Sick of being sick

A commenter responds to my last post thus:

People don't have a right to money from society simply because they have gotten sick.

I disagree. Now what?

Well, obviously, at some level we're just going to have to agree to disagree.

But it raises some interesting questions. Why do you disagree? If we should give money to sick people regardless of need, is it because being sick sucks and we're giving people bonus payments for having sucky things happen to them? If that's the case, why don't we give people bonus payments for, say, being really ugly, or being severely socially awkward, both of which seem at least arguably worse than, say, having chronic asthma.

Also, if they deserve money just for being sick, why give them the money in the form of healthcare? Wouldn't a cash transfer be even better? Then the people who wanted to be treated could spend the money on healthcare, and other people could spend the money on something they valued even more than healthcare. It seems like a Pareto improvement in net happiness over a simple single-payer system.

Finally, if they deserve money just for being sick, why don't we peg the money to the suffering the disease causes, rather than the cost of treating the disease? Inquiring minds want to know.

Comments

If you don't believe in state enforced positive rights, then you must simply disagree with such a position. I hold that the only rights are negative ones for the very simple reason that it is the only clear and logically derived demarcation one can make. Once one starts advocating moral obligations to others as the rights of those others, then you are forced to make purely arbitrary decisions as to what are rights and what are not.

Posted by Yancey Ward | August 28, 2007 2:01 PM

One thing that's at least as annoying as switching back and forth between different lines of argument is picking the least cogent of the oppositional comment responses to one's blog post, and then acting as if THAT's the argument that most of one's opponents can get behind.

Posted by brooksfoe | August 28, 2007 2:08 PM

Megan, since I think that I've made over half a dozen comments on your various posts on this issue, you already have the answers you're looking for.

To reiterate, my moral claim is as follows:

All Americans, without regard to wealth or income, should have access to a full range of adequate health care services.

This is different in important ways from the prior that you argue against below, as shown by your hypotheticals.

If we should give money to sick people regardless of need, is it because being sick sucks?

bzzzt. Assumes facts not in evidence. We are giving money to the health care providers for providing treatment to the person who can't afford it, not a transfer payment to the individual. All the rest of your hypotheticals also assume a cash payment to the sick person; this is a strawman argument.

Posted by Francis | August 28, 2007 2:09 PM

Talking about people "deserving money" for being sick is one (interesting) way of putting it; another is saying that we have a duty as a society to ensure the health of others, even those who cannot afford to pay for their medical care. Because life is precious and all that, even if it's other people we're talking about!

Now of course this principle cannot be extended indefinitely, and ultimately you have to put a dollar figure on what a life is worth and so on.

Simply giving poor people more money has some political disadvantages that you might be aware of. For example (this is probably a big shock to you, but you shouldn't be so naive about how people think) if we simply gave poor people more money, then it might be widely perceived that the poor didn't do anything to deserve that money, and that if they spent it on Cadillacs, cigarettes, booze, and flat-screen TVs it would be stupid and immoral. If you give poor people only money to take care of their health, then you can be more assured that they are not wasting it.

As for your last question, it's not that government funding for health care is a reward for poor people getting sick. Rather, it's a way to improve people's health, which people intuitively place a large moral value on.

Question for the libertarians: most advances in life expectancy over the past few centuries are due to improvements in public health (sanitation, vaccination, etc). Um, do you think this fits in better with a perspective of "why should poor people get a bonus for being sick" or a perspective of "the government should work to ensure that its citizens are healthy" (of course, not that there is no element of personal responsibility when it comes to health outcomes, just that personal responsibility is not the only thing).

Posted by Barbar | August 28, 2007 2:10 PM

AH, then you DON'T think that they have a right to money by virtue of being sick. You think that we should give money to healthcare providers in order to cover the treatment of those who cannot afford to pay for their own. As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it. Is that correct?

Posted by Megan McArdle | August 28, 2007 2:13 PM

I think I'm just gonna cut and paste this in every health care post until you answer it:

I'm still waiting for a post where you describe exactly what you think the 47 million should do to get health care. Preferably one that doesn't involve a)them going into enormous debt, b)sucking it up, or c) "just get rich!".

It's a question that you simply have to answer. Your answer can be "They can drop dead," that's fine. But both you and your commenters indicate that you do, in fact, think that people who need health care and can't afford it should be given the ability to get it. But you need to explain how, precisely, you think they should do that. The best I can find is a few vague references to some sort of payment vouchers. So I really think it's important for you to describe either a) what you think the uninsured in this country can do, in the current system, to get health care, with the caveats I mentioned above, or b), how the system should change to allow them to do so, if not through universal government-funded coverage.

Also, let me just say: I think the libertarian members of this little community need to understand that, for the large majority of our population, the term "wealth transfer" doesn't arouse existential terror. (A wealth transfer! Horror of horrors!) I don't mean to say that that fact proves anything either way about universal health care or not. But people around here seem to think that if you logically maneuver until you can refer to something as a wealth transfer, you've finished the argument. "So you see, what your proposing is in fact a wealth transfer! CHECKMATE!" Most people don't care if you call it a wealth transfer.

Posted by Freddie | August 28, 2007 2:17 PM

Megan, again, there will be a lot of people here who are for universal coverage but not against means-testing. But the other way to think about this is as an insurance policy which people enter when they start paying Medicare taxes. It's not part of the deal, when you start paying, that if you get too rich, you don't get your money. One could redefine the terms of the deal this way, but without having done that, there may be an additional harm to introducing means testing, which is that wealthy people excluded from benefits will see it as a "taking" of money they've put into the system.

Posted by brooksfoe | August 28, 2007 2:22 PM

AH, then you DON'T think that they have a right to money by virtue of being sick.

WHO is arguing? WHAT pundit or commentator thinks that we should just cut a check to someone who gets ill? How can you REALLY not understand that there is a difference between providing health care, through whatever actual transfer of money, and giving someone money as PAYMENT or COMPENSATION for getting sick?

As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it. Is that correct?

Man. If only he had made some sort of statement that made the answer perfectly plain.

Oh, wait: All Americans, without regard to wealth or income, should have access to a full range of adequate health care services.

Posted by Freddie | August 28, 2007 2:22 PM

Barbar,

If it could be shown that life expectancy could be raised by having a government camera in every public and private location, would you be in favor of it? Are you in favor of mandatory colonoscopies? Mandatory breast exams? Mandatory angiograms? Yearly physicals?

Posted by Yancey Ward | August 28, 2007 2:29 PM

Are you in favor of mandatory colonoscopies?

A few involuntary recipients do come to mind, yes.

Posted by brooksfoe | August 28, 2007 2:31 PM

As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it. Is that correct?

This is a strange rebuttal; as far as I'm concerned means-testing is a pragmatic issue, and I haven't thought about the politics or economics enough to know where I stand. Also, it's just bizarre phrasing. *I* am going to pay for health care for people who can afford it themselves? If the government redistributes some wealth to allow poorer people to afford better health care, it's unlikely that people who can afford health care without government intervention are going to come away with a windfall, because you know *they* are going to be paying taxes too.

Megan, quick question: who has paid for the cleaner sewers and uncontaminated drinking water and vaccinations that mean you'll probably live to be over 70 years old?

Posted by Barbar | August 28, 2007 2:32 PM

As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it. Is that correct?

No. In a mandatory system, those who can afford it do pay for themselves, and subsidize those who cannot pay as well.

Megan, note that your comment makes an efficiency claim, not a moral claim. The prior (since when is prior a noun?) remains that as a moral matter all Americans should have access to a certain level of health care (which the current system does not provide).

Megan, you seem to be assuming that any universal health care system must be supported by income taxes. (Hence your comment about a hairdresser paying for Buffet's health care.) That is not the case. The US could, for example, create an entirely separately budgeted system in which shortfalls would be made up by increases in the cost of the policy.

Posted by Francis | August 28, 2007 2:33 PM

"Are you in favor of mandatory colonoscopies? Mandatory breast exams? Mandatory angiograms? Yearly physicals?"

As absurd as it sounds, this is the logical conclusion of the obsession of the left with preventative care. Brad DeLong had a similar idea.

Posted by Klug | August 28, 2007 2:35 PM

I'm still waiting for a post where you describe exactly what you think the 47 million should do to get health care.

That does not deserve a post. Go to the doctor and pay for his services. That is, surprisingly enough, exactly what most of the uninsured do now, except that the price of services available to them (price, not necessarily cost) is artifically inflated by the collective monopoly of health "insurance" companies and Medicare. How do I know? I've been actually reading my "explanations of benefits" for a looooong time; I've also been uninsured (with family of 4) for awhile.

Now, before you start talking about chronic/catastrophic diseases with treatments priced well out of reach of an average American, adjust your 47,000,000 number accordingly, based on verifiable statistics.

Posted by ...Max... | August 28, 2007 2:35 PM

Do you honestly believe that there is no cost to people when the uninsured don't get health care? So you are happy to work in an office where large numbers of workers don't have health care. And when you catch something from them that could have been treated, this costs you nothing?

This seems to rest on a total ignorance about biology. Diseases are infectious, they pass from person to person. People without access to health care become resevoirs of infection, which they pass on to people with health care. The larger the resevoir, the more opportunity the pathogen has to mutate into greater virulance.

Universal care is self defense, which Libertarians should support.

BTW, obesity, heart disease and cancer are now known to have viral components.

Posted by dalea | August 28, 2007 2:37 PM

If it could be shown that life expectancy could be raised by having a government camera in every public and private location, would you be in favor of it? Are you in favor of mandatory colonoscopies? Mandatory breast exams? Mandatory angiograms? Yearly physicals?

Let's turn this around: if you could choose between living in a society where all the government did was enforce property rights but life expectancy was 25, or you could live in a society where the government collected some taxes and ran some health programs and life expectancy was 80, what would you choose?

Geesh. Life is a balance. I understand that there can be conflict between utilitarianism and freedom, and freedom is precious (and in fact there are plenty of utilitarian reasons to protect freedom). So what? The government is not the only threat to freedom in the world (although it does have some special characteristics).

Posted by Barbar | August 28, 2007 2:39 PM

Freddie, calm down. It would be funny, if it were not so sad, to watch you disagree when you actually agree. I'm not saying you believe what you think Megan believes. I'm saying *she* believes what you seem to believe. Correct me if I'm wrong, but while you support universal healthcare it does not appear that you (and Francis and...) think that the justification for single payer is to pay Warren Buffet's medical expenses. Presumably you're largely neutral to Warren getting free healthcare, but that's not the point, right? Based on past posts I believe that Megan supports universal healthcare but not paying Warren Buffet's medical expenses. Is there really disagreement here? Can we move on?

Perhaps you're just tired of arguing with posters who don't support any positive rights, but you need to "stop looking eight moves ahead." If you can be patient, we can work through the discussion step by step. I, for one, am interested in hearing a coherent argument for single payer (not universal healthcare, and there is a difference).

Posted by Bob | August 28, 2007 2:42 PM

"AH, then you DON'T think that they have a right to money by virtue of being sick. You think that we should give money to healthcare providers in order to cover the treatment of those who cannot afford to pay for their own. As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it."

In answer to your question, no, that's not what *I* think, at least.

Let's break it down piece by piece:

"You think that we should give money to healthcare providers in order to cover the treatment of those who cannot afford to pay for their own."

Sure, that's one way of doing it, but there are others. I'm not enough of an expert really to judge between all the options, but I think that in some fashion money should be allocated by society to provide health care for people who cannot afford it.

"As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it."

No. I think it's possible to achieve the first part while allowing those who COULD afford health care to pay for themselves. I do, however, suspect that this sort of hybrid mechanism is in fact likely to be more efficient than the system we have in the US now.

It seems increasingly likely, based on a lot of the comments so far, that much of this brew-ha-ha stems from many different universal health care systems being lumped together as being called "single payer".

Posted by jme | August 28, 2007 2:43 PM

"Are you in favor of mandatory colonoscopies? Mandatory breast exams? Mandatory angiograms? Yearly physicals?"

I mean, the next thing you know, these Commies will be demanding mandatory universal vaccinations. They'll be testing our kids' vision in public schools! They'll be mandating safe public drinking water in every home!

Is there no stopping these totalitarian madmen?

Posted by brooksfoe | August 28, 2007 2:49 PM

Freddie - again I agree with Max. Access to health
care is not the same as having it paid for.

And as to the 47 million.

From the report by the
U.S. Census Bureau entitled
"Income, Poverty, and Health Insurance Coverage in the United States: 2003"

in 2002 fully 20 percent of those that did not have health insurance lived in a household with income of more than 50 thousand dollars. (page 15 near the bottom) ( their number for uninsured is slightly less than 44 million in 2002)

Would anyone suggest that those 8.7 million people are not getting health care?

Posted by martin | August 28, 2007 2:56 PM

Go to the doctor and pay for his services.

Wow, the case cracker! Why didn't I think of that!They should just pay! Like when I was knocked unconsious at work, and the bill, all together, came to $13,000+. If it had happened at home, and I hadn't had the protection of workman's comp, I would have just paid the doctor. You know, with that $13,000 I and many others have just lying around.

If you can be patient, we can work through the discussion step by step. I, for one, am interested in hearing a coherent argument for single payer (not universal healthcare, and there is a difference).

Will try to be more patient.

I think a good place to start with that discussion, by the way, is for Megan to define single payer, because she throws it around constantly, and the definition seems ever shifting.

Posted by Freddie | August 28, 2007 3:01 PM

Barbar,

But that is the point! Where do you draw the line? How much burden for providing positive rights is too much? How much reciprocal control do the providers of means have on the recipients? If I am going to bear the burden of your healthcare, then why don't I have a right to force you to get preventative care? Or why don't I have the right to monitor your every move? I now have a positive right to infringe on your liberty because you have asserted a positive right to my property. In other words, what rights are recipients required to relinquish in order to get someone else to pay for their healthcare? You evaded the question, but I am very persistent.

Posted by Yancey Ward | August 28, 2007 3:02 PM

AH, then you DON'T think that they have a right to money by virtue of being sick. You think that we should give money to healthcare providers in order to cover the treatment of those who cannot afford to pay for their own. As a side effect of this, you are willing to pay for the coverage of those who COULD afford to pay for themselves, because you think this is the best or most efficient way to provide coverage to those who cannot afford it. Is that correct?

Seems good to me, I would slightly alter to say to provide coverage to all of those who cannot afford it, as I am sure that there are some more efficient ways to piecemeal cover most of those who cannot afford it. I also think I probably have a more liberal definition of afford than you, as I don't think its reasonable to push people into poverty simply because they technically can cover their medical bills.

Posted by TomTom | August 28, 2007 3:07 PM

brooksfoe,

Then I take it that you support making all those procedures mandatory. Or were you trying to make a smartass remark and failed?

Posted by Yancey Ward | August 28, 2007 3:13 PM

But that is the point! Where do you draw the line?

Political questions like these are resolved through political debate. So, your answer would be, "Wherever the political consensus of the moment says it should be."

Arbitrary? Of course. But also completely legitimate, as long as the political process itself isn't tainted.

Posted by Immoralist | August 28, 2007 3:14 PM

But that is the point! Where do you draw the line? How much burden for providing positive rights is too much?

Yancey I understand where you are coming from but I think that, like a lot of people who deny positive rights (or whatever), you are engaging in a slippery slope fallacy. Yes, it's true, we will have to draw some arbitrary distinctions between what the public prevents for and what it doesn't, what hardships government will try to prevent and which they won't. But we make arbitrary distinctions as a society all the time. If you have sex with a girl a day before her 18 birthday, you go to jail. If you have sex with her the day after, you don't. If you buy 19 hits of a drug, you go to jail for 6 months. If you buy 20, you go for 3 and a half years. If you earn $40,000 a year, you get taxed a certain amount... you get my point. Sometimes you hear people say, well, if we are going to provide health care as a society to everyone, why not clothing, shelter, etc. In a sense, yes, it's arbitrary. But I don't think it necessarily follows that the arbitrary nature of the distinction means our position is illegitimate.

Posted by Freddie | August 28, 2007 3:15 PM

Yancey, aren't these just messy political questions? It's a bit like asking, "Well what should the government do if 55 percent of the population supports officially lynching members of this minority group?" I don't know where exactly I fall on each of these questions -- I don't think I would support any of the "mandatory" demands that you suggest, probably because I doubt it would be particularly worthwhile from a cost-benefit perspective to enforce mandatory colonoscopies, etc. I get the feeling that you're suggesting that if I were a libertarian I'd have a principled way of saying "no no no" to each of these but that's not particularly important to me to be honest (for example, I support mandatory vaccinations).

Posted by Barbar | August 28, 2007 3:18 PM

What about those people who are not only not insured, but who essentially injured themselves. Say a fifty year old lifelong smoker who now needs three million dollars in medical care to replace his heart and lungs and needs $50,000 a month to keep him alive, which he hopes will be for a few decades more. And he has no health insurance, and the health problems he does have he got from smoking, something he took up despite knowing what it would do to him.

Should we all pay for that? What happens if the amount of money for medical care exceeds the taxes collected? This can be a very real issue as really really REALLY expensive medical procedures become available to keep people, who otherwise would be dead, alive for decades (though perhaps not with great quality of life). Should those procedures just be for those who can afford it, or should all of us pony up 500% increased premiums to cover them?

Posted by Disgusted Beyond Belief | August 28, 2007 3:24 PM

In my hypothetical question above, the government should be a democracy.

It's also a bit like asking, "If you give money to charity, how do you decide who to give to?... Clearly the one way to make a logically consistent decision is to not give to charity at all."

Posted by Barbar | August 28, 2007 3:25 PM

Barbar,

You wouldn't make them mandatory because you think they would not be cost effective, but would you make them mandatory if they were?

Freddie and Immoralist,

It is not a fallacy unless you can show the slope either does not exist or is not slippery. However, the slope clearly exists as both of you explicitly admit.

Now, is it slippery? Only if the majority in the body politic can change it's collective mind.

Posted by Yancey Ward | August 28, 2007 3:29 PM

This comment deleted for off topic and personal attacks

Posted by Walter | August 28, 2007 3:30 PM

Say a fifty year old lifelong smoker

I don't want to belabor the point; as I've said before, I think assigning culpability to people for their illnesses, whatever their risk factors, is pretty dispicable, not to mention ultimately impossible. But I do want to point out that when it comes up, it is always, always, always the smoker with lung cancer who's taken as the example. And that's the case because we have successfully demonized smokers to the point that it's okay to say that they deserve to die of cancer. I don't think it's possible in that context to have an unbiased discussion about the principles involved. Could you guys please choose a different example, so that people's disgust with smokers doesn't unbalance everything? It's like if I took as a counter-example the man who rushes into a burning building to save dying children. I mean, he did knowingly increase his risk factors....

Posted by Freddie | August 28, 2007 3:30 PM

You wouldn't make them mandatory because you think they would not be cost effective, but would you make them mandatory if they were?

Well by "cost effective" I am including the loss of freedom and the invasion of privacy as a cost.

You accused me of evading the question, but I noticed you never answered my question either.

Posted by Barbar | August 28, 2007 3:33 PM

Meghan, please stop pretending you have high minded thinking behind your kneejerk "i don't wanna give my money away" response. As has been said, if you don't care people die, that's a legitimate, if psychopathic, position to take. It seems you refuse to be honest about it because you know how cold and heartless and above all selfish you'll be revealed as if you admit it.
Oh, and by the by, I knew someone who died of chronic asthma back in high school. Way to wave off serious health conditions because you haven't the vaguest understanding of them.
I still think you, Meghan McArdle, deserve a non-life threatening but chronic illness to teach you a thing or two about this system you're an expert on despite having never dealt with, you selfish, horrible person.

Posted by brad | August 28, 2007 3:35 PM

Why does Megan hold health care to a higher standard, when it comes to socialization, than other government expenditures? Certainly if we wanted to start from first principles and question, sector by sector, the federal government's role, she asks all of the right questions. But in early-21st-century America, where the government's roles and expenditures include Social Security, a tax structure that couldn't be more explicit in promoting some things and condemning others, and the underwriting of other countries' defense needs, it seems to be a little churlish to make socialized health care answer to a higher power. Those other humongous programs came about through the usual vulgar mixture of colloquial morality and interest-group politics, and I'm comfortable with socialized health care developing via the same route.

Posted by Rich | August 28, 2007 3:38 PM

Barbar,

You gave me a false choice. There is no such thing as option #1.

Now, if there were a society today that effectively protected negative natural rights only, I would choose that, even if it meant I lived a shorter life. Would you choose to live in a totalitarian society in which life expectancy was 80, or in a libertarian society in which life expectancy was 60?

Posted by Yancey Ward | August 28, 2007 3:43 PM

brad,

Megan knows a lot more about asthma than you think.

Posted by Yancey Ward | August 28, 2007 3:45 PM

Ok, litmus test time. Will you accept --

1) A mandatory (required by federal law) catastrophic insurance for everybody: say, $10,000 annual deductible, $100,000 maximum lifetime out-of-pocket (or pick other numbers, as long as it remains effectively catastrophic i.e. does not cover day-to-day healthcare expenses).

2) The above is sold to everybody by a federal agency which then re-packages and re-sells big batches to private underwriters (a-la Freddie Mac).

3) Tax exempt status of employer-provided health insurance is annulled (perhaps could keep the FSAs in place, I dunno).

4) And here is the balancing act and the redistributive justice provision: (1) is regressively (or should it say progressively?) subsidized by the Fed on the basis of reported annual income using the tax revenue surplus from (3).

(I did not invent the above, just reused and simplified some good proposals I'd read before)

Posted by ...Max... | August 28, 2007 3:49 PM

Freddie - re: "WHO is arguing? WHAT pundit or commentator thinks that we should just cut a check to someone who gets ill? How can you REALLY not understand that there is a difference between providing health care, through whatever actual transfer of money, and giving someone money as PAYMENT or COMPENSATION for getting sick?"

As far as I can tell Megan doesn't suggest that there is a large number of people who think that people should receive a check just because they are sick. She's breaking down the argument about health care and single payer in to little pieces and dealing with the pieces. Possible reasons for being for universal payment for health care, rather than payment for health care for the poor, or those who can't afford important treatment, include the idea that everyone should have their health care paid for by the government as a matter of principle. Megan is dealing with this idea. Its not exactly the same thing as simply cutting them a check but its similar, your transfering wealth to them, including to people who could easily afford excellent health care. There are other possible justifications such as "its easier to just pay for everyone than to determine who really needs it", or "if we exclude the non-poor they won't support the program and than it won't get passed", but Megan is trying to deal with this one first. If the idea that people should have the care paid for just because their sick, even if they have plenty of wealth and very large incomes and could pay for the care as if it was a petty cash expense, is rejected than the idea is probably to move on to the other concerns.

Posted by Tim Fowler | August 28, 2007 3:53 PM

I still think you, Meghan McArdle, deserve a non-life threatening but chronic illness

A loud slap on the cheek. Your choice of swords or guns. Go read the archives of Asymmetrical Information, you [expletive deleted]

Posted by ...Max... | August 28, 2007 3:54 PM

Why would I read her archives? For more intellectually dishonest "responses" to serious challenges to her glib, selfish, and poorly considered positions? At Paglia changes her material, and Althouse is a funny drunk. Meghan is just selfish and repetitive.
If Meghan has asthma, then it's even worse that she'd dismiss the realities of the condition by calling being ugly worse. People die of asthma. If she has a very mild case, she's lucky, and myopic.

Posted by brad | August 28, 2007 4:13 PM

Brad, you are dishonorable. As I learned in the last 20 or so years (yes, FidoNet and CompuServe included), the anonymity of online discourse tends to breed that in people. For the record, there are extremely few well-considered responses to her posts here on The Atlantic, but no one can successfully yell through a crowd if the crowd is boisterous enough.

Posted by ...Max... | August 28, 2007 4:32 PM

It is not a fallacy unless you can show the slope either does not exist or is not slippery. However, the slope clearly exists as both of you explicitly admit.

Wasn't accusing you of any fallacy. The slope is as slippery or sticky as the body politic wants it to be. We can collectively draw the line wherever we choose. We might decide that every woman should have a mammogram but not an angiogram. We might decide that everyone 18 and under should get free health care and everyone over 85 shouldn't. The possible permutations are endless.

Once one starts advocating moral obligations to others as the rights of those others, then you are forced to make purely arbitrary decisions as to what are rights and what are not.

No, they are not purely arbitrary. They are pragmatic, based on all sorts of considerations, such as what we as a society collectively decide we can and cannot afford, or which moral claims to healthcare are more worthy. Again, these are essentially political decisions. Thankfully, politics is not, nor should not be, entirely determined by rigid philosophical/logical arguments.

Posted by Immoralist | August 28, 2007 4:35 PM

Wasn't accusing you of any fallacy.

Well, I did accuse him of a fallacy. Slippery slope arguments are generally considered fallacious, if I remember my logic class correctly. But the salient point is, we make all kinds of distinctions in our political or governmental process. Immortalist said it perfectly: "We can collectively draw the line whereever we choose."

Posted by Freddie | August 28, 2007 4:43 PM

We can collectively draw the line whereever we choose

Unfortunately, the democracy may be too blunt an instrument for that to happen.

Posted by ...Max... | August 28, 2007 4:54 PM

This comment deleted for off topic personal attacks

Posted by brad | August 28, 2007 4:57 PM

But the salient point is, we make all kinds of distinctions in our political or governmental process.

Absolutely, and those distinctions are not legally, morally, or constitutionally obligated to conform to any person's notion of a systematic philosophical system. That's not to say that philosophical arguments can't be used to influence political debate one way or the other. But I am in no way convinced by the purist argument that public policy which allegedly contains philosophical inconsistencies or even contradictions is automatically bad policy.

And that's why I find arguments that any use of legal force to transfer wealth from one person to another constitutes "slavery" so charmingly silly.

...Max... wrote:

Unfortunately, the democracy may be too blunt an instrument for that to happen.

Thank god we don't live in a pure democracy :)

Posted by Immoralist | August 28, 2007 5:02 PM

But it raises some interesting questions. Why do you disagree?

Because it makes the world a better place.

Posted by noen | August 28, 2007 5:05 PM

This entire series of posts and comments is strong evidence for the theory of politics as the mind-killer. If universal coverage is Good, then opposing it is Evil, and likewise so is any argument that suggests that any aspect of it is less than perfect. Subsidizing Warren Buffett can't just be a side effect that's not worth removing; it has to be noble in and of itself, and anyone questioning it must secretly want poor people to die in the streets.

And yes, neither side is immune to this illogic. Plenty of conservatives will refuse to acknowledge any of the glaring problems with US health care because that would be the first step toward Stalinism.

Posted by Brian | August 28, 2007 5:05 PM

I'm just trying to help express the disgust she is creating by having a blog here.

Then let me help attenuate you by expressing my disgust at the quality of commenters here. Which, in itself, would not be a big deal -- if Ms.Galt did not feel obliged to try and respond to the likes of you. As it is, one of the better blogs of the Web, The Asymmetrical Information, is headed downhill.

Posted by ...Max... | August 28, 2007 5:07 PM

A right to healthcare is a new frontier. You can exercise your right to speech or religion without anyone having to serve at your pleasure. But to claim a right to healthcare, then you must necessarily claim a right to time and efforts of doctors and nurses, hospital administrators, to the work of drug companies and scientists. And if placing the burden on these people alone seems too demanding, then the burden must be placed on everyone, through taxes on their time and labor.

Now, there are other shared burdens, no doubt--such as the military or the courts. But these benefits are provided by the government because they are perceived as vital to the survival of the state. Without the domestic order provided by the courts, there would be anarchy. Without the military defense provided by the army, we'd be overrun. The government doesn't provide these things because we like having the government provide them. . . it provides them because we need the government to provide them. You (the varied commentors) might think it would be nice if everyone had health insurance, or more particularly, if the government provided health care to everyone, but the provision of health care is certainly not necessary for the very survival of society.

Thus, healthcare is not like the traditional rights we enjoy (religion, speech, assembly) or the traditional government powers we endure. If you want a healthcare system, you have to understand it as a coerced redistribution. And there are philosophical arguments that favor government redistribution, like Rawls, for instance. But even Rawls concerns himself with the Justice of the transfer of wealth. Megan is simply asking those in favor of a single payer system to address the issues of Justice raised by the current proposals. Other wealth transfers have undergone similar analyses. Affirmative action is seen as remedy for past slavery, segregation, and discrimination. Whether you're for or against it, you have to concede that the arguments about affirmative action revolve generally around its justice. Welfare is seen by some as just because its recipients are actually needy--it doesn't go to everyone, regardless of need. Why should health care be the first entitlement for which Justice is irrelevant?

Posted by Jeff | August 28, 2007 5:12 PM

I'm glad you feel that way, max, because it means the backlash against Meghan's unwanted presence here is having some effect. A shallow, selfish libertarian who isn't even a good representative of that questionable school of thought simply shouldn't have a position at the Atlantic. Either she's the equivalent of reality tv and a sign of creative bankruptcy, like Paglia's spot at Salon, or the executive level of the Atlantic has completely lost touch with everything the magazine is meant to speak to and for.

Posted by brad | August 28, 2007 5:19 PM

"Subsidizing Warren Buffett can't just be a side effect that's not worth removing"

You, and Megan's other defenders, keep saying that. Are you under the impression someone is suggesting a system where Warren Buffet does not pay taxes?

Posted by david | August 28, 2007 5:21 PM

because it means the backlash against Meghan's unwanted presence here is having some effect

Nope. I already knew the left is generally not worth talking to and listening to, so this only serves to strengthen the reflex, as it were. If this comments section is a good indicator of the overall level of this magazine (never seen it in my life) then the publisher is definitely hoping to boost its intellectual ratings by hiring Jane away from The Economist. Too bad the blog had to move too.

Posted by ...Max... | August 28, 2007 5:26 PM

This comment deleted for personal attacks

Posted by Fishbone McGonigle | August 28, 2007 5:32 PM

Can I jump in and address this assumption that uninsured families earning over $50,000 per year could afford insurance and have simply chosen not to obtain it?

I wonder how many of you who do not receive health care through an employer or other group have made an effort to price insurance coverage? I am a self-employed person in my forties, in good health with a husband and son, also in good health. We pay $600 per month for what is in effect catastrophic coverage -- it doesn't pay anything until an individual insured has exceded $3000 in medical expenses. This is the best coverage available in my rural red state. I am sure that getting some kind of brader coverage that would pay for office visits would probably be $1000 or more each month. The fact that someone does not expend one-quarter of their income on health insurance does not mean that the decision to go without coverage is "voluntary".

And don't even talk about people with health problems. Many of them could never afford coverage on a $50,000 income, or even a $70,000 income.

This is the problem with treating insurance consumption as though it involves voluntary choices by people with options. That is simply not the reality most of the time. That is why some variant of universal coverage makes sense.

Posted by sophie brown | August 28, 2007 5:41 PM

max, are you trying to prove my point, or just thick?

Posted by brad | August 28, 2007 5:41 PM

Pearls before swine. Megan, I was going to suggest that you outline your arguments so that the commentors could see where you were going. But on second thought, the usual suspects would read your outline and start shrilly condemning you for being a borderline psychopath who deserves to be sick based on misreading of the titles of the various steps in your argument.

Sheesh.

EI

Posted by Earnest Iconoclast | August 28, 2007 6:45 PM

sophie,

How much do you think similar employer provided health insurance would cost? (I mean total cost for both you and the employer?)

Posted by ed | August 28, 2007 7:15 PM

If we should give money to sick people regardless of need...

I don't think anyone said that. Rather, they said they should get treatment. You seem to like asthma as an example. A childhood friend of my brother died of asthma at the age of 13. In his final death throes, I don't recall him asking for money. He wanted medicine.

Finally, if they deserve money just for being sick, why don't we peg the money to the suffering the disease causes, rather than the cost of treating the disease? Inquiring minds want to know.

An entire subset of the legal industry is built on this. Google "pain & suffering."

Posted by Derek Scruggs | August 28, 2007 7:44 PM

"Bonus payments?" You make it sound like winning a lottery. People want to be able to afford necessary medical treatment so they can go about their lives in reasonably good health, not retire on “bonus payments.” The fact that you find “being really ugly” or “severely socially awkward” being worse than “having chronic asthma” reveals a very superficial person who is clueless about what's important in life (it isn't capped teeth and face lifts).

Posted by Jeff2 | August 28, 2007 7:48 PM

Immoralist,

But if you don't care about principle, then you have no real position on which to base an argument against a step beyond that which you are willing to go. Note my discussion with Barber, earlier. I found a point in the healthcare provision and application at which he found it uncomfortable to his sense of liberty, but he/she couldn't really argue against it other than to write that mandatory medical examinations would not have benefits greater than their costs, but those costs were undefined. In other words, he had no firm ground to stand on.

Lets discuss your amusement at arguments that taking one's property by coercive government is not a degree of slavery. You are amused by such arguments because you think it serves justice for those to whom the transfer occurs. But at what point does the transfer become unjust? Why does it become unjust at that point, but not at an earlier one? Or is it always just because that is desire of the body politic? You can see where this is going, I am sure. Is anything that we democratically decide just because we decided to do it- that we made political distinctions.

Posted by Yancey Ward | August 28, 2007 8:53 PM

Jeff says: If you want a healthcare system, you have to understand it as a coerced redistribution.

No you don't. I understand Universal Access to health care as a method to protect myself from diseases that can be spread by those without health care. It is as much a function of protecting each citizen as the police and army. The police protect us from actions of fellow citizens; Universal Access also protects us from actions of fellow citizens.

What part of the germ theory of disease and the etiology of disease do you not understand?

Posted by dalea | August 28, 2007 8:53 PM

This comment deleted because it responds to an earlier deleted comment

Posted by Yancey Ward | August 28, 2007 9:01 PM

Now, if there were a society today that effectively protected negative natural rights only

The absence of any such society should tell you something, Yancey.

Posted by brooksfoe | August 28, 2007 9:54 PM

dalea-

If I understand your argument, then your version of universal health care would only cover communicable diseases? Is that right?

Posted by Jeff | August 28, 2007 11:12 PM

Jeff,

In researching for this I looked into the involvement of viruses in producing various diseases. It is surprising how much is becoming known, how many previously described as non-communicable conditions actually have a communicable element in their etiology. Cancer does. Heart disease does. Obesity does. Asthma does.

So, it seems to me that while we may not know if there is an element of infection in any particular disease, we should suspect that there is. The HIV Pandemic, which does not have a cure, lead to advances in the understanding of the immune system. Since there is no cure, Meagan would advocate no public funds for treatmant and care. One thing all these public funds bought was proof that Kaposi's Sarcoma was an infectious cancer. This misspent money resulted in a vaccine for cervical cancer. And launched research into the infectious theory of cancer, which is paying dividends.

Meagan seems to regard disease as an event in someone's life, brought about by bad lifestyle choices or growing old. And during this event, a 'cure' may be available. The more I look at this, the more I realize I am hearing a literary narrative of salvation and sin. 'Cure' seems to be a term in literature, not science. Meagans entire framework for understanding disease is not science.

Instead of 'cure', medicine seems to look at managability. Diabetes is a 'managed condition'. Since there is no cure, Meagan would not use public money. Yet it is clear that most diabetics are able to live productive lives when their condition is managed properly. And so do those with other diseases and chronic conditions.

I'm just an accountant and I have figured this much out. Disease has an etiology, it developes over a long period of time. Along the way there are events that set the stage for what comes next. Epstein Barr virus now appears to be a precursor of some cancer, in that it changes some genes to not recognize a signal to stop growing. EB looks like a flu when seen, but it is very damaging in the long run.

So, my view is that the idea of a disease that has major dramatic symptoms which are aleviated by a cure is simply religious opera. It is not reality. Health is promoted by constant and continuous monitoring. It is this type of management that leads to best outcomes. So, I favor Universal Acess for everyone.

How Meagan's idea that since there is no cure, people with TB should not receive public funds for care is irrational. I can not imagine a situation in which it is preferable to have people with TB running around infecting others on transfer payments grounds.

I am a libertarian. Have been so for a long time, actually have met and been in small seminars with Milton Friedman and Frederich von Hayek. It is in my rational self interest for all people to have Universal Access to health care. This can be probably be best achieved by government action. But Universal Action protects each of us.

Posted by dalea | August 29, 2007 12:43 AM

Yancey Ward:

But if you don't care about principle, then you have no real position on which to base an argument against a step beyond that which you are willing to go.

On the contrary. As I noted in a previous post, there are plenty of pragmatic/utilitarian arguments one can muster for or against any particular healthcare policy proposal. Cost is merely one example. Are pragmatic concerns not "real" positions upon which to base an argument?

To be honest, I dislike strict adherence to principles generally. There are no principles which do not eventually become justifications for cruelty in hard cases. In such cases I prefer ad hoc determinations.

But at what point does the transfer become unjust? Why does it become unjust at that point, but not at an earlier one? Or is it always just because that is desire of the body politic?

From a constitutional standpoint, every distribution of wealth which occurs in accordance with the procedures by which a body politic choooses to bind itself are legitimate. This of course does not preclude the possibility that such distributions are ultimately detrimental to the body politic in the long run. If such is the case, then the body politic may choose to modify or eliminate the distribution as it sees fit.

Of course, being an immoralist, I make no moral judgment as to those who see the decisions of the body politic as fundamentally immoral. If that is your view, then you have several recourses:

Attempt to persuade the public as to the morality of your viewpoint and the immorality of theirs;

Move to a different country;

Civil disobedience;

Use extra-political/constitutional means to achieve your policy aims (i.e., violence).

It's ultimately your decision.

Posted by Immoralist | August 29, 2007 1:04 AM

This comment deleted for calling names

Posted by cokane | August 29, 2007 1:10 AM

but the provision of health care is certainly not necessary for the very survival of society.

Thus, healthcare is not like the traditional rights we enjoy (religion, speech, assembly) or the traditional government powers we endure

It is complete nonsense to say that freedom of religion, speech or assembly is necessary for the very survival of society. I have lived in societies that didn't have those freedoms, and they survived. Admittedly, they weren't very nice societies, but they weren't anarchy. And enforcing those rights is not free - that's part of what the law enforcement arms and the courts do. If you claim a right to free speech, you're claiming the time of the lawyers, judges etc, who will help you defend that right.

Posted by ajay | August 29, 2007 6:25 AM

Note my discussion with Barber, earlier. I found a point in the healthcare provision and application at which he found it uncomfortable to his sense of liberty, but he/she couldn't really argue against it other than to write that mandatory medical examinations would not have benefits greater than their costs, but those costs were undefined. In other words, he had no firm ground to stand on.

Eh, please. Yeah I'm sorry I didn't come up with a precise formula for the costs. Neither did you, by the way -- you said:

You gave me a false choice. There is no such thing as option #1.

Now, if there were a society today that effectively protected negative natural rights only, I would choose that, even if it meant I lived a shorter life

in which you dodged a question by complaining that a type of society didn't exist, and then posited another nonexistent society that you preferred. I also don't see you justifying why mandatory vaccinations are a horrible totalitarian imposition.

Now I recognize that we simply have different values, but the idea that you're just following logic while I have no ground to stand on is simply false and irritating.

Posted by Barbar | August 29, 2007 6:48 AM

dalea-

You write: " It is surprising how much is becoming known, how many previously described as non-communicable conditions actually have a communicable element in their etiology. Cancer does. Heart disease does. Obesity does. Asthma does."

Assuming this is true, it nevertheless seems to me that having a "communicable element" is different from being clearly communicable. Now, we can set up a system to deal with any and all potentially communicable diseases if you'd like, but this seems rather intrusive to me. Coercive action to prevent or remedy person A's obesity, for example, may have some limited value to you and others in society, but I doubt that you'd say it has the same value to you and others as preventing a new and deadly strain of influenza. With respect to national defense, we expect our government to take steps to protect us from clear and dangerous threats, but bristle if our government tries to protect us from uncertain or slight ones. We invaded Iraq because we were told (wrongly) that it was an imminent threat. If Bush had told us that Iraq had merely a threatening element, I suspect that the country would not so willingly have supported preemptive action.

Posted by Jeff | August 29, 2007 8:17 AM

Brad, here's a free clue: you're not more generous or compassionate than Megan or any other libertarian. Generosity is when you see someone suffering and you take some money out of your wallet to help him out. But when -- as you advocate -- you take money from strangers' wallets to help him out, you've left the realm of generosity. It doesn't take any generosity to spend someone else's money.

If you think it important to help someone who is sick, do it! But you're really too selfish to do that; what you want to do is make yourself feel better by helping him out at the expense of other people.

Posted by David Nieporent | August 29, 2007 9:27 AM

Well Jeff, it is not clear how we could set up a system where people would present at a health clinic knowing that if they have a new and lethal flue they will get treated but if they have something ordinary they won't. How do you see this working? The problem here is that it can not be known in advance what is being treated. And in my view it is better to be safe than sorry.

What good does it do to look at a pandemic with hundreds of thousands dead and say we saved money by not treating early on? HIV fits this bill.

What is overlooked here is medicine as a learning experience with a feedback loop. We can manage conditions because we have managed conditions. Over a long period of time treating diabetes, methods that work evolve. Each tiny step in treatment leads to progressive betterment. The HIV Pandemic is a classic example of how to move from utter incomprehension to manageable condition. And all along the way the transfer people, like Megan, fought tooth and nail against getting the funding needed. In retrospect, this was short sited.

Jeff, what is your understanding of disease? Mine is that we are each born with a genetic immune system that deals with infections. Every infection leaves a mark on the immune system. Some teach the system what to get rid of, vaccines are a crash course in this. Others alter the system in ways that set it to malfunction later, as in cancer and heart disease. This means a minor flu can be the first stage of cancer.

I favor Universal Access. The French system seems to be the most workable, but there are others. But there must be Universal Access, which implies out of pocket expense must be low. This transfer payment gibberish I find incomprehensible. It is not Classical Liberalism with emphasis on costs and benefits, comparisons of actual systems and so forth. Nor is it Objectivism as it does not start, or even consider, rational self interest. Nor is it Libertarian which would use both of the previous methods.

So Jeff, what is your understanding of disease? And how does this comprehension effect the way you look at health care?

Posted by dalea | August 29, 2007 12:27 PM

dalea-

I guess I don't believe that it is better to be safe than sorry. When the Bush administration says that wiretaps are necessary to keep us safe, or that we need to detain people without due process, I'd rather be free and sorry than unfree and safe. We live in a nation of over-incarceration, and that may or may not make us safer, but it seems pretty sorry to me.

I think it would be rather simple to set up a system where, as you say, "people would present at a health clinic knowing that if they have a new and lethal flue they will get treated but if they have something ordinary they won't." A doctor would make a diagnosis, and assuming the diagnosis fit a specific category, then treatment would be covered. This is how Medicare works now. (I should note that I am not suggesting that I would favor this system. . . I'm just suggesting that it's the least intrusive way that government could address something that seems to really concern you but doesn't concern me nearly as much. Sick people show up at hospitals right now, and for the most part, they are treated.)

You ask about my understanding of disease. I'm no doctor or scientist, but my understanding is that disease is a sad and unfortunate thing caused by a great number of different factors, most of which are not directly attributable to other human beings. If you get sick, I will feel very bad for you, but I will not (generally) feel responsible. It seems to me that government is a necessary device by which we protect ourselves from each other . . . not from nature or genetics or luck.

I wonder where your chain of logic would stop . . . without shelter, we are more likely to be sick. Should government provide shelter? Without proper nutrition, we could be come ill. Should government provide us food? Without rest, we might become worn down. Should government provide us vacation? The more children we have, the faster a disease could spread. Would you restrict the size of families? Their choice of climate? Will you jail someone who refuses treatment, since they might spread some disease down the road? You say that obesity has some sort of viral quality. Would you lock up the obese if they refused to lose weight? Would you force liposuction upon them?

If you look at HIV, of course I'd agree that it is wonderful that medical science has made this manageable and that people who might have died before can now live fruitful, rewarding lives. And yes, the government funded most (I'd guess) of the medical research. But just because there was a wonderful result doesn't mean the government funding of the science was right or just. I don't believe that the means justify the ends, even spectacularly wonderful ends. And the money that was spent for AIDS research had to come from somewhere. Nothing is free . . not even the French system you prefer.

You say that you find the "transfer payment gibberish" to be "incomprehensible." I'm not sure I follow your objection. Money for Universal Access, or whatever you want to call it, has to come from somewhere. I assume that it will come from taxpayers, including some, like me, who are against the idea. However principled my objection may be, it's not going to stop the government from taking my money. I guess you think that I'm being irrational . . . that my opposition to your preferred health care plan is against my own self-interest, such that you can't see how this is consistent with libertarianism. I think you misunderstand one of the great principles of libertarianism . . . that I have the personal autonomy to determine what is in my own self-interest. And if you don't like it, then you have the autonomy to decide that I'm stupid or ignorant or petulant.

Posted by Jeff | August 29, 2007 2:45 PM

Well Jeff, I am the sort of Libertarian who has moved in a Social Democratic direction. Self autonomy is a Libertarian principle, but it is not limitless. The complicated economic arguments always appeal to me. And they show that everyone should have access to health care. So, I think there should be Universal Access, funded through taxation. Within the system I would like to see a host of different approaches. Which the French and German systems do offer.

As a gay guy, the argument that we are free in the US because of our economic system began not to cut it. It was realy clear that gay people were more free in the social democratic states of Sweden and Denmark than in the US.

One interesting book on actual libertarian economies is Mike Davis' Victorian Holocausts.

So, I am a libertarian who has parted with right wing libertarian economic policy. For reasons that derive from economic analysis.

On your list of horribles, there is only one thing I would do. Jail people who spread diseases. I actually did turn someone in for spreading AIDS deliberately.

Posted by dalea | August 29, 2007 5:04 PM

'I think it would be rather simple to set up a system where, as you say, "people would present at a health clinic knowing that if they have a new and lethal flue they will get treated but if they have something ordinary they won't." A doctor would make a diagnosis, and assuming the diagnosis fit a specific category, then treatment would be covered. '

Actually this would be extremely difficult if not impossible. Diagnostics is a long drawn out process. It took one week for my partner to be diagnosed with a shredded gall bladder. I have seen six month periods for a diagnosis to be finalized. It could be months into treatment before it was found out the person was not eligible. Then what? Just drop the patient on the sidewalk?

It strikes me as more cost effective to take patients as they come in, treat them for whatever ails them and deal with the real disasters that come in the same way.

Posted by dalea | August 29, 2007 6:50 PM

'But just because there was a wonderful result doesn't mean the government funding of the science was right or just.'

Diseases are infectious. Compromised immune systems result in people becoming germ hotels. The immune system can not fight them off so they now have a space to multiply and perhaps mutate, which seems to have some relation to size of colony. Giving care to some extent prevented others from being infected with these exotic infections. Which would have had enormous costs.

The horror movie part is that immune system comprimise can give rise to pathogens jumping from othe