So we've arrived at an impasse. I think fiat will screw up the health care system even worse than fiat has already screwed up the health care system, and that this will be bad for everyone in the long run. I think that any program enacted now is likely to be the tipping point--once the government controls more than 50% of the health care system (it's over 45% now), it crowds out private health insurance for most people. I think that this is what the people behind the system want it to do, largely because that's what they keep saying they want.
I think probably most people would agree that if Rand is right, and price controls shave, say, almost a year off of average lifespans, this is not necessarily a good deal for even the squishiest bleeding heart liberal--for the same reasons that socialism turned out not to be a good idea. No, I'm not calling you a socialist. I'm saying that if nationalizing companies and 90% tax rates on the very wealthy had worked well anywhere, a lot more liberals would be in favor of those things, because if you take away the unintended consequences that they turned out to have, they seem to conform to a lot of progressive priorities about justice, distribution, and so forth. But they didn't, and so most progressives have (or so I devoutly hope) abandoned these sorts of ideas in favor of a less intrusive agenda.
So ultimately I'm saying, I think this is the way that our government works, and this is the way that markets work, and for all the screaming, these are not crazy positions. There's plenty of evidence for government crowding out. There's plenty of evidence for price controls. There's plenty of evidence for what happens to markets that are largely governed by price controls.
You may disagree. You think government works better than I do. You think we'll be able to draw a line in the sand and keep the government from crossing over it to take over more of the market. You think government spending can substitute for R&D, because you don't find the socialist calculation debate compelling. Or maybe you say, hey, yeah, well, 0.7 years off the average lifespan isn't a bad tradeoff for covering the uninsured.
I can't talk you out of it. You can't talk me out of thinking that 0.7 years of life is a whole lot of life when you apply it to 400 million people. Numbers like that seem kind of meaningless-it's just eight months!--but this is composition fallacy. Some people won't live longer. Some people will die sooner, because treatment is iatrogenic in at least some cases. And some people will get extra decades of healthy life to hug their children or compose symphonies.
It's a judgement call. Not all values are commensurable. There are multiple theories of politics. And justice.
So why talk any more? I can't believe how nasty this debate has gotten. I can't believe that people who claim to value a classically liberal market society, on the one hand, and people who say that all they want to do is help people, turn into such screaming, hate-filled lunatics when the subject comes up. A debate over health care should not remind me so much of a debate over the Iraq War. I write thousands of words on innovation, and John Holbo boils my concerns about lost years of life down to "indifference to the poor"--as if, first, the poor will not be helped by new treatments, and second, we should do anything at all, no matter how horrific the results, as long as it helps the poor. Well, and third, as if the poor weren't on Medicaid, but that's another rant. This is about as useful as my saying that John Holbo's basic philosophical premise is a desire for my grandchildren to die young. I devoutly hope that if any of his freshmen said anything remotely this silly in a paper, Mr. Holbo would flunk them.
I'm actually happy to be at the impasse, which I knew was coming. All I wanted to do was get some liberals to admit that there might be some reason that someone with basically progressive ethical priorities might be worried. I don't think we'll go beyond that, because progressives also have a lot of priors about the market that I don't share, to wit that it rarely produces anything really useful.
But I'm sad about what's happened along the way. I'm sad that people are carrying guns to protests, even though I think they have a right, and I'm sad that so many liberals have caricatured the opposition to the health care agenda as legions of astroturfed militiamen who accuse Nancy Pelosi of appointing Hitler to a death panel, or something. I'm sad that libertarians and conservatives are casting this as some sort of massive conspiracy of power-mad idiots, when there's obviously a very large left-wing policy apparatus built up around health care that knows a thing or two, and virtually all of the progressives advocating this are for it because they are worried about people who can't get basic health care. I'm sad that liberals are casting their opposition as being mostly about racism and hatred of the poor. I'm sad that the debate has taken place 95% at the level of the gut revulsion Red and Blue Americas are actively nurturing for each other.
So I'm not sure it's much worth continuing beyond this point, unless there's some interesting economic side issue. But it's certainly been interesting, and most of the commenters have remained reasonably civil most of the time. Thanks for that.
Copyright © 2010 by The Atlantic Monthly Group. All rights reserved.
It is sad that it has come to this. The same thing has happened amongst my family and friends, and we have all just sort of backed off the debate for risk of saying or doing things that we might regret.
I actually have appreciated reading your posts, even though I do disagree with you; they have helped me refine and rethink my positions.
It's been frustrating. A lot of it has not been interesting.
And it seems to me that if your sentiment here is widely held, then this means reconciliation, or jamming it through some other way. A lot of people in this country feel (and have felt for a long time) strongly about the need for health care/insurance reform -- enough to be a big part of the election of this president and congress.
If we've reached an impasse, and further conversation (to the extent that there's been any at all) is not helpful, then maybe it's just time for the Democrats to act.
And just to add on to this -- has there been 10 minutes of a real discussion about this at any point in the mainstream media or political circles, or in the majority of blogs? I don't think so. I think we were at an impasse the entire time.
In addition to here, there has been some vigorous discussion at venture capitalist Fred Wilson's blog recently, but without reprising the philosophical and economic points Megan has made, I'll just make two observations.
1) Those who argue we need to socialize the entire health care system because some people don't currently have health insurance never seem to wonder why we don't need to socialize the food industry because some people can't afford food. Subsidizing those who can't afford something doesn't require socializing it for everyone.
2) What's with the left-of-center technophiles who thrill to the latest innovations from Apple, etc., but want socialized medicine? What kind of priorities must you have to want the profit motive to fuel innovation in hipster gadgets but not in health care?
What kind of priorities must you have to want the profit motive to fuel innovation in hipster gadgets but not in health care?
First - Democrats and other pro-socialists have been pushing for a socialized healthcare system for 50 years, it's not like this is a new phenomenon. iPods are relatively new developments.
Second - Democratic voting constituencies such as labor unions have long desired a tax payer-funded healthcare insurance plan. For unions, this is one more expense off their balance sheet (now on the tax payers') which allows them to bargain for higher wages, pensions, other goodies, etc...
Third - There is a certain segment of the population that deeply disdains anyone who profits from treating another person's disease. This disdain applies to doctors, hospitals, healthcare insurance companies, pharma and medical technology compaines, and any shareholder of said institutions.
Re your second point, do labor unions with generous current health care benefits think they'd be able to keep those somehow if we went to a socialized system? There seems to be some disconnect there too. The Teamsters, etc. are among the best-off in the current system. I can see how a single payer system might be a boon to some SEIU types, for whom all the legendary Andy Stern has accomplished is boosting their wages to 50 cents per hour above the current legal minimum, but for the successful industrial union workers chances are, a single payer system would be a step down for them.
1. you might notice food (and even ipod) is a lot, a lot cheaper than health care. the amount of people who can't afford food and the amount of people who can't afford healthcare are obviously not the same. try having people begging on the street for a heart surgery instead of sandwich money.
2. seriously. this is stupid. ipods and tech innovation has nothing to do with basic human needs. But that's obvious so let me say this: i often wonder why megan mcardle's writing doesn't get any better under this highly competitive free market blogsphere. Just because there's money incentive doesn't mean people automatically become innovative. Why is yahoo going downhill when they have enough incentive to succeed? libertarians see no difference between trying and succeeding, as if if somebody stimulated by the almighty market economy starts trying, he or she already succeeded...
I seem to remember a Mr Mackey of Whole Foods trying to get a real discussion going.
Thank you for your posts. They do more to further a fact-based dialogue than most outlets.
Thank you for making the effort. Your posts corrected an obvious flaw in my thinking, which was that foreign price controls raise US prices, when instead they reduce the amount of development. (Well, unless you believe the theory of many on the left that companies don't respond to incentives).
I find it especially annoying that the intense partisanship on both sides prevents us from making reforms that are nearly universally agreed to be good ideas, such as moving away from employer-provided insurance. Of course as Keith Hennessey notes, you then have to decide whether what was formerly done by employers should be done by individuals or government, and that seems unresolvable.
"I find it especially annoying that the intense partisanship on both sides prevents us from making reforms that are nearly universally agreed to be good ideas, such as moving away from employer-provided insurance."
Yes. Really, really annoying.
I don't know anything about the topic one way or another, but could someone who does please explain why increased competition wouldn't lead to a decrease in prices? Wouldn't more patented drugs now lead to more and better generic drugs later, thus reducing price?
Wouldn't more patented drugs now lead to more and better generic drugs later, thus reducing price?
Yes, in theory. The problem lies in the amount of money it takes to develop any drug or class III device - from discovery to development, it's approaching about $1 billion (rough estimate) There are few, if any, other markets like medical technology; imagine being an entrepreneur and knowing the barrier to entry into your market, regardless of what you make and how you make it, will be at least a billion dollars.
More patented drugs means more drugs with these development costs. Medical technology companies have to make these development costs up in terms of profit, regardless of market competition and traditional pricing pressure. Because of our regulatory apparatus, medical technology innovations will always be very, very expensive.
In other words, the prices will not be lower than the costs.
Which is only fair.
You really hit the nail on the head. One of the real questions about the costs of healthcare is "What is government doing already to drive the costs UP?"
Why should it cost a billion freakin' dollars to bring even a simple drug to market? And how much of that billion is directly due to insane over-regulation of the market by the FDA? Also, how many potentially revolutionary drugs get passed over because of that daunting cost structure? THIS is why so many drug companies produce "me-too!" drugs instead of breaking new ground.
Add to this the cost of defensive medicine (which is at heart a political problem, because of the "protection money" trial lawyers give to Democrats), and you begin to get a sense of why medical costs rise at above inflation rates.
I am 100% convinced that once government runs healthcare, even more (certainly not less) perverse incentives will be introduced to this alread screwed-up system.
Another excellent post.
Well done, Megan.
If you feel disheartened by this, imagine how elected officials feel.
Though I am a culturally conservative socialist (as in the Netherlands, Scandinavia, Vermont, and other socialist democratic venues), I appreciate the civil debate. It is an interesting problem, how to actually frame such a discussion. What are the fundamental terms? Which appeals to authority can be accepted? What sort of evidence passes muster? (Having grown up among "hard" scientists, I cannot credit "projections" like price controls reducing life spans by .07 years, for example.) Rawls and Habbermas talk a lot about the problems of such exercises in public reasoning. They have faith in discussion.
The framing put me off. I had earlier raised the difference between framing the issues in terms of "rights" versus "market efficiencies." Since I am fairly old, the whole framework of "market price" justifications for everything, even life, is for me a relatively recent and "youthful" way of legitimizing public policies. I do not think its advocates are unethical, but it does feel, personally, like the slow encroachment of vaguely inhuman and unethical structures.
Still, it has been stimulating to be called a "hate-filled collectivist," a "ranter," a "troll," "uniformed," an "idiot" and such. In the end, it's a blog. A blog. A public sphere in larval form. Part policy discussion, part psychoanalytic session. I wonder if the classic Oxfordian debating rules could be incorporated into browser software?
Here's a Jabermasian sort of question: Who out there entered this "discussion" willing to be convinced of something different than they believed when they started?
I did, to an extent, since I didn't know a lot about what was actually being proposed. I learned that Isakson(R) originally proposed what were later refered to as 'death panels' though he argued that the house bill is different than what he proposed. I learned end-of-life counseling has the capacity to non-coercively reduce costs by eliminating some of the fruitless and costly end of life care based on people's pre-stated wishes.
I learned a few details of the US army medical care.
I was willing to be convinced that there really were huge inefficiencies that regulation might eliminate (especially since insurance and medicine are already regulated into inefficiency in many ways.) I still think a national health registry would be helpful in preventing retesting, but that doesn't seem to be anyone's priority. Doctors frequently retest if a patient doesn't have prior results on hand. I learned that mandates can very readily increase costs.
On the other hand, I've become convinced that there's such a large contingent of people wanting healthcare to grow and willing to spout misleading statistics to make it happen that even otherwise reasonable proposals should probably be viewed as the precipice of a slippery slope.
Yes, a very good point, and I plead guilty, partly. McArdle did at times present the standards by which she might change her mind on something. But outside of science labs, peer review, and case predictions it is very hard to arrive at even the most basic consensus on matters of evidence.
I admit that I put a toe in the debate largely because I have never tried a blog format. And because I am deeply concerned about the market ideologies and that now frame most American policy debates, no matter what the topic.
I do not accept most of the assumptions or evidentiary standards of "market libertarianism." I consider them ahistorical, hubristic, and gravely damaging to policy debates. So I did not come prepared to be redeemed.
I am especially depressed that our current financial catastrophe does not seem to have altered anyone's views of the efficiency of "markets." Since we are being philosophical here, Quine makes a famous and very compelling case that even "hard" science can endlessly revise its supporting hypotheses to accomodate any data or outcome. Policy blogs appear to be good specimens of that process.
Even so, one is always forced to reexamine one's own arguments, and I did learn a great deal about how people reason. And it is better than the echo chambers.
Regarding the efficiency of markets, I think that a lot of us recognize that markets become inefficient when government gets involved. Sure, government regulation fixes some short-term temporary problems, but at what long-term cost? The latest financial problems stem from over-regulation, not under-regulation. Who knows if the problems from under-regulation would have been as bad? I certainly don't; I only see the results of over-regulation.
I have been an active reader, though not an active participant, specifically for the purpose of testing and refining notions I held about health care reform. Frankly, I knew I hadn't discussed the subject with enough well-informed people to have developed a thoughtful, evidence-based opinion.
At the beginning of all this, I was convinced that the era of employer-based health insurance was at its useful end, and that some sort of public option was probably the best mechanism for beginning the transition away from the employer-based system. I still believe that we are seeing the beginning of the end of employer-based health insurance, but have been convinced that a public option would do more harm than good in the long run.
I'm also coming to grips with the reality that there simply are no good choices. Anything we do with have cruel and tragic consequences for a significant number of individuals. All that is left is to make some sort of utilitarian assessments of which options will create the greatest good for the greatest number, without losing our empathy for those who will disproportionately bear the burden of the compromises we make.
I think that the statement that it's "rights" versus "market efficiencies" isn't an accurate was of describing the conflict. Market efficiencies are important to me, to be sure. But my fundamental support for markets is because there are certain rights that I think markets, and only markets, can grant to me. And I see governmentally planned and controlled systems as abrogating those very personal rights in the name of an inhuman, sterile, bureaucratic conception of efficiency. That that efficiency is, in my opinion, a false front over a system that really turns out not to be all that efficient is a secondary issue; the primary issue is that I want freedom to make my own choices even at the cost of being less efficient. And markets grant me far more of that freedom than systems of governmental provision do.
I want to have the money I earn with my labor go to make my own life better, and the lives of the people I care about, and not be drained away to subsidize other people who have political influence of political favor. I want to be able to choose the kind of health care I want, and not be forced to pay for something someone else has decided I need, or forbidden to get something someone else has decided I don't need. I want to be able to shop for insurance structured to cover only catastrophic illness, and not be forced to get all my health care through insurance, or punished for not having insurance. I want to have prices determined by market competition, and not by governmental subsidies to favored industries, or governmental restrictions on competition. I want freedom to engage in consensual economic relations. Those things are precious to me, and I loathe the thought of having them taken away. It's a society that compels or forbids me to buy things, or forces me to pay the prices someone in political power has decided I ought to pay, that strikes me as inhuman and unethical. And so I look at the current debates and I see the encroachment of inhuman and unethical structures in exactly the politicies that the Democratic Party is pushing, and that the Republican Party is not standing against nearly firmly enough.
Do Governments Preserve Freedoms and Destroy Them?
A good, level statement of your personal principles, Mr. Stoddard. But I simply do not accept its premises. It sets up an entirely false dichotomy and then infuses it with strong feeling. Since I have gone on ad nauseam elsewhere about this, I'll just say that the concept of a "free market" apart from "unfree government" is ahistorical and deeply misleading.
Naturally, I share your feelings about personal freedom and systematic coercion. But you seem to base your ideas about the evils of "government" on some sort of cinematic vision of Stalin. I don't know if you have lived in other developed countries or studied much American history, but I simply cannot square your thinking with my own experiences or knowledge.
I raise the issue of "rights" for a reason. I know you say you value your "rights" and you attribute them to private enterprise, freedom of contract, the money system, and corporations. You are referring to your "property rights," of course, as an absolute ideal.
And it it understandable that you do not want to be forced to give "your money" to "other people." The agonized boos and yells of rage at the chant "They want to share the wealth!" vividly illustrate that sentiment. I believe such sentiments have passed far, far beyond a healthy skepticism towards government authority. First, I find them historically delusional.
They imply some phantom ideal of a "pure market" without "government" or any infringements on property "rights." But where is any example of this utopia? Most Americans who tout this view seem unfamiliar with their own country's history. The views seem based on heroic biographies or movies of the cowboy or Cold War genre.
Probably the most affluent and stable period of American history was 1947 to 1970, the growth of a true middle class with some legal securities and pay equity. All of which emerged after two horrible world wars, dozens of financial crashes, a century of labor and civil rights battles, and a ten-year depression in which millions of people truly went hungry and begging.
From 1947 to 1970, America dominated world markets in a historically unprecedented manner. The New Deal structure, however imperfect, produced water, immunization, electrical and highways systems. The federal government backed home mortgages so a broad middle class could own homes for the first time. University systems established affordable education with the highest standards in the world. Scientific research exploded, largely in public funded facilities. Union organization and contracts were permitted by government, and helped stabilized millions of families. Food was subject to inspection. Farm prices were stabilized. Banks and stock offerings were subject to inspection and capital requirements.
I paint a rosy picture, of course, and it is easy enough to jab and sneer at it, or shout, "What about Stalin? What about that wasted gravel in the Tennessee Valley Authority! Etc., etc." My point is very general. By your account and your principles this was the most oppressive era in American history, the one we are still struggling to undo.
Or is it the Western frontier you are imagining? Even after the government grid surveys, government property title systems, government military expansion, government land clearance, and government irrigation system, most Western "pioneers" wanted nothing more than additional government to protect them from financial speculators, railroads, fraudulent banks, domineering ranch combines, mining companies who stole land, and outright thugs. If you imagine it is simply impossible on principle for "market forces" to become violently coercive, to reduce "freedom," you just aren't reading history or the newspapers.
I realize that you do not like the complex level of interdependencies that come with security and social affluence, or even, perhaps, clean water and a literate public. But I fail to see why you think "freedom" equals absence of "government." I assume you want to pay for only the exact amount of "government" that will protect your own private property and your contracts. But that is an enormous amount of government. And paradoxically, it only gets larger and more complex the more you "privatize." It takes a lot of government and funding to "privatize" things and enforce "free" contracts.
My admittedly broad point is to question, to deeply question, the false "free market/unfree government" dichotomy. Someone like McArdle does not crudely simplify in that way. But she helps to popularize that "government is never the answer" ethos. The very word "government" can elicit boos and hoots in any GOP crowd today. McArdle too sets her moral compass by the "market sunshine/government darkness" binary brought to these shores by Austrian and Russian theorists and popularized by the Chamber of Commerce, K Street, and Coors-funded "think tanks." It has become superstitious dogma that subverts rational policy debates or, for that matter, town hall meetings. It is ahistorical, false, harmful, and increasingly, in my view, authoritarian.
Most violent and oppressive power structures arise in new forms under the banner of "freedom." The dogmatic faith in the "free market" and capitalism as the final safeguard of human "rights" is perfectly capable of undergoing this Orwellian metamorphosis. Indeed, I believe it is well underway. The fact that the wealthy, media-mastering, "arch-libertarian" Rush Limbaugh sounds a lot like a chubby Goebbels and calls his own acolytes "ditto-heads" does not bode well for the future of American "liberty." The repeated TV refrains that corporations are "freeing" us sounds increasingly like Politburo cant or Brave New World. I suggest you question the actual, complex content of words like "market" and "freedom." Just keep testing to see what's inside them.
(a) If you are determined not to understand what I am talking about, there's nothing I can do to change that. But I recommend a thought experiment to you. You think of my vision of the government-managed health care you are recommending as a crude caricature. Try entertaining the notion that the vision of the free market you think I am recommending is a crude caricature, one that does no more justice to what libertarians actually want than you think we are doing to your views.
(b) Of course I don't suppose that there is a historical example of a free market society to point to. Libertarianism is not a form of conservatism; it does not advocate return to some imagined virtuous past. Rather, it's about the radical transformation of all of society on the basis of an ethical ideal. That is, it's the twin of socialism, which also seeks a radical transformation of all of society. When I say that my position is ultimately a moral one, and not a utilitarian one, I don't think you are really taking that seriously.
I am not going to try to convince you that my ethical position is correct; ethical debate is even harder to carry on than economic debate, and this blog is no place for it. But I am asking you to accept that some of the people who disagree with you do so not because they are placing utilitarian goals about any thought of morality, but because they have their own moral concerns, which differ from yours. If you simply dismiss them out of hand as "not what I think and therefore wrong," you are begging the question.
If you want the technical language for my views, they are a virtue ethics founded in something a lot like Aristotelian eudemonism, but growing out of Darwinian rather than Aristotelian metabiology, and in turn they give rise to a social philosophy based on the harmony of rightly understood interests. And they have nothing to do with conservatism, or the Republican Party; indeed, the Republicans as they are now thoroughly detest libertarianism, a sentiment I am happy to return.
Please consider that because WWII destroyed Europe's factories, this destruction is what allowed for a competition free American prosperity where you could "have any color car you wanted as long as it was black."
Union organization and contracts were permitted by government, and helped stabilized millions of families.
Unions were successful because America had no overseas competition. Once that changed, the unhealthy corporate-union relationship worked to help eviscerate American industry.
I'm happy with food being subject to inspection (since T. Roosevelt) since one of the legitimate purposes of government is preventing fraud and I'm happy to pay taxes for that so long as the inspections are effective. I'm happy with immunizations, since transmissible diseases are public problems. I think that there's a legitimate role for government. But we quickly get into an area where people see only the benefits of a regulation or service and none of the costs. The point is not that government can do no good, but that in many areas government interference incurs such great and unexpected costs that it cancels out any hoped for good.
Banks and stock offerings were subject to inspection and capital requirements.
I agree here as well, to an extent. If a bank takes people's money it should be required to keep some on reserve and purchase insurance so that it can fulfill its promised duties.
Farm prices were stabilized.
In a free market, prices don't need to 'stabilize.' Things like over-taxation and over regulation or bad regulation can produce both gluts and famine at the same time. Those are typically not problems caused by markets, however.
Most violent and oppressive power structures arise in new forms under the banner of "freedom."
Such structures, if they are oppressive, then centralize power in the hands of the government, or require the equivalent of government commissars.
Good clarification. I am not sure how one merges Aristotle's characteristic moderation and Darwinian dynamism, but never mind. The term "libertarian" has taken on many guises. I agree that your version sounds idealistic and revolutionary, the "twin of socialism," and apparently thought out. That's fine. Does not comport with my own rather Burkean socialism (just to mix the hybrids) but I do not fear that you will be sweeping into political power in the near future, so fine.
I am more concerned with policy defenses of "the market" that do not account for or admit their radical, ahistorical values. It is one thing to debate the financial crisis, for example, as a market failure. But if a Rothbard-type anarchocapitalist is actually arguing for an end to the Fed and all national currencies and the privatizing of the military, I just want to know it up front before they get elected to a Texas senate seat. I have been told repeatedly at this site that I do not grasp what "libertarians" believe--and I am beginning to believe that libertarians do not by nature "flock together."
How did the debate get nasty?
Let me try again: when John Holbo says the only philosophical reason to oppose health care reform is indifference to the poor, he's:
1) making a mistake because healthcare reform doesn't primarily affect the poor but rather the "not literally poor, but not in a good position to buy healthcare" folks. (A point you rightfully corrected me on earlier).
2) saying something you're ok with, because you agree that your objections are all practical.
He was manifestly not saying you're indifferent to the poor:
If you are going to make allegations like that, you really should be prepared to deliver.
So now, tell me: is Holbo a liar? Or are you being sloppy about reading his posts? Perhaps I'm being myopic, but I don't see a third option. And I think you've just implicitly called him a liar.
I repeat: the way he gets to that answer is to abstract away all the particulars that make "Do I want to take money to give to poor people?" the only relevant philosophical question. I've raised others, like the debt we owe to future generations, which is in fact a real philosophical question, one that real philosophers are wrestling with, which most people know because it's usually viewed as one of the two or three central problems of the global warming debate.
I could just as easily say that John Holbo's only philosophical objection to the status quo is indifference to the fate of future generations. Do we really think that this is a useful way to frame the question?
Perhaps I'm missing something. I had thought that a central issue that is up for grabs is whether reform is capable of "bending the curve", and what it would do to the deficit. Everyone admits those are important questions, though some people are manifestly arguing in bad faith about it. But still, it's a question of the empirical consequences of a given plan.
Actually, Von from Obsidian Wings has done quite a bit of making me doubt healthcare reform bills that are currently on the table, precisely by noting their poor effects on the deficit and cost control. He's certainly given me reason to say that, as far as I understand things, Wyden Bennett would be a better bill. I'm completely waffling on whether the current bills are a good thing at all (in the sense of an improvement on the status quo).
But Holbo's central objection is that you're not talking enough specifics (none of his posts actually argue for health care--they just react to you). I don't (think) he wants to debate whether we should give money to 'poor' people. Or at least, he's willing to debate the question of whether this policy that does that actually is effective. There's that really complicated empirical issue on the table. And I think he's right that you're not talking specifics. Most of your arguments have been (reasonable) general frames for why health care might be bad. I'd take them to be compelling reasons why a libertarian, or a Democrat who takes libertarian arguments seriously (me, I hope) should be suspicious, and approach the matter carefully, without assuming that health care reform will be a good thing.
Those arguments you give are important. We need those general frames, because they help us focus our investigation. But those general frames aren't specific arguments that a particular bill will do bad things. They're more like argument schemas, to be filled in with details. I browsed your last 10 or so healthcare posts. It seemed like they were all those sorts of argument schemas. Maybe I can paraphrase Tyler Cowen's libertarian vice post as saying "don't rest content with schemas."
This post goes a little bit farther. You say that the government will now control 50% of the healthcare market, and sort of suggest that would be a tipping point. That's suggestive. But I think you have to admit it's not really all that detailed. It might be a good argument, but it's not enough, not without elaboration. Maybe the Rand study is the necessary elaboration--I can't comment without reading it, and maybe I don't have the statistical or economic sophistication to do so.
Anyway, perhaps I'm just being dense, but I think I've articulated Holbo's challenge in the above, especially the last three paragraphs, and I think it's one you'd admit is serious. And I don't see how you're meeting it. It took me several reads to extract the point from Holbo--the man doesn't write posts that are easily digested. If you'd said "this is just too obscure, I'm not going to respond" that would be one thing. But it just seems like you responded in a dismissive manner, without giving Holbo's argument its due.
Sorry if this was too rambling.
But I don't really understand what "proof" I'm supposed to give. Proponents of reform are allowed to point to other systems as proof of what they're talking about. When I point to those other systems and note many of the same features that appeal to liberals, I'm talking in "broad generalities". When I point to the Democratic pressure on Medicare advantage and the prescription drug benefit, that's apparently not proof either. Maybe if you--or Holbo--could give an example of something that would constitute proof, other than building a perfect model of the universe so I can run a simulation, I could try to provide that proof. But as far as I can tell, the criticism on the specifics amounts to "Well that's just a bunch of airy fairy libertarian theory", as if liberals were doing this with something other than an airy fairy liberal theory of government. I actually think there's quite a bit of empirical evidence for the constituent building blocks of my concerns: the price controls abroad, the increasing American scapegoating of pharma, the penny-wise pound-foolish way that most American government programs work, regulatory capture as a very widespread phenomenon, the log rolling that is going on this very moment to produce an ugly mess of the ideal bill liberals started out envisioning, the fact that health care has been steadily expanding since Medicare, etc.
Until then, I continue to think that the relevant philosophical question, is the tradeoff between help now or help later, not "am I indifferent to the poor?"
In reply to Megan McArdle:
Start here:
Or here:
Maybe here:
Or, hey, there's this:
Or in the comment I'm trying to respond to despite the blog system:
Links in any of those sentences would strengthen your argument. Not everyone reads every post you've written on health care. Whether they agree with you re: Rand, it is your obligation as the person putting forth that study as proof of your claim to point to that study so people can read it.
Sorry, the point of referencing "bending the curve" and the deficit is that it shows that the principled question of our obligation to future generations is blunted--we've got an economic question about which course will create defecits and so on.
There's a residual debate about discount rates, I suppose, but I'd think the prior question about deficits and health care spending (and yes, drug development and so on) is really the big one. I'm somewhat suspicious that we can get very far debating discount rates directly.
Actually, assuming costs correlate with innovation, that's just a problem of future generational welfare tradeoffs.
This is still a good point--a vastly better one than Holbo has raised. But I've long been of the opinion that we worry too much about cost. Cost is a political problem, not an economic one. If our income doubles between now and 2030, and we spend 50% of that income on healthcare, we'll be much better off than we are today. Eventually, the percentage will stop growing, because we'll run out of stuff to do. But it doesn't worry me, which is one of the many reasons I think Orszag is off base.
Bingo! Megan, I know you have made this point before many times, but I think you have frequently downplayed it to your argument's detriment. It may not be the case that you can use it to convince more people of your position, but it would help you if you highlighted it more stongly- it is a point that is missed over and over in these debates.
Holbo has spun all philosophical objections to health care reform as indifference to the poor. It's true that this isn't the same as saying oppponents want people to die (indifference is not the same as malevolence), but is is just as wrong wrong. I can care about the fates of the poor, but nonetheless think that universal healthcare is ethically wrong. He does NOT admit to that possibility, and thus is implying that McArdle is a not-good person.
well you know, what Holbo (and most of us) meant by "poor" is not just people hungry with no food, but also includes ordinary under-insured, part-time jobs working people with less than average income. i don't know about you, but megan definitely does not care about that demographic group or doesn't acknowledge its very existence. we are talking about all your waiters, cashiers, secretaries, small business owners and in my humble observation most young people under 28 in new york city.
Megan:
Yes, they are; or rather, the mere fact that you assert that conclusion in no way demonstrates the truth or falsehood of the conclusion (which is itself "crazy" in the sense of "unsupported by rationalistic discourse").
Here's what you libertarians will never get about this subject. The commodity at issue, "health" and by extension "life" is not distributable under a market mechanism. Unless you can demonstrate an equilibrium price for a "cure for lukemia for my eight-year-old child," unless you can find the "price" at which a parent would let their child die of cancer rather than pay one more dollar, the first four pages of your freshman microeconomics text won't work as an system of allocation.
Unless you can remove duress from your "market," a market in which many if not most transactions are by definition under duress, there's simply no way that price can serve as the primary mechanism of allocation.
That's because, er, if you do allow price as the primary mechanism, it all reduces to exactly what your adversary over at CT says it did: If you don't have the money, you can't have the medicine.
JUST CONCEDE THAT POINT, and argue from there. I'm sure your idol Ayn wouldn't have any trouble conceding it. Then she'd say: "Yeah. So?"
People will die under either system. In fact, people will die under any system because all people die. What's the big deal? Just say "I'd rather have poor people die now so rich people can live later." It's a pretty ruthless and inhumane statement, but it's honest and in any event inevitable from your premises
Why concede a point that isn't true? Health care is a good like any other and can be distributed perfectly well by price. An approach, I might add, that has scarcely been tried in the modern era, though where it has been tried (dentistry, optometry, elective surgery, veterinary care) it works quite well.
Sophistry. "Health" isn't bought and sold any more than "life" or "happiness." But "health care" -- that is, the labor and resources of doctors and hospitals and drug manufacturers and the janitors that clean them and so on -- is indeed bought and sold. And yes, those things have prices, unless you want to enslave all doctors and force them to labor for free.
That being said, I don't think you realize that your example of a child with leukemia supports the conservative stance that one of the reasons health care costs are rising is because a) people don't think of costs when they get treatment, either because of duress or because their care is purchased by a third party. Government health insurance would not address this issue of "consumer" behavior at all; it would just affect what services would be available (either more or fewer options). That is, it merely changes how the services are paid for; it does not lower the costs of those services.
So then, for adults, the problem becomes: how do we minimize this problem? One way you suggest is to put words into others' mouths and sanctimoniously argue with a cartoonish version of something they didn't say, and then go home full of delightful delusions of moral superiority.
Another way, Megan's way, is to recognize that life is full of tradeoffs and opportunity costs as the first step to finding the least-bad way to cope with human frailty and mortality. As in, to paraphrase some ancient Greek government bureaucrat, "first, do no harm."
While the latter option does not provide much egotistical salve, self-satisfaction, and self-righteousness, it does have the benefit of trying to actually deal with the problem. This is quite different, I might add, than saying "yeah, so?" To create such a childish straw man pegs you as unserious and a shallow thinker.
Noah:
Health care is a good like any other ....No. It isn't. While it is true that the Sex in the City gals might say something like "I'll die without those Jimmy Choos" (or whatever the name of those silly shoes), we all understand that that's hyperbole. They won't really die. Not the case with health care. But:
Yes. It can be. But there are some pretty obvious, in fact, as I said above, inevitable consequences in that case, namely, that some people who need health care will be unable to procure it because they can't afford it. Just like when poor Kerry doesn't get to buy her Jimmy Choos.
If you think a system with health care allocated by price, and hence ability to pay, is the best system, just say that. It's not that hard.
Rich people live, poor people die. That's not even that unusual a circumstance in the history of human civilization. Princes had food during famines, the upper middle-classes had Irish substitutes in the Union Army, Steve Job got a kidney transplant.
How about you admit an obvious and true fact, in evidence as we speak right now.
There are three choices (let's say) for that disease. The best treatment choice for that leukemia is relatively new, but has shown an 8% increase in survival rates over the next best.
Your province is hitting a 4.5 billion dollar deficit. (yesterday literally). Your health economists say there are, I dunno just guessing, 300 cases of that leukemia expected. Along with all the other needs.
The new treatment costs $200,000 more per course. 300 X $200,000.
The 8% better survival rate means that more kids live.
The province is already at the top of the Laffer curve, has been for years. Raising taxes will not increase revenue, in fact will decrease it. Already hospital wards are closed. Outlying areas don't have emergency wards anymore. So what happens? If the child doesn't get treatment, screaming and front page headlines.
So the decision is to not use the best and most effective treatment. Kids die.
And since the inexorable 8-10% increase in health costs must be found somewhere, less operating room time is allocated to other things, such as angiograms. Give 'em a pill.
This is how government controlled systems work.
You folks have a $2 trillion deficit. Your government/gdp numbers are hitting the level where you cannot go any higher. You will find this out. To control the deficit means not spending, ie. serious cuts to government programs. Including health care. That is without increasing the size of government health care.
So I would like you to answer. Where are those cuts going to come from and how will you provide care to the already government covered under those conditions?
Derek
Grundles:
Nope. It won't. It simply forces a more egalitarian system of decisionmaking about that "'consumer' behavior." Fiat, as I think the author above puts it. So let me offer the answer to that objection that she's too gutless to offer in the face of Holdo's objection: Yeah. So? I'd rather those decisons be made by fiat than by price.
The bottom line is, the demand curve for that lukemia cure is perfectly flat .... until the line on the heart monitor is flat. That means the equilibrium price is arbitrary even if it's nominally set by the "market."
I'd rather those decisons be made by fiat than by price.
All decisions? Should it be impermissible for anyone to spend their own money to improve their health outcomes? Are you prepared to ban personal trainers and inspect auto factories to make sure the high end models don't have better safety features than the economy line?
You raise an important point re: the leukemia hypothetical -- unlimited demand and scarce resources -- and it's one that is usually raised by conservatives. You must disagree, then, with many liberals who have stated that the source of rising costs is the greed of doctors and profit-hungry insurers. I agree with you for the most part (although I would argue that greed does play at least a small role).
As for fiat-vs.-prices: given that this is an issue of principles, it cannot be settled empirically; there is no "solution," only preferences. You'd rather decisions on health distribution be made by fiat than by price, while Megan isn't sure that fiat would lead to a better solution than price. Presumably she would recommend expanding supply as much as possible to service that unlimited demand. Megan would prefer to err on the side of greater individual freedom, while you would err on the side of greater collective security. We have been having this argument, by the way, for almost 2500 years, since Aristotle critiqued Plato's egalitarianism as unworkable, and Platonists criticized Aristotle for his rationalization of the status quo.
Therein lies the disagreement -- one that originates not in your or her ignorance or moral depravity, but in a difference of philosophical temperament. And to try to turn it into an issue of good vs. evil, as I wrote before, makes it more difficult to hammer out an acceptable way forward. It poisons the discourse and we should avoid it.
That being said, I would caution against mistaking government fiat for "egalitarianism." I would hope that 20th-century history has shown the difference. Sadly, it seems that not even politicians and utopian revolutionaries can rise completely above the fallen state of being human.
I'd rather those decisons be made by fiat than by price.
You have just circled yourself back to the principle reason why people should oppose a fiat system: price controls. The 30,000-foot argument: when a good is subject to price controls, in time it is a net loss for the public at large, because the good is not distributed effectively, or as effectively as it could have been without price controls.
There is no significant evidence that I have seen that shows a system with price controls on health care (or any system for that matter) that has an optimal distribution outcome. The problem is we don't know what an optimal healthcare system looks like. We don't know how to measure it (life expentancy? show me the study that correlates the type of healthcare system to life expectancy, while adjusting for the hundres if not thousands of other factors that influence who lives and who dies.) It would be really nice if socialized healthcare proponents would admit that they have no clue what the best system is before they start a system redesign.
Brian 2:
In a non-real world where there was only a choice between a system where all decisions were made by fiat or all decisions were made by price, Yes. I'd pick fiat over price of delivery of health care.
But we don't live in that world and we're not going to live in that world regardless of what plan is passed, even with the lefty-most of the Congressional bills.
And no, your economy-car analogy is just stupid. Let me explain this again. Health care is a different kind of commodity than luxury shoes or cars. Got that? Allocation models that work well for the allocation of ballpoint pens and table lamps don't work so well in allocating health care.
Look. I've read I think every word Ayn Rand published while she was alive (I haven't read all the posthumous junk, forgive me) and as I said above somewhere, I have not the slightest doubt what her response to Holbo's objection would be: So what? So what if those without money can't get medicine?
Go read her arguments against the Civil Rights Act which I believe are contained in "For the New Intellectual" and apply her framework there to the current health care reform debate. She acknowledged that Segregation was unjust. She acknowledged that Negroes would continue to suffer unjustly. But, she said, and I paraphrase, the destruction of liberty and individual autonomy attendent to the Civil Rights Act was of greater significance to her than the injustice of Segregation.
Point being, she had the courage to follow her premises to their logical and inevitable conclusion--that it was better to let Segregation die a natural death than to kill it off by fiat despite the unjust suffering that would occur meanwhile.
Courage which Megan lacks.
egalitarian?
You should go lie down. At least until you've recovered enough that you don't argue that a tiny group of bureaucrats deciding for everyone is more egalitarian.
Or is that you regard depriving just about everyone of all decision making power the egalitarian technique? And you admit the bureaucrats because we have to have that inequality? I realize that this may come as a shock, but touting equal helplessness as "egalitarian" merely demonstrates that to be "egalitarian" is not good.
Grundles 2:06 am:
Just so. And let me be absolutely explicit. Under my set of preferences represented in practice by HR 3200, the Dems health reform bill, some people will die who otherwise would not have if the system had remained unchanged.
I don't know who those people are exactly, but I know that a re-allocation towards Group A must entail a re-allocation away from not-Group A somehow and some way. That, in effect, is simply a restatement in abstract terms of Megan's original post a month ago that kicked this whole thing off.
Part of the fierceness and vehemence of the objections to Megan's argument is her seeming unwillingness to acknowledge the simple, obvious and inevitable conclusion that under her rubric, some people will die who otherwise would not have if the system remains unchanged. And that most of those people will have been priced out of the market in health care goods and services in a system where goods and services are allocated by a pricing mechanism.
This isn't brain surgery. Any system we have is going to benefit some people and screw others. And at the end, we're all gonna die anyway, so in a sense, we're all screwed no matter what.
Under the current system, rich people are not screwed. Middle class people with catastrophic medical problems and poor people with many ordinary problems get screwed. I think we should change that. My assumption is that some rich people will get screwed.
I know Mac World would've gone batshit if Steve Job had been prevented a liver transplant by fiat, but under my preferences he would have been. And he'd be dead by now.
Shrug. I can live with that.
Libertarians understand this perfectly well. They understand that health care, like any other valuable resource, is scarce and that choices about who will receive it are inescapable.
What left wing liberals will never understand is that treatments for awful things like leukemia exist in spite of and not because of the actions of politicians.
And you prove yourself a vicious troll by calling Megan crazy. Just fuck off already troll.
I don't think your argument makes sense, because I don't think it's the logical construal of egalitarianism.
Under any possible system, there will be some lives that can't be saved because there aren't enough resources to pay the cost of saving them. But if you value all lives equally, then I think you have an obligation to consider the cost of saving lives. If the resources that could save one person who has something expensive to treat could instead save a dozen lives of people who have something cheap, or who can be prevented from getting sick through mass preventive programs, or for that matter of a hundred starving children elsewhere in the world . . . I don't see how saving the one life can be justified on egalitarian grounds. "The needs of the many outweigh the needs of the few, or the one." And the people who are expensive to keep alive are largely old people in their last few months on earth. I certainly agree that Obama did not call for letting grandmother die to keep medical costs down . . . but on egalitarian principles, I think he ought to have, if all lives are equally valuable. And even more so, if we count not just number of lives but years of lifetime saved.
Under a system based on personal self-interest, if people want to spend their money keeping their elders alive, any libertarian would say more power to them. But under a system based on egalitarianism, it's not clear to me how that choice can be justified. Can you give me a reasoned argument that doing so is compatible with egalitarian principles?
William:
Okay. When I said "egalitarian" I was half-assedly shorthanding it. So rather than get into another sterile "Fred" means "rationing" debate, I'll just tell you what I meant. If that doesn't comport with the technical definition of egalitarianism according to the Stanford Encyclopedia of Philosophy, call it "Harry."
What I meant is that in any one particular case, that decisions on what resources to allocate to that case be made on terms other than price. My unstated premise was that any such "terms other than price" would be more egalitarian in effect for any one particular case in which the recepient would have otherwise been priced out of the treatment.
If you assume money as a prior and saving lives as a goal, then you're right. But money isn't a prior - those people got the money by doing things that made lives better somehow. If you'd told them when they were making the money that they weren't going to be able to use it to get what they want desperately(i.e., saving the life of themselves or a loved one), they might not have been bothered making your life better so that they could get money from you.
Expecting someone to help others, and then refusing them the same help when they come to cash in their credit, is hardly egalitarian.
Alsadius:
Fact not in evidence.
Moreover, by logical extension, your system would allow an auction for chemotherapy. Four families with kids dying of lukemia and only enough chemo to cure one. Highest bidder gets the chemo. The rest get Holy Water.
Now, again, let me reiterate what I repeated previously. To repeat myself. And reiterate: I don't have a problem with that. Just say that. It's the inevitable conclusion of your premises anyway, so just follow your premises to the end. I won't think you're a bad person for saying so, I promise. Rather the opposite.
As I also said earlier, it's not even that unusal. Rich people get privileged access in pretty much every other area of human existence and have done so for pretty much the history of human civilization.
Highest bidder gets the chemo. That's what a market-pricing mechanism for delevering health care means shorn of all the hypothesizing and philosophizing and propagandizing.
Okay, I'll grant that not all money comes from doing good things - corruption, theft, fraud, and the like do exist. Still, most income is justly deserved - if I provide a service someone else values, I have made their life sufficiently better to deserve the payment they gave me(or else they wouldn't have given it). It's not a perfect system, and there are things it doesn't deal with very well, but it's a better base than any other method of running an economy ever proposed.
And if you're going to posit a system where there's enough chemo to cure one person and four who need it, I don't see how you get around "the other three get holy water", no matter what your rationing system. At least the pricing system gives it to the person who has done the most good for society over their life, and provides a strong incentive to make sure that more people get it out of the next group of four that need it. If a good is genuinely scarce, it has to be allocated somehow - you're not Jesus, you can't feed the five thousand out of your fridge. Give me a better system of allocation than pricing, and this might be a debate.
As it is, your thesis seems to be "Shit happens". Yes, it does, and yes, it's bad, but the existence of money has very little to do with it. If anything, it helps solve the situation, since the fellow who makes shit happen less often(or chemo more available) will be richly rewarded for it.
And to boil this down to the point you're trying to make, I do not believe it to be a good thing that someone is denied lifesaving care because they can't pay. It is sometimes an unavoidable thing, because the world is imperfect, but I believe that it should be avoided whenever possible, and that government has a role to play in that process. But I do not believe that that role is absolute, and I do not believe in the virtues of a command economy, whether it apply to the whole market or just a section thereof. Prices and money serve incredibly valuable roles, and production systems that ignore them are invariably weaker for it. Not a clear-cut answer, I know, but it's the best you're going to get.
Alsadius:
I don't. As I explicitly stated in the Steve Jobs example, I freely acknowledge that if my preferences were in place, he'd be dead now. There are lots of other ways to decide which one gets the chemo and which three get Holy Water besides an auction. By lot, for instance, or by some other rule like "youngest child first" or "oldest child first."
This:
and this:
Appear to be normative judgements presented as objective. I am simply not willing to agree that the person with more money is morally superior to the person with less money. But that's an argument for another time and place, because:
That pretty much all I wanted to hear. Now we can start the argument Megan thinks she started a month ago and thinks she ended above.
Here's where we start: Some poor people die because the system denies them lifesaving care because they are priced out of the market because the world is imperfect.
Question: What can we do to perfect the world so that that does not happen?
My point with the bit about money was that your financial position is, at root, the judgment of society regarding how much value you provide versus how much you consume. It's not that clean in practice, because we have everything from crime to tax to externalities, but it's a decent approximation.
As for the more important question, I pretty much agree with what Megan has been saying all along(see Practical Philosophy, Again, near the bottom, for example). You don't nationalize food, you provide food stamps. I'm not much of a medical wonk, so I don't know the best way of achieving my goals, but off the top of my head I'd let basic welfare payments cover the low-end needs, and have subsidized/voucherized/nationalized catastrophic care insurance. Unfortunately, politics is going to bugger up whatever I propose, so the second question becomes what we can do to make a function system come out of our political process at the end of the day.
I'll concede that point when I see evidence that the backers and beneficiaries of the socialized health care in Canada concede the point.
Health care isn't free. Economic incentives move participants in the system to act, no different than any other economic endeavor. There are few doctors and nurses who will work for free.
So shed that illusion. The production and labor that generates whatever is necessary to give that child needed care is no different than the production and labor that produces the food on the grocery shelf or the computer that you use. Food is a necessity by the way. We DIE if we don't have it.
In the Canadian system there are multiple examples of sheer stupidity that end up costing people lives, entirely due to centralized control and inefficient allocation of resources that are predictable and working as designed characteristics of such systems.
>If you don't have the money, you can't have the medicine.
Moral preening. The 65-80% of people are happy with their medical care and coverage in the US system, and enjoy arguably the best that any system can offer. There is a system in the US to look after the rest. And that system shows all the signs of an out of control government program, with misallocation of resources, political meddling, etc. And obviously isn't doing the job that you would like it to do, care for those who can't afford it. So lets do the obviously rational thing. More government control.
Derek
Shorter Megan:
"I'm done talking about this (or at least am pretending to be), but in passing, allow me to decree that the measures now being considered will reduce average life expentancy by .7 years. Evidence: my authority. But hey, if that's your bag, then go ahead and groove on the rubble -- you've got the power. Megan out."
I can dig that.
Yea,
I'm not surprised that Megan has decided that debating the left on this topic isn't worth losing her career over.
What was it ... two posts ago ... we read this:
"I'm not saying The Atlantic should fire her. But perhaps her bosses ought to sit her down and have a discussion about the rigor with which one should approach writing, even blog writing."
It's clear that the left had Megan in their sights. They're isolating her, villifying her, they want to damage her career and impact her personal income.
Saul Alinsky's Rules For Radicals # 12: "Pick the target. Freeze it. Isolate It. Hurt It."
I think it's not surprising that Megan has decided she can no longer write about this.
They beat her.
Excessive drama, I think. This isn't being centrally organized, it's just the natural opposition to someone semi-prominent saying something controversial.
From RAND:
"By 2060, this effect would increase for both Americans and Europeans to approximately 0.7"
http://www.rand.org/pubs/research_briefs/RB9412/index1.html
That's for the evidence part that you were confused over.
I don't think any reasonable observer could believe that Megan's comments on health care, or other recent matters, were made in good faith. There's not been dispassionate observation of the political and economic issues involved; there's instead been a series of dubious and clumsy arguments made that tend, not surprisingly, to support Megan's confessed ideological preferences.
This is obviously her right, and I don't really care.
But when Megan approves of, apologizes for, makes excuses for, and otherwise encourages an increasingly alarming environment conducive to right-wing political violence? Well, I start giving a shit, and wondering why she's working at the Atlantic, and thinking that maybe her analysis in other areas isn't exactly on the up-and-up.
And when that first serious, scary attempt is made on the President's life, or, more likely, softer liberal targets are attacked, in addition to blaming the perp, blame must lie on Megan, and the other media enablers, and I will not stop until they no longer have privileged platforms like this from which to injure this country and its fragile democratic ideals.
You still have time to pull out of your death spiral, Megan. Listen to your own diavlog with Michelle Goldberg. Your arguments are silly and sad, at best. It really isn't pretty. I'm serious.
And spare us this concern troll bullshit from your fantasy world where you--you--aren't the problem. You are the problem, Megan.
Ok, this is a totally dickish comment -- but the question remains. Megan, on what points did you enter this discussion willing to be convinced?
I entered this discussion about six years ago, so the better question is, on what points have I been convinced?
I've been convinced that volume matters to various profits almost as much as price, that drugs would cost just as much here if Europe paid more, that medical malpractice is a problem for certain specialties but not a major driver of health care costs compared to most other factors, that the market for individual insurance may not be salvageable, that cost growth doesn't matter as much as people think, that we will always treat people who go uninsured which may make a mandate morally necessary, and that libertarians should start more charity hospitals. That's off the top of my head.
More? Could you name any?
Seriously. I know of Catholic charity hospitals, Baptist charity hospitals, Presbyterian charity hospitals, Methodist charity hospitals, but I've never heard of a libertarian charity hospital.
I meant "more" as in expand the supply, not start more of their many charity hospitals. But I'm sure if you looked, you'd find at least one charity hospital headed by, or substantially funded by, libertarians, the law of large numbers being what it is.
"But when Megan approves of, apologizes for, makes excuses for, and otherwise encourages an increasingly alarming environment conducive to right-wing political violence? Well, I start giving a shit"
LOLOLOLOLOL
Cheetos-stained patriots like you will definitely save this country.
WOLVERINES!!!!!!!!!!!!!!1
What a load of tripe. The country is obviously dividied on health care issues, but I guess in your world, one half (the libertarian, conservative, free market types) should just butt out.
But only you care for our "fragile democratic ideals."
You are the problem, my friend.
If people like Kurzweil, Tipler, and Aubrey de Grey are right, the stakes are much more than .7 years. It's a question of how many people die from disease and aging before the free market achieves affordable functional immortality.
That's why this fight is so important.
Much as I like that sort of thinking, I'm not sure it's exactly wise politics to stake the importance of this fight on what amounts to science fiction.
It's unfortunate, because if you go beyond the loudness, there were actually some very thoughtful, interesting, and (most importantly) substantial debates in these comments. Often, I found myself challenged by ideas both in favor of government-run health care and against, and everything in between; various parties on all sides of the issue enlightened me with statistics, facts, and observations that I hadn't previously known or understood.
But it requires maturity and self-awareness to argue that way. It's so much easier, and so much more emotionally rewarding, to turn the debate into a "who's more evil" shoutfest. Any time a great debate gets going, a few individuals come in and, demonstrating the moral and emotional maturity of a two-year-old, make it about "hating the poor" or "socialism" or who was bought by the insurance companies.
Those individuals should know this: left or right, if, rather than debate his or her points, you called somebody a socialist or a fascist, or if you accused somebody of hating poor people or of being a stooge for the insurance companies, you made true health reform and progress in this country less likely. Because you made it impossible for people of good will to listen and respond to each other's valid concerns, you hurt our nation, just so you could glibly and childishly make yourself feel morally superior.
There are those who cannot or prefer not to conceive of any debate on terms other than the most black-and-white level of good and evil. I like to think that the internet is full of such people not because that is what most people are actually like, but because such people are generally dickheads and are more likely to sit around lonely and online.
Personally, I wish Matt Steinglass, Rob Lyman, Nimed, jmo3, and a few others would start a lively group-discussion blog, and not allow comments.
To clarify: that would be a great and edifying blog.
Hey Megan,
As a physician I would like to hear the following ideas about cost containment discussed by the public. Everytime I talk about these issues with a non healthcare related person they basically have no input or don't realize how important these issues really are when it comes to rising costs of healthcare ( a lot of which does nothing to improve our health.) They rather talk about public option, rationing, expanding coverage etc. These topics are just as important in finding a solution.
1)Self referral for expensive imaging. Doctors are partly business people. Helping people is the most important but for many docs making money is also important. One way many doctors are now making money and as a result driving up the cost of healthcare is through imaging self referral. 10-15 years ago PET,MRI,CT were all owned by hospitals and business men. Physicians did not have any stake. Physicians only ordered these expensive studies when they felt it was necessary. Now vendors market directly to physicians and tell them how much more money they can make if they have one of these machines. Now neurologists and neurosurgeons have their own MRI's. Orthopods have their own MRI's. Oncologists have their own PET, MRI, and CT. Internists have their own CT's. Heck even allergy docs have their own CT's. What do you think they do with these machines now that they are the owners have a financial incentive to order a scan? They order! And boy do they order. Day after day I see so many pointless studies done just because it can be done and because it increases profits. Orthopods ordering $1500 wrist MRI's on people they know have tendinitis and just need some rest and ibuprofen. What was the point? Any doctor can make up an excuse for a study and no patient is going to argue against a study... they probably feel better because they think they are getting high tech, top of the line care that's harmless. I see CT scans all the time for simple viral enteritis just so "something isn't missed." If the same doc did not own the scanner he would just do a good exam and get some basic labs. If there were no worrisome signs he would tell the patient to keep hydrated and that it would likely pass and to call him in 2 days if it didn't. Another example: 90 year olds getting shoulder MRI's to prove there is a rotator cuff tear for which no surgeon is going to operate. What no one seems to understand is that a lot of these studies are unnecessary and would not have been done if the doctors didn't have the profit motive. Acadamic journals have published many studies showing the increased utilization among docs who own their own imaging... It's ridiculous. Stark law was created to stop conflicts of interest/self referral by docs and was a great law. It's what prevents a doctor from referring you to a facility they have financial interest in (rehab facilty they have 20% stake in but may not necessarily be the best). An amendment to HR3200 which would have modified Stark Law to include in office CT,PET, and MRI was killed in committee because too many doctors called and objected. This amendment would have controlled costs immensly and no one in the media even mentioned it.
2)Tort reform - countless studies ordered for no reason but to cover your butt. Ridiculous system. Add tort reform and docs will order much less and costs will go down. No other country has as many lawsuits against docs as we do.
People don't realize how expensive radiology is. It's the fasting rising part of the medicare budget and is being targeted for cuts up to 20%. What they need to do is find a way to prevent abuse by docs who want to increase their bottom line. It's almost fraud. Imaging centers need to go back to being in the hands of business people and hospitals... Not the docs who have a financial motive to self refer and as result overutilize.
Medicine is not your traditional market... There is a huge knowledge gap and the consumer is going to trust anything the doctor says. This is why there is such a potential for abuse.
Does radiology (equipment) fall under the description in your point #1 ever/sometimes/often? If ye, doesn't this cast doubt on the theory in your point #2? And even though awards are probably out of control and their size needs to be contained, don't we in fact want doctors ordering those tests the failure of which do so might eventually lead to a successful lawsuit, even if for a limited award? In other words, are baseless lawsuits the problem (and if so, how do unnecessary tests forestall them?), or are excessive awards causing excessive malpractice premiums causing inflated prices the problem? I'm sure it's both in part, but the distinction seems important to me. Comments?
Hey Rmahan,
I agree with you on #2. I think your first point needs refining though.
For one, we have a lot of scanners, same day service, and low wait times. Much better than most other countries. That needs to figure in somewhere. It's also possible that it costs less because the specialty lab can't charge as much, knowing that if they make too much money people will just bring it in-house.
But even with these minor points, I think you are at least partly correct. The problem is, like you said, asymmetrical information and that health care is a confidence good. I am not sure the Stark law really fixes it though.
Good points.
Hey Jay,
Thanks for commenting (haven't got many so far. Wish Megan would comment)
As for your points. You can still have same day service, lots of scanners, and low wait times without having the ordering physician being the owner of the scanner. Put it back in the hands of hospitals, business people, and maybe even radiologists. Pathology and laboratory work (beyond basic) is largely in the hands of businesses (Quest), hospitals, and pathologists. Since these services aren't owned by the ordering doctor they aren't overutilized. Still have plenty of access to them. Imagine if every doc were allowed to self refer for rehab... They would be giving every single patient rehab to increase their profits. Take out the profit motive... overuse goes away.
As for "cost less because the specialty lab can't charge as much." Insurance and medicare pay a set fee for each imaging study. An interpretation fee for the radiologist and a technical fee for the owner. Insurance companies pay a certain negotiated percentage of medicare (130% for example). I don't see how prices would change (go up or down) just because an imaging center is owned by a business man rather than a doc... The reimbursement is still in the hands of the insurance company.
I won't even talk about pay for performance... insurance companies and medicare are stupid enough to pay for the type of service but dont' care about quality. A low field crappy MRI gets just as much as top of the line MRI. There are some docs who own cheaper, crappy quality scanners who get paid just as much as people who own top of the line. Patients don't even know that there are differences. You can get a volvo scan or ferrari scan and it all gets reimbursed the same. And because of the knowledge gap patients don't know the difference. If anything I think quality may go up if you started paying for performance and drove the abusers out of business.
Seems like the current approach congress is adopting is to decrease medicare reimbursement for imaging so docs stop buying the scanner... but this will also hurt the business men and hospitals and drive them to buy less scanners. This approach would decrease access. Stark law modification will not.
Wow, more great points.
I see what you are saying; I think I am convinced.
Does anyone truly doubt the effects of price controls? They have had the same effect every single time they have been tried in the thousands of years of human history.
And does anyone truly doubt the conclusions of the socialist calculation debate? Even the socialists admitted defeat!
FWIW, Drudge is highlighting tonight an expose on death panels in the UK.
Let me put bluntly what you're far too kind to say: Those who cling to the belief that empowering an authoritarian state to do good is preferable to empowering the individual to do good for themselves are really, really stupid. And they are certainly not progressive; in fact, their belief in the expanding power of the state far predates the belief in empowering the individual and allowing markets to help us all.
And only someone who is really, really stupid can believe that expanding coverage and services while trying to cut coverage won't result in some form of death panels.
last sentence should read 'trying to cut costs'
"Those who cling to the belief that empowering an authoritarian state to do good is preferable to empowering the individual to do good for themselves are really, really stupid."
It's not a question of intelligence, Jennis.
Those who cling to empowering an authoritarian state know full well what the consequences are, and they're out to get that power. They read "1984" and thought to themselves "that's a really, really good way to exercise power over people."
Some people advocate for certain things because they're already in power and want to stay in power permanently. They will always couch their aims in altruistic terms, but history has shown that anytime despotism is allowed to flourish the end is always death panels and large ovens.
I have never found it to be a good strategy to call one's opponents inhuman, obsessively self-interested, or anything else that implies that they are not attempting to do good things for the public as best they can. Yes, there are individuals who are, but it's not like there's just one individual of questionable morality who disagrees with you. There's quite a lot of them, and even if one is being a jerk, most of them are genuine and arguing in good faith. Try to debate them as such - even if the one arguing with you actually is a megalomaniac, the one reading you probably isn't.
No, it's not sad, not one bit. You are utterly full of it, whether on the Iraq War, or in your increasingly-obsessive need to believe that 'crowding out' is now the beginning of a domino effect which will curse future generations, regardless of evidence, or even common sense about ordinary human behavior.
The bottom line is that people like you should never have been read. For our sakes, and yours, actually. You have nothing to say, and you say it poorly, and when you have something heartfelt to say, it's as maudlin and offensive and insincere as the assertion that started it.
The only thing possible to say in your defense is that people (me) are ganging up on you as a surrogate for the mental crimes of others on the right.
The only thing that is really sad is that you may be completely sincere. And that is a bit disturbing. I mean, seriously, if you can't grasp the utter bad faith of your arguments, if you think what you are feeling or what you just wrote, wow. There are many philosophies concentrating on people like you. You apparently blew a fortune on an education, you have been given the luxury of doing this for a living, and yet in the end, all you can do is this? It would be one thing if you were cynical, which, I hope, for your sake, you are. If you are ripping us off for the paycheck, laughing while you get mocked and taken apart, and as you let your infantile commentators believe they have a clue, then by all means, respect.
But if not, wow.
"Mental crimes"? Wow, what is the cure for that? Blue pill, or red pill?
How does one make bad-faith arguments sincerely? Those seem rather contradictory.
This is how Americans have "fun". Hatfields vs. the McCoys. North vs. South. Liberals vs. Conservatives. Blues vs. Reds. It's just one of these periodic convulsions we go through. Really, it's not the end of the world. The more you worry about it, the more your self-fulfilling prophecy will come true. You tried to take it to a higher level, and unfortunately, like all issues in American politics, it immediately went to the mattresses, and then the mud.
Megan, I confess to not understanding where we are at this "end of the debate". As I understand it you've proposed that rather than the plan currently in Congress, we should instead implement the following reforms: scrap the tax deduction for employer-purchased health insurance; set up a reinsurance fund that would help smooth out the differences in premiums between high- and low-risk folks (you haven't specified whether the fund would be financed through taxes or through mandatory contributions by insurance companies); have the government pay for private insurance for anyone who genuinely can't afford it, which you estimate to be 2-3 million people; and impose a buyer mandate so that everybody else has to buy in, eliminating adverse selection problems. This is similar to the proposed reforms in Congress except that it substitutes a reinsurance system for community rating as a way to make insurance affordable to high-risk buyers, it doesn't require insurance companies to take all comers regardless of pre-existing conditions, and it envisions subsidizing far fewer people's purchase of insurance. But it does get to universal health insurance.
This seems like a perfectly good starting point for a compromise reform idea. What needs to be examined is: how would the reinsurance system need to work, how big would it have to be and at what level would it have to pay out, in order to realistically lower premiums to an affordable rate for those who are now too high-risk to afford coverage? If the reinsurance pool is financed by insurance company contributions, how much higher will that push the average person's premium? Will coverage become unaffordable for low-income people, requiring more subsidies? If we have a buyer mandate, how can we not require insurance companies to issue a policy to all comers, regardless of pre-existing conditions? That is, how can we require people to buy insurance if the companies won't sell it to them (at a price they can afford)? There are a number of other points that need to be addressed as well, and one would need some really clear data on the numbers you're talking about -- how much does insurance end up costing under this plan, can everyone afford to buy it, just how many can't and will thus need government subsidies, and thus how much will it cost. But the basic point is that this just isn't so crazily far off from what's now being proposed -- a universal coverage system based on private health insurance with government subsidies and a universal mandate. So I don't understand why your tone at this stage is one of bitter resignation rather than figuring out how to get to a reform you could live with.
But that isn't how it will work. I also favor the Jane Galt Tax Plan. But that won't work either, politically, and it does not convey upon me any obligation to support any old tax plan because hey, they're tax plans. I can propose any number of potentially interesting schemes for dealing with health care. None of them have a shred of hope of being enacted in any form that makes them better than the status quo.
I know, I'm just cynical, and my cynicism is producing the very dysfunctional government I deplore. But I could say the same thing about your optimism. Liberals who believe in government enact regulations on various things, and then, to a first approximation, every single time, they get really super mad when the regulators get captured by the incumbents and do stupid things, or are excessively risk averse, or stop high speed rail projects as well as highways, or what have you. Given a sufficiently dim prospect of an acceptable bill, I choose to support nothing.
See, I don't think that's fair. I don't think you can say you have a much better idea for universal health insurance, except that you haven't really costed it out sufficiently to say that it would work, and it has some internal contradictions that would have to be figured out somehow, but that you would never be able to accept any compromises on your much better idea so there is no point actually discussing it, or how to adapt it to the real world. I think in that case what you have is just a nice cloud-castle whose only function is to provide a moral backstop for opposition to anything that could happen in the real world. And I don't see what you or anyone stands to lose by trying to work out how to make that cloud-castle more realistic, at least at the level of working out the numbers and the practical considerations, forgetting about the political ones for the moment.
I honestly think that if you had come out at the beginning of this whole debate by laying out the proposed reforms you've outlined above, and said this is a much better way to reform health care, and here's why, you probably would've sucked about 80% of the acrimony out of this discussion. I'm not saying there wouldn't have been any viciousness. On a big political fight like this, there's bound to be snark and contempt. But you would not have had John Holbo saying...whatever it was that he was saying at the point of maximum acrimony, I've lost track now. And I wouldn't have thought you weren't being "reasonable". And frankly, I don't see why you still at this point shouldn't work out how your proposal would work, since some of those ideas -- scrapping the employer tax exemption, and how to compensate insurance companies for different risk pools -- are going to be on the table in future years whether the current proposal passes, or not.
For example, in my view, progressive beliefs about utility regulation are the reason that we can't have a climate change bill--which I actually do unequivocally favor unless it's especially terrible. Optimism about the abilities of government, and specifically the abilities of the US government, has created the opposition to solving new problems. Progressive price control programs created the ridiculous employer tax break for health care, and progressive support for unions is maintaining the most powerful interest group arrayed against ending it.
I was describing an ideal plan in the "Megan is dictator" world. I do that fairly often. Then I leave fantasy world and tell libertarians that no, we can't just end social security, even if it would never have existed in perfect Megan fantasy world, because there are now a lot of people who've been planning on it for thirty years.
Progressive opinion-makers generally, I would guess overwhelmingly, support ending the employer tax break for health insurance and disentangling work and health insurance. The fact that progressives support unions and unions support the employer health insurance tax break doesn't mean progressives support the tax break, any more than the fact that crunchy cons support capitalism and businessmen generally oppose higher gas taxes means that crunchy cons oppose higher gas taxes. The fact is, at some point the US is going to have to disentangle work and health insurance. But that's not going to happen until we have universal health insurance, because until then, people will be too scared to abandon their employer-sponsored plans.
I'm not exactly clear on your utility-regulation and climate-change thesis. If you're saying that overregulation of the utility sector discourages investments that would shift the sector away from traditional thermo sources and towards renewables, or building a smarter grid, I completely agree, and I think most progressives at this point would too. I think liberals would see the enemy here as entrenched corporate power. You would (I guess?) see the enemy as the fact of government regulation of the sector in the first place, which allowed regulatory capture; but liberals would then say that imagining there could be a sector like that without heavy government regulation is just a fantasy that doesn't exist anywhere in the world, and you might say, ah, yes, so I prefer to wash my hands, and liberals would say well in Germany and elsewhere they have managed to reward massive green investment within a heavily regulated system, so what's the problem?
I blame the Senate.
Right, but progressives care (I infer from revealed preference) about boosting the unions more than they care about revealing the tax break.
Let me make it clearer then: my system, implemented in the United States, would lead to price controls. It would lead to other bad outcomes. The US government cannot credibly commit to staying on a steady-state system, and the prior interventions mean it can't even commit to trying it out, because no one is going to touch Medicare or Medicaid except probably to make them worse.
"If I were dictator" policies aren't a great guide to current policies. I think second best is the status quo. I'm not going to join y'all in working towards my preferred plan, when I am 100% certain that what we'd end up with would be something that was, in important ways, inferior to the status quo.
Yeah...
So you basically prefer to go the route where we keep the current system until Medicare and Medicaid bust the budget, at which point we'll have to slash Medicare and Medicaid, do I get that right? I mean, the rest of the problems in the current system don't actually force crisis points, they just inflict real suffering on small groups of people and general badness and annoyance on large groups of people in ways that are hard to mobilize a political coalition around. So the idea would be to make sure those political coalitions keep getting defeated, and wait until we hit the crisis point where slashing public insurance becomes unavoidable, and then do that?
I mean, I see that as the other outcome, the "do nothing" outcome. No? The third option would be something more like the McCain plan, where you wipe out the employer tax credit, toss people out on the individual market, provide them with maybe some subsidies but not enough that everyone gets insured, have no mandate (so you've got a lot of adverse selection), and tax-break health savings accounts. That's an option, but it's not the one you were saying you supported. Though I guess that would also effectively be pretty much what happens when we hit the wall on Medicare and Medicaid spending, right?
I think the system is politically sustainable long er than most people do. The American resistance to change is phenomenal. Costs will grow, and we'll pay them.
Re: If we have a buyer mandate, how can we not require insurance companies to issue a policy to all comers, regardless of pre-existing conditions?
If you don't have guaranteed issue and some sort of modified community rating, what's the alternative for uninsurable people? A public program? Seems to me community rating makes far more sense here. Yes, that makes premiums go up, but the alternative is for taxes to go up instead-- and a whole new bureaucracy to exist, duplicating what the private sector already has in place. So community rating is a market-solution, one that limits government involvement (and would presumably not involve government price controls on healthcare itself), and it should also be cheaper overall since the insurance infrastructure already exists and would not have to be set up and funded separately.
I think this is probably right, but I also think that you tend to wind up with something very like Megan's reinsurance pool anyway. In the Netherlands and Germany (and probably elsewhere but I haven't researched it) you end up with something called Risk Equalization Funds that play roughly the same role. That's because when you have community rating and guaranteed issue, you get a problem: any insurance company that offers a generous plan will find all the sickest people signing up for its plan. So it'll get stuck with the expensive clients and be driven out of business. This creates a race to the bottom in private insurance plans, with everybody just offering the same bare minimum plan to scare off potentially sick people. To counter this, the government sets up an REF that compensates insurers based on the risk profile of their clients. Empirically, insurers in the Netherlands often compete for the riskiest clients rather than the reverse, because they get the government handouts that way. This does essentially the same thing as a reinsurance fund would. We'll probably wind up with something like it in the US as well, but it's not in the current bill I don't think.
In the Netherlands it's financed through taxes, though. If you financed it through insurer contributions, it'd drive up premiums and then the government would have to subsidize poor people more heavily to compensate. So, yeah, it seems simpler to go the REF route, and I'm not sure what the advantages of the reinsurance approach are, but I'd be willing to take a look, because maybe it would work better, who knows.
Hey Megan - don't let the bastards grind you down. A lot of the personal attacks and accusations of bad faith are partisan hackery at its finest. If your contribution to the healthcare debate is deemed intolerable or morally suspect then those casting such aspersions show how empty their commitment to debate and democracy truly is. I wish you would reconsider leaving the debate even if you feel you have nothing more of interest to say. I can only imagine how unappealing it would be to have to repeat yourself as the political fight heats up even more once summer vacations ends - but your viewpoint is worthwhile and should be a part of the discussion. It can seem a thankless task to answer the same accusations or arguments by the same people over and over but if folks such as yourself become exhausted and leave the fray the debate is left to the trolls. They win because it is easier to be thoughtless and crass ad nauseum. You do not seem enough of a partisan to enjoy the fight on strictly political grounds and so grow weary. That is a shame and I encourage you to keep fighting for your ideas.
I, for one, will be able to tell which progressives are decent people by seeing if they are saddened if you left the discussion. Those who would celebrate are pretty vile creatures. I think you come in for so much invective precisely because you are a denial of the belief that their political opposition must be stupid or evil. By your wit, knowledge and decency you have proven that a different opinion on this subject can be held by someone of good intentions and intelligence. If the idea that the opposition must be stupid or evil is a lie then what of the rest of their arguments? I think that this is the largest reason for so much of the heat you get.
Hi Megan,
I think it's quite obvious you don't trust government to do anything correctly or manage things well. That's fine, there are certainly countless examples of sausage making, things they've screwed up, etc. etc.
On the other hand, I don't trust the endless drive for profit to always be beneficial toward society either. Financial "innovation" is the obvious example. I don't think pharma innovation always benefits society in general, either ... sure, they spend money on reseraching new drugs that could really help humanity, but they also spend lots of money to pay doctors to use their drugs:
http://www.nytimes.com/2009/09/03/business/03health.html?scp=10&sq=pharma&st=cse
The profit motive is great when it drives more efficiency, real innovation, etc. I don't have any issues when someone invents something really useful and makes a ton of money doing it. But I think government is needed to keep the playing field level and prevent powerful corporate interests from manipulating markets in their favor at the expense of the general public, without actually creating value. I think it's unrealistic to expect totally free markets to be capable of self regulating ... a corporation will cheat (avoid creating value, while still making money) if it believes it can get away with it.
Finally, I also have huge doubts that what we're really going to get from health care "reform" will really restrain pharma companies, insurance companies, etc. in a way that benefits everyone. I suspect the overall system is just too messed up.
--Hansel
The big difference if that if private business sells something really screwed up, I don't have to buy from them. I don't have much choice about buying a screwed up governmental plan.
"The big difference if that if private business sells something really screwed up, I don't have to buy from them."
Not only do you not have to buy it from them, they can be sued for selling an inferior product.
The government cannot be sued when it foists a defective product on us. The government cannot be sued when its incompetent doctors make mistakes. The government cannot be sued when it accepts thinly-disguised bribes to enact legislation beneficial to themselves and their donors.
The govenrment cannot be sued when it creates death panels or (as Mickey Kaus calls them "death pathways."
Having our health care in the private sector is the single best way to protect the most consumers. Once it's in the governments hands, we'll shortly have something very similar to Britian's National Health Service, which kills people left and right and has death panels deciding who does and doesn't get care.
"The big difference if that if private business sells something really screwed up, I don't have to buy from them. I don't have much choice about buying a screwed up governmental plan."
If conservatives had displayed this sense of governmental skepticism and fiscal discipline during the run-up to Iraq, then I would find it easier to believe the current display as a sincere and intellectually honest argument rather than a mere attempt to prevent the opposing party a victory.
Vanity Fair has put the cost of war (factoring veteran care, rebuilding the military, interest payments, etc.) at $3 trillion dollars which would fund national health care for 30 years.
Ignato: I'll assume, for the sake of argument, that these Vanity Fair numbers are accurate.
1) $3 trillion is $130,000 for every person we liberated from Saddam Hussein. Would you pay $130,000 for that privilege?
2) The US is spending over $700 billion this year to provide healthcare. The United States as a nation is spending about $1.6 trillion. That $3 trillion would fund national health care for 2 years, not 30.
3) To be rather cynical about it, everyone is for fiscal responsibility, as long as you're cutting programs that they and their constituents don't care about. Democrats will gladly cut the military and Republicans will gladly cut healthcare, at least until the point where their voters start screaming. Neither of them has shown the slightest tendency towards fiscal responsibility when it would cause pain to things they like. Other nations have been better about this - it's nice living in Canada sometimes - but the US Congress has maybe five people who care about the bottom line for its own sake, and 530 who care about using it to make their opponents look bad. Bar Jeff Flake and Ron Paul, I'm not sure who actually has credibility on this issue, but it's not the Republican Party or the Democratic Party as a whole.
really because most of us don't even buy our own insurance, your employers do, and most times you can't opt out and have no idea what it's even about. most of us are stuck with screwed up products anyway.
I would say, 'no', there is no point to talking about it any more, but that's because I think the vast majority of money spent on health care is signaling (and nothing to do whatsoever with health outcomes), and the vast majority of time spent arguing about health care is signaling (and nothing to do whatsoever with health outcomes).
If 'health care' is mostly about signaling, then you would expect both sides to get increasingly agitated and increasingly 'irrational' (at least in the eyes of the other side). Becoming agitated and endorsing increasingly untenable positions is a very good way to signal how devoted you are to a signal.
I wish more people would blog about health care as signaling and the implications on this debate: http://hanson.gmu.edu/showcare.pdf
Megan - hurrah. The last that's needed is to provide additional bandwidth for the socialists to spout their agenda. Let's get on to libertarian debate. I'm sick of the socialists.
With the money and resources the Obama administration is about to pour on this debate I don't think a blog on the Atlantic is going to be necessary for them to get their word out. I'd prefer for opposing views like Megan's to still be part of the mix but I can sympathize that both you and Megan are sick of this already. I think in a democracy it is a bad idea for people with good ideas to contribute to leave the debate once they are bored or annoyed.
I don't know that there's actually been a national healthcare debate so much as a full-fledged nationwide nervous breakdown of sorts. Like the political equivalent of Elaine from Seinfeld on the dance floor. "A full body heave, set to music."
See now this is the kind of comment that should provide a link. http://www.youtube.com/watch?v=5xi4O1yi6b0
You must be joking, right?
If it is ok for the critics of the health care reform to bring guns to town hall meetings, why are you so perturbed by the mostly reasonable and respectful critics of your meandering plaintive posts? Your stance on the gun issue in this context proves, at least in my mind, that you are quite un-serious about the whole thing, and basically want to engage in a college dorm debate which by definition is ultimately inconsequential and futile. Of course you are not debating in good faith. Just like Grassley and Beck and Palin and the assorted hoodlums, except that they really want to kill any attempts at reform, whereas sitting from the comfortable perch of a national magazine you do not care a whit about the result of all this back and forth on such an important issue. But of course your feelings have been hurt.
You're exactly the kind of troll people here have been talking about.
Samsa moves the debate forward brilliantly.
Q: How to reform health insurance to expand coverage to as many people as possible without exploding costs?
Samsa: I'll psychoanalyze Megan McArdle and explain what she really does and does not think, deep down inside! Because I know the inside of her head better than she does. Besides, since she's clearly way better informed than I am, it's easier than actually addressing her points.
I'm just sad that it is automatically assumed that if one thinks the profit motive isn't all it's cracked up to be for health care that they must think politics is the answer...
Personally I'd prefer if health care were run more "socialist" like, as long as it were the non-state kind. For all that the mainstream statist-left sugar coats their precious "reform", the most likely outcome will be the worst: people forced to buy (newly further cartelized) insurance they can't afford, with the slightest subsidy inevitably cited for budget reasons as excuse for government nitpicking of individual lifestyle habits.
The debate won't stop. The philosophical points have been adequately stated, but what remains is implementation of public policy, and that's continuously debatable. My view of the players' motives is that the health insurance companies and pharmaceutical companies desire a health care reform bill. This is because, in the present economic circumstances, enough people are losing insurance coverage or not buying it that the tea leaves show diminishing returns for both industries. If we accept that no one honestly wants people to suffer without adequate care, then we can start to understand that the motive of the insurance industry for advocating reform is so that government will take responsibility for more of the sickest people off their hands, and they have been signaling that desire through large rate increases and denial of care for ostensively insured individuals. The pharmaceutical companies likewise understand that their future profitability is linked to the ability of people to be insured, whether privately or publicly, and government subsidy is required for more people now than before. I think the congressional Republicans agree reluctantly to a greater governmental role in insuring the sick, while leaving well and young people in the private insurance market. The congressional progressives' desire for a "public option" is a signal that they are willing for the government to accept responsibility for more sick people, but also wish to offset the cost by publicly insuring a proportional number of well people at the same time.
Some bill will pass some way. I'm not sure, but I think that the Senate could pass the House's bill by simple majority, if it was brought to the floor and all amendments were blocked. Yes, the vitriol of many has been lamentable, but after the somnolence of the Dennis Hastert years, it is good people are paying attention. It is phenomena. Perhaps for a libertarian, I would suggest it may sometimes be useful to think a little less like Ayn Rand and a little more like Tallyrand, as in (paraphrased): Which side is winning? "My side." Which side is that? "Let me go to the window to see."
You don't have to let liberals abuse you. Call them out for the bullying scum they are, and for their puny minds and arguments. They have externalized their superiority complex on you for so long that it has internalized in you as a chronic inferiority complex.
A great deal, perhaps a majority, of liberal's intellectual authority rests on people taking this sort of abuse. It is a very simple cycle to break, and it starts by standing up for yourself.
Hey, tehdude, the only name-calling bully I see around here is you.
Really? I see about a third of the comment thread doing it.
So we reach the usual place: McArdle puts failed libertarian dogma on the table, offers no facts, plays victim and gets the usual glibertarian stooges to agree with her. Is this supposed to be an achievement? I can see why you get so scared of those big scary liberals - because you don't have a credible, real world argument against them, other than the tired canard about how big government enslaves you. No wonder real people think of libertarians as immature poseurs who learn about life from a sucky novelist and never get past the resulting adolescent tantrums.
Libertarian dogma would imply that she's in favour of a 100% private system, certainly not the overregulated, 45% public, bureaucratic morass that the American healthcare system is today. Given her stated preferred policy involves things like government reinsurance, I'm pretty sure "libertarian dogma" it ain't.
I think the problem may be that Megan doesn't care about people who don't currently have health care. She values hypothetical future cases at the margins of the medically possible, but she doesn't value actual current cases where the medically everyday is denied for economic and institutional reasons. I agree with her that this has been largely a dialog of the deaf, but the deafness has been overwhelmingly hers.
I think the problem may be that every time over the last six years I have ever read a McArdle blog post where she goes on at length about the tradeoffs inherent in a difficult issue, analyzes them in greater depth than 95% of other bloggers I've ever read, and comes to a conclusion that is explicitly stated to be far from utopian, simpleminded commenters come along and ignore the entire argument to distill her position down to an unrecognizable strawman that they can attack.
Seriously, how do you derive "I hate the poor" from her position of "The current system, for all its faults, has important virtues we can't ignore"? There are leftists on this blog whose arguments I respect, but the ones looking to egregiously mischaracterize their opponents just so that they can get their Two Minutes Hate on are not among them.
Megan, your failing on this issue has been simple, and remains simple: no matter how you shake and dance, there are people in this country who need health care in this country who can't get it. And even now, in this valedictory that you've written, you cannot consider the moral consequence of that fact.
If you want to know why the debate here isn't working, that's why.
Freddie, I've asked you many times for evidence for this assertion.
I've also asked you to define "need", but you've never done that either.
How come you can't even define the terms you are using, let alone provide evidence for your claims?
Erbitux is one of the bogeys for availability of expensive drugs, and your concern is for innovation. Who developed Erbitux? Wikipedia at least show it developed at Weizmann Institute of Science, Rehovot, Israel http://en.wikipedia.org/wiki/Cetuximab. That does not sound like a private enterprise. It is marketed & manufactured by ImClone , B-MS, & Merck.
Unwavering protection of drug companies is protecting the marketing and distribution of drugs more so than the innovation related to them.
Megan,
Perhaps constructive discussion is over. I am not sure of that yet, but perhaps it is. What is next? Lie down and let "democracy" work? The type of "democracy" where individual freedoms are surrendered? No way.
If they are going to cram it down people's throat, we need to make it clear that that is what they are doing. Be LOUD! Make it clear. They are not doing this -for- you, they are doing this -to- you. Tell them what you think about it.
Make them the bad guy, because that is what they are. They are not off doing their own thing and letting you live as you wish. They are telling you how to live; they are forcing you to live as they tell you to live.
They might eventually overcome our resistance, let them at least know it was a show of ugly force. That we are the victims of their aggression. They they have stolen from us.
They do NOT have the moral high ground. They are the worst of despots and thieves.
Elected representatives passing legislation is now equal to despots and thieves cramming something down people's throats in a show of ugly force. If only Congress was "off doing their own thing and letting you live as you wish."
Megan's right that this argument is being derailed by "screaming, hate-filled lunatics," but I'm not seeing that behavior on the side supporting reform.
Ignato,
You can just keep your laws off my body, thank you very much. And keep your hand out of my wallet too.
You have no right to dictate to me how much health care I want or what I am entitled to, none.
Don't pretend you are doing me any favors; be bold and embrace your despotism: I do not want it, you are going to give it to me anyway.
Historically speaking, "elected representatives passing legislation" has been indistinguishable from "despots and thieves cramming something down people's throats in a show of ugly force" about 80% of the time.
Let me see-I'm the "bad guy" because I want you and your children, and Megan and her children, and all the other people who are opposed to reform and their children-to never have to worry that they cannot afford their healthcare; because I want them to have the "freedom" to move from job to job without losing their coverage; because I want them to have the ability to choose to work in a low-paying job such as social work-or to start their own business, and not have to worry that they have enough money to pay for their medicine; because I want them to have the freedom to go to any doctor or facility they choose, without having to see if it is "in network"?
Wow, I'm a really bad, heartless, horrible person...
I was responding to Jay, not to Megan.
Cmm,
We all want these things. Wanting these things does not make you a bad guy.
Stealing from others to get it, that would make you a bad guy. Forcing others to submit to your ideas against their will would make you a bad guy.
Me, and my children, Megan and her children... we will not have more freedom, we will have less.
I'm fascinated that, after all the sturm and drang, heat but no light of this debate, the one thing all seem to agree on is that we should disentangle obnoxious employer-provided health insurance.
Hm. Some folks might argue that one of the few remaining societal perks of working for BigCo (outside the obvious: generally higher incomes) is getting health insurance from a group pool where most buyers are reasonably healthy. This is certainly a perk for anyone with a costly medical condition, a perk that will definitively disappear with ObamaCare. To which the masses bray: so what.
Its been argued that Microsoft created more millionaire secretaries and janitors than any other entity in history. Perhaps this came about as a result of Gates' and Allen's work on DOS in Gates' parents garage, a period where neither Gates nor Allen had any hope of buying into beneficial group health coverage.
But maybe not, you know? Maybe the millionaires were made in the early 80s, when Microsoft was big enough to afford group coverage for its secretaries and janitors, but pre-Windows era, where Microsoft was still threatened by software like Lotus 1-2-3.
In other words, we think of the benefit of entrepreneurism in the context of Gates' dad's garage, but it is possible that the real game-changing entrepreneurism, the kind that enriches secretaries and janitors, occurs in young, established companies like Microsoft circa 1981.
If this is true, than the perk of group coverage for young, ambitious work forces may actually matter, may actually be part of the infrastructure that later enriches janitors and secretaries.
Just a thought experiment - I have no links. But it is fascinating how many people are definitive in their desire to overturn large employer group coverage system because of care for the well-being of janitors, secretaries, and other working class folks.
@ Matt C @ Ryan W. Increased competition will not decrease prices
Because US regulations make drug development very expensive
Vacation in China, and receive treatments not available elsewhere,
which have been proven safe by millions of satisfied Han customers.
Plus which, medical technology covers lots more than pills.
DoublePlus Good, there are medical researchers working now
on technology which they expect will eradicate all disease
in their lifetimes; The bang/buck curve is going up.
@ TallDave A Singularity argument
...How many people die before we achieve immortality ?
VS How many people live now, at the price of crashing
the system, and leaving all of us who cannot afford a
vacation in China to the nonexistent mercies of a
State run Health Care system.
Vacation in China, and receive treatments not available elsewhere,
which have been proven safe by millions of satisfied Han customers.
I hope You're being sarcastic here. I've taught in Nanjing. The people are wonderful. But I don't even trust the food there, let alone their medical care. If you think you need injections of anything while in China, you should carry in your own syringes.
In China, any fruit you buy should have a skin and the skin should be removed. If you just wash the skin, you will get very sick. I've also gotten sick ordering herbal remedies from China. This is a country where a whole village of rural peasants got HIV from selling their blood when the equipment was reused.
If you want to do medical tourism, try India or the Philippines. I've worked in the Philippines, and their hospital care is much better than in the states, even if the technology is a bit behind the times.
Bingo! Megan, I know you have made this point before many times, but I think you have frequently downplayed it to your argument's detriment. It may not be the case that you can use it to convince more people of your position, but it would help you if you highlighted it more stongly- it is a point that is missed over and over in these debates.
movertyperguy, the British National Health system started in the late 40's. Since then the Tory party has been in power more often than not, but no British Conservative prime minister - not Churchill, not Eden, certainly not Harold Macmillan, not even Margaret Thatcher - has even hinted at scrapping the National Health and going over to an American style system. The British are well informed about politics in the US. They have a vigorous democratic system, with higher rates of participation than here. Yet nobody, and I include the Murdoch press, is interested in bringing in something like our system. Similarly with the health systems in every other industrial democracy. Even in Massachusetts and Hawaii, the only two American states with near universal medical insurance coverage, the right-wing party wouldn't dream of trying to abolish their insurance systems. Why is this? Why don't all these people see the logic of your argument? Are they deluded, or are you?
How many government programs ever get shut down? Aside from wartime programs(and even then, only maybe half of them), privatization of explicitly corporate government entities, or programs that are incredibly obscure and unimportant, I'd be hard-pressed to think of more than a couple.
Medical care fits none of those criteria - it is large, important in people's everyday lives, and a tax-supported model can't be privatized. It creates a massive constituency, most of whom don't love the system, but all of whom are afraid of what will replace it, and doubly so after the opposition parties attack the proposal. Nobody has the political will to force something like that through, because even if it would be good, the opponents would be so strident that the political effects would be negative.
It's just like the abortion debate - America is pretty consistently pro-choice, but abortion is nonetheless a winning issue for Republicans, because more pro-lifers are single issue voters than pro-choicers. This state of affairs would change if the status quo was ever seriously threatened, but as long as the possibility is safely distant, Republicans rake in votes in the issue(as a rule, it obviously varies by district and candidate). Create a constituency that cares a lot, and they can outweigh ten times their number who don't care too much.
Well, Megan, suggesting that this debate's turn to nastiness was largely driven by Pelosi and the liberals is really rewriting history. She's always willing to pile on and add her own brand of caricature and nastiness, no question. But it was the usual, relatively bland political platitudes until the really ugly stuff started on Fox News and conservative radio, which drove the protests, which drove the bulk of the ugly reactions on the left.
Other than that, I mostly agree with this post. This debate has been incredibly frustrating. I understand your point about the "burden of proof" being on the left and think that's right. But until I read David Goldhill's very persuasive article in the magazine about a week ago ("How American Healthcare Killed My Father"), I hadn't heard a conservative acknowledge the depth of the problems with the existing system, and I definitely hadn't heard a market-oriented solution fully articulated. So if conservatives aren't articulating a solution then how can they persuade me? I was starting to wonder if a market-oriented proposed solution even existed. Maybe conservatives weren't avoiding articulating their own ideas because it's politically more expedient to just bash the other side -- maybe they just don't have any realistic ideas to begin with.
Usually, I come to your blog for a substantive conservative viewpoint on the issues. But you, too, were caught up pretty quickly in the back and forth of the debate. Executed with your usual equanimity and poise, no doubt, but most posts were meta-posts that tore down some foolish argument rather than build up a coherent argument of your own. Partly that's just the Hayekian tradition, but I suspect that was mostly an artifact of the nasty turn this debate took.
So, it leaves me about where I started, too:
1) Convinced healthcare will be our most pressing future policy problem and, unchecked, will bankrupt our country in the future
2) Willing to let the Dems take a shot at fixing it -- either it'll work despite my and most other people's pessimism, or it'll make things much worse and spur a true innovation in the future
3) Convinced that the conservative political leadership in our country is as unfit to govern today as the liberal political leadership was in the early '80s
Hi Troy,
So if conservatives aren't articulating a solution then how can they persuade me?
I do not think we need to propose a better one yet. We only need to show that the proposed alternative is worse than the status-quo. I believe that it is. We would be better of keeping the existing system.
That is not the same as saying the existing system is perfect, however, it is not as bad as some say. There was no crisis until the Democrats started talking about throwing out the baby with the bathwater.
I like a lot of my Goldhills solutions but I would add many more. I don't think this is the place to go into them, but for starters more HSAs, transportable insurance with terms related to "time of diagnosis" instead of "time of treatment", and a medical loan program modeled on the student loan program (non-bankruptable, garnishable, minimum payment related to current income).
There are other ideas out there, but currently the focus must be on defeating the current proposal.
I think the idea of a medial loan program patterned after the student loan program is an intriguing one (although the student loan program certainly has its problems). I’d rather have a system like that then go down the path of individual or employer mandates.
The fact is a lot of us on the political right have offered our own suggested reforms for health insurance like:
1) Let people buy policies across State lines
2) Let small businesses and other organizations form association health plans (about 60% of Americans who lack health insurance work for smaller companies)
3) Encourage high-deductible policies with lower monthly premiums that cover catastrophic illnesses
4) Give people who buy their own health insurance the same tax benefits as employers who buy health insurance
5) Expand Health Savings Accounts or make all health care costs fully deductible
6) Give doctors who provide charity or unreimbursed care a tax deduction
A lot of us on the political right have also talked about tort reform and I agree with Megan that it makes more of a difference for certain specialties like OB/GYN than overall health care costs although I think defensive medicine probably accounts for a lot of health care spending that doesn’t seem to produce any tangible benefits. I’m starting to warm up to the idea that it might be better to do away with medical malpractice lawsuits altogether in favor of a system like worker’s compensation combined with some sort of review system to remove truly bad doctors. Mind you, I’m not fully sold on the idea but it might be a better way of reducing the costs from our medical malpractice system while providing a more equitable way of compensating the injured. Although that’s something that would probably be better implemented at the State level.
Hey Jay,
Well, we differ on the level of crisis dictated by the status quo. I realize hyperbole is the rule and not the exception today and therefore there's a lot of "the sky is falling" rhetoric coming from the left, but demographics plus escalating costs made it obvious years ago that healthcare spending was going to be our biggest policy issue in the coming years. In fact, I remember telling friends during the Social Security debate in 2005 that it was a red herring, and that Medicare was the entitlement that truly needed fixing.
As for the rest of your post, I don't really disagree with you, but I would offer this: the best way to defeat the current proposal is obviously to persuade Independents (like my wife) and persuadable Dems (like me) that doing nothing is better than doing something. And a much more effective way to do that is to not only shoot holes in the offered legislation but to also propose a reasonable alternative, even if it has no chance of passing right now.
Because if those persuadable Dems and Independents are given the choice between the current option, which many of us think of as completely disastrous for our nation, and a new option, which seems pretty dubious but might work, and those are our only two options, then which are we going to choose? If Rome is burning, and one group is proposing some kind of complicated, elaborate scheme to put it out, and all the other group does is stand around and play their fiddles, pausing only to shoot holes in that scheme, which group would you join? So, I'd argue that a viable alternative is the key to defeating the current proposal. I'm certainly wavering in my support to a much greater degree after reading Goldhill's article than I was before.
Mostly, that's because I became convinced that healthcare doesn't operate like other markets, because of the moral obligations. If someone can't afford cable TV, they don't get cable TV -- but if you're bleeding and can't afford to hire someone to help you stop bleeding, someone helps you stop bleeding anyway. This has to distort the usual market dynamics, right? But how, and what are the implications, and what does that mean for policy prescriptions?...and only the libs were answering those questions. Conservatives seemed to mostly poke holes in those answers from the libs, but I honestly couldn't find examples of them trying to answer those questions for themselves.
Thorley, thoughts on your ideas:
1) and 2) Both of those sound good to me, but neither seem at odds with the main sticking point in the current debate which is the public option. Seems like you could do both of those AND offer a public federal option. In fact, it seems like a system with both of those and the public option would be better than any current proposal.
3) Goldhill's article covered a similar idea. Very persuasive.
4) and 5) and 6) I don't really understand how tax policy does or doesn't affect this, except for the point Goldhill made about how a relatively innocuous tax provision passed in the 60s to treat health benefits as a operating cost rather than as income helped drive the funky economics we see today. Do these ideas fix that problem, or are they band-aids, or something else?
Troy,
Regarding offering a new solution, you might be right. I am not an electoral strategist. I do agree with you that we need to look at some better solutions; I just feel that the time for that is after the threat is passed.
The Democrats have fast-tracked everything, made everything into an emergency. This was a calculated decision. They did it because it presents a false choice between doing nothing and adopting their plan. They justify this with a "emergency" that simply did not exist just a short time ago.
It's all very strategic, but terribly disingenuous.
Jay, I guess what I'm saying is that the threat, as you call it, won't pass unless conservatives offer a better solution. You can't wait until it passes, because it won't pass otherwise. A viable alternative is the key to convincing moderates who think anything is better than the current system that there's another option worth waiting for.
People like me see the current system as unsustainable, and have for the last few years, well before Dems began fast-tracking this debate and whipping people up. I realize you disagree with this, and think that the perception of a healthcare crisis is largely marketing hyperbole being used by Dems to create momentum for change. But, if you can, ask the HR person at your company about how healthcare costs have been rising, look at Medicare outlays, then look at the demographics of aging Baby Boomers. I think you'll realize that this is not some fake crisis being invented for short term political gain.
Well Troy, I appreciate your position and I am slightly saddened that we likely won't finish a constructive discussion before this thread dies out.
You may be right, like I said I am not a strategist. I think your basic desire, for real discussion, is noble, and I would like to see it too. I just think that because of gamesmanship, we are unlikely to see it. From my position, killing this bad bill is the highest priority. I am not saying I am right here; I am only trying to explain why I think we are so focused on the flaws.
But as long as we are here, sure, we can be rational! Just because our congressmen can't doesn't mean we can't!
Let me tell you something from my past. "Republicans", broadly speaking, have been pointing out flaws in great society programs almost since the beginning. From my experience, whenever I have tried to approach the topic of reforming the social security or medicare, I have been called everything but a human being. I have been accused of wanting old people to die and worse; I was once called a social Darwinist. I kid you not.
I completely agree with you that medicare is unsustainable; I have for a long time. I am very glad to see more people recognizing this.
Now my next question is; is the "public option" basically just more medicare? I think it is. We are effectively expanding a failed program. I think that is a real mistake.
Let me also point out that Fannie Mae and Freddie Mac were also formed to offer a public "option" to the private market. We heard the same rhetoric too. It will be separate, with no money from the general fund. It will make something expensive cheap (magically). Everyone deserves it, it is almost a human right, really. Greedy financial companies and their evil profits are the only reason it is expensive. The similarities are really quite breath taking.
For positive solutions, I actually named several. One I think is particularly good is moving the coverage period. Normal insurance works like this: If you have fire insurance in 2009, and your house burns down in 2009, you get the money. Even if you rebuild in 2010. Insurance covers you at the time of the incident, not the time of treatment.
Health insurance should be the same. This means that no condition is pre-existing. It means that your previous company covers your "pre-existing" condition. Your new insurance company covers any new conditions you develop. So if you are with a company, and diagnosed with cancer, they pay for cancer treatment from now until you are cured. This means you can leave and get a new company. You don't worry about losing the cancer coverage you have, and the new company does't worry about your pre-existing cancer.
The HSA is also very promising. If the HSA is eligible for the same tax deductions as the employer benefit, there is no reason the employer couldn't simply deposit the money directly into your HSA account. You and your employer are both indifferent to them doing so.
Finally, medical loans would be a good approach. All medical payments would be performed so nobody would be denied treatment. The patient would still have a good incentive to keep costs down. Assuming they live/recover, they know they will have to repay the loan. However, they will never be expected to pay more than they can afford to, because the minimum payment will be based on their current income. If you have a catastrophic problem, the worst you can expect is to have a few years of loans to repay. Since we already do this to young people nationwide (student loans), it is hard to imagine any serious objections.
There are many other solutions, I am just taking the opportunity to expand on the ones I mentioned only briefly earlier. I wish I had more time to expand on these ideas. I find text is not the best medium.
Good luck, and I hope you continue to expect the most from our political leadership.
Jay, thanks for the discussion. Whatever I think of conservative political leadership, conservative citizens that engage in real conversations always end up making me think harder and often end up moderating my viewpoints. I appreciated the dialogue.
Slag off. The sooner socialists like you stop infesting this blog the better.
Please! It was a respectful comment, and it deserves a respectful answer. The answer to trolling is not to troll other non-trolls.
Dr. Lawrence Hunter On Health Care Reform - KILL BILL. Why We Should Not Get Too Excited About Obama Dropping The Public Option.
Think you know what is going on behind the scenes? Think again.
I think the short answer is, "Yes, but not necessarily with Holbo." I, alas, don't have anything useful to add to the debate because your ideas are already very close to mine, so I haven't said much. (I'm not big on "Me too!" comments.)
I've gone through the same cycle in my own circle of friends, which contains a few people I no longer even think of as friends, who think it's a perfectly acceptable thing to accuse me (to my face, as it were) of lying about my motives in preference to seeing babies dying in the streets for lack of medical care. That Holbo won't engage in a meaningful discussion doesn't surprise me; that he's seemingly a very smart guy only buttresses my belief that a lot of our smarts are dedicated to defending our own bad practices.
I don't have time for that. I will discuss things with those of my friends-- and there are some-- who will actually discuss things. But not the others.
I accept every word of that as true, _now_.
China, however, is changing; They are ramping
up to mass produce latest gen fission reactors,
and they can do the same for Med-Tech, if they
see enough profit in it. USSR was the same way:
Generally cruddy tech, with bright spots where
TPTB decreed.
A little meditation: recall the flayed corpse
art exhibition the Chinese produced, and ask
yourself if those people would hesitate to
sacrifice a few thousand peasants in the
course of developing an Elixir of Life.
Perhaps you would like to claim that Westerners
are too moral to buy ~50 extra peak years of life,
because of the way the Elixir was produced.
Anyone who wants to predict China's future, and
its effect on us, should get in the mood by
reading R. A. Lafferty's "Mr. Hamadryad". :>
I'm not sad at all - rather, greatly relieved. The dishonesty and hubris of Obamacare - cut costs by record spending, keep your plan, trust the government to make your health care decisions, etc. - are staggering. I'm thrilled that ordinary Americans have had the guts not to drink the koolaid.
I'm sad that libertarians and conservatives are casting this as some sort of massive conspiracy of power-mad idiots, when there's obviously a very large left-wing policy apparatus built up around health care that knows a thing or two, and virtually all of the progressives advocating this are for it because they are worried about people who can't get basic health care.
No, they're not. Unless you classify "basic health care" as "anything the middle class gets, the poor should get."
You could provide basic care for everyone without nuking our health care system, or our health care insurance system. The "liberals" aren't proposing such changes, because that's not what they want. Want they want is for no middle class person to be better off than the most poor. What they want is a society where being useful and productive is not valued, and not rewarded.
They hate markets because they are no good at providing things that other people want, and because they've decided that this inability to provide anything useful is a virtue, not a vice.
They are not idiots, but they are losers. And their response is to try to take away the winners' ability to enjoy their victories.
Much of the progressive left is concerned that in very short time even the middle class will not be able to afford basic health care. Period. One of Obama's basic tenets is to "bend the cost curve down" and one of the largest modifiable costs in the current system is the profit accrued from private insurance companies. The question is: "What value do private insurance companies provide tot he health care product?"
Furthermore, why does Megan assume "govt financed" = "decreased innovation"? We have the most innovative military and space industries in history... all completely govt financed.