So I’m not sure that this conversation is likely to be productive, since at least one side of it has decided to substitute sarcasm for engagement. But let’s see if we can’t tone down the nastiness a little, and try to have a reasonable discussion.
I agree with the first sentence. And I agree with the second sentence. Moving right along.
Holbo’s response to me consists of abstracting away all of the potential problems with national health care, and then demanding to know why I don’t support it – I mean, apart from the fact that if millions of poor people die, there will be more room on the subway for me. Libertarians think like that, you know.
This isn’t it at all. And, by the by, I have not by word, implication or heavy hint accused McArdle of wanting poor people to die. I have only said that I don’t think her arguments show what she thinks they show. “Mr. Holbo’s answer is that I am an evil idiot who hates poor people, doesn’t understand how markets and governments really work, and is philosophically incoherent.” Only that last one, if you please.
The problem – I said it before and it remains the same – is not that McArdle’s arguments are bad but that they are weak. If someone says ‘I have a proposal’ and someone objects that ‘perhaps it is a very bad proposal that will cause more harm than good’, that is a very good argument, as far as it goes. Lots of proposals ARE bad (I will stand shoulder-to-shoulder with McArdle against anyone who maintains the contrary.) But this doesn’t go far enough. My argument is that McArdle has failed to notice she hasn’t gotten farther. As to why she has not noticed? I doubt it is out of desire for the poor to die. I think it is probably due to the fact that she has a philosophical abhorrence of certain things; that abhorrence slops over, as such things will, prematurely coloring her sense that she has demonstrated that things she doesn’t like in principle won’t work in practice. But that is just a guess – and a charitable one, I think. On the assumption that I’m right that her arguments are weak, of course.
Well, are they? We see some sign in sentences like this: “It’s not enough to defend the principles of communism if what you get in practice is a nasty, murderous dictatorship every time.” There is a big difference between the general consideration that something MAY go wrong and the knowledge that it WILL go wrong every time. McArdle doesn’t have anything like the latter, yet her level of indignance demands something in the neighborhood. She also seems needlessly bothered by my efforts to get her to articulate what she thinks would be ideal (or at least admirable) goals. Just to be clear: I am not planning to argue that everything that is ideal must be possible. I am merely pointing out that, in a case like this, where there is horse-trading and sausage-stuffing in practice, it is a good idea to step back – once in a while – and say what the point is supposed to be. I don’t think this is intolerably impractical. And, if it is, McArdle is in no position to complain. As she herself wrote just last week: “You seem to be under the mistaken impression that I have a workable political program.” People who write like that should be more patient with other people who write like that.
I have, in previous posts, examined two arguments she has advanced that are, potentially, substantive. Again, round the circuit.
First, killing the private health care market (the status quo) will kill innovation and r&d and the bad of that would swamp the good of fairer redistribution of health care benefits. I have argued this conflates the health care case with a different sort of ‘free markets fuel growth’ argument, borrowing unearned plausibility. Unlike the growth case, in which a planned economy cannot grow as fast as a free market because the planner necessarily lacks sufficient information – the signaling function of the market having been short-circuited – in the health case, there is no obvious reason why the government couldn’t fund r&d if private funding should fail. I’m not going to go through that again, but I invite McArdle to respond. As fair downpayment, a response to her demand that I answer a specific question, as follows:
What if everything goes the way I think it will? What if converting the United States to a single payer system causes the pace of medical innovation to slow to a crawl? People who have diseases for which there are not now good therapies lose all hope, because there is virtually no pharma or medtech industry which might invent something to save their life. Lifespans stop lengthening. Pharma and medtech turn into fat, soft, government suppliers, using the regulatory power of the healthcare agencies to keep out incumbents. There are periodic shortages of various treatments because the government has a budget problem, or has gotten the prices wrong – and knowing us, the whole system comes with a “buy American” mandate.
We’ll get to the shortages in a minute. But first, assuming McArdle is right about the r&d shortfall, I would prescribe: r&d. The government should fund it (if, ex hypothesi, no private party will). I expect that if the single payer system is otherwise performing tolerably the taxpayers will be willing to pay and consider it a fair deal overall. Presumably they want medical innovation. (If they aren’t willing to pay, then maybe things have advanced to the point where everyone is happy with the existing level of medicine. But I would be surprised if that ever happens.) The fact that we have moved to a ‘planned health care economy’ would be no structural barrier to ramping r&d back up. We don’t need private insurance companies to signal where to look for that bold new cancer treatment. (I’m not saying the private market is useless for signaling worthy goals, or working out good systems of provision; but it isn’t indispensable, so far as I can tell, not like the generic economic growth/free markets case.) It isn’t that hard for government to spend money on big programs (I’m sure McArdle agrees with that.) Doing so helps get politicians re-elected. The people like it. So, if there really were a sort of upset, in the wake of a shift to single payer, with r&d sinking, I would expect it to recover when people noticed this had happened.
But IS the single-payer system performing well otherwise? Or are we suffering shortages? Here we get to the rationing question. McArdle implies that I have been unduly persnickety about the ‘r-word’. “I mean, fine, let’s not call it rationing. Let’s call it “Fred”. You’ll still end up with a crappy, overcrowded housing stock and shortages of basic goods.”
I’m happy for people to call rationing ‘Fred’ and I’m happy for people to call Fred ‘rationing’ (so long as he has no objection). But if you start using a word in a not quite usual way, you have to be a little careful. Example: “I might point out that rationing interferes with voluntary transactions, and that if the government wants to redistribute things, it should damn well raise the taxes and buy them.” No, rationing doesn’t do that, because we are using the term the way McArdle wants, as specified in her previous post: “One way or another, we are going to ration care, if you use “ration” to mean “allocate inherently scarce goods.” This is the sense of ‘ration’ that is operative in her argument that health care reformers must engage in rationing. But it is not the case that ‘rationing’ in this sense necessarily interferes with voluntary transactions. Voluntary transactions, involving scarce goods, are themselves only a special case of ‘rationing’. The market is a big invisible ration dispenser, by McArdle’s definition. Again, she can use the word how she likes. And I’m not going to pretend that health care reform will leave all voluntary transations gloriously un-interfered with, which it won’t. But we have no argument yet that the sorts of problems typically associated with rationing in the non-Fred sense – shortages and crappiness – must afflict reformed health care , just because it is ‘rationing’, in the Fred sense. (We aren’t going to argue that the free market itself must lead to shortages and crappiness, just because it is ‘rationing’, in the Fred sense.)
Or maybe this is it: “If the government crowds out private health insurance for many people – a result that a number of analysts on both right and left think (hope) is likely, then the government rationing regime becomes actual rationing for the majority of the population.”
We are considering one of two scenarios here. 1) There is no market for health insurance – or health care – above and beyond what the government supplies, because pretty much no one wants more. Or, more plausibly, they don’t want it at the prices at which it can be provided. 2) There is no market for health insurance – or health care – above and beyond what the government supplies, because the government has made it illegal to buy more.
I could point out that in neither case is there ‘rationing’, in anything like the usual sense. In the first case, this is pretty obvious. In the second case, really it’s just strict egalitarianism, which is quite a different principle. But call it what you like. The real problem is that 1) is not a problem, whether it is ‘rationing’ or not. And 2) is not going to happen, whether it is ‘rationing’ or not. I realize that something like 2) has been proposed outside the U.S. but I think it strains crediblity to suggest we are going that direction, even if we got single-payer (which we won’t get any time soon). And I myself think 2) sounds like a bad idea, for the record.
If McArdle thinks 2) is a likely development in the U.S., she should explain why she thinks it is likely.
I do appreciate that McArdle did take the trouble to list out a bunch of normative principles she hold to, some of which she expects me not to hold to. Let me just say that my biggest disagreement is with this one: “People have no obligation to perform labor for others. I may not force a surgeon to save my mother at gunpoint. (To be sure, I might. But society would justly punish me for doing so.)”
People have no legal obligation to perform labor for others (other things being equal). But they often have a moral obligation even in the cases where there is no legal obligation. I can’t force a surgeon to save my mother at gunpoint, without paying a legal penalty, even if this is just one of those cases in which she’s fallen into a pond and is drowning, and the only cost to him is that he will ruin his expensive shoes. Still, he may be morally obliged to do what he isn’t legally obliged to do. I suspect a lot of my principled disagreements with McArdle could be spun out of this point. But that’s enough for now.