob | August 24, 2007 2:30 PM

liberalrob, look, don't get all uppity when it is accurately asserted that a person who states that he has an inalienable right to that which is provided by the labor of others is, in fact, a supporter of slavery.

Will, your definition of "slavery" can be extended to ALL government services provided through taxation. The income tax is slavery. Sales taxes are slavery. I find that laughable. I pay taxes so government will provide me services. One of those services I want them to provide me is a doctor whenever I need one. You might as well say that the soldier over in Iraq is my slave, or the State trooper who writes my speeding ticket is my slave.

Posted by liberalrob | August 24, 2007 2:38 PM

The sort of wanker who would compare the R and D effort, subsequent demand for the output from the R and D, and the subesequent political/budget implications, of a F-22, and that of a drug that could be used by millions of people, has no business being sarcastic about others' alleged wanking, and the rest of the wanker's post is so similarly ill thought out that it isn't worth any more time.

Posted by Will Allen | August 24, 2007 2:38 PM

liberalrob,

Maybe your right but please consider that one thing for sure we do know about the Founding Fathers intent is that they believed in limiting the scope of government.

While it is possible that the Founding fathers might view health care as you do, you should include their reluctance to enhance the powers of the state into your calculus.

Posted by jbb | August 24, 2007 2:39 PM

Liberalrob:

You're right, of course, about the "blessing of liberty", etc. in the Declaration, but perhaps you can silence your critics by referring to the Constitution (since they seem to want you to).

The Constitution was forged to (among other things) "promote the general welfare". "Welfare" definitionally pertains to, among other things, the health of American citizenry. In real terms, that means -- at the very least -- access for everybody to quality healthcare.

To exhault capitalistic concerns over such a fundamental bedrock principle of this country is, to me, simply and utterly un-American.

Posted by Kman | August 24, 2007 2:42 PM

liberalrob, you apparently are under the laughable impression that you have an inalienable right to protection provided by the U.S. military, or an inalienable right to other material benefits provided by government. You don't.

Posted by Will Allen | August 24, 2007 2:42 PM

Liberalrob,

the soldier in Iraq is a volunteer. he knew he could not control his assignment when he enlisted.

The State Trooper is a voluntary employee.

You act as if the government just creates the money. You personally may want to government to pay for your healthcare. What is someone else wants the government to pay for their shelter? Are those rights equal?

Posted by jbb | August 24, 2007 2:42 PM

kman, the fact the fellas in Philly stated that the promotion of the general welfare is a purpose of the U.S. government says exactly nothing about citizens having an inalienable right to that which is provided by the U.S. government, via the action of elected representatives. Sheesh, it is embarrassing that this needs to be explained. The fact that elected representatives have enacted laws to provide X, or could enact such laws, does not create an inalienable right to X.

Posted by Will Allen | August 24, 2007 2:50 PM

While it is possible that the Founding fathers might view health care as you do, you should include their reluctance to enhance the powers of the state into your calculus.

Posted by jbb | August 24, 2007 2:39 PM

Don't fall into the "strict constructionist" trap of "let's determine exactly what the Founders meant, then do that much and no more." They intended the Constitution to establish a government structure flexible enough to change with the times, not to establish a rigid exoskeleton that would forcibly control all thought. There is no reason to believe that they would not accept a similar growth in the interpretation of the values of the Declaration of Independence; or that new values they didn't consider might not flow from it.

Posted by liberalrob | August 24, 2007 2:54 PM

"the fact the fellas in Philly stated that the promotion of the general welfare is a purpose of the U.S. government says exactly nothing about citizens having an inalienable right to that which is provided by the U.S. government, via the action of elected representatives."

I never postured it as an "inalienable right"; just that it is an objective of our government.

Now that we seem to be in agreement on that (thus mooting McCardle's bullet points), the only thing that remains is how to get there.

Posted by Kman | August 24, 2007 2:55 PM

Correct, it was the "liberal" who claimed he had an inalienable right to the labor of others. My apologies, Kman.

Posted by Will Allen | August 24, 2007 2:59 PM

liberalrob,

No doubt that the Founders wanted a government that would change, that's why we can amend the Constitution.

By asking you to at least consider and acknoweldge the definite intent they had to keep government limited, does that make me a strict contructionist? I never said we shouldn't do more but we should temper our changes with the clear awareness that expanded the role of government too severely has it's own set of dangers.

Posted by jbb | August 24, 2007 2:59 PM

You act as if the government just creates the money. You personally may want to government to pay for your healthcare. What is someone else wants the government to pay for their shelter? Are those rights equal?

Posted by jbb | August 24, 2007 2:42 PM

If we as a society determine that they are, then yes. It's not just about what I want. In point of fact, government DOES "just create the money." Literally (at the printing presses) and figuratively (through taxes). And I have a say, as does everyone else, in how that money gets spent.

As a society we have determined that we want to provide health care to those that need it. Fine, as it turns out over the long haul a market system is a lousy way of doing that; we have all kinds of ugly outcomes and horror stories. It's time to try something else.

Posted by liberalrob | August 24, 2007 3:02 PM

I'm young, and I'm already transferring my money to the wealthy old via a universal health care system. You may have heard of it, it's called "Medicare" and it's been rather popular.

Indeed, single payer would extend health insurance coverage, now the sole province of the elderly, to everyone. Hooray!

Can one argue about using market forces to keep costs down? Sure, and go ahead. But this argument is facile simply because the one group in America that does have universal insurance is the old.

Posted by Jeff Fecke | August 24, 2007 3:02 PM

Liberalrob,

Our system is not lousy, but it is not perfect. The governemnet does not create money - it taxes citizens to both pay for government and also to redistribute it. It does not randomly print money - that would create hyperinflation. The rate of grwoth of the money supply is carefully controlled.

Isn't there a chance that, by changing the health care system dramatically, you can make an imperfect but good system worse? Please at least admit that to yourself.

How would you feel if the system you created did not perform to the level of expectations? Surely worse exists than what we have now, conceivably.

I try and resist dogma, despite the fact that I lean to the right. Please do the same on your side of the aisle.

Posted by jbb | August 24, 2007 3:08 PM

liberalrob, if you want to say that providing health care via market forces is bad idea, because too many people wouldn't get enough service with cutting edge technology, fine. However, saying that health care delivery in this country today is market based is as silly as saying you have an inalienable right to health care.

Posted by Will Allen | August 24, 2007 3:09 PM

liberalrob, you apparently are under the laughable impression that you have an inalienable right to protection provided by the U.S. military, or an inalienable right to other material benefits provided by government. You don't.

Posted by Will Allen | August 24, 2007 2:42 PM

Really? Well, shucks. And here I thought that was why I was paying taxes to provide with all those things. Remind me again why I pay taxes? Is it just to give Congress some Monopoly money to throw around?

Laughable indeed.

"We hold these truths to be self-evident, that all men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness. — That to secure these rights, Governments are instituted among Men, deriving their just powers from the consent of the governed"

Just in case you forgot. (Emphasis mine)

Posted by liberalrob | August 24, 2007 3:13 PM

Liberalrob,

Many people could read your quote and conclude that the government has no right to tax me to pay for your health care. Rights include property rights.

Posted by jbb | August 24, 2007 3:16 PM

You act as if the government just creates the money. You personally may want to government to pay for your healthcare. What is someone else wants the government to pay for their shelter? Are those rights equal?

And you act, jbb, as if "the government" is some otherworldly entity beamed down from outer space that imposes its will on the populous.

News flash: we are the government. I'm pretty sure that the Only Good Republican(tm) uttered that.

That said, there seems to be a consensus that health care as it exists now does not work. And the single-payer system seems to be the best alternative (you got a better one?).

Is it wealth transfer? Sure, but what isn't? Part of my tax dollars go to public schools that I don't attend, wars I don't support, roads I will never travel on, etc. By the same token, some of your tax dollars are going to things you don't benefit from.

Thus it is; thus it shall always be. That's how America works. McCardles argument that "Whoa! Some people will pay for things that they don't benefit from!", aside from being short-sighted to the point of being false, is simply irrelevant. One wonders how much macroeconomics she actually studied.

Posted by Kman | August 24, 2007 3:18 PM

Not to take this too far off topic, but I'm wondering how the single-payer advocates account for the 5% (or more) undocumented immigrants here in the US fitting into a single payer plan?

Are they automatically covered, or not?

Posted by Kevin | August 24, 2007 3:23 PM

Our system is not lousy, but it is not perfect.

We pay twice as much per capita as France for a system whose average quality of outcome doesn't rank in the top 30 according to the WHO. How is that not lousy?

Isn't there a chance that, by changing the health care system dramatically, you can make an imperfect but good system worse? Please at least admit that to yourself.

Sure. But when almost every other industrialized nation has single payer, pays less per capita and has BETTER health care, I think there's a pretty minimal chance of that happening. Don't you?

How would you feel if the system you created did not perform to the level of expectations? Surely worse exists than what we have now, conceivably.

Yes, and conceivably I might win the lottery tomorrow. But up till now I've probably bought a thousand tickets and never won more than $5; I think there's a pretty good chance I won't win it tomorrow. Certainly the lottery isn't living up to my level of expectations! Maybe I should try something else.

Posted by liberalrob | August 24, 2007 3:24 PM

kman,

I am part of the "we" that you call the government. I do not agree with you that health care does not work, on the whole, and I don;t know where your consensus comes from.

I think it is arrogant and foolhardy to change a complex, expensive system that, for the most part, does a good job - not a perfect job, until your solution is clearly an improvement.

If your solution worsens the problem, or creates secondary problems, will you then be able to correct it or will you have created a greater monster.

All I am saying is that I do not think you have a consensus in the US that we should all accept a magical single provider system. Some people, me included, have rational concerns about that.

What does that have to do with whether I am or am not a Republican?

Posted by jbb | August 24, 2007 3:29 PM

Where in Megan's post did she say that she opposed any and all wealth tranfers? She did say that transfers that primarily take from a poorer class and give to a wealthier class probably aren't a good thing in and of themselves.

She also didn't say that if you disagreed with her it was because you didn't understand her arguments. She said that she was asked about A, wrote a lengthy post giving her thoughts on A, then was asked, "Yes, but what about A?". I don't think it was unreasonable to assume lack of understanding was an issue in this case.

Jeebus people, attack her arguments, not whatever mythical neocon bogeyman you're imaging her to be. (And how insulated must the Atlantic's readership be if Megan is considered to be some invading Limbaugh?)

And I'm not an expert, but don't most private insurance plans have risk pools, where risk is shared among people in similar risk classes, not transferred from one class to another? And if true, doesn't that invalidate most of the comparisons to things like auto insurance being made on this thread?

Posted by Sean E | August 24, 2007 3:31 PM

<