What about public health?

I was going to get to this later, but a couple of people have brought it up, so let's get it out of the way now: what about the sewers? Or vaccination? Or the many other public efforts that have made people well?

Those efforts are justified on a completely different moral logic than something like single payer. Because of the way that disease spreads, things like sewers and vaccinations are a genuine public good. That is, they have significant positive externalities from which your neighbours cannot be excluded. If I get vaccinated, that lowers your chance of disease, even if you don't get a vaccination. Likewise, if I treat my sewage, you become less likely to get cholera, even if you don't treat yours.

As long-time readers of my old blog know, I'm pretty harsh on people who don't vaccinate (or use sewers, either, though that one hasn't really come up). The problem with vaccines is that they've been too effective; effective enough that parents are (rightly) more worried about a small risk of side effects from a measles or polio shot, than they are about the risk of blindness, heart disease, or paralysis. That tempts them to free ride on other parents who do vaccinate.

As an individual, that's the smart strategy, but socially it's disastrous, since it destroys the compact by which we keep infectious disease at bay. Also, once there's a new reservoir of unvaccinated kids, their free ride becomes not that free.

But treating infectious disease to keep it from spreading is in a different moral category from a universal health care system. Curing my asthma will not protect the people across the street, or America, from danger.

Comments

Are there diseases that are not in part infectious? This 'compact' would seem to mean that anything that can be shown to have a pathogen in its etiology should be part of public health.

This may surprise you, but cancer, heart disease, arthritis, obesity all have an infection in their etiology. I feel that Universal Access simply notes a fact of life: diseases are infectious.

Posted by dalea | August 28, 2007 2:51 PM

Mmmm . . . no. Treating the cancer, heart disease, etc. doesn't prevent the spread of the infectious agent, which in most cases we have not identified, or found a cure for.

In cases where we can identify, there may be a public health case; I supported mandatory HPV vaccination for that reason. But those are few and far between so far.

Posted by Megan McArdle | August 28, 2007 2:57 PM

Curing my asthma will not protect the people across the street, or America, from danger.

This is likely factually false. If your asthma is part of the total health care budget, then preventing you from getting it in the first place becomes cost-effective. A single, life-term insurer is in a much better position of working with EPA, for example, on developing evidence-based and cost-effective environmental regulations that reduce the incidence of asthma.

Posted by Francis | August 28, 2007 3:00 PM

You're absolutely right about the fact that vaccines have been a victim of their own success, and how that success has led parents to think they can skip out on vaccinating your child. I don't think you're right, however, when you say that it's the right thing to do for the individual. To begin with, I think you're underestimating the chance the average uninoculated child has of contracting mumps or rubella or whatever. But beyond that, I think there's something a little screwy about your logic. Surely if there are enough children that aren't being vaccinated to pose a public health risk, there are enough unvaccinated children for the parents to worry that their unvaccinated child will be exposed to other unvaccinated children, and potentially one of those diseases. (If you think that sentence was hard to read, try writing it.)

Incidentally I think there's a good post out there for some bright blogger about how this situation with vaccines is analogous to health care in general, in the sense of shared risk/shared cost.

Posted by Freddie | August 28, 2007 3:08 PM

Oh sheesh...
Megan, you have no logical reason for drawing a bright line at sewers and vaccinations while ignoring other forms of health care to protect people from infection like, for example, doctors visits which identify and treat _any_ communicable disease.

I don't know why I have to point this out, but by your own terms ( i.e. - promoting public health efforts that "have significant positive externalities from which your neighbours cannot be excluded"), ANY form of health care that reduces shared costs to society (and therefore produces a positive externality from which neighbors (what's with the British spelling???) can not be excluded) should be treated as a public health benefit. But this isn't about logic, is it? It's about your desperate attempt to rationalize a preconceived notion. *smile* Have fun with that.

Posted by Roger Mexico | August 28, 2007 3:21 PM

If these recent discussions prove anything, it’s that ‘moral logic’ can be whatever one wants it to be, and is not necessarily logical.

In terms of economic logic, the lack of public health causes an externality problem. Since we don't deny people emergency room care, so too does the lack of universal healthcare.

Posted by RC | August 28, 2007 3:23 PM

But these arguments are entirely circular. The government should pay for my health care now because . . . otherwise the government will pay more for my health care later. That's not an argument in favour of having the government pay for my health care.

Posted by Megan McArdle | August 28, 2007 3:28 PM

Your justification for participation in public health programs is inaccurate.

My parents were not compelled to pay for sewer access because the neighbor's sewer lines were benefitting my parents. They were forced to pay for the sewer because it would not be a cost effective system unless everyone bought in at the same time. My parents had a brand new septic system that worked just fine. The neighbors who had not recently installed new septic systems profited. Sewer access was intrinsically more efficient, and cheap because of high volume. There was high volume because it was forced. Many of those who benefitted were more well off than my parents. On the whole, the neighborhood was much better off with the sewer system. My parents were not. This was essentially a transfer payment from my parents to some of their wealthier neighbors, but it was a greater good.

Posted by Njorl | August 28, 2007 3:32 PM

That's not an argument in favour of having the government pay for my health care.

Look, we have to get this out of the way. Do you or do you not think that the government should provide access to health care for those who are not insured and who don't have the money to pay out of pocket? I believe you've said that you do, and some commenters have certainly said that you do. But the evidence suggests otherwise. So yes or no?

Posted by Freddie | August 28, 2007 3:34 PM

Megan says: Treating the cancer, heart disease, etc. doesn't prevent the spread of the infectious agent, which in most cases we have not identified, or found a cure for.

Of course it does prevent the spread of the infectious agent. Discovery of the role of pathogens in disease proceeds apace. Even asthma begins with an infection with paramyxoviral virus which in some individuals modifies the immune system so that it does not stop inflammation response to allergans. A normal immune system would inflame and then quickly go back to usual. Viruses make their living by inserting themselves into cells. They replicate themselves and during an attack they spew into the air with the potential for infecting others. Infants are most suceptable to paramyxoviral infection. Asthma is a public health issue as asthmatics are at risk of infecting others. Prompt universal treatment for every sufferer reduces the risk of infection for everyone. Universal Access is the key to reducing infections.

While we may not have a cure, we do have palliatives. The HIV drugs are palliatives, they make things better but do not cure. And they usually reduce infective potential. Which is a good thing.

Posted by dalea | August 28, 2007 3:43 PM

This comment deleted for personal attacks

Posted by brad | August 28, 2007 3:46 PM

The government should pay for my health care now because . . . otherwise the government will pay more for my health care later. That's not an argument in favour of having the government pay for my health care.

True. The argument in favor of having the government pay for your health care is that having people dying in public parks from treatable ailments is unfair to parks workers and lowers property values near parks.

Here's a Modest Proposal. Everyone is covered by some form of Universal Health Care until they're 18. On your 18th birthday and every birthday thereafter, you have the power to opt out of the UHC program by getting a small red tattoo on your shoulder. Once you opt out, you can either get private insurance or self insure.

Doctors, hospitals and emergency rooms are then prohibited by law of treating anyone with the tattoo unless they can pay in advance. Those who can't pay are sent to the Libertarian Room in the hospital to die or get well on their own. (We'll even throw in a phone in the LR so you can call your bank and try to get a loan to cover treatment.)

ok?

Posted by francis | August 28, 2007 3:51 PM

Pathogens cause disease. They live in hosts, like living beings. The more hosts a specific one has, the larger community. And the larger the community, the greater the opportunity for mutation. And the more mutation, the more infections and the opportunity to develope into a more lethal pathogen.

Conversely, the smaller the pool, the less opportuity for infection. The way to reduce the pool is to promptly treat every case of illness. Shrinking the pool with cures and palliatives (like your asthma medicines) helps reduce the chance of mutation. As a long time HIV activist I have had to learn all of this, so my perspective is different from yours.

Megan, you seem to see disease as a one at a time discret event which can be treated by giving people money. I see each case as one event in a cycle and want to see the cycle broken. Which Universal Access does do.

Posted by dalea | August 28, 2007 4:00 PM

"But these arguments are entirely circular. The government should pay for my health care now because . . . otherwise the government will pay more for my health care later. That's not an argument in favour of having the government pay for my health care."-Posted by Megan McArdle

The government mandates vaccinations for schoolage children to avoid the catastrophe of an epidemic. Is it because an epidemic is morally wrong or is it because it is a cost effective means of preventing an economically significant share of medical costs that, one way or another, everyone pays for? It is the latter. There's lots of suffering the government ignores. Suffering that costs society as a whole money - that gets government's attention.

It's supply and demand. If everyone's kid gets chicken pox, I pay more to the doctor to treat my gallstones. If enough kids get chicken pox, maybe it will cost too much for me to get gallstone surgery and I will suffer and die.

The government has a compelling interest in making efficient use of the medical services industry. It is clear that you have accepted the government's right to do so intrusively in some cases like vaccination. The question is, are health care resources becoming dear enough to warrant an intrusive step like single payer coverage which should help control long term costs?

That's the morality of it. It isn't about who pays and who gets. That gets fought over in a hundred different places in a dozen levels of taxation. If one class gets squeezed here they can squeeze back in a different tax fight. It is a question of efficiency. Is single payer going to slow the growth of the cost of healthcare which is about 1/6 of GDP. That is a monstrous sum, anything that controls those costs is worth considering. Moral considerations can be addressed as needed.

Posted by Njorl | August 28, 2007 4:01 PM

That's not an argument in favour of having the government pay for my health care.

Again, this is just an unproductive way of thinking about the situation. It obscures all of the important issues, and stacks the deck in favor of libertarian anti-government bias.

Using your terms (as best I understand them), here’s how I would rewrite your priors in a way that could lead to more productive debate:

1. Not having universal healthcare is an inherently immoral condition. Health care has the same moral status as education: everyone in society should have a right to decent healthcare, just like everyone should have the right to an education.

2. The question of how to best to administer universal healthcare ought to be decided primarily on efficiency terms. The question of how best to finance universal healthcare ought to be decided primarily on fairness terms.

Posted by RC | August 28, 2007 4:10 PM

You say:

"The government should pay for my health care now because . . . otherwise the government will pay more for my health care later. That's not an argument in favour of having the government pay for my health care."

We require hospitals to treat indigent people with critical medical problems. The alternative is to have untreated people dying in the streets, which we've decided, as a society, is unacceptable.

If you're arguing that there are no circumstances in which the government should pay for health care, you're also arguing for people who can't afford health care dying because of that lack. That's intellectually consistent, because you seem to be a utilitarian; but it's not appealing at all to those of us who would prefer not to have people dying in the streets.

You don't address the problem that sick people - and, indeed, dead people - create their own "negative externalities" that we all have to deal with. Sick people spread disease, are less productive, can't take care of dependents, and ultimately wind up getting more expensive treatment that other people have to pay for (or don't and die when they could have been productive citizens). We collectively have to pay for the sick one way or another. The operative question is whether UHC, with its up-front costs, is a better way to do that than the current system, where the costs are largely hidden.

Posted by Aaron | August 28, 2007 4:16 PM

Dalea, you're missing the main point, which is that we don't know how to break the cycle of any of these diseases. To the extent that we do get a vaccine for streptococcus, or gum disease, or h. pylori, or what have you, it might be worth talking about a public health intervention. But we don't have any of these things as of now. With no treatments for those infectious diseases, there's no public health implication . . . or, as with H. Pylori, it's so widespread that there's no feasible treatment.

Posted by Megan McArdle | August 28, 2007 4:21 PM

Brain... about...to explode... please... god... answer... question... should government... blarg... provide access to health care... to people... uninsured and can't afford... to pay out of pocket... fundamental... question in this debate... about... 100,000 goddammed words... on the topic... no answer to essential question... blsaasdgsdg.

Posted by Freddie | August 28, 2007 4:40 PM

This comment deleted for making personal attacks

Posted by HH | August 28, 2007 4:42 PM

should government... blarg... provide access to health care... to people... uninsured and can't afford... to pay out of pocket

Didn't we have Medicaid at some point?

Posted by ...Max... | August 28, 2007 4:56 PM

Max,

We did; we do. What you're missing is that using Medicaid is embarrassing; it's like you don't have any money to take care of yourself. Oh, right, you don't.

The "savings" potential of "single payer" arises solely from "compensation controls" similar to those applied by Medicare and Medicaid. They are not price controls, because the medical community can charge whatever it wishes. They are not wage controls, because doctors can earn as much as they want if they only work longer and harder. However, Medicare and Medicaid pay what they choose to pay, regardless of the amount billed.

One only need look at the tremendous reductions in expenditures in the Medicare and Medicaid programs over time to understand the "savings" potential of "single payer".

Posted by Ed Reid | August 28, 2007 5:19 PM

Well, from my perspective, the question is how expansive we consider the group "those who can't afford to pay out of pocket." I'm willing to bet my notion of that is considerably different from ...Max...'s.

Another question would be wheter or not McMegan (MegArdle?) supports Medicaid or not. Lots of libertarians don't.

Posted by Freddie | August 28, 2007 5:27 PM

The "savings" potential of "single payer" arises solely from "compensation controls" similar to those applied by Medicare and Medicaid.

Yeah, those that helped screw up the healthcare market in the first place.

I'm willing to bet my notion of that is considerably different from ...Max...'s

Oh, I'll be the first to confirm that. If one hasn't forgone cable TV, one's not too poor to pay for his doctor's vists.

Posted by ...Max... | August 28, 2007 5:32 PM

Ummm, no they are not different. Providing for the health of all citizens is also a public good. We know this because the facts proclaim it loud and clear, those societies that offer some form of generalized health care are better off in terms of life expectancy, infant mortality and others, than are those societies that do not.

And there is also another benefit. Providing for the general well being of citizens simply makes us better human beings. This is similar to why we no longer allow people to abuse animals. Not simply because animals don't deserve it or posses "rights", but because it makes us better people. To abuse an animal debases you and makes you less human.

This is again also why we ought not to torture. Not because it might or might not "work" but because it dehumanizes those who practice it.

These should be obvious to anyone.

Posted by noen | August 28, 2007 5:33 PM

What you're missing is that using Medicaid is embarrassing; it's like you don't have any money to take care of yourself.

A feature, not a bug. Being a recipient of charity is supposed to be embarassing. Wealth redistribution is (or, rather, should be driven by) charity. What's wrong with that?

You're not suggesting people will die on park benches rather than be embarassed, are you?

Posted by ...Max... | August 28, 2007 5:36 PM

Max,

When I voluntarily redistribute my wealth it is charity. When the government redistributes my wealth, it is socialism. I perceive a difference. Currently, there are lots of people willing to redistribute my wealth in more ways than I am.

Posted by Ed Reid | August 28, 2007 5:42 PM

Socialism:
A political theory advocating state ownership of industry.

Providing for the common good is not socialism except among internet trolls.

You are a part of a community, you are part of society. Everything you are is due in some measure to your participation in society. In no way are you a "self made man", that is a delusion. You do in fact owe your livelyhood and general well being to the fact your were born here, that you want to reject your community is simply a measure of your greed and avarice.

Posted by noen | August 28, 2007 5:57 PM

I perceive a difference.

So do I -- note the parenthetic "should" in my post. And, damn it, I missed the sarcasm in yours. Speaking of myopies...

Posted by ...Max... | August 28, 2007 6:08 PM

Providing for the common good is not socialism except among internet trolls.

"The road to hell is paved with good intentions"

Posted by ...Max... | August 28, 2007 6:09 PM

Providing health care to everyone is a public good.

Providing education to everyone is a public good.

Providing transportation to everyone is a public good.

Providing shelter to everyone is a public good.

There is no doubt that having the "government" providing everything to everyone would be great... but it's not possible. And so you have to draw lines and make distinctions. And all of these public goods must be paid for by someone. The "government" can't magically create money to pay for stuff. Well, it CAN, but that's a bad thing and doesn't work in the long run.

There seems to be a fundamental disagreement here between those who see taxes as a fair way to redistribute income and those who see taxes as more of a necessary evil to pay for things that can't be provided through markets.

Noen is a perfect example of the latter. He seems to feel that no one has any inherent claim to their paycheck and that what they should only get to keep whatever is left over after society has taken what it needs to make sure everyone has everything they need. Of course "need" is a highly subjective term...

And the ad hominems still abound...

EI

Posted by Earnest Iconoclast | August 28, 2007 6:24 PM

"Because of the way that disease spreads, things like sewers and vaccinations are a genuine public good. That is, they have significant positive externalities from which your neighbours cannot be excluded."

Ok. This blog is an utter waste of time.

The entire discussion of "single payer" is premised on the understanding that health care is a public good. That is: NO ONE who honestly considers (whatever Megan is arguing against as) "single payer" to be a viable means of providing health care also considers providing health care NOT to be a public good worth providing by some mechanism and in the same category as public health, public education, and public infrastructure projects.

Which is why it makes basically no sense at all to protest that "single payer" involves a wealth transfer between two classes of society: of course it does, but so does providing for any public good. The wealth transfer is justified precisely because it's a PUBLIC good - you can argue about way to mitigate the impact of that transfer on certain classes, but it's prima facie assumed to be morally justified. It's like whining about having to pay to build those interstates you don't use, or having to pay to educate other people's children, or railing against welfare because you'll never be poor - sure, you can do that, and you can even call it a "moral" argument, but it's a total waste of time: everyone has decided to fund those things, and insofar as you don't actually have the capacity to take place apart from everyone, you have the privilege of funding them too. Welcome to society.

And, anyway, why would anyone care what someone doesn't think that helath care is a public good has to say about the desirability of one option for providing that health care?

If you want to make an argument that health care isn't a public good, that's one thing - and by the way, good luck with that... - but why are you even talking about how to provide something you don't think is necessary?

Posted by cs | August 28, 2007 6:27 PM

"Public good" is a technical economic term for things like militaries and fire protection that, because of the free rider problem, cannot be provided by the market. It is not a term for "things the government provides".

Posted by Megan McArdle | August 28, 2007 6:36 PM

There seems to be a fundamental disagreement here between those who see taxes as a fair way to redistribute income and those who see taxes as more of a necessary evil to pay for things that can't be provided through markets.

Gee, ya think? I knew about Ayn Rand 30 years ago when I was a snot nosed adolescent. I grew up, what's your excuse?

Noen is a perfect example of the latter. He seems to feel that no one has any inherent claim to their paycheck and that what they should only get to keep whatever is left over after society has taken what it needs to make sure everyone has everything they need.

That's "she" if you please. No, that is not my position. Like many here I feel I have to keep the discussion very elementary for a couple of reasons. One, it's really difficult to have an in depth argument in a comment on a blog. And two, Megan's political and philosophical ideas are infantile, self absorbed and narcissistic.

Posted by noen | August 28, 2007 6:42 PM

Meagan, we do not have cures. But we do have palliatives, amelliorates and education. You sound like most conservatives during the early years of the AIDS Pandemic. There are no cures so there is no reason to do anything. There has never been a medicine that worked against viruses.

Surprise, by treating all PWA's, usually through public clinics, a system for ameliorating the condition arose. The clinics were able to do outreach which resulted in the spread of the disease being stopped to a very high degree.

Your idea is simply to give up unless there is a 100% perfect way to go. Not a wise choice.

Posted by dalea | August 28, 2007 6:56 PM

"Public good" is a technical economic term for things like militaries and fire protection that, because of the free rider problem, cannot be provided by the market. It is not a term for "things the government provides".

No, "public good" is that which benefits society as a whole, like equal access to health care. It also benefits the individual members of the society. For example, the reason we ought not to torture is because to do so debases the individual members of society and because the practice of torture destroys those societies that use it.

Societies that practice some form of universal health care are, to use a Darwinian term, more adaptive than those that do not. The individuals within such societies, and therefore the community as a whole, are better able to survive adversity. In the long run it is in your interest or your dna's interest, to live in such a society.

Posted by noen | August 28, 2007 6:57 PM

Tell me again how "Public Good" is a technical term? Please, oh, please condescend to me some more.

Anyway, the discussion does take place with the premise that health care is a public good - "some goods needed by the public cannot be provided through the private market." That's the ONLY context in which the discussion of "single payer" makes sense - e.g. to provide health care needed by the public which we know empirically is not being provided through the private market.

If you don't believe that that description applies to health care, why are you even talking about a solution premised on the understanding that it does?

"Public Good" from Brittanica online (I'd link, but it's behind a subscription wall):
"
Economists have sought to provide objective criteria for public expenditures through the so-called theory of public goods. It is generally recognized that some goods needed by the public cannot be provided through the private market. Lighthouses are a classic example. The costs of a lighthouse are such that no one shipowner will want to finance it; on the other hand, if a lighthouse is provided for one shipowner, it can be made available to all for no additional cost. Indeed it must be available to all, since there is no practical means of excluding ships from using the facility provided by the lighthouse, even if their owners have refused to pay for it. The only practical method of providing such services is by collective action.

If goods are to be provided in this way, rather than through the private market, it is immediately necessary to confront the twin problems of deciding how much to provide and who should pay for that provision. Even if all individuals wanted the service equally—as, perhaps, with lighthouses—their views on the extent of the service would be influenced by the allocation of the costs. Where different households may have different preferences and some may not want the service at all—as, for example, with defense by nuclear weapons—these difficulties are compounded. Economists have tried to devise abstract voting schemes that would reconcile these difficulties, but these appear to have little practical application.

Moreover, others would challenge this whole approach to the problem. It would be absurd to say that the consumer has a taste for national defense and that it is the job of the government to satisfy it. The task of national leaders is to evolve a defense policy and persuade the public to accept it. Similarly, conservationists must attempt to awaken the public to the importance of parks and wildlife. In the context of public policy, the efficient allocation of resources consists not merely of distributing funds in the pursuit of given objectives but also involves determining the objectives themselves.

Genuine public goods pose severe problems for the national budget; it is very difficult to decide how far particular goods—the arts, national parks, even defense—should be supplied, and therefore no formal procedure of determination is likely to evolve. What should be given to each will continue to be the subject of intense political debate, with allocation changing as the government changes.
"

Posted by cs | August 28, 2007 6:58 PM

Wait, do you not think there's a "free rider problem" with the provision of health care?

Weird.

Have you looked at the numbers on this? You probably should, and, really, you should probably look at those numbers before you write any more about this.

Posted by cs | August 28, 2007 7:38 PM

To wrap up this ongoing shooting pain in my brain, Megan just decimated her own arguments against universal health care, and has provided the key rationale to adopt it posthaste - the role of the government in preventing communicable disease.

One of the key truths of illness is that sick people, left untreated, tend to get sicker - and often with different diseases than the one they started out with.

Your asthma isn't contagious, but the respiratory infections you're more susceptible to are. Your cancer isn't contagious, but the viruses your weakened immune system can't fight off are.

If we accept Megan's (current, sure to change) premise, then it behooves us as a society to make sure all people are covered with comprehensive health insurance. Those who suffer from chronic, non-communicable diseases are prime locus points for communicable disease if left without treatment for the primary disease.

Posted by Starscream | August 28, 2007 7:46 PM

Starscream, one thing I found when I began to look into this is that far more things are communicable diseases than I had thought.

Over the last decade, researchers have been investigating the role of pathogens in cancer. Currently at least 30% of all cancers can be shown to have a pathogen in their etiology. For at least one of these, a vacinne has been developed.

Heart disease is now associated strongly with clamydia infection.

Even obesity, which seems like an easy thing to throw at people, has been discovered to have a viral component.

So, actually, one's cancer can be communicated to others. As can one's asthma.

Where Megan goes astray is she did not study what disease is and where it comes from before moralizing. Had she done so, the role that infection plays in disease might have taken her down a different path.

Posted by dalea | August 28, 2007 9:27 PM

This comment deleted for making personal attacks

Posted by Charles GIacometti | August 28, 2007 11:09 PM

we don't know how to break the cycle of any of these diseases. To the extent that we do get a vaccine for streptococcus, or gum disease, or h. pylori, or what have you, it might be worth talking about a public health intervention. But we don't have any of these things as of now. With no treatments for those infectious diseases, there's no public health implication . . .

Huh, this is interesting. I think the claim that there are no public health implications for diseases unless we know how to "break the cycle" of the disease would be rejected by pretty much any public health professional. Viral diseases like AIDS or strep are a good example: we do have "treatment" (as we do for strep; treat the symptoms, treat the disease), but that treatment (ARV drugs) doesn't "break the cycle" in the way a vaccine would. Still, every wealthy country on earth has embraced universal treatment for HIV, not just prevention; we have it too, via the Ryan White Act. That is in part because everyone recognizes that if you don't offer people treatment for HIV, they won't come into the health system to be tested, and then you won't be able to do any of the counseling and other services that help stem the spread of the disease. Here again, "inclusion" is a public health priority.

Universal ARV treatment isn't some kind of namby-pamby goody-goody ineffective public program. It is the baseline public health strategy for curbing AIDS in every country that's serious about stopping its HIV epidemic. (Countries that drag their feet on it tend to be countries like South Africa that aren't serious about fighting their HIV epidemics.) We're so convinced it's necessary that we are now willing to pay for other countries, poor countries, to launch universal ARV treatment, through the US's PEPFAR program, the Global Fund to Fight AIDS, Tuberculosis and Malaria, and so forth.

So I think this comment expresses an overly mechanistic view of the way public health works. You don't have to have a "magic bullet" drug to justify public intervention; what you need is a public health strategy that has been proven to improve the health of the population.

Posted by brooksfoe | August 28, 2007 11:58 PM

This comment deleted for making personal attacks

Posted by noen | August 29, 2007 1:06 AM

This comment deleted because it responds to a deleted comment.

Posted by dalea | August 29, 2007 1:31 AM

There is a big difference between saying that a health care system has failed and saying that it doesn't provide health care for everyone. The health care system in the US has hardly failed. The 250 million+ who have health insurance have access to excellent medical care.

Of those who don't have insurance, some could have it, but have chosen not to. Those who are left are the ones who need some sort of help.

Single payer is only one possible way to make sure that those who are not getting what they need do so. There are other ways, too. The fact that some people are too poor or don't have insurance is not a reason to scrap our current system and switch to a single payer system, necessarily.

As an aside, someone said (either in a comment on this blog or a link from a comment on this blog) that the only way to effectively provide health care to 300 million people was through a government controlled system. I disagree strongly with this. It's easier to manage a smaller system through central government control than a larger system. Just because a system works for a small (and possibly homogenous) country doesn't mean that it will work for the US.

EI

Posted by Earnest Iconoclast | August 29, 2007 9:50 AM

EI, I disagree with your point that "The 250+ million who have health insurance have access to excellent health care." Although the plight of people who simply can't afford insurance (or aren't allowed to buy it at any price), is serious, a lot of people who have insurance don't necessarily have access to even good health care. Just because I have insurance doesn't mean that it will cover all the care I actually need.

Single-payer and other forms of UHC aren't the only way to solve the nation's health care problems, but there is a serious problem and it needs to be addressed one way or another.

Posted by Aaron | August 29, 2007 10:39 AM

So my comment above was deleted for making personal attacks? I merely pointed out that McArdle is a complete incompetent, and that the Atlantic should either instruct her on how to write something of value or should dismiss her.

I was a decades-long subscriber to the Atlantic, and always admired the writing, even when I disagreed with it. It was thoughtful, well-researched, and well-honed. This blog is none of those things.

Go ahead and delete this one, too, and you lose me as a reader--of the online and of the newsstand copies I still buy regularly.

Posted by Charles Giacometti | August 29, 2007 1:25 PM

To be a "Public Good" something must be non-rivalrous (a consumer of the good does not reduce its supply for others) and non-excludable (a member of the public cannot meaningfully be prevented from consuming the good). The classic example is the national defense - it benefits ALL our inhabitants. There is no practical way to weaken our defenses against invasion from Canada to allow just MEGAN to be carried off by some soldier from Montreal (he will have to try romance rather than invasion, I suppose).

Health care fails on both counts.

Posted by Jens Fiederer | August 31, 2007 8:21 AM

Let's go way back to vaccinations that lead to asthma, autism spectrum disorders, and other new chronic illnesses. As far as money goes, whooping cough, mumps, etc. are FREE to treat. Asthma, allergy shots, years of therapists for autism are very expensive. Healthwise and moneywise, the accute is less dangerous and less expensive than the chronic. Childhood diseases used to kill people who ate just bread, just rice, just potatoes, or just corn as their main source of nutrition. With the hotdog diet amongst American kids, maybe these things would still kill. But with the waking up of parents, the organic thinking, these diseases are not a big deal. My three fully unvaccinated children 12 and under caught whooping cough and mumps when we lived in a primarily unvaccinated country. We weren't "opting for a free ride". We knew our kids might catch a few things. They weren't a big deal compared with a lifetime of learning disability. What's a few nights of lost sleep in comparison with that? And guess what? These diseases are viruses.....no treatment involved. Just wait it out, give high protein food such as eggs, raw milk, lots of vitamin C. You're fixed! Now when my girls grow up and possibly have their own children....and breastfeed, their kids can't get whooping cough and mumps for the first year, the only dangerous time for these diseases to be caught! This is the cycle as God intended. Immune systems work better than mercury, formaldehyde, the witch's brew of pig and monkey cells that are today's vaccinations.

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