Discussion is perking along in my McArdle on rationing thread. For the record: she articulates her general case against national health care here, then follows up here. I think it all adds up to a nice illustration of the point I was making in this post (I wish I had made it more clearly, to judge from comments.) McArdle’s opposition to national healthcare is based entirely on slippery slope arguments, arguments from unintended consequences, and suspicions that those who are proposing national health care really want different things than they say they do. Now, this is reasonable. But only up to a point. Because at some point we need something more, but McArdle is quite strident in her insistence that what she has said is enough.
What does she leave out? Arguing only in the ways she does leaves it unclear what she would think about national health care reform if it worked. And the reason it is important to know that is that we really have to know what McArdle’s values really are – her ideals. Let me show how it goes.
Suppose (just suppose) we got a national health care guarantee (public option) that covered preventative care, standard procedures – even some quite expensive ones; but doesn’t cover experimental treatment or triple-bypass surgery for 99-year olds. Suppose the idea behind the program (for thought-experiment purposes) is that we will let the private market take up some slack, between minimal coverage and maximum. Optimal coverage is probably somewhere between but we won’t presume that the government knows best exactly where it is; and, honestly, it’s somewhat variable between individuals with different taste for risk. We low-ball the public option, reasoning as follows: no one sane would want less than a modest safety net, so we are doing the best we can not to force people to buy something they might not want. Sane people might well want more. So we let them top up on the private market, if they can afford it. Reason being: why the hell would anyone want to make it illegal for someone to spend their own money on something experimental or expensive, if they want? (Or make a side bet with an insurance company that they’ll need triple-bypass surgery at the age of 99. If that’s the sort of bet that inspires their gambling spirit.) Also reason being: the government can sort of eye-ball what the private sector gets up to and adjust its own minimum coverage accordingly. If there is something that everyone clearly wants to the point of being mostly willing to pay for – as shown by the success of insurance companies – either try to include it; or, if the private sector really is doing a good job of meeting this demand, let the private sector keep on keeping on.
In sum, you provide a public minimum by way of meeting basic demands for justice (care of one’s fellow citizens). And you do your best to let people make individual choices, in areas where they plausible might like to (do I buy the premium or settle for the minimum or somewhere in between?) which is good in itself, and a means to a further good end: harnessing the power of the market to signal important information about what works and doesn’t, what is wanted (as expressed by private individuals willing to pay for it.) So this is our social democratic utopia: a mixed public-private affair.
Now, before we get the the practical question of whether we can get there from here – and setting aside the question of whether some people would think this minimum wasn’t nearly enough – are the ideals expressed by the little toy set-up BAD? Is it a bad plan, even ideally? If so, why?
[UPDATE: before anyone makes the objection that this is nothing like the sausages actually being stuffed in committees, let me say: I know that. The point of this thought-experiment is just to clarify a plausible balance of values. The overall point is that there is not much point arguing about whether this is or that sausage is good enough, or not, or slightly better than that sausage, if you don’t even know what you want.]
I’m honestly not sure what McArdle will say. Either yes – the set-up is just bad in principle. Or no – the set up is not bad in principle, it just would be in practice. Let’s take these in order.
McArdle says yes. Yes, she doesn’t think this would work.Yes, it would have bad unintended consequences or be hijacked by extremists and self-serving bureaucrats. But that’s only objection 1, and it’s only a secondary objection. The main objection is that, yes, even if it worked more or less as advertised, it would still be bad because it’s nationalized health care and the government really just shouldn’t be involved in private health care decisions. Period. As a matter of principle. To have even the minimum of public health care foisted on private individuals, possibly against their wishes and principles, is an intolerable restriction on negative freedom and a clear case of an actor, the state, with no proper business doing a certain sort of thing, doing that very thing on a large scale. The bad of all these in-principle violations swamps any good consequences. In fact, we aren’t counting consequences. However that whole cost-benefit analysis rattles out, it’s a sideshow. (We think the costs would be high but, honestly, we don’t care. We aren’t utilitarians about this question.)
Possibly McArdle would say no. That is: if it worked moderately well, that would be great – or at least fine. But it just won’t. If this is her answer, then her objections are purely practical and utilitarian. (Not that she has no non-utilitarian principles, but at the level of principle, she has nothing against what is proposed.) But then her objection style is totally insufficient. She writes:
When I wrote the other week about why I am opposed to national health care, a number of people angrily demanded to know why I was writing about something that “no one is proposing”. Now, this is clearly a lunatic statement. I was writing about something that many people were proposing. I just wasn’t writing about the nebulous bills currently wending their way through various committees.
No, it’s not a lunatic statement. To say it all again: McArdle is right that it is reasonable to worry about slippery slopes, the bureaucratic mind, and unintended consequences. But it is not at all reasonable loftily to ignore what is actually being proposed, or to refuse to be the least bit imaginative and charitable about how it might work (as opposed to fail). Let me say that again, because it’s very important: McArdle would be justly disdainful of any reform proponent who simply refused to consider the risk of unintended consequences. But reformer are just as right to be disdainful of any opponent who simply refuses to consider the benefits of intended consequences. Most actual policy results are a mix that way, after all. You have to consider both, but McArdle isn’t willing (so far as I can tell).
Another angle: if your objection is purely practical, you cannot in good intellectual conscience just abstract away from all the actually existing practicalities into a kind of public choice theory Platonic Heaven of ideal tendencies for things to go wrong. ‘Hey look, a proposal to reform health care.’ ‘If that were a real proposal, some bureaucrat would have sabotaged it by now.’ That’s just not a sane way to think, on the assumption that you grant a certain sort of ideal reform direction would be, in principle, good. (If you admit that something would be good, but show no interest whatsoever in any possible ways of approximating to it, even in a limited way, that suggests that you don’t really think it’s good at all.)
To put it yet another way: if your objection is purely practical, if it really all comes down to utilitarian weighing of pros and cons, it makes no sense to refuse, in principle – and in the loftiest tones – to weigh anything but the cons, and only in an idealized ‘probably there are cons that look sort of like this’ way. Weighing the cons is necessary but not sufficient to conducting a fair weighing of the pros and cons. (This really ought to be obvious.)
Which makes me suspect that McArdle is really just opposed in principle. She hates the camel’s nose just as much as the whole camel that might follow. From which it follows that her objection to the camel’s nose – namely that it’s attached to the camel – isn’t her actual objection. From which it follows that she doesn’t actually have an argument against the camel getting its nose in the tent.