I think this post wins the prize for boringest title ever. Also, it seems to be roughly one squintillion words long. But stay with me. This is important.
A post from my old blog on the morality of healthcare transfers has attracted an amazing amount of ire from the liberal bloggers and commenters flocking to complain about how evil I am. Most of them, in the course of criticising it, display what seems to me like an Olympic-caliber ability to miss the point. However, given how many of them did not understand what I was saying, it seems likely that I was more in error. Let me see if I can clarify.
There are some arguments that the market for health insurance is different and special, and therefore can be best provided by the government; I find those arguments unconvincing, for reasons I will explain another time. But that is not really an argument about the moral merits of the system; it is a claim about efficiency.
In discussing the morality of a single-payer system, those efficiency considerations are irrelevant. In discussing the morality, one thing matters1: who is made better off, and who worse off, by the system?
Most advocates of single payer, I think, care most about this justice claim. They may also think that they can make the system more efficient, but if one could somehow prove scientifically that a private system would be cheaper and better, they would still favor a public system as long as a substantial population remained uninsured.
But wholesale transfers to large classes, from large classes, are not good moral philosophy unless those classes are very well specified to the moral effect you are trying to achieve.
For example, we could take money from taxi drivers and give it to surfers. Some of the taxi drivers would be bad people who don't deserve their money; some of the surfers would be sterling chaps whom society has failed to justly reward. But still, we all2 recognize that this would be moronic, because virtue and vice are fairly randomly distributed within and between the two populations. There is no reason to think that on net, we would have enhanced social justice.
Now, Ezra's original post criticized Giuliani's health care plan on the grounds that it will transfer less money from young, healthy people to old sick people:
If you're healthy, a world in which Giuliani's plan was law would be a world in which it was economically foolish of you to purchase high quality, comprehensive coverage. And that would be fine -- for the healthy individual. But insurance works based on risk pooling. If our hypothetical 23-year-old only uses $10 of health care a year, but is now paying $80 rather than $100 for his plan, that's less money that can subsidize someone with a chronic illness.
This post makes what I think is a very common assumption among single-payer advocates.
A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class. This is why discussions of particularly deserving or undeserving people within the larger class, such as your fine old Uncle Bob who served his country in two wars before becoming a minister, are irrelevant; as with the surfers and taxi drivers, almost any class we can specify will contain some very worthy members who deserve more from society than they have gotten. What we need to know is whether the class of old and sick people as a whole are much more deserving than the class of young and healthy people; whether our transfers do more good than harm.
Single payer advocates seem to invariably assume that the answer is yes. This is a natural reaction; the old and sick inspire our sympathy. But I am not sure that, as a group, they should also summon our sense of social injustice.
How do we decide which class is more "deserving"? Our intuitions offer dozens of ways, but I think these are the major metrics:
1. They are needy. The class we propose to benefit has greater need for the money than the class from whom we propose to take.2. It's not fair. The class we propose to benefit has been unluckier than the class from whom we propose to take.
3. They are responsible. The class from whom we propose to take has in some way contributed to the problems we are trying to rectify.
How well do any of these describe the old and sick en masse?
Start with a stylised fact: most people who use a lot of healthcare do so because they are above the median age of the population. There are people with horrible congenital diseases, but there are not that many of them. Most people use healthcare because their body has been around long enough that something has broken down, or the law of large numbers has had enough time to deliver an unpleasant accident. As a class . . . let me say it again, as a class, they are sick because they have already lived a long life. Individuals within the class may have a different story, but if you are only interested in discussing a particularly unlucky, and small, subgroup, such as young people with cancer, then what we should be looking for is a transfer which benefits that subgroup.
As a class, are the old and sick needier than the young and healthy? No they are not. They have more assets and less poverty than any other group.
As a class, are the old and sick unluckier than the young and healthy? Considering people as beings with duration in both time and space, no they are not. The overwhelming majority of old and sick people were once young and healthy. They got to be young and healthy, and old and sick.
But consider the young and healthy as four dimensional beings. Some of them will not get to be old and sick; they will die young instead, which is worse than being old and sick. Weighing the bad luck of those with congenital diseases who never got to be young and healthy, against that of the members of the "young and healthy" group who will die young after paying a lot of money for someone else's healthcare, it seems likely to be, at best, a wash on the luck front.
Getting old is not, as many of my interlocutors seemed to believe, unlucky. It is, rather, inevitable--unless you're really unlucky, unlucky enough to die. The elderly have no fairness claim on the young.
As a class, are the young and healthy more responsible for the bad health of the old and sick? Quite the reverse. Many people in the old and sick category did nothing at all to deserve their fate; they just aged or were victims of fate. But some members of the "old and sick" class contributed to their fate. Contra many of my interlocutors, there are a lot of very expensive diseases that have a substantial lifestyle component: high blood pressure, coronary artery disease, diabetes, lung cancer, emphysema/COPD, congestive heart failure . . . many of our nation's biggest killers, and consumers of health care dollars. So as a class, the old and sick are somewhat responsible for their poor healthcare outcomes, although I will leave it up to the doctors to argue exactly how much responsibility they bear.
But even a small amount of responsibility for their condition obviates a justice argument for transfers, since the young and healthy bear no responsibility at all. A few members of the young and healthy may have contributed to the conditions of a few of the sick and elderly, perhaps by failing to get a flu shot, or driving dangerously. But it would be ludicrous to go after the entire class just to settle the liability of those few, like taxing the entire state of Oklahoma to pay for a car accident caused by one drunken Okie.
By none of these three standards, therefore, can I make a compelling case for taking money from one huge group of young healthy people, and handing it over to another huge group of old and sick people. Even if I leave aside things like property rights, coercion, deadweight loss--things I realise my liberal interlocutors aren't particularly concerned with, but my libertarian inquisitors will be--I don't see how the massive transfer implicit in single payer is justice-enhancing.
But I think many of those who read the post attributed to me a much broader claim that no government transfer would be moral. That is not so. I was questioning the moral justice of the enormous, blunt transfer between huge classes that is necessarily embodied in a single payer system, or at least one such as the versions of mandatory pooling envisioned by wonks like Ezra. Many people took that to mean that I believed there was therefore no moral argument in favor of caring for the sick. I confess that I'm surprised that someone like Scott Lemieux would make such an error, but as I say, perhaps I was unclear.
There is indeed a very compelling moral argument to be made in favor of some sort of government sponsored health care finance, which is simply this: no one should die, or suffer unduly, because they don't have the money to pay for treatment. Some of my libertarian readers will say that this still doesn't give the government the right to take the fruits of our labor by force, but in fact, I find this argument fairly convincing.
However, that doesn't mean that I should therefore be in favor of a single payer system. The fact that some people cannot afford some good, even a really important and valuable good like food or healthcare, is not a good reason to nationalise the production of that good. We do not collectivise the farms in order to ensure that everyone will have food; we give those who cannot afford food the money (or food stamps) with which to buy it. Section Eight vouchers are generally regarded as a much more successful system than housing projects (though arguably they could be better funded and structured.) If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
Now, there are arguments against this: means testing benefits raises transaction costs, for example. But there is fairly compelling evidence that government purchases of goods and services do a better job of serving the poor than government provision of same3; and those targeted transfers really would be obviously justice enhancing (to all but hard-core libertarians). So the drawbacks to such a smaller-scale system would have to be pretty massive for me to endorse a single-payer approach.
1 To people who are advancing a social justice claim
2 Except maybe surfers
3 And no, that doesn't mean I think we should privatise the welfare offices; I am talking about buying things for which there are already robust private markets
Very well done. It is about time that someone made a clear and succinct argument concerning the morality and fairness involved in a single payer system. Sadly, Republicans have elected to argue against such a system only by reference efficiency/quality issues that are hard to quantify and generally involve suspect or anecdotal evidence. By arguing on these grounds, they have essentially ceded the fairness/morality/justice issue to the Democrats.
Reagan would have argued the issue on your grounds, and he would have won.
It seems that we've already made the decision for a large scale transfer to the old and the sick: we have Medicare. The old already have universal health care in the United States. They're all covered.
The question is how to deal with the uninsured, and most importantly the sick uninsured. These are the young and the sick (sometimes very young). Universal health care clearly has winners and losers, but we've already made the choice to transfer from the young to the old. Now we're talking about the cheapest way to go from the lucky (the healthy) to the unlucky (the sick), and when you look at other countries, it appears that universal health care is cheaper than our current system and covers all of the unlucky.
You're insisting on viewing the issue through a lens that isn't appropriate to the situation -- one that's designed to reach the libertarian conclusion you want to espouse. I might as well complain about the wealth transfer from consumers to producers, as the latter supply goods at a higher cost than their expenses.
It doesn't make any sense to talk about the old and young as classes that can participate in wealth transfers. Most people will be members of each at different times in their lives. Given the escalating cost of health care and the fact that currently-taxed young people will some day be old people receiving taxpayer-supplied healthcare, this is less of a wealth transfer than a mandatory investment — one that looks like it will have an excellent rate of return.
. Those people view single-payer primarily as a vehicle for providing health care to people they think are deserving, at the expense of other people whom they deem need the money (or in some cases, perhaps, the health care) less.
What is so incredibly difficult for you to understand about a moral responsibility for universal health care coverage? What is so hard to understand about the basic notion of morality that those who are sick should have the ability to receive appropriate care? I don't agree with the people calling you stupid. But if you think this
If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
is a rational response to the moral imperative to use our available means to heal the sick, then I'm afraid they may be right. Saying we can "just give them the money" is an incredibly dull thing to say. Just give them the money? You think Section 8 amounts to the government simply cutting checks? That is a delusional vision of government, and, yes, as your critics have pointed out, it demonstrates either an inability to consider these issues with the necessary intellectual seriousness or a refusal to do so.
What's worse, I'm not convinced that you honestly do understand the moral imperatives at work here. You made it very clear in a Bloggingheads episode that you weren't particularly sympathetic when you dismissed 47 million uninsured as some sort of insignificant minority. And, on a personal note, someone who traffics in assigning moral blame to sick individuals for their illness is beyond deviant. Ugly, ugly, ugly.
And, by the way, your whole taxonomy of the old and the young and the sick and the healthy is just about the most confused, rhetorically bankrupt thing I've ever read, and I have to grad freshman papers. I mean really. That would get you flunked in a high school philosophy class. It's a tautological mess.
This post deleted for conflating liberals with socialists
How do we decide which class is more "deserving"? Our intuitions offer dozens of ways, but I think--
Oh, blow it out your ass, Howard.
"Someone who traffics in assigning moral blame to sick individuals for their illness is beyond deviant."
But... some people *are* to blame for their illnesses. If I end up with cancer in 20 years because I smoked all through my 20s, I suppose it would be unkind to make a big deal of reminding me that the condition is my own fault, but it would still be, you know, true.
"A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick."
But the young and the healthy will become the old and the sick (you may be too young and naive to realize this, and I pray cancer does not ever come to you). As such, it can not only be viewed as the young paying the old, but rather, the young paying their future older selves.
The young go in debt (school loans) with the knowledge that doing so will increase future earning potential. This is in an attempt to increase and optimize lifetime utility.
Healthcare can be viewed in a similar fashion. You pay more when your health costs are low, and receive more when your health care costs are high. think of it like consumption smoothing, only its healhcare cost smoothing.
If you dispute the optimization mechanisms of smoothing, then you'd have to throw out practically all the theories of neo-classical economics.
You can also make an anology for families, where the parents care for their young in infancy in exchange for the young looking after the parents in their later years (or will you just ship your parents far off in a home somewhere, ignoring them save sending a card on mothers day?).
You also conveniently dismiss to "explain another time," that single payer systems will decrease per capita costs through the tremendous reduction in bureaucracy. It doesn't say much for the efficiency of the market that 25% of the healthcare industry is dedicated to paperwork, not healthcare.
The healthcare discussion is an important and a complicated one, but your theories on how the poor young people (such as yourself), are being asked to unfairly pay the wretched old (which, if you're lucky and don't die young, you will become) is more an expression of the naivety and arrogance of youth than anything else.
Freddie said: "someone who traffics in assigning moral blame to sick individuals for their illness is beyond deviant. Ugly, ugly, ugly."
Well Freddie, all I see here is your refusal to address a claim of fact and a resort, instead, to namecalling. Now that's what I call ugly.
Megan made a claim of fact, namely that some sick people could bear some responsibility for their healthcare outcomes. In her words: "there are a lot of very expensive diseases that have a substantial lifestyle component: high blood pressure, coronary artery disease, diabetes, lung cancer, emphysema/COPD, congestive heart failure . . . many of our nation's biggest killers, and consumers of health care dollars. So as a class, the old and sick are somewhat responsible for their poor healthcare outcomes, although I will leave it up to the doctors to argue exactly how much responsibility they bear."
Either it is true that smoking contributes to lung cancer, and an unhealthy diet contributes to coronary artery disease, or it isn't. If it is true, then Megan's claim of fact is correct. She isn't ruling out other factors that bear on a person's responsibility for being sick, like genetics, but she is saying that there is some level of personal choice that can affect one's likelihood of being sick.
Instead of arguing with her about the factual basis of her claim, you just call her names. That's ugly.
Even with way too many words and the boringest title ever, you still miss the point. National healthcare is much more than just a big transfer from young and healthy to old and sick. For example...
I am old and healthy, making the best money I've ever made in my life. I'll be working full-time at least until I'm 75 or 80 to pay off my debts.
But two months ago I was old and sick. I had prostate cancer. Without health insurance, I'd be bankrupt, and maybe dead. With health insurance I'm back working again and paying my way. So by your calculus, I'd now be a victim of the single-payer system, just like you and the rest of the "young and healthy."
Ten months ago my wife -- who is 10 years younger than I -- had uterine cancer. Without health insurance we'd be bankrupt and she'd definitely be dead, given the circumstances of the illness. With it, she has been given the privilege of working and paying her way for another 25 years or so.
Sixteen years ago, my daughter developed a brain tumor. Without health insurance, she'd be dead and we'd be bankrupt. With health insurance, she's alive, and when she finally graduates from Harvard she'll be a statistician, making more than I make.
Not only does your line of reasoning lack moral value, it lacks logic and consistency.
Either it is true that smoking contributes to lung cancer, and an unhealthy diet contributes to coronary artery disease, or it isn't.
It is true, and I guess the logic is that younger people shouldn't be forced to pay for the medical care of older people, especially those who caused their own distress. By the same logic, those who are older should not be forced to pay for the education of children of younger people.
Millions of older Americans, without children, transfer billions of dollars annually to younger Americans with children to build schools, buy books and all the rest. Perhaps if they weren't forced to pay $8,000 a year for schools they could better afford their own health care. School taxes should only be assessed against those younger people with children. We can play this game all day.
Here is another fact. Even if you don't smoke, aren't overweight, exercise regularly, don't engage in risky behavior and avoid stress, you will become sick and die. And your medical expenses are likely to be astronomical.
But... some people *are* to blame for their illnesses. If I end up with cancer in 20 years because I smoked all through my 20s, I suppose it would be unkind to make a big deal of reminding me that the condition is my own fault, but it would still be, you know, true.
You are all taking an incredibly complicated subject-- the degree to which someone's illness is the product of their own behavior-- and talking as though there are clear lines to be drawn. There most certainly is not. To begin with, the idea that exposure to an individual carcinogen is directly responsible for cancer is flat wrong. There are many people who never smoked who contract lung cancer. There are many people who smoke for 50 years who never get lung cancer. Does one or the other deserve to get sick? It's a disgusting question.
The truth is, it is often impossible to pinpoint the "causes" of illness. Cancer, we are reasonably sure, has a genetic component. Many diseases have both genetic and environmental factors. And it is impossible to separate which environmental factors are responsible for individual illness. Lung cancer, for example, could be contributed to by airborne pollution. (Honestly, you could hardly have chosen a worse example than lung cancer.) The best oncologist in the world couldn't tell you precisely how a cancer came to develop in someone's system. When you widen your perspective to simple questions of general health and life span, you're making the distinctions even more difficult to understand. Some people who never drink or smoke and eat right die at 60. Some who do the opposite die at 85. What process, exactly, do you propose to sort out how responsible any individual is for his personal health?
Here's the answer: you don't make moral judgments about individual culpability for illness. I know that libertarians like to engage in self-promotion by demonstrating how "contrarian" they are, and in doing so lead themselves down truly reprehensible ideological paths. But we don't all have to follow you. I don't know, I think "don't blame people for being sick" is a pretty basic moral proposition. And I'm willing to bet the vast majority of humankind would support me in that. But then, we can't all be philosopher kings....
Among the things that's really bizarre about this post is that it assumes that single payer = single rate.
That may end up being the case, given the power of the AARP lobby. But it is entirely possible to structure a single payer system in which health care taxes vary by age.
(in fact, i could swear that the federal government collects another tax that has brackets in it. the ingo tax? outcome tax? oh yeah, income tax!)
while we're playing the morality game, it's worthwhile noting that as a society we have already made some very expensive commitments for moral reasons. 1) Everyone has access to emergency room care. 2) The very poor have access to Medicaid. 3) The elderly have access to Medicare.
Now, it would appear that Megan wants to revisit those commitments because of the responsibility of the elderly as a class for their current health crises and their access as a class to more assets and less poverty (*cough* social security *cough*).
But those of us who have basic logic skills at our command might recognize that the key way in which the elderly differ from the rest of us is that they are at the end of their ability to have the INCOME necessary to pay their medical debts.
Let's be blunt. The elderly have as a class some capital (often not all that liquid) and little income. For the elderly not to be seen as needy (compared to those of us who can borrow against future earnings), McArdle is arguing that it is appropriate for elderly to first impoverish themselves before getting the benefit of taxes paid by those younger.
I'd like to see if one of you brave, wise people (who have the courage to speak the truth to the ignorant masses!) is really such an abhorrent creature that they explain to an individual that they are to blame for their terminal illness. See it's easy when it's the non-specific-- someone with lung cancer. It's harder when you actually have to confront an individual who has a family and a life who is dying, yes, maybe because they smoke. That's worse than impolite.
And spare me the bogus distinctions between what people are responsible for and what they deserve. If you're going to make this kind of argument, and pat yourself on the back for your "honesty", then I insist you actually confront the consequences of your position.
Wrong, wrong, wrong, wrong, wrong.
The problem with the entire thesis is: classes don't get sick. People do.
Classes don't break their necks falling off horses, get compound fractures skiing, develop cancer at 22, go blind from an unexpected case of meningitis at 24, or contract a freak tropical illness while traveling and end up spending a month in the hospital.
Sure, "As a class" 23-year-olds are healthier than 70-year-olds. But that's not a relevant way of evaluating the issue.
We live in a society. All of us. We make decisions about healthcare as a society, because we have to do it that way.
The 20-somethings don't get to opt for a different version (other than by moving to Canada). They either pay for health insurance - or they pray they don't have an accident or get sick, just like the 30-somethings and 70-somethings do. Because being part of a class that, on average, is much healthier than they are won't get them healthy again.
pobody wrote: It doesn't make any sense to talk about the old and young as classes that can participate in wealth transfers. Most people will be members of each at different times in their lives. Given the escalating cost of health care and the fact that currently-taxed young people will some day be old people receiving taxpayer-supplied healthcare, this is less of a wealth transfer than a mandatory investment — one that looks like it will have an excellent rate of return.
pobody...you can't deny that a wealth transfer is occurring and then go on to describe a garden-variety wealth transfer, while calling it something else.
An actual investment would involve the persons' own money, made available to the markets as productive capital, and then returned later with earned interest. A wealth transfer simply means money is taken from one person and given to another, which is exactly what Social Security does; is exactly what Meidcaid/Medicare does; and is exactly what the envisioned universal healthcare would do.
Banking one's hopes on being on the receiving end someday is foolish at best, because it relies on long-term population dynamics that are not only out of your control, but also trending in the wrong direction. For example, Social Security originally transferred wealth from about 30 contributing workers to one recipient. Due to improved healthcare and a number of other factors, people are living longer while fewer babies are being born; and the number of contributing workers per recipient is now down to about 5. Within my lifetime, it is expected to decline even further (provided the impending solvency issues do not result in fundamental changes such as means testing, which they most likely will).
If that's an investment strategy, it's a remarkably poor one -- or put more correctly, it's not an investment strategy, and nobody sensible would really call it one unless, say, they were trying to hide the details of a wealth transfer behind a screen of palatable language.
If that's an investment strategy, it's a remarkably poor one -- or put more correctly, it's not an investment strategy, and nobody sensible would really call it one unless, say, they were trying to hide the details of a wealth transfer behind a screen of palatable language.
Fine, you're right: it's not an investment. I was simply responding to Megan's dishonest framing of the issue -- when individuals will inevitably move between "classes", speaking in terms of a wealth transfer from one class to another is remarkably misleading.
If you must call it a wealth transfer, then it's a wealth transfer with the promise of a reciprocal, interest-added (so to speak) wealth transfer in the future. It's too bad we have to make this imposition on your liberty, but I think it's a hell of a lot better than leaving folks without medical care.
If you don't believe that our society will be able to make good on this promise -- ie, you don't think it'll be able to take care of its older citizens in the future -- then that has larger implications. I suppose we may as well just call the whole thing off, stock up on ammunition and hunker down in our respective compounds.
pobody wrote: If you don't believe that our society will be able to make good on this promise -- ie, you don't think it'll be able to take care of its older citizens in the future -- then that has larger implications. I suppose we may as well just call the whole thing off, stock up on ammunition and hunker down in our respective compounds.
You and that shark must be on a first-name basis by now.
There is no grounds for assuming that this debate must be a matter of 'all' or 'nothing', nor can you move forward by simply imagining that 'all' is possible and will be magically provided for somehow. That approach neither advances the debate, nor does is offer any usable policy directions.
Maybe it is society's responsibility to provide for specific needs, but society certainly cannot provide everyone with a turkey in every pot and a flying pony in every stable. So, the proper question is: What is a plausible middle ground solution, is it politically feasible to implement it, and do we actually have resources to meet it while mitigating the law of unintended conseuqences?
A couple of questions:
Isn't part of the point of single-payer that it pools the young and healthy with the old and ill in the same risk pool, so that the cost of health care services is reduced? Put another way, isn't one of the moral virtues of single-payer that it will reduce the health care costs for everyone? Isn't the moral virtue of single payer that it is the best kind of government action: that which uses market mechanisms to offer better services to more people at lower prices than would exist without government intervention?
Put yet another way: isn't the moral virtue of single payer that we each pay in more when we're young and healthy so that services are cheaper when we consume them when we're old and sick?
It seems to me that Megan is defining the moral case for single payer too narrowly.
We are not going to see a single payer system in the US because the insurance industry will buy off enough members of Congress to defeat it, just as it did with the Clinton health plan. What we will see, I think, is a universal coverage plan resembling the one in Singapore. In this plan employers who do not provide medical benefits will be assessed a fee based on the number of their employees, and the money from these fees and from tax revenues will be used to subsidize privately purchased insurance for those who do not receive insurance benefits from an employer. A plan of this type forms part of Senator Edwards' platform, Governor Romney helped enact a similar plan in Massachusetts and would probably try to enact it nationally if he wins in 2008, and even Mayor Guiliani has endorsed a version. I imagine Jane and people with her social views will oppose this type of plan also, but I'm convinced they'll lose.
"A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class."
We already have this in the Medicare program, and that is not a sustainable program without major changes in either payroll tax rates, means testing or an increase in age for eligibility.
Though I agree with you on single-payer efficiency, I don't think your moral calculus holds up. Compare health care with the Fire Department: if your house is on fire, it's likely you share some guilt in the matter (as a member of the class of people with houses on fire -- some are just unlucky, to be sure, but not really unlucky, as they have a house to begin with), but we invest public resources to save you from this circumstance because your house is on fire.
Walter Scott gave a good response to this twaddle from Megan McArdle when he wrote "Oh, what a tangled web we weave, When first we practise to deceive!"
There's a very poor understanding among many commenters here about how insurance works. "Actuarially fair insurance" means that I pay the certainty equivalent of all risks to Guy X (an insurance company or government). Because I'm risk-averse, I get more utility from this certain payment than from a risky future with the same expected payments. Because Guy X "pools" thousands of people like me, he almost certainly will only pay out the certainty equivalent and therefore also bears no risk.
Imagine 1 million people who all have the same risks:
Risk Cost Chance
Cancer 100000 .01
Broken Arm 10000 .1
Flu 500 .5
The total expected health payments are .01*100000+.1*10000+.5*500=2250. Without insurance, someone might have all three ailments occur and have to pay out 110500. Probability tells us that the average person will pay out only 2250, and therefore insurers can offer insurance at that price despite the chance of paying out 110500. The pooling does not decrease average cost but merely spreads risk.
Insurance in health is often thought of quite differently. Here, we have two sets of 1 million people. The first has the same health risks as above. The second group has double the probability of each ailment. They therefore average 4500 in health spending per year. Everyone knows who is in each group.
National health insurance, without differentiated payments, would make both groups pay 4500+2250/2=3375. This is, in effect, a huge transfer of wealth from Group 1 to Group 2.
It gets even worse when we talk about moral hazard, which Freddie thinks we oughtn't do. If some people engage in risky activities (say, drink heavily, play rugby, don't get vaccinations, etc.), their expected health costs are higher than those who don't do these things. Making the payments equal for both groups encourages unhealthy behavior. Sure, we never know whether smoking gave someone lung cancer, but likewise a drunk driver may have crashed his car had he been sober. We don't typically think of this as an excuse.
As for the fact that the young will one day become the old, Megan points out that
a) this is not true, as some will die young
b) the old are part of history's richest generation, and are far richer per capita than the young
and
c) were quite aware that one day they would be old and they could have saved rather than consumed
If everyone wanted 70th birthday parties, it would be much more sensible to save while young to pay for that party than to force the young to pay for every party on the expectation that, some day, the future young will pay for the current young's birthday parties. That's a Ponzi Scheme, not an effective way of organizing society.
Megan McArdle writes:
This transfer is, of course, precisely the effect of Proposition 13 in California. It causes an enormous transfer of money from young healthy people buying houses today to old and sick people who bought their houses decades ago. Warren Buffet had the decency to point this out during the Gray Davis recall a few years back. I eagerly await a blog from McArdle suggesting, on justice-enhancing grounds, that California abandons Proposition 13.
Nice 10th grade essay.
Anyway, once you get to the people who didn't make poor lifestyle choices and still got sick you might find that the line you draw is pretty freaking arbitrary.
Also, Megan is very afraid of this logical conclusion to her argument: If we adopt her system, we must let people who purchase too little insurance for the level of care they need to live get sick and die. Any other response would be immoral, in her eyes.
She couldn't bring herself to say it after what, 1881 words?
So, instead she says this:
"There is indeed a very compelling moral argument to be made in favor of some sort of government sponsored health care finance, which is simply this: no one should die, or suffer unduly, because they don't have the money to pay for treatment. Some of my libertarian readers will say that this still doesn't give the government the right to take the fruits of our labor by force, but in fact, I find this argument fairly convincing."
Pretty much a refutation of the entire preceding argument - because the only way to get this to work is to have young people invest in health care for the old. But she can't seem to find any reason except it bad for people to die when we can afford to pay for it as a society - but somehow this is just too freaking wimpy or liberal or something, or maybe it just isn't mean enough of an opinion to hold. To me, its a perfectly good reason. Try saying it aloud: "I don't want people to die, if we can afford it."
And beyond that, there is another way to see this issue: It's an investment in your potential health care. Catastrophe insurance, if you will. Here is something - it is properly priced black swan health insurance. For the first time, you will be truly paying what you should be for insurance. Read the private policy - I have, and let me tell you, for very bad cases, you are screwed.
Thats right, if you see this as an investment in your own, potential future health care, you might freaking understand that yes, Megan, the only way to fund this entire system of decent health care is to have people who aren't sick pay for people who are sick. It must be this way. This involves the transfer you seem to argue against until this critical paragraph.
Damn the "moral hazard" of having people receive a "free put" on health care, just give it to them.
So many excellent comments here in response to the idiocy being peddled by McArdle and by the (usually more intelligent) Julian Sanchez that I'm not sure how much added value another one can bring. Freddie in particular at 7:59 was spot on. Another point Sanchez might want to consider: presumably the point of considering people's responsibility for their own health behavior would be to encourage better health behavior and thus increase overall population health and reduce the cost of the medical system. And yet it is transparently clear from any comparison of health care systems which rely on individual responsibility (like the US) against those which have universal coverage (like Europe) that the universal coverage systems are better, not worse, at encouraging better health seeking behavior and promoting overall population health, and at keeping the medical system's costs down. People in France, Germany, the UK, Canada, the Netherlands and Japan eat and drink better, exercise more, and go to the doctor earlier to treat routine problems before they become severe and expensive. Why? In large measure it's because governments are much better and more responsible about promoting national health and saving money on health care than individuals are.
One might try a traffic analogy: one would think that countries which treated safe driving as an individual responsibility, rather than a public one, would have more careful drivers. And yet places that have few traffic lights, lane markers, or police issuing tickets and revoking licenses (like India and Nigeria) have much more aggressive and risky drivers than do places like the US that treat traffic safety as a matter for government to handle. Libertarians find this a mystery, but nobody else does.
Well, props for the self-awareness that the earlier post was unclear. When you write that "the old and sick are already luckier than the young and healthy", people might think you are saying that the sick are lucky. Or when you say the sick are culpable for being sick because they didn't go to the doctor enough, without acknowledging that maybe they didn't go to the doctor because they couldn't afford it, people might think you are stupid. So let's call it a Learning Day.
I mentioned this on your old blog, and tgb1000 touched upon it, but I think you're forgetting that diseases are communicable. Under a single payer system, you're going to have the insured dropping dead of diseases that were allowed to propagate by the uninsured (TB immediately springs to mind). Also, the uninsured are going to exacerbate the rise of drug resistant diseases as, if they've scraped the cash together to see a doctor, they're less likely to be able to afford a second round of antibiotics if the first have failed. You're also going to find (as I did as an undergraduate when I visited the student health center) more doctors taking pity on them and prescribing precautionary antibiotics, instead of doing the costly blood work up. In short, single payer systems will increase the cost of health insurance (as we're going to need newer and newer and fancier and fancier drugs to deal with this situation) while decreasing the care.
How cure at 9:53 is wrong, a few samples:
The pooling does not decrease average cost but merely spreads risk.
In a fantasy word-problem world, perhaps. In the real world, pooling decreases average costs because:
a. health care providers are certain of being paid, and hence have no need to charge huge prices to some consumers to hedge against the risk of non-payment by others. The risk premium drives up total average prices, not to mention saddling those who can pay with staggering costs.
b. negotiators for immense pools of patients can and do bargain down prices with health care providers, whereas individual patients have essentially no bargaining power in health care transactions (unlikely to negotiate prices while bone still protrudes from arm, etc.).
c. Large pooled insurance systems raise the number of people who have access to any given form of care, resulting in economies of scale. As a limit case, in a 19th-century world where health insurance did not exist, only the rich ever got treated. Reintroducing that system would probably cut chemotherapy numbers by 50% or more, destroying economies of scale and making chemo that much more expensive.
d. In systems where insurers of small pools compete against each other, they naturally spend much of their time and money trying to figure out who to exclude from their pool. The costs of their efforts to exclude the sick from their pools are passed on to customers as rate increases. As a more general way to think about this, you have excluded from your word problem the cost of item number 4: all the activities of the insurer itself. (Not to mention item number 5: the activities of the health care provider required to deal with the insurer.) In the US these amount to about 25% of the entire cost of the health care system.
Empirically speaking, the prices of any given treatment fall dramatically when large insurers begin covering it. As an example, prices of IVF on the US's East Coast, where insurers rarely cover it, are nearly double those on the West Coast, where insurers often cover it.
If some people engage in risky activities (say, drink heavily, play rugby, don't get vaccinations, etc.), their expected health costs are higher than those who don't do these things. Making the payments equal for both groups encourages unhealthy behavior.
In the real world, countries with universal health insurance have better health-seeking behavior -- higher rates of vaccination, higher rates of prenatal care, better cavity prevention, lower rates of obesity, etc. -- than those that don't. Individual responsibility is an extremely poor vehicle for encouraging long-term healthy behavior. Think Russia (no public health care system left to speak of) versus France (universal public health care). Universal health insurance is part of a healthy societies; societies which have it take responsibility for their national health, while those that don't...get fat and sick. Like the US.
For example, we could take money from taxi drivers and give it to surfers.
Is this one of those "thought experiments" I keep hearing about? Ah, don't bother answering that. I'm just going to stop reading there, because it looks like a bunch of wanking to me.
I wonder what it is about Libertarians' brain that has failed to develop. An incredibly stupid post. Neither considerations of social justice generally (in the vaguest and most abstract terms you prefer) nor Ezra's points about single payer system have diddley squat to do with giving money to "deserving" people while taking it from "undeserving" ones. It's amazing to me that the Atlantic continues to inflict these morons on us.
I agree with the way you pose the question, but think that liberals (rightly) believe that universal healthcare does satisfy metric 1 & 2, and I would add a couple of moral considerations as well.
1 is satisfied because old and sick as a class are more needy -- or certainly would be if forced to absorb the full cost of their own health care; health care can be very expensive. So while the old (not so much the sick) are on average richer than the young, they would not be in a world without Medicare.
2 is satisfied in many to most cases, I don't know the statistics but I think liberals believe a lot of health problems are inevitable to pretty much random - fit people have heart attacks and non-smokers get cancer. Additionally, I think liberals (rightly) have the moral intuition that people should not always be made to bear the full cost of their mistakes. If some dumb kid jumps off a roof we are taking him to an emergency room (health insurance or no) even though he is completely at fault, because we don't think it is just for the kid to suffer the consequences of his dumbness when the cost to us alleviate it is less. The same goes for health insurance, yes, you shouldn't be 50 pounds overweight and you shouldn't smoke, etc., but that doesn't mean you should die rather than have us spend money.
Finally, I think that universal entitlement policies capture another important moral intuition - call it parts greater than the whole. To illustrate what I mean take Social Security. Now by the moral intuitions above Social Security is a bad idea - the old as a class are richer than the young, and bear a significant amount of responsibility for their retirement savings - as a class they are less worthy of a transfer. Nonetheless - we don't want even one person who really is too old to work to be too poor to retire - that is just cruel, whereas working class people paying between 8% and 16% of their income (depending on how much of what the employer matches would be returned as salary if SS ended) simply isn't. So even though the bulk of transfered money goes to people better off than the transferees - the transfer's universality makes a net moral improvement as the worst members of the recipient class would be qualitatively worse off than the worst and average members of the transferor class.
Now - you could say that we should transfer only to the individual "worthy" people rather than have universal programs, but then I think liberal objections would be more practical than moral. Mainly that the information gathering costs to determine the relevant "worthy" people + moral costs imposed by false negatives in that calculus + political costs in that universal programs are easier to get supported than targeted programs would outweigh any gains from having less transfers.
Like your writing though - congrats on your move to the Atlantic.
Might I quote: "...this post wins the prize for boringest..." but let's go all out: not just boringest title, but Hey! Ya! Nothing like an outkast from common sense to try and provide entertainment and fall way, way short...
Also, as an added bonus, this itty bitty bloggity wins points for stupidest: "But it would be ludicrous to go after the entire class just to settle the liability of those few, like taxing the entire state of Oklahoma to pay for a car accident caused by one drunken Okie..." when that's exactly what we do for legal infractions, as the entire state is responsible for the cost of prosecuting and incarcerating said thought-felon and yes, the taxes are incurred by the state. What about that?
Congratulations, Viriginia McBardle, you were in error in your earlier post, and you continue to keep falling down!
But wait there's more: we have a winner (whiner) for gratuitous use of buzzword gotchas: "A gigantic single-payer system", "collectivise the farms" and, hey, we'd be remiss if we didn't mention the whoring for insurance, "constructing a giant government-run system [let's just slip that in there one more time, darling Virginia -- ed.]; we could just give them the money to buy it." Whew! Giving more money to insurance companies is the good sh!t right there!!
Boring, wrong, and slutty: that's how I likes my posts!
Trying to look at the particulars of health care finance as a moral issue is tiresome in the extreme.
There's nothing more important than the consideration of moral philosophy, but something as dry and policy wonkish as health insurance should be reserved for the utilitarians.
In my view making sure everybody has robust insurance coverage via the use of taxpayer money just makes sense. It's not necessary to talk about justice.
If the US were to enact guaranteed, universal health insurance -- adapting the best practices in place throughout the rich world for use in America -- the country's wealthy would hardly be worse off, even if their taxes were to increase. If you don't believe this, ask rich folks in Australia or Denmark whether or not they enjoy high standards of living. They can afford to pay more in taxes. When you've got a lot of money you can afford things.
Middle and upper middle class people don't have much room in the family budget for higher taxes, but theirs wouldn't have to increase very much - and in some cases they'd come out ahead (I guarantee you some poor schmuck paying 1400 bucks a month for cobra coverage would be better off financially were he to pocket the premium and pay Ontario levels of taxation). And the freedom -- yes, let's call it by it's real name -- the freedom to never have to worry about losing your coverage, the freedom from job lock, the freedom to join an exciting but risky start up, the freedom from the threat of disease-induced penury, the freedom of knowing your children's health insurance can never be canceled -- the value of such freedom would be priceless to average people.
And, the poor, of course, would come out ahead with a robust system of universal health insurance -- no calculus required.
Oh, and lots of businesses would realize a net advantage, as well.
Let's keep it simple. Leave the discussions about angels and pinheads for the philosophers. The rest of us can debate and discuss costs and benefits.
Yeah, I didn't even want to touch this incredible bit of ignorance:
However, that doesn't mean that I should therefore be in favor of a single payer system....If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
That is the definition of a single-payer system: we give them the money to buy it. McArdle is conflating the single-payer system with a national health care system. The former is like Canada; the latter is like Britain. You can pick either version, and still be in favor of guaranteed universal health care. For that matter, you can also be in favor of something else: a French-style system, which, in addition to a national-supported system, also has private health care institutions and private supplemental insurance. Or a German-style system, which puts more accent on the private elements in the mix, while also including a baseline universal insurance program to catch anyone who falls through the cracks.
It is really not a good sign for McArdle that she is still ignorant, at this late date, of all the various forms of universal health insurance systems in the world's other economically advanced democracies, all of which cost less than the US model, provide equal or better care (apart from a few narrow categories), and ensure the citizens of those countries that they will never go untreated for lack of funds. If she wants to have a blog on the Atlantic, she has to become literate in this issue. The best thing to do is just read Ezra Klein and accept his conclusions, because he knows what he's talking about and he's right.
I mean, I'm starting to wonder whether the "asymmetrical" in the title of this blog refers to the fact that the blogger has less information than the commenters.
I mean, I'm starting to wonder whether the "asymmetrical" in the title of this blog refers to the fact that the blogger has less information than the commenters.
Very funny, brooksfoe, and an apt interpretation of the foregoing discussion as well.
Megan wrote: However, that doesn't mean that I should therefore be in favor of a single payer system....If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
brooksfoe wrote: That is the definition of a single-payer system: we give them the money to buy it. McArdle is conflating the single-payer system with a national health care system.
Isn't a single-payer system also a "giant government-run system"? Even if single-payer is one method of giving people money to buy healthcare, it seems perfectly consistent for Megan to prefer a less broad method.
I'm sure it's lots of fun to shout "ignorance!" and poke jokes, but I think you've misread what Megan has written.
I read the comments here and I'm struck by the consistently high level of smugness and condescension.
Welcome to the Atlantic, Megan. Enjoy the opportunity for being flayed by your self-appointed moral betters.
I'm sure it's lots of fun to shout "ignorance!" and poke jokes, but I think you've misread what Megan has written.
Okay. Describe for me how Megan's idea-- "we could just give them the money to buy it"-- doesn't amount to a) a single payer system, or b) a giant government run system. Even if she's not describing a single payer system, which I think she is, what precisely do you recommend as the mechanism for this check-cutting service?
I read the comments here and I'm struck by the consistently high level of smugness and condescension.
Welcome to the Atlantic, Megan. Enjoy the opportunity for being flayed by your self-appointed moral betters.
That contains not a word, of course, that actually confronts the arguments of the people who you are insulting. But then, it's easier not to, isn't it?
In a world of infinite resources, I am sure a single-payer system, aka "socialized medicine" would work fine. Alas, resources are finite and so must be rationed. In our current system this is done by money, in other systems by time. Check the waiting lists for operations in Britain, France, and Canada.
In addition, the well known adage, "he who pays the piper calls the tune" applies especially well in this context. I am not sure that I want the government telling me what I can and can't eat, drink, smoke, or do in my spare time. But that is what is already happening in other single-payer systems.
Regarding justice & morality, where is the justice in holding a gun to one taxpayers head to extort money to pay for a stranger's illness? If this is indeed your conception of justice, why stop at healthcare? Food, shelter, cellphones, TVs, and clothes are also deemed by many to be essentials so why shouldn't the government provide those as well?
Finally, let's stop pretending that we are talking any longer about health insurance-- if you can't choose the participants and adjust for risk it is not insurance, it is a massive means-tested entitlement program. For many in this group, that is not a bug, it is a feature apparently.
Check the waiting lists for operations in Britain, France, and Canada.
The idea that countries with universal heath care have significantly higher waiting times to receive medical care than the United States is utterly unsupported by data. The idea that there are not long waiting times for medical care in the United States is flatly wrong.
Sir Charles Trevelyan, the British civil servant in charge of efforts to relieve the Irish potato famine of the 1840's, believed that 'calamity must not be too much mitigated' because relief efforts would disrupt the normal workings of the economy. Although Ireland was a net exporter of food during the famine, Trevelyan opposed using it to relieve the misery caused by the famine because doing so would cause food prices to rise in England and he felt that it was unjust to harm part of the population for the benefit of others. An additional reason for his inaction was his feeling that the Irish, a "selfish, perverse and turbulent" people, were unworthy of help.
Nice work, Megan. You're channeling one of the 19th century's worst human beings.
It's hardly worth anyone's time slogging through and correcting the willful misinterpretation and ascribing of bad motive by The Atlantic's commentariate, but I'll offer one point.
Freddy said, "Someone who traffics in assigning moral blame to sick individuals for their illness is beyond deviant."
Leaving the word "moral" aside (did I mention "willful misinterpretation"), there is a huge industry that traffics in assigning "blame" to sick individuals -- the life insurance industry. You don't even have to smoke (or scuba dive) to pay a higher rate. You just have to get older.
Maybe life insurance is evil and should be quashed. But for now it is a legal and widely utilized service.
Life insurance is not the same as health insurance, but its acceptance does suggest that assigning cost ("blame") to people for their own health issues is NOT inarguably "deviant."
Interesting argument, but only really applies to Medicare itself, not to universal care. "Old" sick people get Medicare already. The desperately poor (the unproductive 'undeserving' needy) can get care from Medicaid or our highly inefficient free clinic/emergency care system.
The uncovered group is the working poor, what maybe used to be called the middle to upper lower class. They are a) needy - they have less access to health care than the rest of us. (I'm assuming most readers here are middle class and up). They are b) unlucky - they work hard, but lack the talent and/or education the middle class has. The question of responsibility is harder, no one, strictly speaking, is at the end of the day responsible for their 'plight' of being poor. But two out of three ain't bad. Financing it without mucking up incentives is the issue.
From a pure efficiency standpoint, even if socialist medicine is inefficient, it may well be less so than the existing system. At least in that case, only the health care system is messed up. In our current system, the employer-based health care regime distorts labor markets (raising equilibrium hours worked per employee and lowering per hour wages, both for labor demand reasons(employers want fewer workers going longer hours, to minimize health insurance premia) and labor supply reasons (it is riskier to change/leave jobs, because it often leaves an uncovered 'gap' in coverage between expiration of one employer's plan and the initiation of the next), which in turn distorts every other market in the marketplace.
Think of socialized medicine as a kind of quarantine, isolating an invariably disfunctional part of the market from the rest to minimize contagion. (Think we aren't distorted, now? We have a retail market where no one either markets based on price or even posts prices, and where cash business pays considerably more than business which involves more paperwork. That is just absurd.)
It gives a pious sense of self-satisfaction to declare that there are no classes but only cases, and insist that we can warn folk against smoking but are monsters to then ascribe any portion of ensuing lung cancer to their agency. Well, unless we're governments, in which case we're perfectly willing to ban behaviors that run up our health bills, suggesting that governments have a rather more robust conception of medical cause and effect. They may perfectly well allow that your Aunt Hettie smoked cheroots until she was 114, but they recognize that in the aggregate, smoking will increase your odds of lingering, expensive sickness. And with universal health insurance, the aggregate is the only thing that matters.
It would also be nice to see a little less preening ad hominem and a little more substance to some of the critics. I know that the vast majority of posters here have skulls that bulge with the incandescent lightning of the gods, but the ones who make substantive criticisms might win a few more converts if they took the "Evil Overlord Berating Minions" filter off their keyboard.
Well, unless we're governments, in which case we're perfectly willing to ban behaviors that run up our health bills, suggesting that governments have a rather more robust conception of medical cause and effect. They may perfectly well allow that your Aunt Hettie smoked cheroots until she was 114, but they recognize that in the aggregate, smoking will increase your odds of lingering, expensive sickness. And with universal health insurance, the aggregate is the only thing that matters.
You and your side consistently use the example of lung cancer, because as we all know, smokers deserve to die horrible deaths and burn in hell. The fact is, though, that it is simply medically impossible to determine the level of responsibility that any individual has to his illness. How on earth are you going to police that? How on earth are you going to draw those kinds of delineations? (And why is the aggregate the only thing that matters? Oh, right, it helps you leverage your argument.)
It would also be nice to see a little less preening ad hominem and a little more substance to some of the critics.
What's good for the goose....
I'm curious about this odd "morality" that I keep reading about in the comments in which it is moral to force people to pay for the unluckiness of others. I thought the moral position was to advocate personal charity and compassion towards others who are unlucky. Not to allow individuals to get off the hook by claiming that their moral responsibility has been taken care of by huge government-run wealth transfers. I guess I missed that Bible verse in which Jesus told people to give extra taxes to Ceasar so they could ignore their fellow man and feel simultaneously smug about it.
And the freedom -- yes, let's call it by it's real name -- the freedom to never have to worry about losing your coverage, the freedom from job lock, the freedom to join an exciting but risky start up, the freedom from the threat of disease-induced penury, the freedom of knowing your children's health insurance can never be canceled -- the value of such freedom would be priceless to average people.
That's not freedom, that's security. And I'm sure everyone here knows the old proverb about freedom and security.
I'm off to call State Farm to cancel my auto insurance since it transfers money to bad drivers. For the same reason, I won't be replacing it with another policy.
Brad:
McArdle wrote: there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
brooksfoe wrote: That is the definition of a single-payer system: we give them the money to buy it. McArdle is conflating the single-payer system with a national health care system.
Brad wrote: Isn't a single-payer system also a "giant government-run system"? Even if single-payer is one method of giving people money to buy healthcare, it seems perfectly consistent for Megan to prefer a less broad method.
The only daylight between "we give them the money to buy it" and "a single-payer system" would be a system like the French or German ones, where the government ensures a baseline level of insurance for all citizens. The German model is essentially Medicaid for everyone, with better-off people buying supplemental insurance. In other words, "we give them the money to buy it" means, at a minimum, Medicaid for everyone. If single-payer insurance is "a giant government-run system", then in what sense is Medicaid-for-everyone -- or, for that matter, today's Medicaid-for-some -- not "a giant government-run system"?
It's important to keep in mind that single-payer systems put less than 3 percent of the entire health care system's budget into payment and assorted management issues. Our current system puts, as I said, about 25% of the entire health budget into those issues. So this "giant government-run system" is a tenth of the size of the giant, incredibly wasteful private system it would replace.
Moreover, a government agency which sends money only to those who can't afford to buy health care themselves has to be LARGER than one which simply pays everyone's bills, because it needs to have a bureaucratic system for determining who can't afford to buy insurance. An agency that just accepts receipts and pays bills for everyone has much less overhead.
All of these issues are very familiar to anyone who has looked seriously at health insurance policy. There are reasons to prefer non-single-payer systems, like the French and German ones, but these reasons have nothing to do with what McArdle said, which was incoherent and self-negating. And to 'boldface', I'm sorry if this sounds "condescending", but people who have no idea what they're talking about deserve to be condescended to.
A moment of silence for the poor, shattered wreck of the straw man before me. He was set upon brutally and without warning, having had no part in the dispute until his sudden savaging. May he rest in peace.
That said, let me spell out slowly the premise that a government which is obligated to pay for all sickness will discourage or prohibit behaviors which they believe to increase its expenditures. I like to think that this is not a controversial premise.
Organ transplants are a case in point. Right now, there's something of a scandal in South Africa over the minister of health alledgedly receiving a liver transplant while declining to curtail her alcohol intake. Normally, if you are a heavy drinker, you simply will not receive a liver transplant, whether or not you'll die without it. The doctors not only know "how to draw those kinds of delineations", the delineation they draw is that they will let you die if you don't go off the sauce.
Therefore, there already exist cases in which a limited health resource is rationed in part by patient behavior, even to the point of countenancing death. Those who believe that this is a grave injustice are advised to think about why these doctors want heavy drinkers to "burn in Hell", and are so heartless and money-grubbing as to refuse to transplant a liver into them.
[ Posted by Walter Crockett | August 21, 2007 7:40 PM
Without health insurance, I'd be bankrupt, and maybe dead
Without health insurance we'd be bankrupt and she'd definitely be dead
Without health insurance, she'd be dead and we'd be bankrupt ]
And without a store to sell bottled water before going into the desert you would have been in a heap of trouble in your walk. But there was and you're still here.
Didn't you just describe what insurance does? Provide you money for events that would normally be economically hard?
And would you have been dead? Not that I would try it out but there are programs for healthcare for those that can't pay.
Well, unless we're governments, in which case we're perfectly willing to ban behaviors that run up our health bills, suggesting that governments have a rather more robust conception of medical cause and effect.
CardinalXimenes, that is EXACTLY THE POINT. Governments can promote healthy behavior through pre-emptive, preventive action that applies to everyone. This is fair, just, and effective: no one is allowed to smoke in public places, no matter what their genetic background is. Trying to accomplish the same aim -- healthy behavior -- by forcing those who engage in the behavior to pay for the devastating consequences, if they happen to be vulnerable, is empirically ineffective and unjust. Most people did not quit smoking because they knew what the consequences were; they quit because government action makes it increasingly difficult for them to continue.
Look: most people, for both genetic and character reasons, can get along just fine with a moderate heroin habit. The health effects are far less damaging than smoking or alcoholism -- no comparison, really. We could just legalize the drug, warn people of its risks, and let those who are vulnerable to severe heroin addiction suffer the consequences of their bad behavior. But you know what? That would be cruel and, from a public health standpoint, idiotic.
[ brooksfoe 10:30AM The health effects are far less damaging than smoking or alcoholism -- no comparison, really. We could just legalize the drug, warn people of its risks, and let those who are vulnerable to severe heroin addiction suffer the consequences of their bad behavior. But you know what? That would be cruel and, from a public health standpoint, idiotic. ]
So you're a nu-Temperancist then? What's your criteria for not making into law your beliefs of what makes for good living ?
You are all taking an incredibly complicated subject-- the degree to which someone's illness is the product of their own behavior-- and talking as though there are clear lines to be drawn. There most certainly is not.
Can't the same thing be said, Freddie, for the relative success of business decisions, or scientific research, or education and career choices, or whatever other speculative activity we may engage in?
We cannot begin to comprehend the immensity of chance shaping our lives. But even so, smoking today seems a lot like opening a buggy whip enterprise in 1950. We don't feel super obliged to bail out the latter kind of bad decision, not even because tons of people make wise business decisions and still end up bankrupt.
I thought the moral position was to advocate personal charity and compassion towards others who are unlucky. Not to allow individuals to get off the hook by claiming that their moral responsibility has been taken care of by huge government-run wealth transfers.
Christina, you are suggesting that by paying my taxes and desiring that they go towards guaranteeing my fellow Americans will never lack health care, I am trying to "get off the hook". In fact, I would like to pay MORE taxes if they would go towards ensuring that no American goes without health care. (According to polls, most Americans now agree with me.) I do not want my fellow Americans to have to rely on the unpredictable whims and moral tics of others in their hour of need; I want them to have the same sense of security and freedom as people in, say, France. You are saying this makes me an immoral person. I think that refusal to extend this solidarity to fellow citizens would make me an immoral person. Do you understand why I consider your attitude insulting?
Trying to accomplish the same aim -- healthy behavior -- by forcing those who engage in the behavior to pay for the devastating consequences, if they happen to be vulnerable, is empirically ineffective and unjust.
If that position were prima facie obvious, brooksfoe, we wouldn't be having this discussion. No one lobbies for injustice and ineffectuality, unless we want to start ascribing demonic evil to our opponents.
Forcing people to suffer the consequences of bad choices is by no means a universally-abhorred moral concept- even if they are "vulnerable", in the sense that the consequences of their bad choices could produce great misery for them. A very common complaint about universal healthcare is that it produces its own justification for its demands- it puts everyone into the same risk pool, and then quite reasonably declares that if it's going to be forced to pay for your doctor's bills, it gets to decide what constitutes an imposition on the public purse.
Many, many people do not like that one bit. There are worse things than having to get your health care from an overcrowded emergency room, and giving the government a semi-plausible justification for legislating any element of your personal behavior that the solons in Congress think is relevant is much, much worse to these people. It would be an interstate commerce clause for our own bodies.
brooksfoe,
Giving money to those unable to purchase health insurance is not a single-payer system any more than food stamps is a single-payer system for food- unless, of course you ignore all the other people who purchase food without taking funds from the government. The point that McArdle is making is that you don't have to create a single payer system to cover those who can't afford health care.
So you're a nu-Temperancist then? What's your criteria for not making into law your beliefs of what makes for good living ?
I don't have a general rule on that, and I tend to have a pragmatist attitude towards these questions -- I don't think one needs such general rules a priori. But rules are important when you have to resolve contradictions, and the case of drug addiction is a good one, since the best solutions for different drugs are different from each other. Thinking about heroin, a few things come to mind:
1. Heroin addiction imposes a significant cost on society, in terms of infectious disease from shared needles, income support for people who are no longer able to hold jobs, emergency-room health care costs, and crime committed to support habits.
2. Heroin is highly physically addictive: once someone develops a habit, they leave the realm where they can be held personally responsible for their actions. Heroin addicts cannot be trusted to pursue their own best interests. It's not terribly meaningful to talk about users' "freedom" to "choose" to continue their habit.
3. The fact that those who develop severe addictions are a susceptible minority means that the whole thing is profoundly unfair. Individuals are unable to make such calculations rationally.
4. There is a cost to parents in raising their children in societies where heroin use is widespread. Parents have a legitimate interest in asking government to reduce the risk of their children becoming addicted.
That said, the evidence is clear that the best way to handle heroin -- reduce abuse, reduce addiction, reduce its tangential harm to society -- is through "harm reduction" programs such as those in Australia and the Netherlands. These involve needle exchanges and providing free government heroin to registered addicts at police-controlled injection sites, with health staff monitoring injections and providing counseling on HIV and other addict issues. This makes shooting up so unsexy and tedious (but free!) that new-addict incidence falls dramatically. Heroin addiction rates in both countries are now much lower than in the US.
Megan, I’ve read and enjoyed your blog since the Live at the WTC days. Congratulations on the new gig!
That said, these two posts on health care strike me as amazingly wrongheaded. As other commenters have already noted, treating the young and the old as fixed social classes makes no sense, since today’s young will become tomorrow’s old people.
If we are concerned about inter-generational equity, then we have to look at each age cohort, and how they make out over their entire life cycle. It is true that under your scenario, at any given point in time, the young people will be subsidizing health care costs for the old. But if we assume that both living standards and health care costs continue to rise, then when today’s young people become old, they will grow up to be richer than today’s old people, and will also receive a greater health care subsidy than today’s old people. Assuming a constant population, each age cohort subsidizes their elders, but in return receives an even larger subsidy from younger generations.
Of course population isn’t constant, so there are potentially issues of demographic sustainability here, especially with regard to the retirement of the baby boomers. But that’s not the objection you raised.
More fundamentally, this whole issue has absolutely nothing to do with the debate over single payer. It has to do with the basic logic of risk pooling and insurance.
For example, I currently get private insurance through my employer. The insurance company charges the same rate for everybody, regardless of health or age status. As a young healthy person, I’m currently subsidizing my old and sick co-workers. Since I happen to live in the only industrialized country without universal healthcare, I could lose my health insurance at any time. So not only do have to currently subsidize the old and sick, I get no guarantee of a reciprocal subsidy should I become sick before becoming old enough to qualify for medicare. By your criteria, the current system is even more unjust than single payer.
In fact, a single payer system is actually better equipped to handle the equity and moral hazard concerns you’ve raised, since it could be funded through a combination of progressive taxes, age based taxes, and sin taxes. Trying to do the same thing in a private insurance market would risk segmenting the risk pool and causing the whole market to insurance market break down, since insurance is based on pooling risk. In fact, that was whole point of Ezra’s original post!
"The modern conservative is engaged in one of man's oldest exercises in moral philosophy; that is, the search for a superior moral justification for selfishness."
- John Kenneth Galbraith.
I've enjoyed the excahnges here and don't have much to add except that for more information on single payer, I offer you two web sites:
Physicians for a National Health Plan at www.pnhp.org and my single payer blog at
http://cmhmd.blogspot.com
Cheers,
This topic defies rational discussion. I think Megan is incorrect in saying efficiency is a topic divorced from morality, and she dosn't address the fact that we don't need to put in place a single payer system to have huge wealth transfers from the young to the old. We do very well in operating our gerontocracy in this country, even without single payer. I did appreciate this statement, however....
"The elderly have no fairness claim on the young."
...because it increasingly appears as if the primary function of our political system is to have young people serve old people. Yeah, we tax old people to pay for schools for the young, but that is dwarfed by the taxes young people pay for the old, and the old get get a pretty good return for the taxes paid for educating the young; who do you think is staffing the cruise ship companies and airlines that the old utilize, to say nothing of the clinics and hospitals? In contrast, when a 20 year old pays for the medical care of a 75 year old, what does he get for it?
Now, a moral argument can be made that if a 75 year old desperately needs medical care, the 20 year old has a responsibility to pay for it (I'll forgo an examination of whether it is moral to physically coerce people to fufill their moral responsibilities), but what is galling about our current situation is that the 20 year old is typically quite poor in assets, and often so in income as well, and the 75 year old typically is far, far, wealthier in assets, and frequently much better off in income as well.
How about this for a compromise? Before we put the arm on some poor 20 year old sap who is going to get unlucky and get killed in a car accident or by disease before he hits 50, we examine what ways the comfortable elderly can finance their own health care? Let the unlucky 2O year old keep more of his money to have some fun, or to do with as he or she pleases, before the premature dirtnap starts, and tell the codgers' children and grandchildren that dear ol' ma and pa's estate is first going to be use to reimburse medical expenses associated with the last five years of ma and pa's life? If the codgers are really, really, desperate to leave wealth to their descendents, they can talk about it with their doctors.
Yancey Ward, you're kind of right, as I said above. McArdle wrote:
If we are worried that some people cannot afford healthcare, there is a much simpler solution than constructing a giant government-run system; we could just give them the money to buy it.
As I said above, if this idea were implemented with a non-single-payer system, then what you would have would be a German or Dutch-style system of baseline national insurance for the poor and more costly private insurance for those who can afford it. But if McArdle is saying she wants a Dutch-style universal health care system, then she has very little difference with Democratic advocates of universal health care, and she should vote for John Edwards, because that's pretty much what his health care plan is. I seriously doubt that she understands this.
This doesn't get into the obvious and familiar problem with government "giving [those who can't afford it] the money to buy" health insurance, which is that it immediately leads private insurance companies to inflate their premiums, since anyone who can't afford to pay them will simply have government pick up the tab. For this reason, McArdle's solution necessarily entails more government regulation of private insurance companies, or the establishment of a government-run insurance program which will pick up anyone who can't afford their premiums for whatever reason (in other words, compete with the private sector). That then leads private insurers to engage in more aggressive cream-skimming, so that the oldest and sickest people all wind up in the public program, which again leads to huge costs to government. The remedy for this is to ban private insurers from discriminating on any basis -- preexisting conditions, etc. Again, these are all doable, and are perfectly legitimate solutions to the problem of the poor or the sick not having access to the health care they need. But all of them involve what McArdle considers "massive transfers of wealth from one class to another" -- basically, from the healthy to the sick. And they entail "giant government-run programs", much like the ones we already have -- Medicare and Medicaid. What I'm responding to is the basic incoherence of "instead of having a giant government-run program, we could just give money to everybody who can't afford it." What exactly does McArdle think "giant government-run programs" do?
It is clear that self righteousness and notions of self evident "moral superiority" will prevent a reasonable solution to the health care question from ever being achieved in the U.S.
Megan's critics miss the point entirely. Phrasing her points differently, the old as a group have no special moral entitlement to healthcare because 1) as a group they are richer than the population at large and thus more capable of paying for their own care; 2) as old age is an entirely natural and forseeable event, end of life healthcare is not an "unfair" calamity like having one's house destroyed by a tornado or having one's teenage daughter develop a brain tumor; and 3) no one else is responsible for the old developing the health problems associated with old age.
Even Megan's most Marxist critics must perceive the injustice of the Medicare system, which provides all you can eat healthcare to the aged, whether they are Warren Buffett or a penniless bum. Why do we countenance such massive transfers to the most asset rich segment of the population? And why do so many middle class old people find it a howling injustice that they be asked to use their assets (such as home equity etc.) to pay for end of life care? So many old folks are willing to take Medicare for $300k for 6 months of ICU hospitalization for terminal lung cancer, funded by payroll taxes on $8 per hour busboys, while still wanting to leave their house and stock portfolios to the grandchildren. How is that "fair" or "moral" to the busboy (who probably doesn't even have health insurance himself)?
Megan is not proposing that we kick old folks out of the hospital. She is proposing that the richest demographic segment of the population shoulder more of the burden for their own entirely forseeable healthcare needs. It is the demands of asset-rich old folks for free health care which is the elphant in the room. Single-payer will never work here without a radical restructuring of Medicare and the introduction of significant means testing.
I would have though the Atlantic's lefty readership would have embraced this idea. But as hypocrisy is the compliment that vice pays to virtue, it is apparent "universal healthcare" is for many here just cover for "more free stuff from Uncle Sam, please."
I wonder how all these deeply concerned people have the time, a computer, and internet access to be able to post on this subject. All of those are resources that could be going to support some sick person who's going without health care.
Snark aside, my point is that government provided health care doesn't just come appear for free. It costs people's time and money. This doesn't mean that it's not worth doing, but it's not the magic wand that some posters appear to believe. At the margin, everyone (or at least everyone productive) will have less time and/or money.
Not to say that I think there's no place for public financing of health care, but if your health is important enough to spend my money on then your health is important enough to spend your money on it first. Since unless your name is Bill Gates (and even he's going to die from something) health care can ultimately cost more than anyone can afford I'd like to see some sort of publically provided catastrophic insurance that comes with reasonable and well understood limits. Public insurance should be a safety net, not the high wire itself.
None of this should be taken to mean I agree with the orginal post. Old and sick as a class bear moral culpability for their sickness? Middle aged and sick I could entertain, but old and sick is practically redundant. Bad health is the price of aging. But I also can't understand the reasoning of those who think that it's morally preferable to take from others before providing for themselves and preen over anyone with the temerity to disagree with them.
Check the waiting lists for operations in Britain, France, and Canada.
The idea that countries with universal heath care have significantly higher waiting times to receive medical care than the United States is utterly unsupported by data. The idea that there are not long waiting times for medical care in the United States is flatly wrong.
Freddie you are clearly the only intelligent person in the room. Would you like to give some evidence for this statement, beyond "flatly wrong"?
I think that one way to illustrate Megan's point would be to use a slight counterfactual: Imagine that we decided to move to a fully funded health care system.
This change wouldn't affect the programs to deliver services. We would still have Medicare, Medicaid, SCHIP et al. The difference is that we would change the way taxes are set. Today taxpayers of all ages pay each year for the costs incurred by beneficiaries of all ages. Under this proposal, people born in each year would pay taxes over the course of their lifetimes which would cover the benefits received by people of their age over the course of their lifetimes.
Now how would this work? Since very few people under age 16 pay much in taxes, the government would have to borrow on behalf of each cohort for those years. Similarly, since medical expenses are far higher after age 70 (when few are still working), some of the taxes paid by each cohort would be saved for that time. If we don't want taxes to vary by age, then taxes during each person's working life will need to be higher than medical expenses during that time. Fortunately, the required taxes are still significantly smaller than what we pay today because investments grow faster than total tax revenue (this is true even of bonds over the long run, so I'm going to avoid talking about the amount of the difference since that will get the discussion sidetracked on questions like whether the investments are individually or publicly held and the effects of that decision).
Of course, the lower taxes required by this system aren't a free lunch. They come because I've ignored the fact that existing people over the age of 16 have not been paying into the system and therefore we haven’t set aside any money to cover their medical expenses in old age. In order to transition to this system, we would need to find a way to pay for their health care when the costs exceed the taxes they pay over their lifetimes.
The implicit moral reasoning of those who prefer the current system is that those costs should be paid by current workers in proportion to the number of years they have remaining in the labor force and that no one who is receiving or will receive benefits _regardless of income or wealth_ should contribute to those costs.
Will Allen,
I liked your idea when you first mentioned on Megan's old site. This actually addresses the problem that gets missed over and over- the young paying for the old today is not the same as the young saving to cover their cost in the future, despite what most of the readers here believe. What we have now is Ponzi financing, and it includes an enormous problem of moral hazard- people have no incentive, with regards to healthcare financing, to take extra care of themselves throughout the course of their lives. They have no incentive not to consume every resource they can in order to live just one day longer.
Of course, we already have a version of your idea with regards to Medicaid, the elderly, and the elderly's assets, and it is illuminating how much contention that causes by itself. If implementation of your idea demonstrated that everyone was outspending their assets on healthcare, it would tell everyone something extremely important, would it not?
"Though I agree with you on single-payer efficiency, I don't think your moral calculus holds up. Compare health care with the Fire Department: if your house is on fire, it's likely you share some guilt in the matter (as a member of the class of people with houses on fire -- some are just unlucky, to be sure, but not really unlucky, as they have a house to begin with), but we invest public resources to save you from this circumstance because your house is on fire."
Historically, cities invested in fire departments because an unchecked fire spreads to other houses. Rome, London, and Chicago have all had fires that spread and destroyed much of the city, as have countless smaller towns.So the fire department races out to put out small fires before they become big fires - and it will do so even if my own carelessness started the fire. However, it's not free. At least around here, they will send out a bill to cover at least part of the cost of their run.
Likewise, anyone with a serious acute illness can walk or be carried into an emergency room and get treatment. The bill comes later. What most uninsured people worry about isn't getting treated, but paying the bills afterwards. I don't see that possible distress as a sufficient reason for the government to put a gun to my head and take a large chunk out of my paycheck.
"In the real world, pooling decreases average costs"
No, as long as you and your doctor are deciding how to treat your ailment, pooling increases average costs because you'll choose the more expensive option because you aren't paying for it. The only way it decreases costs is if some clerk in an office faraway is dictating which treatment you get. And that results in many people not getting the treatment that they need.
Just curious, if universal health care is a moral issue, whatever happen to the whole, "you can't legislate morality!" crowd?
The only way it decreases costs is if some clerk in an office faraway is dictating which treatment you get.
The clerk in the faraway office isn't dictating which treatment you get. He is dictating how much he will pay for it. That's how it decreases costs.
You have to keep the benchmark evidence in your mind: every other economically advanced democracy has universal health care. Every other economically advanced democracy has lower health care costs (mind-bogglingly lower -- none higher than 60% of ours). Every other economically advanced democracy has substantially better health care, even for the rich. Our current system is the absolute worst health care system of any economically advanced country, by far. I don't care which other country's system you pick -- England, France, Germany, Sweden, the Netherlands, Japan, Canada. But you have to pick one, because what you've got is simply untenably awful.
It would certainly focus some previously unfocused minds, Yancey, along with causing some tensions around some dinner tables during intergenerational family gatherings, I suspect. I fail to see, however, why our society should be more concerned about the fifty year old who is eyeing an inheritance, as opposed to the 20 year old working at Wal-Mart.
This is an area where the people who are strongly supportive of an estate tax can have their bluff called. Let's have one which recoups 100% of all Medicare benefits paid, with no exemptions. I'm all for it.
Again, and again, with the smoking. What about other health concerns? What about other risky behaviors? Does a guy who goes skiing and breaks his leg not deserve to have his bones set?
And, again, does someone who smoked deserve to die of lung cancer? That is not a straw man. That was explicitly stated by Julian Sanchez above.
brooksfoe, when people who adhere to your position make untenable statements, they discredit their postion just as reliably as when people who oppose your position make untenable statements. The only people for whom it is "better", for instance, to be diagnosed with cancer in Great Britain, as opposed to the U.S., are those who welcome the prospect of dying from cancer.
We could kill the elderly population and feed it to the prison population. Or vise versa.
The former scenario makes more sense in terms of economic efficiency. The second makes more sense in terms of moral reasoning.
Discuss.
Freddie, I would take issue with the notion that anyone "desrves" health care, which for me is synonymous to saying that health care is a right. Health care is the by-product of other people's labor and ingenuity, and unless one is an advocate of slavery, one does not deserve or have a right to the labor and ingenuity of other people.
I can make a case that we can rightly use state power to compel others to pay for the health care that someone needs, but that isn't the same thing as saying the recipient deserves or has a right to it.
Owenz, discuss how it came to be that you equated the elderly using their wealth to pay for their health care with killing the elderly.
With only limited revisions, I could make Megan's article a compelling case *for* single-payer health care. Given that (a) most people eventually get sick or old-and-sick, (b) the etiology of disease is only partially known, and (c) bad health episodes can befall anyone, perhaps the appropriate "class" (to use Megan's fraught and perhaps unfortunate word) is the population as a whole, in which case single-payer makes both instinctive and reflective sense.
Yes, by all means let's go to a system like Great Britain. Then all of you can have the experience I had when "treated" there, which led to the loss of the central vision in my right eye at age 41, because they don't bother to run fluorescent dye angiograms there when people have blurred sight.
Had I been in the US, they'd have run one at the cost of several hundred dollars, and I'd have been treated with the newest laser therapy and BE ABLE TO F*CKING SEE FOR THE NEXT 40+ YEARS.
And I assume you've all seen the recent article about the woman in the UK who was forced to GIVE BIRTH IN A TOILET, aided only by her mother, because no one would help her, since she was in the wrong ward or the wrong nurse was on duty or some g*ddamn thing.
Or the article about the rampant hospital-acquired infection rates in the public UK hospitals versus the zero rate-of-infection in the private hospitals.
Or how a neonatal unit in a Montana town of 55,000 had to handle the birth of quads of a Canadian mother, because the ENTIRE COUNTRY OF CANADA (30,000,000 people) didn't have the facilities.
You can take your public medical care and shove it sideways. Idiots.
Please stop using footnotes where a parenthetical would perfectly suffice. It really disrupts the flow of trying to read your article when I have to scroll down to find out wtf you're footnoting. It's really annoying, and although I'm not an expert in the area, I think grammatically incorrect.
This argument doesn't fly on its own terms. The transfer is not from old to young. It is from the uninsured who are wealthy enough to buy insurance to the insured. Under single payer, the insured pay to the government instead of an insurance company, and if we aren’t talking about efficiency then we are assuming this is a wash. Obviously, the increase in income taxes of the uninsured isn’t offset by the decrease in insurance payments because they didn’t buy insurance. So who are the uninsured? They are either people who can’t afford insurance, who by and large don’t pay income taxes anyway, or people who can afford it and choose not to. So by this articles own terms this group largely falls into the needy (the poor uninsured) who get the coverage they deserve, and the irresponsible (those who choose not to be insured) who have to pay into the system. Sounds right to me.
Megan says,
"A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick."
This is, in a very generalized sense true. Of course private insurance does EXACTLY the same thing. It's called risk-pooling and we humans have been engaging in such behavior since the very beginning of society. A single-payer system merely ensures that everyone participates in the pool and has the potential to utilize it's benefits if needed. As opposed to our system now where size-able portions of our population are excluded by economic circumstances largely beyond their control.
I'm quite certain as to which system is more inherently moral.
Yes, a very AMERICAN assessment of a social issue. We see "young and healthy" pitted against "old and infirm" . . . "rich elderly" pitted against "young people of lesser means"... Us versus them. . . . How American. Providing good medical care for our fellow citizens really is a secondary concern.
What I find most sad about Ms. McArdle's calculation is the complete absence of the notion of a "samenleven", as the Dutch call it. Our "living together" as a single society --not a slew of sub-categories defined by their own competing financial/interests and selfishness. So younger people pay more for health care that benefits elderly! And when those young people get old and are no longer working --if the social contract remains in place-- then their health care will be subsidized by the generation that comes after them.
McArdle strikes me as the typical Republican. For generations now there has been a kind and compassionate social contract whereby the younger and more able have subsidized the medical care of the elderly. Generation after generation no one questioned this respect for the elderly and this manner of honoring our elders. Now comes McArdle's generation . . . the solipsistic selfish types (GOP members mostly) and they have no patience or understanding for the social contract that subsidizes health care for the elderly. What they see is old people getting a free ride on their dime... and they don't like it on bit!! God forbid Ms. McArdle should ever grow old or very sick and be personally responsible for her own medical insurance. I'm sure she would be screaming like a stuck pig --the loudest most demanding voice in the senior's center.
Though Ms. McArdle couches her article in terms of pure economic analysis, the fact is within the article itself, she unwittingly reveals herself to have a very clear, very industry-driven agenda. Consider Ms. McArdle's conclusion that on average the elderly are better off than the young (when has that ever NOT been the case?) and therefore should not be the recipients of "largesse" from the youthful.
This completely ignores the following:
) the cost of healthcare in America is such that only a minute fraction of the elderly could personally afford their own health care costs. A health insurance policy of self-paying is completely out of the reach of all Americans except for the most exceptionally wealthy --the vast majority of the elderly do not fit into that category.
2) if the cost of healthcare were not subsidized by the young and middle-aged, the elderly would not receive the health care they need --unless McArdles want to take the logic of her article one step further and deny health care to the elderly so they will die --which is very cheap on the health care system.
3) McArdle states that the elderly are not worse off because they are old --since they have lived their lives and were youthful once... she goes on to make many other assertions that suggest that the elderly should not receive 'special treatment' because they've lived the same lives that young people are living today. However, when she considers the negatives of the lives of the youthful, she fails to make the reverse assertions. For example: Ms. McArdle states that the old have lived their youthful lives... but then she goes on to say that the young are less affluent than the elderly. She completely fails to mention the correlated fact that the youth of today will have their wealthier days in their "Golden Years". The failure to make parallel comparison shows Ms. McArdle's bias and political motivation.
McArdle Ms. McArdle's article is a perfect example of the selfishness that increasingly pervades American society. The fact that a person can pretend to be speculating out loud about why it is "unfair" for younger people to "subsidize" the health care of the elderly is, on its face selfish, self-absorbed, destructive of the social contract, and simply indicative of a personality that has been formed in a nation without any notion of citizenship --the participation in a societal organism that is larger than the four walls of one's home --a cut throat selfish ethic. America wasn't always this way. Believe it or not, there was a time that the thoughts that run through McArdle's article would never have entered into a person's consciousness because such thoughts were so vile. So self-serving. So uncharitable.
"What is so incredibly difficult for you to understand about a moral responsibility for universal health care coverage?"
There is no such moral responsibility.
"...if you think this...is a rational response to the moral imperative to use our available means to heal the sick, then..."
There is no such moral imperative.
Have a nice day.
Will Allen, Noah Yetter: Everyone for themselves!! No social contract. No taxes! Yahoo!
I think much of this comes down to the obligations and respect that one citizen has for another. Would I want my neighbor to be free of extreme worry and poverty should he get seriously sick at a time when he just lost a job and is uninsured. YES! I want that for my fellow citizen. Yetter and Allen DON'T want that for their neighbor. They do not believe in a social contract to help those who cannot help themselves.
Sometimes I think this just boils down to the difference between people who are decent and concerned about others and those people who care only about themselves. I consider Mr. Yetter and Mr. Allen to simply be selfish, solipsistic people. They don't owe anybody anything, ever. And I'd bet that they extend that attitude to their own family, parents, sibling, etc. Sounds like they grew up in some dysfunctional, selfish households. Sad that people are this way, but understandable.
I am left to wonder whether Mssrs Yetter and Allen would even care for their infirm parents or a bed-ridden sickly spouse. Just how stingy is your charity, Mr. Allen? Just how stingy is your charity, Mr. Yetter? Please tell us.
And Ms. McArdle, how stingy is your charity? Care to share?
Don't we already have an unfair system? Care for the old, pay for the uninsured, pay for the insured (my insurance plan pays for someone else's cost, since I rarely need any healthcare), etc...
Not sure what to think anymore. It all seems the same.
"A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick."
Wrong. It transfers money from taxpayers to bureaucrats.
The only people for whom it is "better", for instance, to be diagnosed with cancer in Great Britain, as opposed to the U.S., are those who welcome the prospect of dying from cancer.
Or those who wouldn't be able to obtain treatment in the US because a reviewer at their HMO found an excuse to reject it, in order to save the company money. Overall, cancer survival rates for those who are diagnosed are significantly better in the US, but at the lower end of the care spectrum there are likely to be some people who would be better off in the UK. And those are the rates for those who are diagnosed; there are no figures on how many people fail to be diagnosed at all in the US, because they lack health insurance or are otherwise locked out of the system.
Freddie said, I think "don't blame people for being sick" is a pretty basic moral proposition.
Why?
Smokers get put at the bottom of lung transplant lists, but I never hear liberals complaining about it. Quite the contrary, actually.
Consider:
Group A consists of people who exercise for two hours a day and abstain from cigarettes, drugs and alcohol.
Group B consists of people who never exercise, eat poorly, smoke cigarettes and drink.
Both groups may end up with genetic cancers, so let's stipulate that it's immoral to blame someone for sicknesses with primarily genetic causes like Hodgkins disease, brain cancer, or multiple sclerosis. Let's also include accidents such as head trauma or blunt force paralysis as immoral conditions in which to assign blame. Let's even include diseases caused by environmental concerns such as involuntary mercury ingestion or tactile lead poisoning.
Group B is at risk for a whole host of chronic, expensive procedures that group A is not (obesity, diabetes, heart disease, knee replacements, hip replacements, high blood-pressure, emphysema, cirrhosis). The causes of Group B's increased risk (compared to Group A) are their own bad and/or lazy choices. Bad and/or lazy choices that Group A did not make.
Under mandatory government-run health care, Group A would be required to pay for treatment for Group B's chronic and preventable illnesses, while Group B does not reciprocate.
Under this system, all the people you can see in the Boston Marathon will be forced to subsidize the self-destruction of all the people you can see on Jerry Springer.
And Freddie thinks it would be "immoral" for the marathoners to point this out?
I (unlike Michael Bloomberg) will defend another's right to eat, drink and be merry to his or her heart's content. But I've never seen a valid argument as to why I (or anyone other than the reveler) have a moral (or any) responsibility to pay for such a person's fun, laziness, self-destruction or irreverency.
"Again, and again, with the smoking. What about other health concerns? What about other risky behaviors?"
What about them? I fail to see the controversy in the statement that some people's health problems are due at least partially to their own choices.
"Does a guy who goes skiing and breaks his leg not deserve to have his bones set?"
Sure. Does he "deserve" to be fully insulated from that cost? If so, then we artificially lower the price of risky activities, and total costs will increase. Or we can just ban skiing, along with everything else bureaucrats decide is too dangerous.
"And, again, does someone who smoked deserve to die of lung cancer? That is not a straw man. That was explicitly stated by Julian Sanchez above."
Absolutely false. "Bearing responsibility for" does not equate to "deserve". It's closer to "could possibly have avoided". Say I leave my car with the windows down and an iPod in plain sight on the dashboard, and when I return the iPod is no longer there. I didn't "deserve" to have it stolen, but it would be silly to say that it was just a random unfortunate event.
Here's my proposal to the uncharitable Ms. McArdle, Mr. Yetter and Mr. Allen. Put your money where your mouth is! When you are old and infirm, simply refuse on principle to accept any government-related health care benefits. After all, you wouldn't want to be taking undeserved money from the less-than-well-to-do younger set. Believe me, we will gladly omit you and like-minded indivduals from the health insurance coverage provided by the government. And when your deductibles and co-pays put you in the poorhouse --and they will put you in the poorhouse-- you can hear the comments of the unchariable youth cursing you because you failed to stay young... and because you are unable to afford health care coverage.
Come to think of it... so much of what people like Allen, Yetter and McArdle are about is simply their incapacity to imagine life as another person. As a cancer patient, as an infirm elderly person, as a parent of a child needing round-the-clock medical observation . . . they are solipsistic type personalities. The only needs they can imagine meeting are their own. The only suffering they care to alleviate is their own. The only fears they seek to quell are their own.
There are two principal strains of commentary in the above comments. One straing belongs to those who care about others... who have a fully developed range of human psychology and emotion --including empathy, sympathy, imagination of the struggles of others.... and then there's the ugly strain. . . those who simply cannot find it within themselves to care about the well-being of others. [As an aside, I have a nephew who is very much the type that cannot understand the reason why anyone would ever give a helping hand to anyone else.... once my sister was asked directions to a building in her town, and her son (my nephew) asked why she did that! Why did she stop their walk to talk to those people to give them directions. He's an extreme case in not understanding the human imperative of "helping others"... helping others is simply part of a healthy fully formed human personality, in my opinion. To a lesser degree, maybe, Mssrs. Allen and Yetter and Ms. McArdle are like my nephew: They just don't get it! I believe they have truncated personality development. There's a segment of normal human psychology/emotional development that they are simply missing. A discussion between readers on this topic can never be solved, because the uncharitable ones simply do not have a fully enough developed human personality to understand the basic notions of a social contract... you help me when I'm in need and I help you when you're in need WRIT LARGE on a societal level. They don't understand this... though they benefit from it every day. For them, the equation is: I never help you, and if I need help, I'll scream for it till I get it.
There's no discussion really.
Steve, I guess you're joining the ranks of the selfish and uncharitable... and ignorant, I might add.
First, your own examples prove you to be wrong. You say that a person who leads a healthy life style can develop colon cancer... and he is not responsible.
Then you talk about an obese person with a history of no exercize and you suppose that such a person's colon cancer was caused by the food he ate and his lifestyle...
Well well well... the epidemiology shows that the increase risk for colon cancer between such individuals is less than 6%. Just as a healthful person can develop colon cancer, so too can an obese person's colon cancer be unrelated to his obesity or lifestyle... in fact, the increased liklihood of developing colon cancer in an obese person is FAR TOO LOW to be able to attribute a causal connection between the two. Any oncologist will tell you that colon cancer is typically of unknown etiology. A 6% increased risk is just barely scientifically statistically significant. The fact is that even the obese person's colon cancer is more likely due to a combination of personal genetics and UNKNOWN factors just as it is in the healthful persons' colon cancer.
Which means that in the VAST majority of cases, t
"Sometimes I think this just boils down to the difference between people who are decent and concerned about others and those people who care only about themselves."
Yes, that's exactly it. Your side's motives are nothing but pure, and the other side wants sick people to die so they can afford slightly bigger mansions. Also, you're either with us or you're with the terrorists.
"Would I want my neighbor to be free of extreme worry and poverty should he get seriously sick at a time when he just lost a job and is uninsured. YES! I want that for my fellow citizen."
As do I. What I question is why Warren Buffett should have an automatic claim on the income of 20 year old waiters. I'm open to the argument that means testing is too expensive and so it's cheaper to let the old and rich freeload, but I see no *moral* reason why age should trump all other factors.
Dan Cobb,
Care to share information on how much of your income you freely give away to others?
However, there was an important point in your very first comment:
This is why the government has such a large unfunded liability in Medicare. Many elderly, as they age and die, are consuming far more resources in the form of medical care than they ever saved during their productive lives, and then some (in a lot of cases, consuming more medical resources than they ever produced in their entire lives). This situation only gets worse as the population ages, medical science advances, and the productive fraction of the population declines. As we tax the young to provide the resources for this, they lose the ability to save for themselves, thus making the burden even heavier for future generations. This problem is actually the core of McArdle's argument. Resources are finite, compassion and generosity have costs. We are asking those with the least to provide the resources to those with the most, and in return for nothing other than a promise we have no power to deliver on.
"...if you think this...is a rational response to the moral imperative to use our available means to heal the sick, then..."
There is no such moral imperative.
Interesting. You know, I was out driving today, and I passed by a guy who'd just been hit by a car and was lying on the curb, bleeding. Looked like he had a head injury.
Sucked to be him! I didn't stop -- I had some shopping to do.
Yes.
Megan McArdle 4tw!
Lost in this column is any acknowledgement of what "insurance" as a concept is supposed to do---spread risk. Ms. McArdle implies that a single-payer system would require higher individual premiums---more than what private insurance companies now charge workers AND employers together. On what basis does she make that claim?
Right now in an effort to maximize profits, health insurance companies try to limit their pool of insured to the healthiest people. But in a single-payer system only ONE pool exists--so the risk is spread the farthest.
I have a better analogy than her taxi driver/surfer: how about social security recipients and workers? The nation agreed that in return for an income floor for all Americans in retirement it was worth taxing all workers and employers. Yes some of these workers will die before retirement and never collect. But isn't that the same bargain health insurance companies make now? People may pay premiums for years and never incur more than an annual physical. But that helps insure another person who may need a costly operation.
I have always been a libertarian-leaning conservative who used to scoff at single-payer proponents. But done right I think it offers a much better solution than a myriad of for-profit companies and "plans" all scrambling after the healthiest people. Corporations are the bedrock of our economy. But they are always beholden to shareholders which means they can never implement healthcare that puts patients first.
Dann Cobb wrote: First, your own examples prove you to be wrong. You say that a person who leads a healthy life style can develop colon cancer... and he is not responsible.
Then you talk about an obese person with a history of no exercize and you suppose that such a person's colon cancer was caused by the food he ate and his lifestyle...
If you'll read what I said (this time), you'll notice I didn't say anything you attribute to me. In fact, I didn't mention colon cancer at all.
Contrarily, I stipulated that people can be at the same risk for the same diseases (I noted certain cancers) regardless of how they choose to live.
Verbatim: Both groups may end up with genetic cancers, so let's stipulate that it's immoral to blame someone for sicknesses with primarily genetic causes like Hodgkins disease, brain cancer, or multiple sclerosis. Let's also include accidents such as head trauma or blunt force paralysis as immoral conditions in which to assign blame. Let's even include diseases caused by environmental concerns such as involuntary mercury ingestion or tactile lead poisoning.
I then pointed out that obese people (and smokers and drinkers and drug users) put themselves at much higher risk for expensive diseases that they would otherwise not be at risk for were they not obese (not smokers, not drinkers, not drug users).
Those are choices, plain and simple. The higher at-risk people looked at the costs of obesity (or smoking or drugs) and the costs of health (abstinence from enjoyable food, hundreds of hours per year spent jogging and lifting) and chose obesity.
Freddie claimed that pointing out that the obese or any other preventably-sick might be responsible for their sickness was immoral. I disagree.
I also disagree that the healthy or disciplined have some obligation to pay for the self-destruction of the self-destructive.
If some of that's not to your taste, take issue with it. But when you take issue, take issue with the argument I made, instead of the argument you wish I'd made.
From the ranks of the ignorant, uncharitable and selfish,
Steve
In graduate school, when I studied actuarial process insurance was always thought of in terms of 'gambling'. National health insurance means that each person buys a lottery ticket in a game no one wants to win. No one is promised tomorrow. There are many young sick and old healthy people about. And each one bets that should something come along, you will win the lottery.
Probably the clearest way to clean up health care costs would be to control who has children. Simple family health geneologies on every citizen, then an audit, constant monitoring and then people would apply for permission to have a child. After reviewing the family history, permission would be granted or denied. If denied, the person would be forcibly sterilized. If granted, the fetus would be monitored with frequent genetic testing. Any problems or propensities would result in a forced abortion.
How's that for a Libertarian solution? If you base an argument on behavior causes disease, you then need to take into account genes which are increasingly known to play a role in many cronic conditions. Which rather quickly leads to eugenics.
Also missing here is any understanding that diseases are infectious. And can spread quickly when those without access to health care infect all around them.
To Steve, the uncharitable and selfish:
A great moniker for you, by the way. I guess selfishness and lack of charity is the way you deal with the world around you. THere is something that one day will hit you hard: it's called the human condition. And the condition of humanity is something that is and always will be imperfect. Yes, our world will include people who smoke, and people who are obese, and people who are prone to unhealthy behaviors and people who are uncharitable and selfish. It's called humanity. People. And one day Steve, even as implausible as it may seem to you and your perfect wonderful world... one day the dam will break and you will find yourself included in that imperfect world --no matter how much you try to keep it at arms length and pretend that you can control all things in your body, in your life and all things around you. I hope you learn the lessons you should learn when that happens... something tells me you're likely to shut them out --and distance yourself from the person who is causing the cognitive dissonance in your perfect life. YOur terminally sick wife --you could leave her like Newt Gingrich left his cancer-ridden wife and divorced her-- maybe you'll suffer an illness to your otherwise perfect body. I often think of Lee Atwater, the propagadist for Ronald Reagan... he hung around with a lot of guys who think just like you... and when he developed cancer, well, let's just say that people dropped him like a hot potato... he was just too much of a bummer in their perfect worlds. When Terry Dolan --the great fundraiser for CPAC-- developed AIDS, he died alone. But then maybe you consider the extension of sympathy and consolation to a dying person to be a waste of energy and time. After all, technically it is a waste of time, huh? Must be nice living in a half-human world. Sometimes I wish I was as robotic as all that.
Steve, you're so proud of your callousness and uncaring. I guess that makes you cool?
The libertarian economist Ludwig von Mises had a point he was fond of making. Quoting from memory: It was the central failing of Classical Economics to think in terms of large classes.
Which is the defect in this analysis. Taking from the youth collective to give to the aged collective? On what planet is this considered libertarian? Why doesn't she just call them 'proletarian toilers'?
An Austrian economics approach would be to look at it from the viewpoint of each individual. And that is where the strong points of Single Payer come in.
Those are choices, plain and simple. The higher at-risk people looked at the costs of obesity (or smoking or drugs) and the costs of health (abstinence from enjoyable food, hundreds of hours per year spent jogging and lifting) and chose obesity.
Most obese people are already fat as adolescents, before they're responsible adults. Losing large amounts of fat, and keeping it off, is more difficult than kicking heroin or quitting smoking, for physiological reasons: your body reacts to dieting and crash exercise programs as it would to starvation, and starts burning fewer calories to preserve the fat. Between the fast food industry, the television and video game industries, and the automotive industry, much of the US economy is devoted to persuading Americans to spend money doing things that make them fatter.
I also disagree that the healthy or disciplined have some obligation to pay for the self-destruction of the self-destructive. - Steve
Ultimately, you will pay the costs of their obesity, whether or not you consent to it. You will pay for their emergency-room visits when they have heart attacks. You will pay for their diabetes treatment, if they can't. Why? Because unlike Noah Yetter, doctors do not accept that there is no responsibility to save people who are dying, even if they can't pay; so the doctors will treat them, and pass on the costs to you.
You do however have a choice. You can follow a preventive public-health model and help pay to stop people from getting fat, by regulating the fast food industry and banning advertising to kids, paying more taxes for schools so they can afford P.E. programs, planning development to encourage walking and discourage driving, etc. (New Yorkers now live 9 months longer than average Americans, partly because the design of the city forces them to walk a lot, which cuts obesity.) This preventive approach will save you money and make your country healthier. Or you can leave it all to individual responsibility, and end up paying more and living in the world's fattest country.
BRIAN WRITES TO ME:
"Your side's motives are nothing but pure, and the other side wants sick people to die so they can afford slightly bigger mansions. Also, you're either with us or you're with the terrorists."
Brian, considering your argument that young people are paying more to cover the health needs of the elderly, can you tell me exactly what it is that the young people plan to spend this money on that they will now have in pocket? I think probably many of you ARE interested in spending thatmoney on a slightly bigger mansion!
That's because your interests are material and acquisitional. Frankly, I couldn't think of a better thing to spend it on that to assure good quality health care for the elderly.
Bottom line: You people are just providing no argument whatsoever... what I'm reading from McArdle and your writing is one tedious unending rationalization after another for your own selfishness and greed. Sorry bud.
Dan Cobb,
How long before you invoke Godwin's law?
I'll repeat: if some of what I've said is not to your taste, take issue with it. But when you take issue, take issue with the arguments I've made, instead of the arguments you wish I'd made.
If I've said any of what you accuse me of saying, I suggest you quote it.
If I think any of what you accuse me of thinking (without having said), please explain how you've developed the ability to read minds by glancing at typeface.
And please use paragraph breaks.
M. Davies,
I don't consider myself selfish, ignorant or uncharitable. It was Dan, in his bizarre hysterics, who accused me of such by citing statements I never made. Scroll up.
McArdle's argument here so completely tangential to the actual moral issue of providing care for those who need it (as opposed to just those who have big bank accounts.) Surfers and Taxi drivers?! WTF?
Mr. Cobb, I'll point out that I explicitly wrote that I think a case can be made for forcing people to pay for the care of others who cannot provide for themselves, and note that I also plainly said that I favored not the elderly paying for as much of their care as possible, but rather the estates of the elderly, and then I will ask you to achieve a third grade reading comprehension level prior to endeavoring to converse with me again. Fair enough?
I believe your posts belong to the strain of commentary known as "illiterate".
Minor point: it is not at all clear that this is true, as a general proposition.
This article could not miss the point more profoundly and seems to be the sort of sophistry that right-wing idealogues from the Heritage Foundation will likely pawn off on the public. We simply do not need insurance companies to skim so much money out of the healthcare system, in the United States we spend more than double PER CAPITA on healthcare and yet we do not provide coverage to nearly 50million people. I am very healthy and so according to you I guess I deserve to be covered, whereas if I had smoked or whatever I should be left to die...ouch...how about an ounce of solidarity between your fellow human beings??? It is amazing how far those opposed to single payer(usually due to financial interests) will go to sell their nonsense.
This statement is inaccurate. A gigantic single payer system transfers money from the young and the healthy to the health care industry, ostenisbly in the name of the old and sick. Can this be emphasized enough? The old and the sick do not get money, the health care industry does, whether or not it actually serves the interests of the old and the sick. This is the biggest problem with universal health care. The same industry that has mercilessly exploited the old and the sick in order to transfer money to themselves from the young and healthy will continue to do so, using the moralistic stick of "universal health care" to justify its theivery.
A couple of years ago I cut my hand, and went to the doctor to get stitches. The doctor wouldn't see me, so I had to go to some HMO operation. I don't have insurance. Getting six stitches in my hand cost $1100, when it terms of time and materials, even for very well paid staff, it should have cost about $200. The industry simply is designed to rip people off, all the way up and down the line. Universal health care under such conditions would simply allow them to rip off more people with fake expenses that don't actually serve patients' needs. The problem isn't the "universal" nature of the health care, it's who is ripping off whom, and it's not the old and the sick who are ripping off the young and healthy. Get that part straight.
The argument for a single payer system is only moral in the indirect sense that it would furnish the resources to provide healthcare for the roughly 45 million who are uninsured. At bottom it's an economic argument assuming we start from the premise that we want American citizens to have convenient access to affordable healthcare. As has been widely reported the current US healthcare system costs about twice as much per capita($6500) and GDP (about 16%) as the variety of different single payer systems throughout the western world. It is also increasing in cost at about twice the rate of these systems and is forecast to double from an annual spend of two trillion today to around four trillion in ten years. Assuming some real growth in real GDP that means that in ten years time we could be spending 25-30% of GDP on healthcare. This is clearly unsustainable for both US companies who are already being made uncompetitive and the wider economic system. Despite all this expenditure we clearly have some inferior outcomes although in other respects we also offer high quality medicine for those with insurance. But rather than get into arguments of the "We have the best system in world" variety which are rather silly, we need to focus on the cost problem because ultimately that is what is going to force change. Basically American companies can't afford it anymore and they have reached the limit of the costs they can lay off to their employees who are in any case living in a much more insecure work environment than their parents and therefore much more anxious about the loss of insurance. It is simply unsustainable much longer to stay with the existing model for the funding and delivery of health insurance in the US. This has very little to do with the tort bar and everything to do with the nature of the product and mechanisms we have for financing it's delivery. IE. arguments about who picks up the tab and protection for the drug industry which gets about three times as much for its products in the US as it does elsewhere. All these debates about allowing the young, healthy and rich to opt out are really red herrings. I almost wish some of the advocates would get their way and then the public would see a mega disaster unfold elsewhere. The govt is already paying about 55% of the healthcare tab that is delivered primarily through private systems, with the notable exception of the VA. Ultimately, we are going to have to adopt a more cost effective model whether we like it or not and that is going to be a model which looks very like those in Germany, France, Canada where they are all working if not perfectly at least as well as ours and at half the cost.
Brooksfoe, thank you for responding in a substantial, non hysterical way.
Two minor quibbles:
I disagree that most obese people are not fat before they're responsible adults. If that were the case, more than 66% of children would be overweight or obese. Last time I checked, it was still under 20%.
I also disagree that beating obesity is harder than beating Heroin (though you may have a point with cigarettes). Heroin withdrawal can actually be severe enough to kill an otherwise healthy person.
Your point about crash diets is totally correct. There are ways around this, but they aren't common knowledge and this isn't a fitness debate, so I'll spare you the boring details.
Something that bothers me, though, is this:
and the subsequent suggestions that certain "programs" are necessary.
Both are making the assumption that the American citizen will simply do whatever it his he or she sees on television without a second's thought. If there are more McDonald's commercials, he or she will eat poorly. If there are more commercials from the FDA, he or she will eat better.
This kind of categorization reduces the American citizen from a thinking individual (who can weigh the costs and benefits of various actions and choose what's best for his or her personal life) and supposes he or she is a blank slate to be written on by either government or evil private industry. Worse, it wastes other people's money.
For my thinking, obesity isn't caused by advertisements or lack of regulations on what McDonald's can and can't sell. It's caused by human beings looking at the costs of fitness and the costs of non-fitness and choosing non-fitness.
Look, I'm a health nut. I do a bare minimum of one hour cardio and one hour of other exercise every day of the year, for about four years now. My diet ranges from things that taste bland to things that taste horrible and have to be sucked through a straw. When all is said and done, the cost of fitness for me is that I don't get to enjoy cookies and doughnuts and I'll spend 800-1000 hours per year running around and pushing things around. But at the end of the day, I'll look better and be healthier. That's a worthwhile bargain for me.
For others, that cost is too much. Maybe Joe Six-pack wants to watch more of American Idol than he that which he would get to see between benchpresses. Maybe those 1000 hours per year are worth more to him than what he has to spend on future healthcare. Maybe a life without Tasty Creme doughnuts and beer is, for Joe, a life not worth living at all. It's his decision, it's defensible and I respect it.
What I don't respect is that, in a national single-payer system, I'm obligated to pay some of the costs of his non-fitness, but he is not obligated to pay any of the costs of my fitness (I don't know how he could even in concept).
It's an additional incentive for non-fitness and a recipe for exponentially increasing cost.
If ever there was any good argument for increasing government involvement in Healthcare(I'm still not sure there is), it's this. The taxpayer already pays for the Healthcare of others and that's never going to change (unless we want to become accustomed to seeing untreated stabbing victims in the dumpsters in front of hospitals--which we never will), so why shouldn't the taxpayer get charged the same rate as an insurance provider?
Everyone is missing the point.
The problem with single-payer systems is that market competition has been removed from the system. As soon as you divorce individuals from the cost of the care they are getting, the market incentives break down. Inequities and inefficiencies build up in the system. Care providers are no longer subject to the constant demand of quality for dollars that the market system provides. The result is scarcity of health care and lower quality. I am from Canada, so I can assure that has happened here and will happen anywhere the same system is implemented. Take a look at Cuba or any other single payer-system.
You can all argue about who deserves health care, but the health care you are talking about does not grow on trees. It is produced by skill and technology and completely ignoring this aspect of the debate will inevitably lead to a huge error. Today in Canada, individuals are sent to the US on a constant basis because the waiting lists for MRIs, surgeries, specialists appointments, neo-natal care units, and almost everything else are in shortage.
If you want to destroy the supply of any good, base it on morality instead of market forces and you can be sure things will get worse.
Will Allen says,"health care is the by-product of other people's labor and ingenuity, and unless one is an advocate of slavery, one does not deserve or have a right to the labor and ingenuity of other people."
Nor do other people (i.e. doctors) have a right to form a cartel that limits who can compete with them. If the government permits the medical profession to artificially limit the number of doctors who are permitted to practice, thereby increasing the prices charged by those who do practice, then the government has a responsibility to compensate those who are adversely affected by such interference in the marketplace.
SF: one of the reasons for the huge cost of our current system is its fragmentation and inefficiency. As usual you mix up financing and delivery. In many European single payer systems delivery is by a mix of the public and private sector. Medicare is a single payer system, delivery in the main is by the private sector. You make the usual Canadian claims without any statistical backing, it the usual anecdotes about my brother's wife's uncle. I'm not saying Canada is perfect, just that it delivers a lot more bang for the buck than our system.
Megan,
Glad to see that you have so many "old and sick" readers but that may not bode well for your future.
I don't disagree with the premise but I think it really misses the point. As others have posted, we already have what amounts to a single-payer system for the elderly called Medicare. The transfer of wealth from the young to the old, with Social Security and Medicare, has be ongoing for quite a few years and will likely come to a crashing halt just before I'm eligible to start drawing a return on my "investment". The real focus of the new call for universal health care are those individuals who haven't mastered the ability to buy insurance, the alleged 45 million uninsured. It's tough, if you can't read a phone book you just can't buy insurance.
The moral question you should be asking, and answering, is do you support theft? If I choose to not buy insurance and I take your money because I suffered some misfortune should I be praised or condemned? Some appear to favor praising my actions while others, quite rightly in my view, condemn me as a thief. By not buying insurance I'm stealing money from the taxpayers, the hospital, the insured, and the doctors. The only ones I'm not stealing from are the insurance companies as their costs are passed on to the insured (or as they're known in the trade "those stupid people"). I'm not saying that we shouldn't treat the uninsured, what I'm saying is that they shouldn't be allowed to escape the costs associated with their care. Surely there are floors to be mopped, grounds to be mowed, bedpans to be emptied, or the uninsured have some specialized skills that can be put to use. If you don't pay your bill (via insurance or otherwise) then you go into the hospital's employment pool and you work at whatever job they find for you at the princely sum of $4 per hour, with the wages applied to your bill. If they're smart they'd rent you out and make a profit. Yeah, it's punitive and you might spend the rest of your life paying off the debt. Tough, there's a cost for stupidity. Wouldn't it be cheaper for you to buy that insurance after all?
What do I gain with a single-payer system? More government control. Yeah boy, that sounds attractive. It's a bit baffling that those who favor the single-payer system for the "old and sick" don't understand that the "old and sick" are the very ones most likely to suffer in the rationing that will occur. Answer this AARP members... who will the government healthcare gate keepers allow to be treated: the "old and sick" who don't pay money into the system or "the young and sick" who will recover and pay money into the system for years to come? Who has the greater value to the system (and the government)? I'll give you a clue, it's not the "old and sick" or even the "old and healthy". Oh wait, now I understand. Advocating universal healthcare is the same advocating euthanasia. Hmmm... that would solve the Social Security funding problem but how do I get the system changed when I'm old?
Sadly all the universal healthcare advocates are promoting is the Canada system with private insurance for those with enough money. Or, would they suggest the "full Canadian" and prohibit private insurance and then, for good measure, prohibit private retirement plans, the "full Cuban"?
The Atlantic Monthly continues its downward spiral with Megan McArdle, who fits their criteria for clever writing that leaves aside those quaint notions of morality, as Alberto Gonzolez has said. Entertaining!
The benchmark for this kind of dross ran a few years back, positing that the earth could easily support 30, 50, who knows how many billions of humans! and that our human population could vary by huge amounts — 30 billion to 3 billion! — within a few generations, without problems.
Right. Unless, I suppose, you consider starvation, war, pestilence and economic dislocations problematic.
Megan accuses those of us who see single-payer financing as a way out of the immoral and deadly morass in which healthcare is now mired in the United States. We are, she thinks, simply in love with government, and would be in favor of single-payer even if it could be proven that private health insurance could do a better, cheaper, more efficient job — "as long as a substantial population remained uninsured."
What?
Huh?
Megan. How is a system better if it leaves "substantial" numbers uninsured? How could that be cheaper in the long run? How more efficient? You've been reading too much Ayn Rand.
That's like accusing progressives of being against torture, even if it could be proven that torture does a better, cheaper, more effective job — "as long as a substantial amount of the information gathered turned out to be false."
Torture is wrong because it's immoral AND it doesn't work. Same as our private health insurance system.
Megan's argument that single-payer is a way to transfer money from the young and healthy to the old and infirm sounds like a trial balloon from the health insurance industry. Will we learn in a few years that she was lavishly compensated by that industry for this bit of "journalism"?
The fact is that our current system transfers money from the young and healthy to the old and infirm without benefit to the young and healthy. Everyone does contribute to a single-payer system, but its efficiency and appeal lie in the fact that there is benefit for the young and healthy. They have the satisfaction of knowing that if they hit a tree snowboarding next winter, they'll be cared for. They have the security of knowing that if they're one of the unlucky few who wake up tomorrow morning suddenly transformed by a diagnosis of cancer, suddenly no long one of the healthy but one of the stricken, that their children will continue to have a parent, and they can concentrate on recovery, not the consequences of bankruptcy.
Shame on you, Megan, for working to divide people, to set the healthy against the sick, and suggest to people that their interests are served by turning their backs on others. You complain that liberals have been calling you "evil," but in fact, to work to divide people, one from the other, is an evil action.
First they came for the Socialists, and I did not speak out -
because I was not a Socialist.
Then they came for the Trade Unionists, and I did not speak out -
because I was not a Trade Unionist.
Then they came for the Jews, and I did not speak out -
because I was not a Jew.
Then they came for me - and there was no one left to speak for me.
We're in this together, Megan. Because it's moral, and because it works. That's not from anecdotal evidence, anymore. There are too many studies showing better outcomes for less money.
The flaw to all of these arguments is that they miss the point. Health insurance is only a means to an end, and an increasingly more expensive means. The issue is health care, which we have greater than any other nation. ANYONE (including illegal immigrants, criminals, and destitute) can enter any emergency room in the nation and get treated. This is not the right answer, but it does punch holes in the whole uninsured discussion. There will never be a right answer until we focus on individual responsibility for health care, and tort reform to control our lawsuits to allow competent doctors to practice without paying millions in malpractice insurance. When individuals start asking doctors about the cost of that $10 tylenol, or the real need for an expensive MRI instead of just an X-ray, and get rid of the notion that it is someone else's bill, our health care system as a whole will be on the road to recovery. HSAs would help with much of this.
Stop looking for someone else to fix your problem, and just pay your own bills. I dare say the benevolence of this nation will not let people just die. When they don't expect that their tax dollars should be caring for their neighbors, they will step forward and do it.
Just a simple calculation: currently US has about 40 million people with no health care. If government just hands them out money to buy the insurance, it would have to hand out ~$250 per person per month.
So, yealry budget of such a handout would be:
250*40000000*12 = 120,000,000,000 that is 120 billons dollars a year. with the current federal budget situation this money could not be found unless insurance rates would go drastically down or military budget is cut by that amount.
Single payer system actually might be cheaper if rates are agressivly nogotiated by the government and in the end might cost much less to the "young and healthy".
Am I missing anything here?
A slight digression to prove the impossibility of
assigning blame in this feedback distorted world.
In the early (NIXON) nineteen seventies, the CENTER FOR DISEASE CONTROL sent a memo to hospitals stating (roughly) that "It has been determined that the hospital and medical care facilities who test furniture,rooms and equipment for bacterial and viral contamination are wasting money. It is proposed that this practice be stopped. This was carried out and, upon further investigation it was found that the infection rate in hospitals increased by a factor of 32 times.
This reccomendation is still in effect today.
in August this year President Bush outlined his proposal that to save on Medicare costs he will cause the Medicare system to no longer pay for what he described as "preventable health care events". Among which he, chiefly, stated were hospital infections.
Is this a merry-go-round or simply murder.
The arguement centers around the implications of group interaction and progresses on a logical basis following some moral guidelines concerning the subject. The error, however, exists on the ability to group society in this way. If membership in a group is not made of free choice -- I can be a taxi driver, a surfer and a taxi driver again but 16 only once -- and if every member of the first group becomes a member of the second -- I will always be 25 before I am 55 -- then the definitions of the groups become arbitrary and irrelevant with respect to time. Unless a tighter definition of grouping can be applied, the moral argument based on group dynamics becomes thoroughly unconvincing. The moral horror of contributing to an unneedy, inequitable and unresponsible group fades the magical minute when the first group becomes the second.
HBT, you'll hear no defense fom me regarding the doctors' cartel.
I remember when the fight was for affordable health care, now it's universal coverage. Liberals can't criticize the exorbitant profits of pharmaceutical companies and insurance companies, but give the not-for-profit hospitals who are making billions in profits a pass. Want to see real hypocrisy by liberals regarding health care? Try www.obamatruth.org or www.wherethemoneygoes.com
Unfortunately, your final argument for a private system is flawed in that food is not like healthcare; healthcare is much more difficult to obtain. Perhaps this is an argument for reforming healthcare in a different direction, but right now, I can go to any corner store with food stamps and purchase food, but if the government alotted some money to me to purchase healthcare, perhaps pharmacies would be forced to accept it, but there are a lot more steps and variations involved with seeing actual doctors. If the government were to provide me (suppose I am needy) with health stamps, could I see any doctor or only special private ones? Would there be an efficient system to determine a healthcare allowance? If I am hit by a drunk driver and have no private insurance, will the government determine how much it will pay the ambulance driver? Will the government deny claims? Is this essentially a government-sponsored insurance company, then?
Now, I'm diabetic -- diabetes, you will recall, is an auto-immune disease acquired often by children whose insulin-producing cells are destroyed by the body. Will my health stamps allowance cover the necessities -- insulin pump, test strips, supplies, and so on? How will it know what my necessities are? How will it determine how much I have to pay out-of-pocket?
So long as there is a medical infrastructure designed to handle these people, your solution is fine, but in our system, more than just the fringes of society are forced to go without healthcare, and since the government will not want to pay market rates, doctors have little economic incentive to participate. The current market does not satisfy the needs of these people, and your solution assumes that it does. I happen to be of the opinion that a single-payer system would work much better than the current system, but if you can find a different way to ensure that all people in this country have the health care they need -- including children with diabetes like I used to be, young men with testicular cancer, people with congenital heart conditions, phenylketonurics, "bubble boys", children who happen to contract meningitis or a particularly bad infection of some sort, victims of a stabbing by a dirty knife or who sustain spinal injuries and become paralytic, and I could go on with all sort of afflictions -- then I will be convinced that single-payer is not the best answer. It isn't that single-payer is better; it's just easier to conceptualize. But as it stands, giving out "health stamps" would require massive changes in our health infrastructure and possibly some large market regulations to ensure that those with health stamps can get actual care rather than just the remote possibility of it.
We could start to reduce the number of uninsured by checking the citizenship of those using our emergency rooms. Discharge them directly to the INS for deportation after swearing out a bill due in full should they return to the US. And, if they want, they can pursue family reunification on the other side of the border.
Also, some comments about the moral argument:
The people who would benefit from universal healthcare are not the old and the sick -- they are the people who need healthcare. Unfortunately, we can't class "the sick", because EVERYONE, at some point, has gotten sick or needed medical attention, or at least needed a checkup to make sure that they did not. Therefore, the moral argument here is not that we need to redistribute from the young and healthy to the old and sick but that we need to get everybody's health costs paid somehow and not everybody can afford them. The redistribution is from wealthy to insolvent, not healthy to ill. Morally, should we as a nation allow people to die from lack of healthcare? If our private system made sure that this did not happen, we wouldn't be complaining about it. That is the moral question. I think you answered that question very well in your column, but I also feel that what you took issue with was something other than the actual moral argument for single-payer healthcare.
I don't understand why Ms. McArdle, and some others here, find the idea that the young and healthy owe a moral obligation to the elderly and ill -- based on generational responsibility and reciprocity rather than individual merit -- so novel, unnatural or controversial.
Generational obligations -- obligations of the mature to the young and of the young to the elderly -- are universally recognized, across human societies, as essential to moral communities. As is the understanding that the strong and powerful owe, in some form or another, protection to and charity toward the vulnerable and powerless, and that the whole and healthy have a responsibility to care for the disabled and ill.
Although societies differ in how, and how poorly or successfully, they live up to these basic obligations, such mutual, and understood to be, over time, reciprocal, obligations -- not judgements of individual merit -- form the moral structure of all human societies. They do so because they are based in unavoidable, universal human realities. The young and healthy adults of today were yesterday's weak and vulnerable children -- and will inevitably be tomorrow's ill and elderly.
Whether it is through the mechanism of government, family obligation, charity, private insurance, etc., it's impossible to devise any system of health care that does not rely on using the resources of the young, healthy and whole to provide and pay the cost of care for the elderly, ill and physically compromised.
In terms of whether we, as a society, should or should not use government to meet that obligation, the only important question is this -- can we, by doing so, maximize the benefit to those requiring care while minimizing the sacrifices required of those who must provide and pay for it?
In other words, by acting together through our government to spread both the cost and the benefit of health care more broadly across the community, can we lighten the individual cost burden (of care for elderly and ill family members) for the greatest number of young and healthy members of our community -- thereby allowing the young and healthy to keep more of their individual resources for investment in their own futures and that of their children?
Based on experience, the answer is "yes." For instance, the payroll taxes young people pay for Medicare and social Security may be irksome -- but they are a much lesser financial burden than the one a majority of working and middle class young people might be faced with if those resources weren't available for their parents and grandparents. Not every, but almost every, dollar of benefit most elders receive from these programs is one that their children or grandchildren do not have to take from their own pockets -- or, for some, their future inheritance.
The real question is do you wish to be priced or triaged out of health care?
If the former, keep your present system - for the latter go to a single payer universal scheme.
Both are making the assumption that the American citizen will simply do whatever it his he or she sees on television without a second's thought. If there are more McDonald's commercials, he or she will eat poorly. If there are more commercials from the FDA, he or she will eat better.
It's not that Americans do not think. It's that thinking and making rational decisions are only a part of what influences any human being's behavior. Otherwise, advertising would not work. (There is no rational component to an advertisement which simply shows Yao Ming wearing Nikes, and yet it's empirically verifiable that such an ad causes more Americans to buy Nike shoes.)
Advertising works. It shapes people's behavior. It shapes their assumptions about what is "normal", from the size of drinks to the frequency of fast-food vs. home-cooked meals. It works the same way that getting kids to salute the flag makes them patriotic: at a subrational level. And what it is doing to America, along with a whole host of other corporate-influenced decisions -- agriculture policy promoting cheap corn syrup, the highway system and its rest stops, suburban development with houses so widely spaced and commercial areas so far away that no option but driving is plausible, with no sidewalks or playgrounds but plenty of fast food outlets, transit policy that sends money to highways rather than subways, and so on and so on -- has created a culture that makes Americans the fattest people on earth.
Rising obesity in the US is a public health crisis. Other countries are also facing the problem, but the US has it worst. It is not a problem that can be meaningfully addressed at an individual level. When an entire country suddenly gets 30% fatter, something is happening that can't be explained at the level of individual "choices".
I happen to be one of the lucky ones: my metabolism keeps me at an even 143 lbs pretty much no matter what, which makes it easy for me to go running two or three times a week, which keeps me in shape. But I have friends who are not so lucky, like one who put on large amounts of weight while on a prescription for Prozac to treat post-traumatic stress, and now finds it impossible to lose it. I just can't see blaming her for being overweight. I have done very little to deserve being thin, and she has done a lot to try to escape being fat, and it doesn't work.
I think the moral argument is a waste of time.
Everyone at some point is young and healthy and vice versa sick and old. That's the life cycle. Everyone deserves to have health care, and it should be clear that a private system will never cover everyone.
A single payer system, without a profit motive, will always cover everyone at the "lowest" cost.
It seems to me that the obligations inherent in socialized medicine have to go both ways. If society has an absolute obligation to care for the sick and pay the entire cost, no matter what ails them, then it stands to reason that all individuals have an equal obligation to die and get out of the way when their lives are no longer useful to society. Socialized medicine must be accompanied by a legal obligation to die, enforced by special courts, that will impose euthanasia on those who insist upon living after their cost-benefit analysis has gone negative. Since money will be scarce, euthanasia will be necessary to make the system affordable. In order to function, appeals can't be allowed, and the decisions of jurors to impose a Civil Termination Order must be final. A Federal Medical Police will be necessary to enforce the judgements and to hunt down and execute those who try to escape. The arm of the law must be longer than the leg of the defector in order to set the proper example, and so the CIA will have an obligation to hunt down and kill those who leave the country to escape termination orders. Obviously, contracting medical care privately must be absoultely illegal and punished by death, since to do otherwise would allow the best doctors to desert the socialized system and leave only quacks behind. Only with mutual, 2-way obligations between the individual and society can we have a system that will stand the test of time and endure for the long haul.
Let's make this as simple as possible. A 22 year old gets a lymphoma. Insurance means 60 years of life. Absent insurance? Maybe death. The incidence of lymphoma among 22 year-olds is small, but the treatment is incredibly expensive, and the reward is very high. No one knows who will need it, but I know one person who did, my sister. That is why we have insurance. Insurance is for protection against risks distributed across the population randomly.
Let's try another simple example. You drive a car. You must have insurance. I am sure you are a great driver but the law requires you to buy it. Why insist on insurance for drivers? Because accidents happen even to good drivers, and there is no reason to inflict the costs of accidents on the random people who have them. Why is that not the case with illness?
Your notion that insurance should be treated as a "transfer" is simply wrong, and has led you down a meaningless trail.
Megan--
Masaccio's right.
And I stopped after the first two straw man arguments. Sorry if anyone has already made these comments.
"A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick."
Let's say one of the simplest, and, in my view, best plans is followed through, that Medicare is simply expanded to the 45 million uninsured Americans. That's it. Among the many things this would change is that the U.S. would save a rather large amount of money. How's that? Well, a lot of people who are uninsured don't use preventative care, and so, get sick a lot more than they would if they were insured. So expanding Medicare would save us money. (But wouldn't our taxes go up? No, probably not… we could use the $ we were going to spend on Iraq.)
This is really, really simple.
2) 18,000 Americans *die* every year due to lack of health insurance. I think we'd all benefit, probably in some unexpected ways, if fewer of those people died.
3) Another strawman: "the class of old and sick people" The *class* of old and sick people? A lot of young people get sick. A lot of people, at various ages, have catastrophic things happen to them. There is no such *class* as the "old and sick."
Apologies; Larry Greenfield, pobody, and Freddie already got there.
Esmence,
You miss the point. The young and healthy use little healthcare, and are less wealthy than the elderly. A universal system that recognizes that the elderly have to pony up more for their healthcare, because they have more to start with, might moot the argument, but that is not what happens. The elderly's healthcare today is paid for by people who are less wealthy as a class than the elderly. Medicare financing is inherently non-progressive. The only way I see to address this in the structure of universal healthcare is to means test such healthcare provision. There was a suggestion earlier, by Will Allen, that the estates of the deceased reimburse, to the extent possible, all government healthcare costs incurred by the deceased. If we find that these estates regularly cannot cover these costs, then that tells us that what we are expending is unsustainable.
There is no one right solution to health care. Let me say that again. There is NO one right solution to health care. Having a single payer government system eliminates any ability to indiviudalize health care, destroys any innovation or creativity, and will not provide the solutions it promises. It is a lazy solution to a difficult problem because people assume that there is one solution, and if we got all of our smart people together and forced everyone to follow it, that it would work. This is just not true.
With 300 million Americans, there are at least 300 million different solutions. Only the free market will allow people to pick insurance products that meet their risk tolerance, provider preference and cost basis.
Stop looking for one solution, because it will be the lowest common denominator, and it will lead us to a new age of tyranny. As we pool our resources together, the single payer will do what all payers do--look for ways to lower cost. The added advantage of government as a single payer is that it can fine, imprison, and steal from people for behavior it deems inappropriate, or in this case, behavior that raises costs. Watch as the smokers, the fatties, drinkers, etc. are taxed, arrested and imprisoned. Watch as new non-productive government positions are created to reduce cost of the payer system. Our rights will dwindle, our freedom will disappear, and watch as our health becomes abysmal. All for a standardized $10 copay.
Excellent post, Megan. I enjoyed seeing someone examine the morality of a political issue. As a philosophy student who has studied biomedical ethics, I found your argument to be very well reasoned. Unfortunately, the average quality of commenters is far lower than at your blog's previous site.
Two points:
What is the single greatest cause of death and illness in the US and the rest of the World?
Aids, infant mortality, lack of vaccinations, sars, west nile virus, cancer?
Hypertension kills more than ALL other causes combined by several orders of magnitude. It is responsible for most of the strokes , heart failure , heart attacks and sudden death events.
So , the US have been trying to improve the control rates for 30 years and after all this time control has gone from 17 % in the 1970s to a whopping 39 % in 2002. Pretty bad , you think?
Well it is spectacular compared to the rest of the world , all those universal coverage coun tries of Europe, and elsewhere, where it is 9-15% controlled. Why is that? If these health systems were so great, far better than ours, more efficient and all the rest of the "claims" made in the above comments, why can't these great systems control the most significant killer of people there is? All medications are free, no copayments, no deductibles, no insurance hassles, just pure universal coverage. The pathetic US system of 'patch work " care has nearly triple the control rates. Do you have any idea how many people die from hypertension in these medical systems of universal coverage who would ot die in the US. Millions!
A friend of mine was a refugee fromm the old Soviet Union. He told me that there was never unemployment there . Everyone was working . Then why were there shortages? Well my friend told me:
"Yes , 100 % employment but nothing got produced. Shelves were bare and food scarce. You see, he told me, the Soviet Government pretended to provide us the jobs and we pretended to work!"
The reason our present , flawed health system saves millions of people per year here in the US compared to those same type of patients with hypertension who will die in the "utopian universal healthcare systems of Europe" is that we don't pretend to give people healthcare. The waiting lines , the long dealys for surgery , the lack of modern technology ,a work force with a low incentive to produce , broken down hospitals, restrictions on medications and the flow of patients from Canada to the US for care are the true characteristics of the of these systems .
I know those of you who think our system in the US is 37th in the world , will never believe the truth , but will feed on the propaganda and fantasies they they read about and become fanatics in promoting about these other systems . "There are none so blind as those that can see , but won't" But it is true . The US despite all its flaws , saves millions of people here each year compared to the rest of the world where the same patients will die due to poor care.
How do I know this ? Where does all this come from? Well I am a clinical specialist in renal and hypertensive diseases , I went to medical school , I go to medical meetings and I listen to the facts as presented by physicans from these "Universal Coverage countries". These statistics are available from the American Heart Association, the CDC , NIH , WHO and many other organizations. So if thats an issues, look it up yourself. The foreign physicans from these countries tell me that the healthcare work forces in these countries are depressed, unmotivated , robotic and have no incentive other than to collect a salary and work 9-5. Like the motor vehicle dept. Wouldn't that be great? Now you die hard socialists who are secretly thinking that the Soviet Union was on the right track , but just screwed things up, are still also thinking the doctors and nurses who work 60-70 hours per week "like to" or are "supposed to" or "its their job " are still believing in "from each according to there ability and to each according to his needs". Well, that slogan does not treat hypertension very well nor does it grow wheat well .
My second point: Why is it so hard for people to understand that todays Medicare patients are paying so far under the true market cost for the services they get , that so much of the loss is passed on to non-Medicare patients? A cholesterol panel for somone who has to pay out of pocket may cost 70 bucks from a commercial lab. THe Medicare patient gets it for 11 bucks. If the commercial labs could not make up the difference , the loses they experience from Medicare patients, by shifting it to younger non-Medicare patients, they would go out of business. Remeber , 1 X 0 = 0 as well as 100 x 0==0. So then , what devine right would a millionaire Medicare patient have to ask a for a service provided by a health care provider at a loss to the provider ? We are not talking about those pictures of the elderely in wheelchairs being asked to pay their way, I am talkling about the people who are palying golf and hosting parties at there multimillion dollar homes , drivening there Mercedes , who expect the young struggling parents of a newborn baby to fork over enough taxes so they can contine to get subsidized , saving enough money each month by paying artificially low Medciare premiums so they have money to pay for there trips to Italy. What a country! Taking money from people who are day to day to give to millionnaires. The first thing tha needs to be done is to means test Medicare. I have spoken to a few of my greedy wealthy older Medicare patients. They have an amazing sense of entitlement. "I paid my premiums and I deserve to get my Medicare at the unrealistically low rates which must be supplemented by young poor people" Disgusting . Of course it's AARP and the politicians from both parties that keep reinforcing this warped mentality.
Most of you reading this probably have no clue pertaing to the history of Medicare. But here is one little fact: When it was enacted in the 1960,s, the law called for the beneficaries to pay up to 50% of the premium costs with the rest funded by tax payers. Well, the beneficaries never came close to paying 50%, now the tax payer funds most of the premium. But the original law gave Congress the option of sticking 50 % of the premium costs to the Medicare patients . It is time to have the wealthiest demographic in the country, the "elderely" to pay their way. Remember , we are not talking about the poor eldery.
"Even if I leave aside things like property rights, coercion, deadweight loss--things I realise my liberal interlocutors aren't particularly concerned with..."
Part of the reason they, nor others, might be "concerned" with deadweight loss is due to the fact that, sadly, a solid majority of the people do not have a basic understanding of economics. They probably think the quality of life in the U.S. started improving a quarter century ago solely as a result of Reagan's sunny personality. That's why I think more and more of using my higher education in the field to educate others.
Yancy Ward --
You miss my point. As I stated in my earlier post: "Whether it is through the mechanism of government, family obligation, charity, private insurance, etc., it's impossible to devise any system of health care that does not rely on using the resources of the young, healthy and whole to provide and pay the cost of care for the elderly, ill and physically compromised."
Wailing that this basic human reality is "immoral" is just another way of wailing that life is "unfair." Which it is.
This article, of course, is complete nonsense. The basic logical flaw of this article -- confusing morals, which are dictated from above, with ethics, which are personally decided -- leads to most of the rest of the fallacies.
If you want to talk about morality, here it is, from a Christian perspective: The issue of who "deserves" our help is irrelevant. Christ said "Feed my sheep." He didn't say, "Feed my sheep if they deserve it" or "Feed my sheep if they've been dealt an unfair hand." He wants us to care for each other, regardless of these points. Similarly, the issue of culpability for problems isn't even on the table.
Are the old needy? Yes, they are, indeed. Health care costs for serious, chronic illnesses are greater than nearly anyone can afford by themselves, and they're the issue here. Nearly anyone would be bankrupted by a bout of cancer, for example, if forced to go it alone, financially.
If you prefer a more religiously-neutral, ethical paradigm, there's also the concept of enlightened interest: We transfer wealth to the elderly to ensure they're taken care of in the hopes that we, when we are elderly, will be taken care of, too.
Indeed, that's the social contract that America signed up for several generations back, that they young would support the old through a variety of government-sponsored programs, with the knowledge that they, themselves, would benefit from those programs when they get old.
This reveals the straw man of the entire "transfer of wealth between classes" argument McArdle makes. Yes, there's a transfer between age groups, but it's a transfer that's repaid when those paying now receive their own benefits in time.
McArdle also engages in another egregious logical error: "young" and "old" aren't classes, they're age groups. Her arguments sound much less compelling when you actually add in class distinctions. The money flows from those who are financially stable (or even well-off) to those who are in the midst of what would, without the transfer, be a fiscal crisis of apocalyptic proportions.
Our society helps out in the same way for the benefit of many groups of people. We transfer money in this fashion to the poor and disabled as well as the geriatric. The real Ebenezer Scrooge moment in McArdle's thinking came when she incongruously separated the elderly from those she seems to believe "deserve" our help.
She picks on the elderly because their relative affluence -- largely meaningless given the staggering scale of health care -- separates them from those who've simply been screwed over by life. She even (with no small skill) tries not to seem mean when she blames the elderly for problems to which they contributed, even when the consequences of their actions (such as smoking) were poorly understood when they were made.
Ehreval
Well, that was a mouthful, only to get to about the third paragraph from the end, and there you have it in a nutshell -- the compelling argument FOR universal health care. Delivered in a single sentence. Not even Ronald Reagan could put lipstick on this pig.
As we now have a simple declarative statement supporting universal health care in terms of the morality of individuals being bankrupted by health care expenses, let's also add one about government stewardship.
It is not moral for government to preserve a system that undermines our economy by driving health care costs so high that it forces business to move their activities abroad -- especially when that very expensive system fails to be the best in its class or indeed anywhere near the best in class.
What we have now costs twice as much as its peers, delivers worse overall outcomes, leaves many uninsured and at risk of medical bankruptcy, and undermines our economy. It's no wonder even McArdle produces a far more effective liberal viewpoint than she ever does a libertarian one, because not even the libertarian wants national self-immolation.
Nothing like the smell of ageist bigotry in the morning. Let's check back with our intrepid blogger--- after she grows up.
Yawn.
Okay, let's try again. I don't actually expect to convince anyone, but remember all those remarks about inheritance earlier in the discussion?
We are in the middle of creating a system in which many young people (healthy or otherwise) cannot hope to achieve middle class status unless there is a massive transfer of resources from older generations to younger. This can involve parents paying for education, grandparents leaving money, and so on. Some families can do this, but many cannot. Children from the latter sort of families are the ones who end up with crippling student loans, a complete inability to buy real estate, and in many cases no chance of starting a family.
Young people in this category are very likely to be uninsured for some period of time. I was. It's the only rational choice when facing the kind of life start-up expenses that people starting adult life near zero actually face. A health insurance mandate would have been just another huge hill to climb, another obstacle towards getting to the point where things the last generation took for granted become even remotely feasible.
I would note that the tax system is already a huge problem. Payroll taxes are the big hit for 20-somethings in hourly jobs. Income taxes are the problem for 30-somethings who have finally landed better jobs, but who do not yet have the mortgage interest deduction or deductions related to children.
So, if you want to force future generations into a permanent two-class system, one for the people who get family transfers and one for those who have to start life from scratch, just saddle the young and healthy with yet more financial obligations.
If you are advocating this primarily so that old people don't spend their own money on health care and leave it to their grandchildren instead, you are only compounding the problem.
There's nothing wrong with a means-tested program that serves as a safety net for people who are unusually unfortunate, whether because they became disabled young or because they outlived their assets. But there is also no reason to believe that health care should be free for people who can afford to pay, especially if that would mean taxing people who can afford it less.
Megan--
I think you neglected the important fact that the young become the old, the healthy the unsick. The morality of this transfer of wealth is similar to that of Social Security.
There would be a moral problem if the young of 2007 had to pay for the old of 2007 and got nothing in return. But they DO get something in return and that's the resources of the young of 2047.
Mostly excellent follow-ups to a truly woeful article. Speaking from the UK, I'd ask anyone who does not believe in a national service to come here and try and talk anyone in the street out of their NHS entitlement, which is quite simply based on need and not ability to pay. Our primary care system, in particular, is far better than yours.
A single system would also attack one of your biggest problems - gross overtreatment for the well insured - which in turn should free up resources to treat more older people more equitably.
Another point is that people go on funding the system through tax - wealthy older people pay more through tax on large pensions. A progressive taxation system - which we just about have - means poorer younger people are hardly being excessively drained. House prices are a different matter though.
I love this bit in her article:
'no one should die, or suffer unduly, because they don't have the money to pay for treatment.'
A bit of suffering is just fine and dandy, I take it.
Formerly Uninsured --
We have already forced the current younger generation into a "two-class system, one for the people who get family transfers and one for those who have to start life from scratch" -- by flattening the tax structure and failing to make adequate investment in the public educational, cultural, social (of which health care is one part), technological and physical infrastructure that helps to broadly create opportunities and provides the resources for taking advantage of them.
We got to this point, in part, because too many middle class members of my own Boomer, and the preceding Silent, generation resentfully embraced facile and false arguments -- similar to the one made here by Megan -- that taxation is a transfer of resources between individuals, rather than recognizing that in a broadly middle class society (as we once were, but less and less are) progressive taxation is actually a transfer of resources between generations.
If younger people, who are now left holding the bag, and paying the cost, of this short-sighted thinking, want to start righting this situation they better act fast -- and, before it is too late, start demanding more in taxes from their richer Boomer elders. In their youth, the Baby Boom enjoyed the benefits of unprecedented public investment in their future, paid for by their elders. It is time to ask them to pay that debt back.
Doing so won't erase the raw deal handed to your generation, but it may go some ways to saving you from having to make some very ugly future choices -- between the welfare of your parents and that of your children.
The analysis fails to examine the benefits the healthy have already gained from the old, which includes or soon will include most of the people responsible for the science that helps the healthy stay healthy.
I don't know about the rest of you, but I sure want the government to take care of me when it comes to health. Look how wonderful a job they have done with retirement. The benefits are fantastic, and it is fairly cheap. Where else can you put in the same amount you do for Social Security and retire at the same level? I am sure that the medical will be just as good, and since health is so much less important than retirement, it doesn't even matter if it doesn't work as well as Social Security.
The best part is how secure the hand out, I mean social justice programs are. Every so often the stock market has a downward adjustment so portfolios drop in value, but Social Security and Medicare are so well funded that they will never run short, and the 10-20% of our paycheck that goes in will never have to go up. How fantastic would it be if we could all drop our private insurance, give the government another 5-10% of our money, and have a health plan as robust and secure as Social Security is.
Either that, or I could buy an HSA for a fraction of the price, and when I get old I will have this thing called money to buy medical care with. When I am young I will have this thing called insurance to buy health care with. If you don't like Bush's HSA just think of it as Clinton's MSA, they are both the same very good idea.
I'm just wondering what books or articles you're basing your opinion on. It's mighty odd to me that you would imagine that other countries just "socialize production of the good". You can buy private health insurance in England, France, etc.
Why not learn a bit about other countries? Try taking a look at the Callahan and Wahunna book on the topic:
http://www.press.jhu.edu/books/title_pages/3375.html
or Dutton's "Differential Diagnoses," on the US and France.
Health care is too important for ideologues to opine on it without having a basic understanding of the nature of "socialized" provision in the countries whose successes they ignore.
Raising the idea of risk pooling is off base once we mandate universal coverage. We have a big bucket of money and make transfers to everyone eventually over the course of their lives. When, not if, you get sick, we pay for it no matter what it is. There is no actuary involved.
There may be a way to do this right, but if it is done in such a way as to substantially damage the profit motive from innovation, you are going to kill a lot of people. Even taking whatever figure is floating around for the number that currently die due to an inability to pay in our current system at face value, that number is miniscule next to the number of people that die if you defer the development of a life saving treatment.
Say single payor fans had their way 20 years ago, and say that public availability of statins were deferred that same 20 years for lack of investment incentive. How many dead people is that?
Whatever else the argument is, it can't be morally justifiable to pat yourself on the back for univeral coverage while shrugging your shoulders at the pile of bodies on the opportunity cost side of the equation.
Ave Cassandra - Re: "First they came for the Socialists, and I did not speak out"
Arguing against "universal health care" doesn't even vaguely resemble running or supporting Nazi concentrations camps, and the attempt at implying it does is very unreasonable, and either dishonest, or an example of an incredible lack of perspective.
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Alex -
If the government pays for insurance for anyone who doesn't have any, than it provides an incentive for people not to have any non-government provided insurance. So you might have to make your 40 million more like 200 million.
Also to the extent that not having insurance really means not having health care, providing insurance means increasing the demand for health care, and thus its price. To the extent that your just providing insurance to people who previously got health care without insurance than your not talking about "40 million people with no health care".
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esmense - re: "Generational obligations -- obligations of the mature to the young and of the young to the elderly -- are universally recognized, across human societies, as essential to moral communities."
"If we accept an obligation to help the old that need help, that doesn't imply an obligation for a general transfer of wealth to the old, or to pay for large parts of the expense of the old, for older people that have sufficient income and wealth. You might have a case for taking care of the poor elderly, esp. the infirm poor who can't not take care of themselves, by why should a wealthy old person receive benefits paid for by a young struggling worker, barely making ends meet, or by parents with below average income who could use the money to improve the welfare of their children?
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Greg - Re: "Well, a lot of people who are uninsured don't use preventative care, and so, get sick a lot more than they would if they were insured. So expanding Medicare would save us money."
An uncertain, even dubious assertion. They would get more preventive care, and that would in some cases save money, but its likely to cost more overall.
See
http://www.nytimes.com/2007/08/08/business/08leonhardt.html?ex=1344225600&en=d7df12bae3f08026&ei=5090&partner=rssuserland&emc=rss
and
http://www.marginalrevolution.com/marginalrevolution/2007/08/words-of-wisdom.html
---
...and when I get old I will have this thing called money to buy medical care with. When I am young I will have this thing called insurance to buy health care with.
Paying out of pocket is not a realistic option for most old people. Even someone with very significant assets could be wiped out by a single illness - not to mention the multiple medical conditions that many people run into between, say, age 70 and 90. I mean, a single battle with cancer could set you back a seven figure sum in the United States. Your reaction may be "not my problem, they just didn't save aggressively enough, or invest with the Warren Buffet-like wisdom that I possess." Well, you're certainly entitled to your opinions, but fortunately most voters don't share them.
Interesting how libertarians persist in the belief that individualism is the be all and end all, and that poor people getting government handouts is the fountain of all evil. Everyone - and I mean everyone - needs help at different points in their life. Libertarians and conservatives don't seem to mind when corporations or wealthy individuals get things given to them like favorable tax laws that enhance their wealth. But discuss entitlement programs that benefit the middle or working classes and the screaming begins. Megan McArdle, hell bent on examining the morality of a single payer health care system seems to forget the most basic moral issue involved: Having a society where everyone has equal access to health care, not restricted by their ability to pay is the right thing to do morally because it makes us a better stronger more civilized society. Our current health care system which is driven by insurance company profits is immoral because its goal is to make profit for shareholders, not provide health care for everyone.
She fails to neglect that a recent study showed over 50% of bankruptcy is due in part to medical debt. And that includes people with insurance who still have to pay their 20%. She touches on the luck issue but ignores the fact that people who are unlucky enough to get a disease as a young person can be productive happy members of society with appropriate care. But that ironically, young people with illness such as type 1 diabetes (which is surely not due to lifestyle) often get hit with a double whammy - they can't buy health insurance because the insurance companies won't insure them, and without the care, they can't stay healthy enough to work regularly to get employer paid health care.
Though I have my reservations, Single payer is the only way that I can see to take the insurance companies and their profit motive out of the equation. It's not perfect, but it's likely to be better than what we have. And if the libertarians don't like paying taxes so everyone can get health care then fuck them - they shouldn't be using any public services. Hell, I pay taxes that fund roads I'll never drive on. It's part of the price of living in a civilized country. I'd rather my taxes went to fund other people's healthcare than to wage useless endless wars and enrich defense contractors.
The math here seems to be a problem. How is it that after paying taxes on so much income over so many years, these wealthy old folks haven't already paid far, far more into the system than the poor youngsters?
Perhaps they've already -- every one of them -- consumed public services commensurate with their tax contributions, but Ms. McCardle has not demonstrated that. She cannot demonstrate it.
The healthy subsidize the ill in any shared-risk plan. Trying to discern who needs more from the system and who pays more into it is a fool's errand. The argument is pure generalization and speculation.
Why be concerned about the elderly as a group ripping off the young but not about the reckless 22-year-old skateboarder getting full treatment on the public dime after a devastating head injury while a clean-living 64-year-old dies without ever tapping the system to the same extent?
There are plenty of arguments to be made about the efficiency of various health-care programs, the rationing required in public versus private systems, and the morality of expropriating the labor of medical professionals. This debate is a childish waste of time.
I just want to point out that to all of you in the rest of the world, who are all about having America adopt one of your systems because of its delivery of the "good" of healthcare because of moral imperatives, sociocultural norms of "taking care of the older folks" etc...
YOU GET YOUR NEWFANGLED MEDICAL CONTRAPTIONS AND PILLS FROM AMERICA! WHERE WE HAVE TO PAY THE ENTIRE F*****G COST OF DEVELOPMENT BECAUSE OF YOUR GOVERNMENTS' POLICIES.
It's one thing for a country like India (or one in Africa, or Central America) to protest "the high cost of new lifesaving drugs" because they, due to historical, geographical, social, colonial, whatever -al you prefer, have a very clear inability to pay for such developments in medicine, but the benefits from those same developments can allow them a (however great or small) edge in reaching a comparable level of economic prosperity for their citizens.
You in Canada, France, the UK, Germany, etc, or those of you who tout the incredible power of "aggressive government negotiations" that amount to "might makes completely right" (which i seem to recall being the antithesis of the moral idea behind socialism in general, benign Swedish socialism or the ideological idea behind even the Bolshevik/Maoist catastrophes), I feel compelled to wag the finger at you, or maybe even "flip the bird" as we say here in the backward provinces that have never produced a shred of innovative technology because of our "so barbaric and uncaring" reliance on free(r) business and labor laws, etc.
You are what is called in economics "FREE RIDERS" on a distribution scheme.
This is not some impassioned defence of the pharmaceutical industry, but for the moment let's leave their evils (like convincing people that normal everyday inconveniences are medical "syndromes" and that they absolutely have to have perfectly clear noses, oh wait, the cost of that class of drugs (Allegra/Claritin) dropped dramatically once the cost of development was recouped, too) to the side and look at some practicalities.
I, most unfortunately, am not a researcher into the actual numbers of the cost of developing a new drug (or class thereof) or working out a new system of medical technology (how're y'all folks enjoying your Doxycycline, medical ventilators, and angioplasties, btw? we kind of developed those, too) but having attended college at a prestigious medical-research university (University of Pittsburgh) for three years, I have known many an undergraduate and graduate who has worked in fields of research as varied as gene enconding/tracing and physical chemistry of organic compounds, a computer/mathematical application of which often generates and tests new classes of chemical compounds used in the pharmaceutical industry.
All of them talk about how much time (read, labor cost of people whose training already took an enormous financial input) and specialized (read, developed at an enormous research and development expense, as well as the aforementioned cost of training said developers) equipment was necessary to reach any modicum of success in creating or "discovering" a new drug, procedure, or other article of technology. And these are not anarcho-capitalists bent on hating their fellow man for taking their resources, and therefore wanting to make pharmaceutical companies and the other medical-research industries look benevolent and charitable. Most, if not all, are registered Democrat/Liberals with whom I have had many an interesting and compelling dialogue over the healthcare question and such questions as liability, etc, and they without even trying to come up with economic arguments for or against support single-payer. Therefore I think we can claim their representation of research costs as unbiased for purposes of this discussion.
Such research can ONLY take place in a society and an economy where a company has an INCENTIVE (oh, wait, is that a dirty word in the world of government compulsion and socialism?) to develop a new drug, rather than a group of researchers being handed a problem at metaphorical gunpoint to solve? (ignoring, again for the moment, the issue of WHAT they research... that would draw us back to developing vs. developed countries, which is immaterial since both sides are hurling developed at developed in these arguments.)
Do any of you really, truly, when you, as it has been so sweetly and charitably put, "place yourself in someone else's individual pair of shoes" think that you would have much motivation to create a viable drug and delivery system (the latter of which contains a great many of the snags/costs in the development of modern pharmaceuticals, surgeries, etc)
Maybe you could clamor for your government to actually pay the full cost of development and see what a burden it places on your healthcare system and indeed your nationalized paid-for-by-tax infrastructure in general. In light of this, and the fact that all new and safety-tested/approved drugs/techniques/devices are somehow in your world conferred ab origine as rights to everyone needing them, would you consider perhaps STOP BEING SO SELFISH (as clearly Dan Cobb so self-righteously would proclaim all who don't like their stuff being taken at-threat-of-incarceration) and pay your share of those costs?
If the US were to go to a system in which the government mandated the costs of medical technology without consideration for the costs of their development, not only would Americans have fewer options, but a VERY large share of the world's innovations in medical care would cease in their creation, invention, and discovery. Many other countries undertake medical research... a quick perusal of Wikipedia across a broad and source-citing range of articles would seem to point somewhat tellingly to a superiority of innovation systems in America, one that the rest of the developed world has fallen so inexplicably? behind in.
Yes, the post is jingoistic and condescending against other nations. It's 4:30AM and I have had a long day. (and yes, this is a personal excuse that may border on whining)
BUT THINK! JUST THINK MAYBE! that there is more on the line than getting those 45 million unfortunates (of which I am one, just for the record) insured than a concept of social justice (the morality of old vs. young and sick vs. healthy) or a concept of the correct regulation of an industry (the medical insurance industry)
The fact that all of you unquestioningly touting the single-payer system COMPLETELY AND UTTERLY (and I read every comment) ignored this problem inherent in the current international system and market really, really irked me. And yes, to those who posted in support of single-payer but had qualms and may have mentioned the problem of development in passing, i apologize. I can't remember every word.
But just think about this very real and pragmatic fact. Without the US being so horrifically unequal and "immoral" you would not enjoy the standard of medical care you so vociferously demand be highly regulated.
Neal, you are absolutely correct. You are also sleep deprived and cranky, but still correct. However, you make the case. Without getting into the specifics of the worthwhile poor people research being done in academics and the luxury medicine being developed by Pharma (how's your restless leg these days? any ED lately?), the inherent problem is cost shifting. In a world where we only get one body, periods of even starvation are ok- if not desirable- but a single episode of untreated brain fever ends everything.
Whether it is our moral, human desire to keep people from losing that single body or Pharma determined to make money, someone will always pay for the utility of another. Small private pools are inefficient and ineffective. They are quite understandably maximizing the wrong (morally) good.
So do you allow people to die or do you assume some shifting will occur (with the worst by far being in our system- hello? who subsidizes the drug companies? it's us. Subsidize a million TB treatments for poor people or a million little blue pills, which is more moral?) and plan for it!
As a side note To discount the contributions of the French to medicine is to deny history.
esmense -
What children? I can't afford 'em!
Yes, I recognize that a two-tier system is already partly in place... I live in it, after all. I just don't think that government is the solution to all the problems, and I do think that it can be the cause of some of them. Roads and schools are the government's business, although problems with the latter are influenced by a lot of cultural developments that have nothing to do with funding levels. Helping the very poor and disabled people who can't work is also a government function, in my mind. Anyone can end up in those categories, either by birth or by accident, and social programs for those groups are a form of insurance.
Where I part company with the single-payer advocates is that I don't believe there should be one-size-fits-all government coverage that isn't means-tested (or else premium-based for those with the ability to pay). Everybody consumes some health care, and the way people consume it is fairly predictable barring major emergencies. The major emergencies are easy to insure for, because relatively few people have them in any given year.
The problem is how to fund routine expenses, which of course increase as people develop diseases of aging. And, for the present, it seems that the generations that enjoyed low taxes all along should pay out of their assets (to the extent they have some) rather than expecting the rest of us to pay out of current income. What happens after that is anyone's guess -- Gen X and beyond may choose to raise taxes on itself and establish better public benefits, or we may choose to keep taxes low and pay as we go. What many of us won't do is let the Boomers raise taxes on us in order to pay for their benefits.
There's a certain basic animosity there, of course. Boomers have been our bosses all along, and we know how they handle things on average. Maybe we would think differently if they had been nicer to us when we were in entry-level jobs, but it's probably too late for that now.
Or maybe not. How about this? Ask all executives and professionals making over $250,000 a year (i.e., people currently in their prime earning years) to take pay cuts until either (1) all of them are down to $250,000, or (2) enough savings are realized to provide everyone working in their organizations with employer-provided health insurance. People should be ashamed to take salaries that are too many multiples of what ordinary employees get, and this sort of thing used to be enforced by social pressure rather than government action.
Bill White —
What is your source for control of hypertension? You say the U.S. does best, and yet a 2006 study published in The Journal of the American Medical Association found that English people suffer from lower rates of diabetes, hypertension, heart disease, heart attack, stroke, lung disease, and cancer. The study's press release, says the differences are vast enough that "those in the top education and income level in the U.S. had similar rates of diabetes and heart disease as those in the bottom education and income level in Great Britain."
What's your source? Did you make it up?
rueben -
re: Interesting how libertarians persist in the belief that individualism is the be all and end all"
Most libertarians don't believe that.
It is interesting how many non-libertarians persist in the belief that opposing a large, expanding, intrusive state equals belief that individualism is the be all and end all.
re: "Having a society where everyone has equal access to health care, not restricted by their ability to pay is the right thing to do morally because it makes us a better stronger more civilized society."
Having a society where everyone has equal access to health care can only be realized by reducing the access to health care for some, probably many. Its anything but the right thing to do morally. Pulling others down because they have it better than you, or than some third person is quite immoral.
Megan,
David Hogberg makes a good argument that single-payer is even more immoral than even you suggest:
http://freemarketcure.com/blog/?p=161
Right, the fact that Health care is simply not affordable for me right now, (600$/per month for me and my wife for not so good coverage, with lots of caveats, and jumps up to 900$ if we have a kid, or 10, doesn't matter). And the fact that a freelance mobile workforce is what the companies are pushing towards, means there's a real problem here.
The system *Doesn't* push for preventive care. And I pay a 28% flat tax in taxes. That is the government sees a lot of my money.
The Plans I can (and oh boy I have looked) buy, DO NOT cover me in a large amount of situations, including out of state emergency care, etc. Why spend 6k+$ a year on a plan that doesn't cover me? has a $1,000 dollar deductible, etc... There aren't really any real plans available to anyone in many states. Also, 6,000K per year for a single doctor's appointment is unreal.
I know I'm risking a lot, but the reality is look at in terms of gambling, it's a reverse lottery. I'm not likely to catch any debilitating disease, have an accident etc... as I don't drive (NYC), eat healthy, don't smoke,
THE COST SHIFTING IS ALREADY HAPPENING, it's just many young people are opting out, And the MARKET is so slow to respond, and simply doesn't provide an answer for the millions in my situation.
One of the victims of this is American industry, Because American industry is forced to pay for prohibitively, to for profit, Insurance companies to provide employee coverage, They have been gouged and forced to outsource employment.
By shifting to freelancers and Outsourcing, you are increasing *your* companies profits, but essentially funneling money away from American interests, and slowly bleeding the country, not to mention the further costs of higher unemployement to medicaid and welfare (to which I'm sure you'd like to abolish), but also to crime (rise in cost of law enforcement), education (parents forced to work longer hours at lower paying jobs due to a glut in the worforce) which again leads to more crime.
By denying safety nets, it becomes a necessity for workforces to organize to try to legislate a change, and thereby further hampering the "free" markets. Forget about disruptive technology that could cause thousands or millions to lose their jobs but could possibly save time and money, because you force organized labor, and you force ineficiencies.
I'm not calling on the clearly obvious moral problems with the above argument.
I'd like to mention that in this American Free Market System, I have less choice than my family in "socialist" France in the following things: Doctors, Pharmaceuticals, Telecomunications (wireless, internet and cable) and Labor.
In my personal finances, my (out of pocket) taxes in france would be *lower* and I would receive more services and more choices in those things.I would however have to pay a 20% sales tax as opposed to a 8.25% sales tax.
Things are far from perfect in france, and it should not be held as a model for our far larger country (with 50 states and a relatively weak federal government), I'm not michael moore.
Employee based Healthcare also reduces employee choice. As it forces the employee with any comdition or kids or spouse to work in sub-par conditions, not rock the boat.
The Free Market needs to work both ways. IF companies hold insurance and get discounted rates (through pooling employees) and big tax incentives, (as they count health costs against employment tax etc) while individuals and freelancers do not get such benefits, Is that a truly a free market? Especially when insurance becomes mandatory in more states that Massachussets.
http://www.kcrw.com/etc/programs/so/so070819a_severe_case_of_bil
But don't listen to me, a stupid young freelancer, listen to a doctor.
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"The fact that some people cannot afford some good, even a really important and valuable good like food or healthcare, is not a good reason to nationalise the production of that good."
Herein lies my biggest qualm with McArdle's approach to the subject of a single payer system through the lens of morality. If we're talking about morals, let's begin with this statement. Sadly, it seems that our current system has deceived people into fundamentally believing that health care is a commodity; rightfully so, since just as in the case of designer jeans and iPhones, poor people or even self-employed people can't afford it. But health care is a basic human right, one that cannot be affected by the same market forces and under the same umbrella as even a valuable good like food.
I also take issue with the division of groups based on needs and responsibilities. The young and the healthy ARE the future old and sick. Imagine the drop in rates of morbidity and mortality, of which McArdle claims the old and sick to be "responsible" if preventative care were actually affordable and accessible to the young "class" that will be the old.
In the end, morality cannot be the question. Issues of government and policy must first and foremost answer questions of efficiency, this is true. And nothing demonstrates efficiency more accurately than "the market." Therefore, whatever complementary system of employer provisions, private coverage and government coverage most evenly and simply distributes health care is the most "moral" option. Issues of moral obligations obfuscate arguments over health care more than addresses them. Providers, patients and politicians that focus on efficient models of health care will find answers to a problem that has already proved too nuanced to be answered subjectively. Efficiency IS morality.
Way too many unproven assumptions. Argument made way too complex. It's really not that difficult. First, the author is an economist - and an apparently conservative one (me/us VS them) as well. Ms. McArdle is not someone involved in the practice of providing healthcare services. I AM a healthcare provider. I deal on a daily basis with the sick, old, young, wealthy, poor, etc. Yep, the whole cross-section of society and cultural diversity. What blatant hubris you have to pretend to know or even suggest what kind of ethics I employ in the practice of my training and experience. I took an oath to provide quality healthcare to WHOEVER requires it. Let me throw something out - Step outside of your role as economist for a moment. Forget, for a moment the focus on the process of trying to achieve EFFICIENCY. Healthcare needs first of all to achieve EFFECTIVENESS. The economics must be secondary to the practice, not the other way around. If the effectiveness is secondary to efficiency then the purpose of the practice of healthcare has been co-opted - by accounts no less. Let go your hubris of judging the deserving vs undeserving members of society. That's not your job (nor mine). We are both quite unqualified for that activity. Your viewpoint implies (although this is never directly stated) that you, for whatever arbitrary reason, are one of the "deserving". Well pardner, the conditions that you use to determine this particular social/economic status could change in the blink of an eye. Would your persecitive remain the same. We are all in this together. There is no me/us VS them. There is only US. If you doubt this just reflect on how well and how long you would survive without anyone else (or without the mechanics of the universe). Get over your hubris.
To Shaili R. With all due respect, EFFICIENCY is NOT morality. If that is so then we are all reducible to an economic equation. Given my own experience of this life thing I find myself born into, and my daily interaction with literally thousands of people of widely diverse socioeconomic and cultural situations, I think we, as human beings, are much, much more than that. We are unimaginably complex, dynamic, adaptive. We also share certain things in common. The paradox creates no problem for me. EFFICIENCY is EFFICIENCY, not morality. Morality needs account for the whole of the complexity that we are. If we take morality seriously, we must look far, far beyond the limitations of the material issues that efficiency considers. MORALITY is not EFFECTIVENESS either. MORALITY is MORALITY. There are no other synonyms. Morality asks the very pertinent questions - "How do I relate (with life and life experiences)". "Do I relate as if I am separate from other beings/things/processes? Or do I relate as if I am not separate to (in relation and interdependence with) all things. I would make the argument that evil is a misunderstanding of this relationship. Relating as if we are separate leads to harm and suffering, even untold atrocities (i.e. each and every case of attempted genocide in history.)