And Again

by John Holbo on September 2, 2009

Megan McArdle replies to my post:

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.

{ 230 comments }

1

Jay Livingston 09.02.09 at 1:01 pm

“assuming McArdle is right about the r&d shortfall, I would prescribe: r&d. ” We have pretty much a single-payer system for the military. That system may have killed a lot of things, but innovation and r&d are not among them.

2

John Emerson 09.02.09 at 1:07 pm

I think it is probably due to the fact that she has a philosophical abhorrence of certain things….

“Philosophical abhorence” in the sense of “an unphilosophical gut rejection”, which (entirely coincidentally) helps her get jobs at a much higher pay scale than is justified by her talents and abilities.

I know this goes against the principles of liberal pluralism, but sometimes arguments are more intelligible once you realize that they are motivated by opportunism, malice, dogmatism, and narcissism.

3

Albert Jensen 09.02.09 at 1:17 pm

A lot of writing that in essence is simply the “not my money school of thought”, it is always easier to moralise when spending other peoples money. Especially easy when moralising from Ivory towers that are funded with tax payers money.

Let us take your last paragraph, and assume it is YOU that is morally obliged. YOU are morally obliged to give me free lessons because I do not have the money, YOU have the moral duty. If the response is “well it is not the same as healthcare”, I say why not ? surely people have the right to free education, so I demand that YOU give me that free tutoring. I emphasize the YOU, because if a certain moralising viewpoint is not adhered to by YOU then do not expect others to. So please let us meet up I want YOU to give me those free lessons please.

4

John Holbo 09.02.09 at 1:22 pm

““Philosophical abhorence” in the sense of “an unphilosophical gut rejection””

Well, what do YOU get when you get a philosophical abhorence?

5

Donald Johnson 09.02.09 at 1:30 pm

“I know this goes against the principles of liberal pluralism, but sometimes arguments are more intelligible once you realize that they are motivated by opportunism, malice, dogmatism, and narcissism.’

Call me a liberal pluralist, but I think this is unfair. Strike the word “malice”.

Seriously. Look at David Brooks, for another example. I never have the impression of malice coming from him. Opportunistic and narcissistic and dogmatic in an understated way, but there’s no malice there. He wants everyone in the Beltway to like each other.

6

John Emerson 09.02.09 at 1:44 pm

You guys are just liberal pluralists.

If “philosophical in the sense of unphilosophical” is OK with you, John, it’s OK with me. You know what I think about that biz.

How about “sly malice” for both Brooks and McMegan? They both habitually muddy the waters, they both snipe at liberals more than they ever affirm anything, and they’re both subtly misleading whenever they can get away with it.

7

dsquared 09.02.09 at 1:57 pm

I agree with nearly every word of this post, but would substitute “ever” for the final appearance of “now”.

8

Barry 09.02.09 at 1:58 pm

Donald, that runs into the ‘typewriter vs machinegun’ syndrome. For example, I could be a propagandist for a very nasty political system (internally, or in the US, perhaps even acting as a reporter for a US publication). I do my part to enable the system’s brutality, possibly far more than any single thug does, who spends his mornings in torture and his afternoons in mass executions and bulldozing bodies into mass graves.

However, I don’t have to *see* people tortured, let along do it; I’ll probably never encounter the victims.

In one sense, I’m nicer than Mr. Jumper Cables, but only in the sense of not having actual, wet, blood on my actual hands.

9

John Holbo 09.02.09 at 1:58 pm

“YOU are morally obliged to give me free lessons because I do not have the money, YOU have the moral duty.”

Why is this plausible? I mean: why do I – of all people – have to give you – of all people – free lessons – of all things – just because you don’t have the money? The argument isn’t going to be the same one that gets us to general public education, I take it. Nor is it like the saving a drowning stranger case.

I do admit that IF I, personally, am morally obliged to give you free lessons – maybe because you gave me free lessons last week – then I, personally, am morally obliged to give you free lessons. But by telling a story that makes the duty make sense, I only succeed in making it make sense that it is really MY duty. Which you evidently deny.

10

John Holbo 09.02.09 at 2:00 pm

“I agree with nearly every word of this post, but would substitute “ever” for the final appearance of “now”.”

This makes a lot of sense.

11

Steven Chabot 09.02.09 at 2:01 pm

In terms of rationing, we Canadians really look at this argument from a completely different perspective than those in the US.

From my limited reading the argument over there seems to be all about coverage. Who is going to be extended (public insurance) coverage and how will that affect private insurers and the costs of health care.

I think for us here it is all about rationing. Realizing there are finite resources, and deciding who is going to get them: the most in need (i.e the sickest) or the most able to pay (i.e. the richest).

Why should we be scared of the r-word? If we called it like it is it would be easier to frame the problem in terms of ethics and society’s well-being, which should be the topics under discussion.

But again, I am from a different world on a lot of issues, living only a few degrees north.

12

John Holbo 09.02.09 at 2:02 pm

If “philosophical in the sense of unphilosophical” is OK with you, John, it’s OK with me. You know what I think about that biz.

“Metaphysics is the discovery of bad reasons for what we believe on instinct.” – C.D. Broad (I think it was.) I always thought that was pretty funny.

13

zic 09.02.09 at 2:29 pm

n the health case, there is no obvious reason why the government couldn’t fund r&d if private funding should fail.

Government already funds r&d; a discussion of weeks on McArdle’s blog. She initially said, “No” (exact quote) when I said it; evolved to, ‘yes, government funds early r&d, but doesn’t bring drugs to market.” And even there; I would question the validity of the statement. Much of the early research is funded by National Institute of Health (NIH); comparative clinical trails are funded by NIH. And on the other end of the process, safety is evaluated by FDA. Government investments straddles both ends of the r&d process.

The other faulty argument she makes in saying innovation would be stalled with healthcare reform comes in the form of saying r&d and innovation don’t happen in countries with nationalized systems. We have a global market, but a lopsided reimbursement system; products developed in other countries are often brought to market in the US first because we’re willing to overpay compared to other nations.

Anyone who really believes reform will strangle innovation ought to pay more attention to our education system, the real feeder for new, improved, and innovative. Funding for research at universities, teaching hospitals, and non-profit groups has a long, well-proven track record, not only for innovation, but for weeding out dangerous or ineffective treatments. And it’s investment that feeds for-profit industries, particularly pharma; a form of social welfare libertarians/conservatives fail to recognize in their zeal to prove government is always the problem.

14

Salient 09.02.09 at 2:36 pm

Oh, so much to say. This first:

borrowing unearned plausibility

So, um. When one borrows unearned plausibility, does the interest rate drop?

15

John Emerson 09.02.09 at 2:37 pm

I think of Brooks and McMegan as Republican niche operatives whose job is to slice off a tiny percentage of the potential Democratic vote by making plausible, clever, less-batshit-crazy, non-Michelle-Bachman arguments that might convince a few comfortable professionals and hip libertarian units that it’s OK to move into the R. camp. Neither one of them has to convince more than 1% of their audience. Division of labor.

16

Jerry Dworkin 09.02.09 at 2:38 pm

Just to point out that in some states–Vermont is one–the surgeon does have a legal obligation to rescue John’s mother who has fallen into the pond.

Duty to Aid the Endangered Act (Good Samaritan Law) Vermont

Title 12, Chapter 23 ;SS 519:

Emergency Medical Care

(a) A person who knows another is exposed to grave physical harm shall, to the extent that the same can be rendered without danger or peril to himself or without interference with important duties owed to others, give reasonable assistance to the exposed person unless that assistance or care is being provided by others.

(b) A person who provides reasonable assistance in compliance with subsection (a) of this section shall not be liable in civil damages unless his actions constitute gross negligence or unless he will receive or expects to receive remuneration.Nothing contained in this subsection shall alter existing law with respect to tort liability of a practitioner of the healing arts for acts committed in the ordinary course of his practice.

(c) A person who willfully violates subsection (a) of this section shall be fined not more than $100.00 — 1967 No. 309(adjourned session) SS 2-4 effective March 22, 1968.

17

Salient 09.02.09 at 2:40 pm

Also. I have never seen so much time and energy spent trying to convince someone that they are using a word in two different and incompatible ways, sometimes one way, sometimes another way.

Dear. Moloch. In. Heaven. Above. If. That. Is. Indeed. Where. Moloch. Lives. c/o. Megan. McArdle. Ambiguity. In. What. You. Mean. By. A. Word. Ought. Not. Be. This. Effing. Hard. To. Resolve. Love. Salient.

18

Ray 09.02.09 at 2:40 pm

I think it’s significant that McArdle is still refusing to address the two possible meanings of rationing, preferring to bounce between them as suits her argument.
Suppose the government decides that housing is a right, and every citizen over 18 gets a house.

RationingA – ‘Housing’ will mean a small apartment, a cramped duplex or rowhouse. Hot and cold running water, electricity, basic furniture. The government can’t afford to buy anything better for everyone.
Everyone agrees that RationingA is necessary and will happen.

RationingB – the government says everyone has to live in the house they provide.
No-one believes this will happen, no-one is even arguing for it. Yes, there will be some crowding out of private builders, and yes the cost of land may go up, and prices for privately-built homes may rise as a result. But that is not the same as a ban on buying a private home.

19

nick s 09.02.09 at 2:41 pm

she has a philosophical abhorrence of certain things

Such as coherent thought.

20

Salient 09.02.09 at 2:42 pm

Neither one of them has to convince more than 1% of their audience.

Really, not even that. They just have to persistently distract us.

21

roac 09.02.09 at 2:45 pm

It is very evident to me that McArdle is on the other side of the divide between those who have become resigned to their own mortality, and those who have not. (She had a very revealing post a couple of weeks ago in which she admitted that thinking about making a living will upset her so badly she had to go lie down for a while, or words to that effect.)

I think her constantly-repeated argument about the importance of medical innovation amounts to a version of Pascal’s Wager: Whether she would admit it or not, she thinks there is a real possibility that the pharmaceutical industry, as presently constituted, will come up with an immortality drug in time for her to benefit from it, and reducing the industry’s profit margins will lessen or destroy that prospect. In comparison, nothing else matters at all.

22

Salient 09.02.09 at 2:47 pm

Why should we be scared of the r-word?

If you operate on the premise that the rich ‘earned’ their richness, and are entitled to unconstrained expenditure as a kind of natural right corresponding to earned-ness, it starts to make sense.

Go so far as to entertain the belief money is a reflection of one’s worth as a human being — in other words, take as axiomatic that the value one has contributed to society by time T can be fairly measured by the total wealth you have at time T — and everything falls into place.

If we called it like it is it would be easier to frame the problem in terms of ethics and society’s well-being, which should be the topics under discussion.

Well, if you see “society’s well-being” as irrelevant to ethics, and you see ethics as a set of principles derived from the two axiomatic principles I’ve suggested above, you start to see why we are where we are, here.

23

Glen Tomkins 09.02.09 at 2:49 pm

“Rationing” is a proxy for managed care

The actual basis behind the exaggerated and mislabeled fears of reform leading to government “rationing”, is the fact that proposals for reform tend to call for the government payer (the public option, or single payer) to manage the care it pays for in order to reduce costs. Obama, specifically, seems to think that this is a key feature of reform, in that this management of care by the public option payer is seen as the means of making the public option cheaper, and thereby forcing the private insurers to practice the same management of care to drive down their costs, so that their premiums can be competitive with the public option’s.

Yes, it is misleading at best for opponents of reform to throw out the accusation of “rationing” as a reason to be against reform, when what they are actually referring to is the same managed care that the industry practices under the status quo. But this way of formulating the matter sheds light on the why the opponents of reform prefer to call it “rationing” rather than managed care. The industry already does managed care, and its demand management feature is wildly unpopular, especially with its victims, beneficiaries so uncooperative as to generate claims. So industry defenders want to tar the reform proposal with the same brush, by pointing out that the public option will also practice managed care, but they can’t be open about it, because they don’t want to remind people that the status quo already involves the industry practicing managed care. So their faxed talking points have to call it “rationing”.

Dishonest or not, they do have a point about the government practicing managed care, attempting to manage medical care top-down in order to reduce costs. While I think that having a government entity doing the managing for the public good is not as bad as having it done by the industry for profit, I think that the fundamental problem is letting any payer manage medical care. The payer’s role should be just that, to pay for any medical care that the patient requests that is also dictated by the standard of care, a standard of care that should not be defined by the payer.

Leaving the patient in control, letting the patient do all the managing that is allowed to control medical care, will not bankrupt the payer. Medical interventions, mostly, have a high monetary cost only insofar as they carry a high human cost. A bone marrow transplant is in itself so horrendous that no patient will ever want one except the very few with some even more horrendous condition that will benefit from a bone marrow transplant. Patients will manage their care so as to minimize the human costs, and in so doing, will minimize the monetary costs from the bottom up.

We need a single payer in order to kill off the industry that now controls the providers, but we have to structure the way it pays so that this single payer doesn’t simply replace the industry in its control of the providers. The simplest way to do this would be to let the patients control a sizable “continuity bonus” that they can confer or withhold from primary care providers by staying with, or deserting, such providers. Primary care will start working for patients, and the rest of the providers will start working for primary care.

24

akatsuki 09.02.09 at 2:50 pm

Her philosophical abhorrence does nothing to address the facts on the ground. Ideology can only carry you so far when US outcomes are so poor for so much money and we have so many examples of better systems. By the way, Megan, rationing is a nice bugaboo for political hacks but people who actually care about the future of this country and the provision of healthcare should talk about morbidity and mortality rates.

Regarding her R&D point, she should answer (1) the question why, as a libertarian, she feels it is okay to impose an additional burden on the US taxpayer over the rest of the world, and (2) provide a critique of the recent articles showing that Europe is doing more development anyway. Government funded R&D might also have the advantages of not being faked and not having poor outcomes buried (e.g. statins).

Other points, like, that government intervention will destroy the private insurance industry also have no validity- perhaps they might have a takings claim, but I even doubt that since they aren’t being regulated out of business, merely being out-competed. They don’t have some inherent right to exist.

Frankly engaging with a paid off political hack is a waste of time.

25

Barry 09.02.09 at 2:58 pm

Megan “Freudian Projection” McArdle: “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. “

26

Uncle Kvetch 09.02.09 at 2:58 pm

McArdle is more anti-left than anything. Her function is to piss on all things “left” and “liberal” and “progressive” and to reassure her readership that however badly the Republicans screw up the country, “liberals” (however she chooses to define them that day) would be far worse. The only thing worse than a war of aggression is the people who protest against it. The only thing worse than having 45 million people without health insurance is any attempt to fix the problem (and remember, she’s under no obligation to put forward a workable alternative plan–she’s a libertarian).

She doesn’t really have to support or advocate much of anything beyond her hatred of smelly hippies.

In contemporary American political discourse, you can build quite a following on that basis and nothing more. And in McArdle’s case, as with that of Mickey Kaus or Ann Althouse, I really do mean nothing.

27

Salient 09.02.09 at 2:59 pm

Megan “Freudian Projection” McArdle: “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. ”

She’s using sarcasm to mean “allocate inherently scarce humor.”

28

Barry 09.02.09 at 2:59 pm

“Regarding her R&D point, she should answer (1) the question why, as a libertarian, she feels it is okay to impose an additional burden on the US taxpayer over the rest of the world,…”

I note that there are two areas where right-wingers suddenly insist that the USA is and should subsidize the rest of the world:

1) Maintaining a vast military empire,
2) Our current healthcare system.

29

Salient 09.02.09 at 3:01 pm

Megan “Freudian Projection” McArdle: “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. ”

She’s using sarcasm to mean “allocate inherently scarce humor.”

And engagement to mean “allocate inherently scarce patience.”

30

Albert Jensen 09.02.09 at 3:06 pm

John Holbo, just to clarify, I am fully libertarian, so any support I write for the “common good” is purely sarcastic, Let me clarify my point for you, you claim that the surgeon has the moral duty to save your mother, I say he does not. So I wanted to compare your surgeon scenario to somebody demanding from you that you do something for them out of moral grounds, how is somebody demanding something from the surgeon out of moral grounds different from me demanding something out of moral grounds from you ?

If you sat that is different because the surgeon is a emergency while your tuition is not, does that then mean free health care is fine because of the emergency aspect ? but then why do you support free education as well ? If free education is a “human right”, what about free housing, free cars (the right to movement of course), free cellphones, free clothing (the right to decency), free soap (the right to personal hygiene), free electricity etc. etc. For each of these free things, I can easily use your moral arguments to justify them, with your arguments one can never draw the line, one can keep on adding something and claim it as a fundamental human need.

31

Salient 09.02.09 at 3:10 pm

I WILL get the joke right this time. Sheesh.

Megan “Freudian Projection” McArdle: “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.”

She’s using sarcasm to mean “allocate inherently scarce humor.”

And engagement to mean “allocate inherently scarce patience for my bullshit.”

32

Salient 09.02.09 at 3:11 pm

Let me clarify my point for you, you claim that the surgeon has the moral duty to save your mother, I say he does not.

Just to make sure, you’re not a doctor, are you? There’s this thing called the Hippocratic Oath…

33

engels 09.02.09 at 3:14 pm

To add to Uncle Kvetch at #24, it really can’t be stressed too often that if you are a conservative, in the broad sense of being someone who is more-or-less happy with the status quo, it is really not necessary most of the time to argue, to advocate for anything, to express any clear opinions, observations or sentiments, or even to think. All you really have to do is piss on anybody who tries to do any of these of these things. The most efficient way for conservative intellectuals to advance their goals in a great many situations is simply to aim make meaingful discussion impossible. And judging by the general level of the current US health care ‘debate’ they have once again been extraordinarily successful.

34

Bloix 09.02.09 at 3:16 pm

“I have not by word, implication or heavy hint accused McArdle of wanting poor people to die. “

She didn’t say that YOU said that. She said “ONE SIDE” said that. I’m on that side. I said in the last thread that that’s the logical consequence of her argument, and either she understands the consequences of her argument, or she’s an idiot. Of course, there’s no reason she can’t be both – the world is full of evil idiots.

The logical consequence of McArdle’s argument is that it was unfortunately necessary for Eric de la Cruz to die, because providing him and others like him with health insurance would have diverted valuable resources from the development of new drugs. http://www.nytimes.com/2009/09/01/health/01well.html

To paraphrase a famous Time correspondent, this isn’t sarcasm, it’s fact.

35

Salient 09.02.09 at 3:17 pm

Also.

For each of these free things, I can easily use your moral arguments to justify them, with your arguments one can never draw the line, one can keep on adding something and claim it as a fundamental human need.

OK. So, what do you see as a fundamental human need? Let me rephrase that question. In your opinion, what is a human being entitled to, by sole virtue of being a fellow human being, regardless of what they do or say?

36

Albert Jensen 09.02.09 at 3:24 pm

Salient
The oath says the doctor shall not harm the patient, nothing about giving free service.

37

Albert Jensen 09.02.09 at 3:29 pm

Salient
The right to be protected from violence from others, the right to private property, the right to free speech, a government defined on its limits not on the free goodies it gives out, a defense force to guard against foreign aggression, the rights of the smallest minority that is possible – the individual.

There I have listed mine, you dare to list yours ?

38

Salient 09.02.09 at 3:29 pm

“I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”
–from the Hippocratic Oath

“I will apply dietic measures for the benefit of the sick according to my ability and judgment and the sick person’s ability to pay; I will keep them from harm and injustice if the price is right.”
–from the Hippocratic Oath, alternate version

39

Sam C 09.02.09 at 3:31 pm

Albert Jensen at 28: ‘For each of these free things, I can easily use your moral arguments to justify them, with your arguments one can never draw the line, one can keep on adding something and claim it as a fundamental human need.’

There are plenty of arguments distinguishing needs from mere desires, and there’s a large literature on human rights and what they do and don’t cover. John H, so far as I can see, thinks that some things – e.g. basic health care – are human rights, which create communal (not necessarily individual) duties, and that some other things – e.g. elective plastic surgery – aren’t (sorry if I’m misrepresenting you, JH). This isn’t an unusual or undefended position.

So, I don’t see any reason to think that one can ‘keep on adding’ indefinitely. Why do you think so?

(Idle background thought: as it happens, JH already is giving you free education, by writing these posts; but that’s probably supererogatory not obligatory.)

40

Albert Jensen 09.02.09 at 3:32 pm

Salient, I think you are using the alternate version, I cannot find the pay part you mention.

41

John Holbo 09.02.09 at 3:33 pm

“how is somebody demanding something from the surgeon out of moral grounds different from me demanding something out of moral grounds from you ?”

Look, I’m not demanding sincerity – I could tell you weren’t being sincere. I’m demanding coherence and argument. Explain to my why, hypothetically, the view that you have sketched – namely, one on which I, specifically, owe this specific duty of giving free lessons to you, specifically – is plausible. (I don’t require that you believe it yourself. But, before we can get started, I think we need to understand a bit better why someone might believe this thing.)

42

roac 09.02.09 at 3:35 pm

Since we have a Fully Libertarian Person present and answering questions, here is one that I have always wondered about: Do libertarians believe a newborn infant has a right to be fed?

43

Albert Jensen 09.02.09 at 3:36 pm

Sam C
One can keep on adding indefinitely, because that is exactly is what is happening ! Those free things I mentioned, care to debunk any of them as not being a fundamental human right ? I can easily find some number that states that because of lack of soap, x number of people are dying, therefore it is the “collective duty” to supply this soap. So please tell me which of those I mentioned do not count as the fundamental need, I will quickly use your arguments to show that they are !

44

Albert Jensen 09.02.09 at 3:37 pm

roac
Yes they have the right to be fed, next stupid question please.

45

Salient 09.02.09 at 3:38 pm

There I have listed mine, you dare to list yours ?

Eh, you must not know me very well. That’s okay. I’ve done this before on this site, but sure, here we go.

A human being is entitled to a life that is free of suffering induced by material deprivation.

That requires a couple definitions. In particular, “deprivation” is defined time-dependently as that which mean-averages as positive over the human population of binary answers to, “True or false. If X did not exist and was therefore unavailable to you, you would inevitably suffer as a result.” (Roughly, if more than half the human population answers yes for some well-defined material good or well-defined category of material goods X, then lack of that X is defined to be material deprivation; we can assume honesty in the answers because we’re assuming rationality, etc, etc.)

From this, approximately what I mean by “suffering” should be obvious.

What I’m discovering is, this is both a very weak condition (because it doesn’t take into account rights to non-material things like education) and a very strong condition (because not much value is assigned to the “right” of owning lots of wealth). So don’t hold me to it for the rest of my life. But for now, there you go.

46

Albert Jensen 09.02.09 at 3:40 pm

John Holbo
How is the moral duty for a surgeon to help every person that asks him, any more plausible ?

47

Salient 09.02.09 at 3:44 pm

I can easily find some number that states that because of lack of soap, x number of people are dying

Really? Please, do so.

Yes they have the right to be fed, next stupid question please.

No, not next stupid question. To answer the question, you have to explain how by your list of rights alone, we can see a human baby has the right to be fed. A logical-deduction argument, please. Otherwise, you forgot to list an important right!

48

dsquared 09.02.09 at 3:45 pm

For each of these free things, I can easily use your moral arguments to justify them, with your arguments one can never draw the line, one can keep on adding something and claim it as a fundamental human need

yeh, but it’s going to get a lot less persuasive with every iteration, and (ironically) at some point you’re going to look so crazy that you’ll end up being treated (for free!) as a public health problem.

49

John Holbo 09.02.09 at 3:45 pm

“Yes they have the right to be fed”

Isn’t that just another moral demand? You wrote: “how is somebody demanding something from the surgeon out of moral grounds different from me demanding something out of moral grounds from you ?” But a baby is just another life-and-death situation. Helpless baby needs feeding. Helpless person needs rescuing. Potato. Po-tah-to. How is demanding that you save a drowning person, at little personal inconvenience, on moral grounds different from demanding that a baby be fed on moral grounds?

It seems, by your own argument, that if you admit the baby needs to be fed, I can demand free lessons from you. Have I got that right?

50

Albert Jensen 09.02.09 at 3:45 pm

Salient
The material deprivation can imply basically anything, including my free soap argument. Are you for free soap, free hot water, free beds, free housing etc. Can you answer which is material deprivation ? Or do we need material deprivation committees that decide on it ?

51

roac 09.02.09 at 3:48 pm

next stupid question please

Here it is then: So an infant has a right to be kept alive by being fed, but an adult does not have a right to be kept alive by having her infected appendix removed. Wherein lies the difference?

52

Sebastian 09.02.09 at 3:50 pm

“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. “

You’ve asserted this, but it really doesn’t make much sense. Last time you wrote:
“If you massively publicly funded r&d, the results would be as good as massive private funding. Dollar for dollar, all you need is money.”

What makes you believe this is true? A huge part of the currently existing system involves scientists passionately believing in an idea, getting venture capital to start a small bio-tech firm, spending years researching it, with the only likely hope for money being paid back in being bought out by a large pharmaceutical company if the start up can show enough promise to get the drug near stage III trials. The economic calculation is done at a level pretty close to the specialization of individual scientists (and in some cases may initially be made by only a single scientific specialist and the 1-4 venture capitalists he can convince to back him). No government controlled system is going to operate anything like that.

A government system is going to have an enormous apparatus of bureaucracy which will be strongly influenced by politics (remember all those anti-evolution school boards you like so much?) and which will not have the specialization employed in all the right areas of the bureaucracy at all the right times. There is a reason why breast cancer research is funded all out of proportion to its incidence and mortality rate.

It is ironic that you use the military as your R&D example—surely you’ve heard of how political the R&D projects get. We finally killed the F-22 after spending more than $62 billion on a plane that hasn’t made sense in more than a decade. You say that all the government has to do is provide money, but you don’t seem to understand that the whole calculation problem is that absent a price signal the government generally sucks at deciding which projects to provide money for when it has a host of options when the choice requires an enormous level of specialization. (Arguably it sucks even when the choice does not require an enormous level of specialization—see agriculture subsidies. Ethanol subsidies are dumb. Full Stop. Have been obviously dumb for more than a decade. They’re still going. Corn subsidies have been dumb for my entire lifetime. Still going).

It also seems like you gloss over Megan’s objection about why no other country does what you suggest with respect to research. If governments really can do as well with practical therapies on a regular basis, why not let them prove that? You suggest that it is currently a free rider problem (and I agree) but you don’t offer any suggestion about how to get European countries to start paying. You seem to non-explicitly assume that if the US stops paying, Europe will start paying. But that isn’t really how most free rider problems get solved, so it isn’t clear why you think it would work in this case. It isn’t clear that most European countries would want to add a large line item like that to their budgets at this point or at any other point in the immediate future. Especially since if they were committed to it, they could have already done so.

53

John Holbo 09.02.09 at 3:50 pm

Albert, doesn’t it seem plausible that material needs is a somewhat vague category, with a grey area in the middle – possibly shifting over time. And on both sides there are fairly black and white items like: not drowning. That seems needful. And: getting lessons right this second for free. Not so needful.

You can organize a committee if you are a committee sort of guy but that isn’t always necessary. Baldness is a vague category. It doesn’t follow that we need committees to decide who is bald and who is not. Nor is it absurd to call some people bald and other people not, and still others sort of in-between, without committee approval.

54

Salient 09.02.09 at 3:51 pm

Can you answer which is material deprivation ?

Can you see and read the second paragraph, in which I define a metric that determines what is material deprivation and what is not? Or does your Internet browser cut off comment paragraphs beyond the first?

I still want to see the study which demonstrates people are dying specifically for lack of soap (those who would otherwise not die, where there are no alternative non-soap things they could be provided which would prevent these deaths). So, the soap study, please.

If you don’t provide it, and continue on as you have been, I personally hope that someone in power will recognize you’re just spouting and will have the good sense to ban you as a nuisance, some time fairly soon. Sigh.

55

engels 09.02.09 at 3:53 pm

The material deprivation can imply basically anything, including my free soap argument … do we need material deprivation committees that decide on it ?

cf.

The right to personal property can imply basically anything, including the right to keep slaves, prisoners, .. Do we need rights committees that decide on it?

(Hint: yes, we do. We call it ‘the legal system’.)

56

Sam C 09.02.09 at 4:00 pm

Albert Jensen: I haven’t made any positive arguments for particular human rights or fundamental needs. I just asked you to clarify your objection to a right to healthcare, which I still find obscure. Let me try to explain why.

You claim that there are the following human rights (call them A-rights):

The right to be protected from violence from others, the right to private property, the right to free speech, a government defined on its limits not on the free goodies it gives out, a defense force to guard against foreign aggression, the rights of the smallest minority that is possible – the individual. (your comment 35)

You also claim that there are no such rights as e.g. a right to healthcare (call them B-rights). What I don’t understand is how you’re distinguishing between the two sets. You’ve gestured at two arguments:

(1) there’s no particular individual who is the subject of the corresponding duty for B-rights. But the obvious answer to that the subject of the duty is a group.

(2) that if we once accept a B-right, we’ll have no principled way to reject any and all claims of B-rights to all sorts of important things – soap was your example. But the obvious answer to that is that you have no such principled way to reject additions to your list of A-rights, either. What makes them special? You haven’t offered any justification of that particular list at all, so why think it’s resistant to additions?

57

Albert Jensen 09.02.09 at 4:01 pm

John Holbo
You clearly do not think to highly of humans, if you think they need to be told by philosophers that they have to feed their baby ??? To stay on topic, does the surgeon have the moral duty to offer free care to your mother, it is a very simple question ?

If you want to know where the most babies have been starved in the real world, I suggest you look at those countries that were attempting the “common good” idea.

58

Albert Jensen 09.02.09 at 4:02 pm

engels
Slavery implies violent force, it violates all libertarian principles !!!. Next stupid question please.

59

Sam C 09.02.09 at 4:03 pm

(I note that roac has offered you a very nice example of just such an addition.)

60

Albert Jensen 09.02.09 at 4:04 pm

Sam C
It is very easy to distinguish, you have no right for me to pay for someone elses health costs.

61

John Holbo 09.02.09 at 4:05 pm

Just to be clear how the vagueness problem interlocks with the legal system: sometimes the reason we don’t encode moral obligation in the legal system is precisely that it seems unencodable – due to vagueness, for example. But that doesn’t mean there is no obligation. Vague things aren’t unreal. And other times we draw a legal line, which can be a bit artificial. You could (and sometimes this has been done) pass laws mandating assistance to those in need, if it can be readily extended in a non-heroic manner. Those sorts of things are hard to legislate because it’s hard to say how far you ought to extend them.

62

Sam C 09.02.09 at 4:06 pm

(another note in passing: Salient, your metric is nice; you might be interested, if you don’t already know it, in David Wiggins’s piece ‘Claims of Need’, in his Needs, Values, Truth.

63

Sam C 09.02.09 at 4:08 pm

Albert Jensen: ‘It is very easy to distinguish, you have no right for me to pay for someone elses health costs.’

That’s not a way to distinguish, that’s just a reassertion of the very distinction I’m asking about. What is the principle on which you make this and other, similar distinctions? Because if you don’t have one, you’re just dogmatically committed to your particular favoured list of rights, and your argument against John Holbo’s different list fails.

64

someguy 09.02.09 at 4:08 pm

I am curious as to why you think signaling is so crucial to growth?

“Efficienct” signaling means an “efficient” allocation of resources but how does it relate to growth? If we re-arrange everything efficiently at any one point in time we can get more at that point in time but why is it that you think doing so will result in more growth?

Market A is size 8 when inefficient and will grow at 10% next year. We re-arrange it efficiently so it is 9. Why do you think growth will be greater than 10% next year?

As far as I could tell your argument regarding why signaling isn’t necessary for the health care sector consisted mostly of it isn’t needed.

Why do you think your arguments regarding signaling within the health care sector don’t appply to other sectors?

I mean it isn’t rocket science is it? We want faster computers so lets invets in R&D for faster computers. Why do we need private R&D for anything?

Are you concerned about signaling between sectors? Surely that is important? How will you know how much to spend on health care R&D? How will you know to spend enough?

[Pretty funny stuff on the last thread regarding the right to buy more insurance. The classic CT scenario. CT poster – no one is arguing X that is just a conservative stawman. CT commentators – X is a fine argument. Meanwhile Quebec just missed banning it by a 4-3 court decision. But no one is making that argument! How utterly debased that we need to debate whether we allow others to seek more treament for their maladies. ]

65

engels 09.02.09 at 4:09 pm

Slavery implies violent force, it violates all libertarian principles

Using violent force to defend one’s property violates all libertarian principles?

66

zic 09.02.09 at 4:11 pm

Albert Jensen, I pay for someone the health care costs of others. I pay a lot, and I do it through my private-insurance premium.

I have a high-deductible plan; it costs over $800/month for my family of four, there are no other plans available to me where I live, and it rations my care despite the fact that it’s never paid a single cent of my health care costs.

I’m happy to pay for my insurance and my health care. But I’m very unhappy that this conversation breaks down to free care for the poor when there are many people, like me, subsidizing the care of folks like you who get full coverage.

This discussion is faulty in that it’s binary; those with and those without insurance. The bigger issue, the issue that has made it such a political horse race, is not simply those without insurance, but the analog shades of gray where the insurance market is failing customers.

67

zic 09.02.09 at 4:13 pm

Excuse me, delete the ‘someone’ in the first sentence.

68

Uncle Kvetch 09.02.09 at 4:16 pm

To stay on topic, does the surgeon have the moral duty to offer free care to your mother, it is a very simple question ?

Under what health care systems are doctors expected to provide “free care”? Even in the British system, the doctors collect a salary. No one expects doctors to work for free.

69

Albert Jensen 09.02.09 at 4:16 pm

Sam C
The difference is 1 )physical force unto me versus 2) me paying for someone to go to the doctor . Me not paying for some else to do go to the doctor is not me forcefully violating him in any way, if you cannot see the difference between the two, then I cannot help you.

You are no less dogmatic in demanding free health care, except you claim it as being undogmatic of course, unless you want to openly declare in front of everyone that perhaps you are not for free health care.

70

Albert Jensen 09.02.09 at 4:19 pm

Uncle Kvetch:
The doctors get paid, because people are forcefully(yes they have to) taxed to pay that free health care. Those people are morally forced to provide that free care. If the doctor feels like he wants to provide free care, let him.

71

roac 09.02.09 at 4:20 pm

Engels, libertarians have a highly technical definition of “violent force,” as you will no doubt learn shortly.

By way of full disclosure, I was once a libertarian myself, though I didn’t know the name for it. I was converted to libertarianism by a science fiction story — I don’t remember the title, but Eric Frank Russell was the name of the author. Nor do I remember how old I was — say about 13 — nor how long elapsed between the time when I said to myself “This explains everything!” and the time when I said “Oh, wait, no it doesn’t” — say about 48 hours.

Fortunately I kept the whole episode to myself from that day to this. But I find it useful to keep in mind.

72

Donald Johnson 09.02.09 at 4:21 pm

John Emerson and Barry–

I basically agree with you–I was just quibbling. Brooks, who I observe and read more than Megan, wants to be liked by his inside the Beltway buddies and others in his social class–he wants to joke around and spar on a friendly basis with Mark Shields and Jim Lehrer, while writing columns advocating ruthless tactics in Iraq (back in 2003 or so, before the Abu Ghraib story broke). He is opposed to torture trials because those are his social equals (and people who shared his views a few years ago) that would be on trial.

73

John Holbo 09.02.09 at 4:22 pm

“CT poster – no one is arguing X that is just a conservative stawman. CT commentators – X is a fine argument.”

Well, these are actually consistent in a practical sense – not a strict sense, obviously. From the fact that some CT commenters want something, it follows that some folks want something. But those who are opposed, in principle, to letting anyone buy extra insurance are much more egalitarian than anyone with serious influence over the health care debate. (I mean: single-payer isn’t really seriously on the table at the moment. How far off the table is single-payer with no one even allowed to buy more on the private market?) I’m not saying that no one could ever institute this sort of egalitarianism, just that arguing that we shouldn’t do X because it might put us on a slippery slope to the other thing seems very far-fetched, in a US context. Slippery slopes should look slipperier than that.

So conservative commentators who say the trouble with reform is that it will lead to this other thing really are attacking a strawman. I think that’s fair

74

Albert Jensen 09.02.09 at 4:23 pm

I wish everyone here good luck, you sure will need it. Because if you actually looked at the numbers and the future aging demographics of your favourite European country (I am German btw), you will quickly see that all your ivory tower moralising will quickly meet the “there is no money” real world.

75

Sam C 09.02.09 at 4:23 pm

Albert, I haven’t demanded anything about health care, and I’m not going to. I’m a philosopher interested in human rights, and you’ve made some claims about such rights which I think are problematic.

You have at least now offered some kind of grounding principle for your list of real human rights: they’re all rights not to be subject to ‘physical force’. OK, that’s a familiar position. The equally familiar problem with it is: there are all sorts of things people can do, or fail to do, to one another, which are as bad as exerting physical force. People can die just as painfully from lack of oral rehydration salts as from gunshot wounds. So what’s so special about physical force?

76

Richard Cownie 09.02.09 at 4:24 pm

“assuming McArdle is right about the r&d shortfall, I would prescribe: r&d.”

Notice also that market-driven r&d will inevitably allocate the scarce r&d resources
to work on drugs and treatments which appear likely to have a profitable market:
hence lots of research into treatments for sexual dysfunction, arthritis, high blood
pressure etc which target mostly middle-aged, and thus relatively wealthy and
well-insured, people. Not so much research into pediatrics.

Now that *might* perhaps be the allocation of resources that we want. But it would
be naive to just *assume* that r&d driven by the profit motive will achieve the best
health outcomes for the population as a whole – after all, it isn’t even *trying* to
do that. No money in your disease ? Sorry, no research.

In the extreme case, if Bill Gates and Warren Buffett contract a rare, fatal, and
hitherto-uncurable disease, would it be a good idea to spend $10B looking for a cure ?
Or should we prefer an r&d funding system that targets people, rather than dollars ?

[With the usual caveats that governments often screw up and fail to pursue their
objectives effectively.]

77

Substance McGravitas 09.02.09 at 4:25 pm

So what’s so special about physical force?

Libertarians will never be numerous enough to raise an army.

78

Bunbury 09.02.09 at 4:26 pm

If someone can come up with a list of places where people are dying because of a lack of soap I will happily send some.

79

Albert Jensen 09.02.09 at 4:31 pm

roac
There body is sovereign, to violate it for the “collective good” is violent force. Is that too technical for you ? The altruists and the “moral guides” of society their definitions are will take pages of heavy impenetrable philosophical jargon, to basically mask “the sacrifice on the individual for the good of the whole”. The same ilk that in the 1930’s “saw the future and it works” are basically here moralising from their ivory towers. The only solace is that all these ivory towers are crashing down, I will never hire an American student again, they have been tarred with too much of this “common good” brush, many Indians and Chinese are thankfully not afflicated with the Soviet style thinking anymore.

80

The Raven 09.02.09 at 4:31 pm

People have no obligation to perform labor for others. I may not force a surgeon to save my mother at gunpoint.

We do have legal obligation to feed, clothe, and otherwise care for our minor children to the best of out abilities. This statement is false-to-fact. I see no reason to accept as principle the rejection of all such obligations–I wonder if Ms. McArdle does?

On the other hand, there’s more food for us corvids if this becomes a widely-accepted principle.

81

Albert Jensen 09.02.09 at 4:33 pm

Bunbury
Many sub saharan countries have deaths due to lack of basic hygiene, a fact that if you had the most rudimentary understanding of the death rates of the pre hygiene world should know, you had better start sending those billions soaps.

82

scarn 09.02.09 at 4:36 pm

“I will never hire an American student again”

Most Americans I know are hard-shelled Marxists. It’s True!

83

Substance McGravitas 09.02.09 at 4:39 pm

Most Americans I know are hard-shelled Marxists. It’s True!

You can tell when they wear their iPods just so.

84

Sam C 09.02.09 at 4:40 pm

Albert, you keep asserting, more and more aggressively, that your account of rights is correct (and that anyone who disagrees with it is stupid or evil). But the thing is, I don’t believe you, and why should I? You’ve given no reason at all for your confidence. Let me ask you again: what’s so special about physical force?

85

engels 09.02.09 at 4:46 pm

Albert, just out of interest what do you hire all these international students for anyway?

86

Mrs Tilton 09.02.09 at 4:47 pm

(re: Albert Jensen, passim)

Smarter libertarians, please. This one doesn’t even provide much entertainment value.

Och, und Albert, Schatz, verpiss Dich doch nach Somalien, dort kannst ein libertäres Paradies bis zum Abwinken erleben.

87

Glen Tomkins 09.02.09 at 4:51 pm

@Albert Jensen

That “aging demographic”

Well, in the US, we already have the aging demographic on a public option/single payer, Medicare. Sure, the Medicare-aged present a cost problem if they are a growing demographic compared to the demographics still working, who therefore have to be relied on to do most of the paying. But the public has already eaten that potential problem, we’ve already socialized that risk so that those Heroes of Libertarianism in the health insurance industry can ply their trade on the lower risk younger population, unencumbered with the responsibility of caring for the elderly.

What’s under discussion now is not how we pay for the care of the elderly in the US. That’s a cash loser, so no one wants to take it from the government. We’re trying to sort out who controls the health care contributions from the positive-cash-flow demographic, the young. Based on prior experience, the smart money says that we will find a way to continue, and even enhance, socialization of the risks and privatization of the profits.

88

roac 09.02.09 at 4:58 pm

Going back a bit, to the issue of the newborn needing to be fed: I take AJ to be saying that (1) babies have a right to be fed by their parents, and (2) this presents no problem as natural instinct will impel the parents to satisfy that need in every case.

Factually (2) is simply not true (even leaving aside the many, many societies that have practiced systematic infanticide). Newborns are regularly found abandoned in public places in western countries. When this happens, public employees paid with tax money (extorted by force from libertarians, among others) will take the baby to a hospital, where other public employees will (as a minimum) feed it bottles of formula paid for from the same source of ill-gotten funds.

Are you outraged by this, Albert? Is it distinguishable from using public funds to pay for removing the appendix of an adult who is found without identification lying unconscious in the street? If so, how?

89

John Emerson 09.02.09 at 5:05 pm

Oh, fuck. A sincere libertarian. Less fun than even McMegan.

Libertarians are worse than Hitler. I declare this thread closed.

90

roac 09.02.09 at 5:14 pm

Does a thread-closing post take effect if it contains a Godwin’s Law violation? Just trying to stay abreast of all internet traditions.

91

nick s 09.02.09 at 5:33 pm

It just shows that George W. Bush had one distinct capability: to make doctrinaire libertarians look less insufferably tedious than they really are.

92

jdkbrown 09.02.09 at 5:55 pm

Though I suspect Albert Jensen will not trouble to read it, let me recommend Allan Gibbard’s “Natural Property Rights” to anyone interested in libertarian principles, property rights, social welfare, etc. Therein Gibbard argues that the hard libertarian position that nobody can be deprived of a property right without their consent in fact fails to justify unencumbered property rights–so that even hard libertariansim plausibly supports a fairly robust social welfare system.

The paper originally appeared in Nous, and excerpts can be easily found via google.

93

Robert 09.02.09 at 5:59 pm

I have a great idea. If I could form a company to market my product, I think I’ll make a lot, even after paying off any venture capitalists. But I am having difficulty finding one to lend me money. I don’t have a problem with the interest rate, but they want collateral.

I’ve found one venture capitalist, though, with whom I can come to a mutual agreement. He’ll lend me capital if I agree to be his slave-for-life after a designated date if I haven’t paid him back by then.

Why does the supposed “libertarian” on this thread want to use force provided by the state to prohibit capitalist relations between mutually consenting adults?

94

someguy 09.02.09 at 6:05 pm

John Holbo,

What Megan said. A very large number of folks who support this proposal (which is at the very least counterfactual in some very important aspects, which seems to me makes it more difficult to argue about it concretely) want and believe that it will result in a single payer system.

Given that. I am not sure why it isn’t permissible to say but a single payer system will/might result in X and so lets not support this proposal. The slope might not be that slippery. But hey lets at least talk about it.

Anyway. You answered the quip but not the pertinent questions. I would especially love to see an answer to the first.

95

Stuart 09.02.09 at 6:09 pm

I think for us here it is all about rationing. Realizing there are finite resources, and deciding who is going to get them: the most in need (i.e the sickest) or the most able to pay (i.e. the richest).

Why should we be scared of the r-word? If we called it like it is it would be easier to frame the problem in terms of ethics and society’s well-being, which should be the topics under discussion.

Because it isn’t rationing. To compare to food for example: in WWII (and for years after) Britain had rationing of many types of food – black market aside, if you didn’t have a ration book with a spare slot available you couldn’t get any more of that type of food.

In the US currently you have food stamps, so that in general a minimum level of nutrition should be guaranteed no matter how poor you are. I don’t think any reasonable person is going to argue that food in the US is currently rationed.

There are no mainstream proposals for US healthcare I have heard about that would go any further than the food stamps example, and most aren’t even in that ballpark even. While you can make arguments that the Canadian system is essentially rationed (with travelling to the US for private healthcare being the equivalent to the food black market), it seems unlikely anyone (with political power) is going to suggest the Canadian model or anything remotely like it in the US at this time.

96

Uncle Kvetch 09.02.09 at 6:12 pm

I am not sure why it isn’t permissible to say but a single payer system will/might result in X and so lets not support this proposal.

So, you and McArdle would only support a proposal to reform health insurance on the condition that liberals are against it?

97

roac 09.02.09 at 6:14 pm

He’ll lend me capital if I agree to be his slave-for-life after a designated date if I haven’t paid him back by then..

Change “be his slave for life” to “donate my heart for transplantation into his ailing relative,” and you get a 16th-century example of flagrant State interference with the sacred right of contract — The Merchant of Venice.

If you eliminate the distraction created by the anti-Semitism, the play would be an excellent litmus test to separate the true libertarians (the ones rooting for Shylock) from the wishy-washy ones.

98

Ginger Yellow 09.02.09 at 6:19 pm

Hold on. This thread has gone on for over 90 comments and nobody has properly called up Jensen for this: “Let me clarify my point for you, you claim that the surgeon has the moral duty to save your mother, I say he does not”?

Is it any wonder libertarians are held in such low regard, however noble their principles might seem to be? You’re seriously arguing that a person has no moral duty to save someone else whose life is in peril, even without putting your own life in jeopardy? And you call other people’s moral systems evil, ivory tower elitism? How dare you. Regardless of the Hippocratic oath, in pretty much any moral system you can name there’s a moral obligation, and rightly so.

99

Lee A. Arnold 09.02.09 at 6:24 pm

McArdle’s argument is confused long several angles! For another: she quotes Hayek on the functions of the price mechanism, not realizing that his argument applies to supply and demand over an ENTIRE system, and does not invalidate the making of one portion of it into some other sort of rationing mechanism. So even with a totally nationalized healthcare system, outside of it the private suppliers of goods to it would still exist, and be innovating according to its demand.

Indeed there would be MORE demand, because more people would be in the system.

Of course in the U.S. reform debate, a national healthcare system is not on the table: merely a public insurance choice for consumers in the market. Here, her argument appears to jump to the position that this would crowd-out, and put an end to, private insurance. But by the Congressional bills being offered it would not, and she offers no theoretical or empirical argument that it would.

This makes it difficult to accept her implication that one’s own philosophical opinion on a policy issue should make reference to particulars. In fact, she appears to be making the general “slippery slope to communism” argument again, vacillating as usual between the liberty and efficiency aspects of that old chestnut. Unfortunately for her, The Road to Serfdom never came true in a democracy, and by the way, Hayek was in favor of national health insurance.

100

someguy 09.02.09 at 6:27 pm

Ray,

RationingA in many cases really means effectively RationingB.

In a single payer system you can purchase additional health care but to some degree you are very much stuck within the system provided by the govt. You really are stuck living in the house they provide. Repurchasing such an expensive item is effectively impossible.

Maybe that is great since it is a swell house and more people would have housing but lots of people would be stuck.

101

Stuart 09.02.09 at 6:41 pm

In a single payer system you can purchase additional health care but to some degree you are very much stuck within the system provided by the govt. You really are stuck living in the house they provide. Repurchasing such an expensive item is effectively impossible.

So given that the NHS is a single payer system, you are saying that BUPA, Aviva, Standard Life, etc. don’t exist? Seeing as their coverage must be so expensive no one would consider buying it?

102

Moleman 09.02.09 at 6:43 pm

Amusing bit here, which may have been touched upon already:

People have no obligation to perform labor for others. I may not force a surgeon to save my mother at gunpoint

While Megan may not be brandishing the gun herself, there are, in fact, numerous situations in which a medical professional is legally obligated to treat patients- EMTALA’s been in effect since 1986, nearly all hospitals are bound by it, and until you’re at the very least stable for discharge, you can’t get rid of them. And as the libertarians are so fond of reminding us, all these laws are enforced by the threat of “men with guns.” So if her mother’s life was actually threatened, then yes- there is a gun pointed at that surgeon, even if it’s at a remove. They can ruin her mother with medical bills later, but they can’t withold their labor.

103

scarn 09.02.09 at 6:47 pm

Given that. I am not sure why it isn’t permissible to say but a single payer system will/might result in X and so lets not support this proposal. The slope might not be that slippery. But hey lets at least talk about it.

Well, given that my government isn’t proposing a single payer plan, and given that whatever reforms (if any) that are passed are going to seriously change my relationship with healthcare, I’d really rather spend my time talking about what’s actually on the table. It really does seem that reform opponents want to focus on single payer because they feel that it’s a debate that’s easier for them to win.

104

urgs 09.02.09 at 6:47 pm

Right, she doesnt want poor people to die, but apperently her level of indifference is high enough to let them die if it would cost a penny to save them.

105

Sebastian 09.02.09 at 6:58 pm

“Right, she doesnt want poor people to die, but apperently her level of indifference is high enough to let them die if it would cost a penny to save them.”

This seems a common misreading of her post, which is mysterious since she explictly says:

“If it were up to me, I’d combine a broad income subsidy like the EITC with some sort of reinsurance pool for high-risk patients, then I’d probably force everyone to buy some sort of catastrophic medical coverage on the grounds that otherwise, people with adequate income but few assets will be too tempted to freeload off the generosity of the public. “

106

LizardBreath 09.02.09 at 7:04 pm

105: I do remember noting that, and wondering what the principled distinction was between her desired health-care reform and what’s making its way through Congress.

107

Henri Vieuxtemps 09.02.09 at 7:10 pm

The right to be protected from violence from others

Some nerve. Why should I pay for your protection from violence? If you need protection, hire your own bodyguards, mister.

108

Dan 09.02.09 at 7:20 pm

Is it any wonder libertarians are held in such low regard, however noble their principles might seem to be? You’re seriously arguing that a person has no moral duty to save someone else whose life is in peril, even without putting your own life in jeopardy? And you call other people’s moral systems evil, ivory tower elitism? How dare you. Regardless of the Hippocratic oath, in pretty much any moral system you can name there’s a moral obligation, and rightly so.

I wish libertarians were clearer on this, but I think what he probably means is that there is no enforceable moral duty to save someone whose life is in peril, rather than that there is no moral duty tout court. Personally I think that there is a general moral obligation to save someone whose life is in peril provided the cost is reasonable (I’m well aware we can have all kinds of arguments about what ‘reasonable’ costs are), but that this is a duty which can and should not be enforced. My impression is that other libertarians (crazy Objectivists aside) would most likely agree if you put it this way, although they often state it very badly.

109

Phil 09.02.09 at 7:21 pm

The doctors get paid, because people are forcefully(yes they have to) taxed to pay that free health care.

I have never experienced being forced to pay taxes, for any meaningful sense of the word ‘forced’. I freely give my consent to being taxed. The fact that, if I were to withhold consent, my compliance might ultimately be coerced by MEN WITH GUNS means very little to me; apart from anything else, any regime which was so illegitimate that I would want to withhold my taxes would probably have MEN WITH GUNS coercing the citizenry in any number of ways. And this last-instance possibility of coercion certainly doesn’t suggest that my situation actually is one of coercion (“objective” coercion, perhaps). Do Libertarians have a theory of false consciousness to deal with people like me?

110

Phil 09.02.09 at 7:22 pm

Stuck in mod. Soc1alism not mentioned. What up?

111

jdkbrown 09.02.09 at 7:23 pm

“Maybe that is great since it is a swell house and more people would have housing but lots of people would be stuck.”

And under the current system, those people are also stuck–they are stuck *without* access to adequate healthcare.

112

Chris 09.02.09 at 7:30 pm

Given that. I am not sure why it isn’t permissible to say but a single payer system will/might result in X and so lets not support this proposal. The slope might not be that slippery. But hey lets at least talk about it.

It’s not permissible to JUST say that system X might result in Y, because you’re not giving any reason to believe that system X actually might (let alone is reasonably likely to) result in Y. You have to present actual argument and evidence leading from X to Y or you have nothing but baseless speculation.

For example, during the 2008 U.S. presidential campaign, some people said that electing McCain might lead to war with Iran. If that had been ALL they said it wouldn’t be much of an argument. But there was, in fact, plenty of bellicose rhetoric from McCain that made it seem quite likely that electing him really would have led to war with Iran. Since he wasn’t elected, I guess we’ll never know. But the thing that made the argument reasonable was that evidence – the actual argument part.

That’s the thing that McArdle perennially excuses herself from providing in “health care reform might lead to (insert doomsday scenario here)” speculation.

(A single payer system is not currently even being considered by the government – at least in the US. So what it will and won’t lead to is irrelevant.)

113

Dan 09.02.09 at 7:36 pm

Though I suspect Albert Jensen will not trouble to read it, let me recommend Allan Gibbard’s “Natural Property Rights” to anyone interested in libertarian principles, property rights, social welfare, etc. Therein Gibbard argues that the hard libertarian position that nobody can be deprived of a property right without their consent in fact fails to justify unencumbered property rights—so that even hard libertariansim plausibly supports a fairly robust social welfare system.

I just checked this out, and from the looks of it what Gibbard calls “hard libertarianism” is not a view that any libertarians actually hold. He seems to assume without argument that the world is somehow jointly owned by everyone, whereas libertarians usually believe (quite reasonably, I think) that this is not necessarily so, and that the default status of the world is unowned. So if he is trying to derive the legitimacy of the welfare state from principles that actual libertarians would accept, he fails because we do not accept the principle he mentions, and if he thinks that the principle he mentions is superior to the alternative that libertarians actually hold, he owes us an argument (which is lacking in the paper) to this effect.

114

someguy 09.02.09 at 7:52 pm

scarn,

Really?

Ok lets discuss a/the Republican plan

http://coburn.senate.gov/public/index.cfm?FuseAction=HealthCareReform.Home

vs the Democrats plan.

115

Stuart 09.02.09 at 7:56 pm

(A single payer system is not currently even being considered by the government – at least in the US. So what it will and won’t lead to is irrelevant.)

Isn’t the problem that a Public Option is still on the table, and that means that because the government is so much better at providing healthcare than private corporations (one side arguing the issue would never admit it of course, but the evidence around the rest of the world makes it fairly clear this is the case), that amounts to something that will approach a single payer system in the long run anyway, as the superior government system will marginalise private health care to those for whom price/cost effectiveness is an irrelevant consideration.

116

jdkbrown 09.02.09 at 8:07 pm

“from the looks of it”

As they say, read the whole thing. He does, in fact, consider the Lockean scenario under which the default state of property is unowned, and unowned property can be appropriated by mixing labor with it.

117

someguy 09.02.09 at 8:08 pm

Stuart,

Is Medicaid superior to private insurance?

118

Martin Bento 09.02.09 at 8:17 pm

Given that. I am not sure why it isn’t permissible to say but a single payer system will/might result in X and so lets not support this proposal. The slope might not be that slippery. But hey lets at least talk about it.

The problem is that Mcardle’s doomsday scenario slips further than that: to single-payer where private purchase of additional insurance is illegal. This is not what has generally happened in the world, and it is particularly hard seeing it coming about in the US where the prevailing political forces and culture have already prevented universal health care by any means for decades longer than any other developed country, and have made the chance for even a public option, much less single-payer, quite dubious.

119

scarn 09.02.09 at 8:27 pm

Someguy,

I’ll say this – Coburn’s plan is an improvement over the status quo. A national exchange goes a long way towards solving the problem of affordability. Pooling, properly regulated, is a great idea. I’d rather see risk-adjustment overseen by a government agency that is responsive to voters, but that cuz I’m a liberal. A tax credit is a by and large fine way to subsidize costs. I’ve got no problem with throwing in tort reform to keep doctors happy. All in all it’s workable, but I don’t think it provides quite the same level of good outcomes as the Democratic plans on the table. From what I understand this does not differ too significantly from Democratic plans that do not contain the public option, but maybe you can enlighten me on that score.

120

Cryptic ned 09.02.09 at 8:35 pm

Uncle Kvetch:
The doctors get paid, because people are forcefully(yes they have to) taxed to pay that free health care. Those people are morally forced to provide that free care. If the doctor feels like he wants to provide free care, let him.

So, your point is, taxation is theft. That seems to be the point of a lot of libertarians on a lot of topics.

121

Bloix 09.02.09 at 8:35 pm

The fundamental factual premise of McArdle’s argument is false.

http://www.prospect.org/csnc/blogs/tapped_archive?month=09&year=2009&base_name=the_atlantics_mcardle_problem

She ridicules Holbo for not dealing with the world as it is, and then she constructs her entire argument around the world in her own head.

It’s not worth arguing with her. It’s not just that she argues in bad faith. It’s that she doesn’t understand what a good faith argument looks like.

122

Dan 09.02.09 at 8:36 pm

As they say, read the whole thing. He does, in fact, consider the Lockean scenario under which the default state of property is unowned, and unowned property can be appropriated by mixing labor with it.

Admittedly I read it quickly, but his argument here is still extremely unconvincing – he himself manages to find a perfectly plausible moral principle underlying appropriation, and then proceeds to dismiss it with “to me, this principle is far from self-evident.” With all due respect to Gibbard, a lot has been written on this topic since his paper (I would have expected most people posting on here to have read Cohen’s book especially); self-ownership, in particular, is a pretty good reason to reject the kind of taxation on labour that he suggests is a possible alternative to sole appropriation, and he doesn’t mention it once.

123

Cryptic ned 09.02.09 at 8:37 pm

In the US currently you have food stamps, so that in general a minimum level of nutrition should be guaranteed no matter how poor you are. I don’t think any reasonable person is going to argue that food in the US is currently rationed.

Oh yeah? Good luck taking $50,000,000 out of a bank and spending it all on Goldenberg’s Peanut Chews, even at market rates. Some people will be unable to get what they want.

124

Donald A. Coffin 09.02.09 at 8:43 pm

And, not, this from The New Republic’s group blog:

Megan McArdle’s Word Games
Isaac Chotiner

Atlantic blogger Megan McArdle wrote a post on pharmaceutical companies last month, and while replying to one of her commenters, she said this:

“The United States currently provides something like 80-90% of the profits on new drugs and medical devices. Perhaps you think you can slash profits 80% with no effect on the behavior of the companies that make these products. I don’t.”

Last week, during a Washington Post online chat, this exchange took place:

“Anonymous: You said that medical innovation will be wiped out if we have a type of national health care, because European drug companies get 80% of their revenue from Americans. Where did you get this statistic?”

“Megan McArdle: It wasn’t a statistic–it was a hypothetical.”

The mind reels…

The mind reels, indeed…

125

Cryptic ned 09.02.09 at 8:47 pm

Why did she say “80-90%”? Her point would have been more convincing if it was 100%. See, this is why Republicans never win arguments, they’re too timid.

126

dsquared 09.02.09 at 8:52 pm

Actually if you look at the a/c of Glaxo et al, the figure is more like 40%.

127

Ceri B. 09.02.09 at 8:56 pm

On the libertarian principle that the fruits of coercion and theft are tainted, there’s basically no clearly legitimate private property anywhere in the world. In the US, for instance, we did in fact have Woodrow Wilson, state governments dominated by the KKK, internment and theft of the interned people’s goods in both world wars, sundown towns, restrictive covenants imposed in law, and a whole lot more. It is certainly possible for someone to do the research and establish that their real estate and the things on it do not depend on ever having displaced someone coercively or fraudulently, but it’s hard to do, and in practice it’s much more common to assert “my stuff” than show it.

(Libertarian philosophical discussion of the fruits of theft and force don’t get into statutes of limitation, and I remember David Friedman being equivocal about whether he thought they were actually a good idea for acts that would count as violations of rights libertarians recognize. But I’m not trying to be sophistic about this and definitely not insisting that statutes of limitation are anti-libertarian or anything. I note it as a point of vaguery, at most.)

How many libertarians can show, rather than simply assert, that no significant part of what they are pleased to call “mine” depends on the violent and/or fraudulent taking of others’ labor and goods?

128

someguy 09.02.09 at 9:20 pm

40% is sales? At least that is the US percentage for all drug sales. That would imply a somewhat higher profit percentage.

129

roy belmont 09.02.09 at 9:26 pm

Without a eugenic trim and a subsequent maintenance program of population stabilization, our health care is good enough, technically, to keep lots and lots of us going, at resource consumption levels that are already past terminal.
Most of the anti-reform side on this issue really want a eugenic program, to take control of that runaway train.
Most of them are fine with lots of people dying as long as it happens outside their clads and affinity groups. But overt championing of that direction is socially prohibited, and has dangerous public consequences in reaction. So it gets masked as harsh but necessary policy and ethical toughness. And regrettable loss at the lower edge.
It isn’t.
It’s a softly held, invisibly present desire for a eugenic solution to the nightmare chaos of modern civilization’s mindless consumption of everything.
And it’s creepy and evil.

130

Salient 09.02.09 at 9:52 pm

In the US currently you have food stamps, so that in general a minimum level of nutrition should be guaranteed no matter how poor you are.

As a side point, I hope people realize just how unbelievably hard it is to apply for and receive food stamps, welfare benefits, et cetera.

You have to be personally interviewed by a heavily overworked case-worker who in worst-case scenarios can’t see you for weeks if not months, etc. There are emergency provisions for emergency situations, allegedly, but even if you technically ought to qualify the burden of proof is on you and is quite stringent. Additionally, you’re required to take basically any job offered at any legal wage, which apparently means minimum wage for work that everyone else is getting paid $8 or more to do.

The system, paid for by state budgets which are inflexible and can’t handle stress, is frankly ridiculous. Even just shepherding someone through the process is unjustifiably burdensome. And, for anyone who has racked up a lot of student loan debt, there’s no good way out: you’re forced to drop out of school and work instead, which triggers exit consultation for the loans, which…

131

Salient 09.02.09 at 9:57 pm

Also, thank you to Sam C: I am currently in the “trying to read enough fundamental philosophy of ethics to ensure the basic idea is not absurdly incompatible with reasonable systems” phase of self-development, and will take a look at Wiggins’ book.

132

dsquared 09.02.09 at 10:01 pm

That would imply a somewhat higher profit percentage.

Not obviously. Only Sanofi-Aventis and GlaxoSmithKline give geographical breakdowns of operating profit and Sanofi’s is meaningless because they have a huge lump of unallocated costs (oddly enough, Sanofi don’t feel able to give a meaningful geographical allocation to any of their basic research & development budget, which is .. evocative). But in the case of GSK, the implied margin is actually slightly lower; for Glaxo, the USA is 39% of revenues by location of customer and 30% by location of subsidiary, but only 27% of operating profit (source: p116 of the 2008 annual report, which is page 118 of the pdf file.)

133

dsquared 09.02.09 at 10:02 pm

You have to be personally interviewed by a heavily overworked case-worker who in worst-case scenarios can’t see you for weeks if not months, etc. There are emergency provisions for emergency situations, allegedly, but even if you technically ought to qualify the burden of proof is on you and is quite stringent. Additionally, you’re required to take basically any job offered at any legal wage, which apparently means minimum wage for work that everyone else is getting paid $8 or more to do.

yeah, but at least there’s no rationing. If the government bought everyone an ice-cream (and thus created a distribution of ice-creams different from what the free market outcome would be), then it would be rationing ice creams.

134

Salient 09.02.09 at 10:08 pm

Shucks, maybe nobody would be able to ice-cream-eat themselves headachy and sick for hours on end each day. And that would be rationing freedom, my friends.

135

Nayagan 09.02.09 at 10:51 pm

Would it be more palatable if she expressed ( in not so many words) that her general opposition to national health care (but not all alternatives to the status quo) was a clinical observation, made in a professional capacity, that the probability of increased ‘bad’ outcomes was notable enough to disseminate among your audience an imperfect exposition of your analysis? Some of the comments here seem to be imputing a Glenn Beckian disjunction between rational thought and flights of ideological fancy in McArdle’s mind but, for such long-tail problems, neither party will realize the gains/losses from a potential change for quite a few years. Longitudinal studies (some running right now) will be crucial in assessing whether or not people experience the better health outcomes that all politicians/pundits/bloggers promise. Causation cannot be determined until the data is gathered.

136

nick.t. 09.02.09 at 11:23 pm

John, I wish you would stop implicitly conceding the point that ONLY the screwed up mess that is US health care and pharmaceutical research can produce adequate research and development. The British do an awful lot of drug innovation, despite living with “socialist” healthcare. The point to be made is that government subsidies, not the free market, are responsible for a vast amount of research in the US, and a rigged “free” market makes the US an attractive place to market grossly overpriced drugs first. McArdle’s arguments on this point are based on libertarian fantasy, not the actual state of the market. I think it’s heroic of you to keep educating the MoDo of glibertarianism, but at some point you really have to challenge the pseudo-facts she uses for her claims.

137

urgs 09.03.09 at 12:03 am

Btw, ever heard of non assitance of a person in danger?

Ah wait, right you have a legal obligation to help people…. )-:. Damn socialist countries.

138

someguy 09.03.09 at 12:58 am

scarn,

The Republican plan would replace SCHIP and Medicaid with the credits and exchange.

I am guessing that is a pretty big difference from the Democrats proposal which I really need to read about in more detail.

139

Salient 09.03.09 at 1:23 am

someguy, you said:
In a single payer system you can purchase additional health care but to some degree you are very much stuck within the system provided by the govt. You really are stuck living in the house they provide. Repurchasing such an expensive item is effectively impossible.

Umm, right now I’m stuck living in the health-care house my employer provides. It’s not a terribly good health care plan — it does not cover any preventative care or maintenance/follow-up care, and the coinsurance for even non-catastrophic care is prohibitively expensive — but I don’t have much of a choice. I am very much stuck within the system provided by my employer.

I’d much rather extend Medicare for all, but really, “stuck within the system provided by the government” is moderately better than “stuck within the system provided by my employer” …if only because the government has greater power to negotiate a good deal.

140

Steve LaBonne 09.03.09 at 1:56 am

I’d much rather extend Medicare for all, but really, “stuck within the system provided by the government” is moderately better than “stuck within the system provided by my employer” …if only because the government has greater power to negotiate a good deal.

The even more important reason is that you would no longer have to stay in your current job just to maintain access to health care. Which of course is why our owners hate the idea. Serfs are so much easier to manage.

141

chuck 09.03.09 at 2:13 am

The government cannot conduct health reaseach, of course, such as this report, which will probably save a lot of you guys from your melanomas in 10-15 years

http://www.rdmag.com/Life-Sciences-Study-reveals-genetic-culprit-in-deadly-skin-cancer/

142

Pogonisby 09.03.09 at 2:43 am

@21: Is anyone resigned to their own mortality? Really? This is what Larkin’s best on.

143

Robert Waldmann 09.03.09 at 4:06 am

I haven’t read the thread (sorry). I’m sure it has been pointed out several times up thread that the US federal government already spends a huge amount of money on medical R&D via the National Institutes of Health (about 85% of the money goes to investigator initiated peer reviewed grants). I believe this is a similar quantity to total R&D spending by US based pharmaceutical companies.

Also I wonder if McArdle is aware that PhrMa (the big pharmaceutical company trade association) is running advertisements in support of health care reform. Odd if it would be so horrible for them.

144

Tom West 09.03.09 at 4:30 am

So given that the NHS is a single payer system, you are saying that BUPA, Aviva, Standard Life, etc. don’t exist? Seeing as their coverage must be so expensive no one would consider buying it?

Apparently I’ve misunderstood. In the UK you can legally bypass the NHS to purchase health-care within your country and *you people all approve*?

In other words, none of you have any problem with wealth buying you a greater right to life? What happened to people having an equal right to life itself?

(Note, I understand the *reality* of having to allow the wealthy to purchase more life. I’m just a little shocked by the widespread (apparent) *approval* of the posters here.)

145

KLS 09.03.09 at 4:52 am

It’s the lack of innovation that scares me, imagine the sorry state of aeronautics if the government squeezed out the private militias? While the invisible hand may have identified polio as market, without the kind of cost-plus contracts only a government can provide, innovation would have stopped at outsourcing the manufacture of braces & iron lungs. Without medicare, it would be all viagra, allergies and restless leg syndrome. Instead of smart prosthetic limbs we’d be seeing all-terrain rascals.

146

KLS 09.03.09 at 5:11 am

“Apparently I’ve misunderstood. In the UK you can legally bypass the NHS to purchase health-care within your country and you people all approve?”
Tom,
Those who can afford it, buy it as a supplemental. But by all accounts, for the most sophisticated procedures, they rely on the NHS. Why would I care if you buy monkey gland therapy provided the rest of us can get treatment for testicular cancer?

147

Martin Bento 09.03.09 at 5:14 am

(accidentally posted in old thread)

I missed out on part of the previous thread on this, but hopefully the participants are still around,

Dan,

Yes, some Libertarians do attack limited liability ( although the Russell Long article you linked to just had a footnote stating LL was controversial among Libertarians, and then stipulating it as legitimate. It mostly is arguing that government is intrinsically responsible for the existence of big business, a completely different argument). They do not, however, from what I have seen, follow through with the consequences of that position. Limited liability is why the corporation exists. Without it, there is no corporation as we know it. There is no stock market. No ability to raise huge quantities of anonymous capital well beyond what a small group of owners could manage on their own. Vastly reduced liquidity. In short, no modern Capitalism. Without this huge mobilization of capital and the research and technology, as well as economies of scale, that can come from it (especially if you exclude the government from mobilizing capital or doing research as Libertarians are wont), most of the benefits of modern Capitalism would not be possible.

Yet Libertarians claim the successes of actually existing Capitalism as successes of their philosophy. Calls for cuts in regulation or taxes imposed on corporations seem never to mention that the corporation should be abolished. The limited liability position seems dragged out only to explain what Libertarians would advocate in place of regulation in cases where regulation seems necessary – in the wake of Exxon Valdez, or the recent financial debacle. But at no other time do Libertarians seem to suggest that Exxon and Citigroup have no right to exist; instead their interests seem to loom rather large as aspects of “liberty”.

Many of us on the Left accept limited liability for its practical advantages, but recognize that corporations, being not fully responsible entities (liability is just a legally-enforceable form of responsibility) are not entitled to full rights either. Therefore, we are untroubled by restrictions on corporations that are not legitimate to impose on individuals. Others reject limited liability, while embracing the logical consequences: opposition to the corporation as such, which is manifest in opposition to public recognition of the legitimacy of “corporate interests”. Both of these are more consistent than the Libertarian position.

148

nick s 09.03.09 at 5:38 am

In other words, none of you have any problem with wealth buying you a greater right to life?

Apparently, you’ve misunderstood. BUPA et al. let you jump the queue and/or provide a nicer room, while you are treated, mostly, by the same doctors who provide the same care to NHS patients.

This can be split into two separate points. The first is that allowing consultants (i.e. specialists) their private hours was part of Nye’s grand bargain to get them working NHS hours. If stuffing their mouths with gold was what it took, then that’s what it took.

The second idea — that wealth might buy you a private hospital room, slightly nicer food, more attractive jimmy-jams, 47 cable channels, and even a chance to jump the queue for elective surgery — ought to be distinguished from it buying ‘a greater right to life’. If (as happens really quite often) the private hospital messes up, you end up wheeled down the road (or corridor) to A&E, where NHS staff will do their best to set you right again.

In the meantime, Bumfrak County Medical Center, serving a population where a quarter of adults lack health insurance, is still obliged to have a mahogany-veneered and overstuffed-leather-seated front reception because doing otherwise would be somehow uncouth. And emergency room dramas in the US will never do a scene where someone is bleeding at the billing counter and a janitor is asked to mop the floor.

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nick s 09.03.09 at 5:41 am

Ugh. It’s especially galling that healthcare discussions get plunged into the moderation pit because ‘spec!@list’ in its proper form contains ‘c!alis’.

150

glenn 09.03.09 at 6:41 am

I think this R&D issue is pretty much hogwash. So, according to her, pretty much all the heathcare R&D is done in the US, right, since that’s the only place where the good ‘ol capitalist system is allowed to flourish in heathcare. So, it’s either all in the US, or the result of the US system? Secondly, at least when it comes to pharma, there’s alot more R than D going on. True innovation has been dragging for years. It’s hardly a bright star to point to. Thirdly, the companies spend almost as much on Marketing as R&D, so I question whether these are innovation machines or advertising engines. I say these companies should not be able to market directly to the consumer (like pre-1996, I believe), allowing them to convince people they suffer from ‘an illness,’ and see if they put that money into R&D.

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JoB 09.03.09 at 7:34 am

Isn’t this enough on McArdle or whatever she’s called? I mean: you’re preaching to the choir (it appears that even David has given up his mock-defense), repeating yourselves and there’s very good stuff on the rest of this site.

I know it’s a very therapeutical thing to do but as long as you do it McArdle will respond, this is getting her the attention she desires & makes her a little bit of a martyr for the cause (& even the libertarians like their martyrs, I guess).

Or, well, carry on!

152

keydiary 09.03.09 at 7:59 am

Obviously, youe misunderstands. BUPA,etc. let you jump the quene and/or offer a better room, main, provided the same careful the same doctor for NHS patient, when you are treated.

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Phil 09.03.09 at 8:20 am

Incidentally, is there an academically respectable version of the Libertarian “taxation = coercion (in the last instance) by MEN WITH GUNS” argument? Ted’s version of it seemed silly, but it had the look of an nth-generation photocopy of a stronger argument. Who’s the Libertarian Rawls?

154

Phil 09.03.09 at 8:21 am

Brainfart – s/Ted/Albert/. Sorry.

155

Ceri B. 09.03.09 at 9:06 am

Phil: Probably Jan Narveson.

156

Bunbury 09.03.09 at 9:23 am

glenn, they spend twice as much on marketing as on R&D (and I suspect that their accounting policies have changed over the years to make this look better). Typically a merger of two big drug companies will end up keeping both marketing operations and halving the R&D capacity. Fake journals, golf tournaments, ballpoint pens and armies of Willie Lomans don’t pay for themselves you know.

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Alex 09.03.09 at 9:44 am

GSK: UK
AstraZeneca: UK/Sweden
Sanofi-Aventis: France
Roche: Switzerland
More medium-sized pharma firms than I care to list: Germany

It doesn’t seem to be happening in practice, does it? But then, the ‘totherside’s position is roughly “it works in practice, but does it work in theory?”

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Sam C 09.03.09 at 10:57 am

Phil: along with Narveson, the obvious candidate for libertarian Rawls is Robert Nozick. Other important names includes Tibor Machan, Peter Vallentyne, John Hospers. There’s a good introduction to libertarian political philosophy at http://plato.stanford.edu/entries/libertarianism/ .

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Dan 09.03.09 at 11:25 am

Phil,

Nozick is probably the man you are looking for, but this paper by Ed Feser (and I’d just like to point out that no, I do not endorse everything he says) is IMHO a pretty good reconstruction and development of the argument: http://www.independent.org/pdf/tir/tir_05_2_feser.pdf

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Dan S. 09.03.09 at 11:48 am

People can die just as painfully from lack of oral rehydration salts as from gunshot wounds. So what’s so special about physical force?

Possibly: evolved moral intuitions that (for bettter and/or worse) because of their history tend to focus on direct, personal, proximal, physical action rather than indirect action/action at a distance/etc.? (Gestures in the direction of recent research on morality – Marc Hauser, etc.)

(What’s so special about pushing the big guy onto the trolley tracks?)

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Sam C 09.03.09 at 12:14 pm

Dan S. – sure, there are such intuitions. But, even assuming that intuitions are authoritative: (1) actually-existing morality is a lot more complex than that, and it importantly also includes a capacity for empathy which can be cultivated (gestures in the direction of the great naturalistic moral philosophers – Smith, Hume, Mill – on whose shoulders Hauser is standing). (2) Intuitions against direct, personal, etc. physical action don’t apparently apply to tax demands. And (3) Albert Jensen wasn’t claming just that physical force is bad, he was claiming that it’s the only bad thing, and therefore that it’s completely impermissible to ‘force’ him (through taxation) to save someone else from a painful death, even if the cost is no more than getting his shoes dirty. This view strikes me as… implausible (or perhaps I mean ‘vile’). What I was trying to do was show AJ that the good reasons for resisting violence are also good reasons for resisting disease.

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someguy 09.03.09 at 1:54 pm

Salient,

Have you considered the possibility of switching employeers? I think most folks would find that a bit easier than say switching nationalities.

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someguy 09.03.09 at 2:02 pm

Salient,

Why not give people a choice? The govt can sell SCHIP or Medicare or whatever coverage they like at the cost person of the program. We can provide whatever redistribution is needed in the form of vouchers or tax xredits or debit cards or whatever. The same rules would apply to public and private. Wouldn’t that be the best way?

Why wasn’t say SCHIP set up that way?

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Tom West 09.03.09 at 2:18 pm

The first is that allowing consultants (i.e. specialists) their private hours was part of Nye’s grand bargain to get them working NHS hours.

Again, let me make it clear: the reality of how these things get decided was not my concern, it was the reaction here.

Perhaps I have misunderstood the current system. Let me ask: I am assuming that the NHS, like most national systems, uses rationing. For example, you may have to wait a month or two for cancer treatment if they feel it is not in a critical stage. There is, of course, risk there that it will metastasize during that wait, but medical professionals feel that the money saved from that risk can be more effectively used elsewhere. Seems rational to me.

Likewise, there may be *effective* treatments of certain diseases that are simply too expensive to be performed. The money saved by letting one person die may be able to provide better care for substantial numbers of others.

Under the British system, can someone purchase medical services to reduce or eliminate that wait time, and thus increase their chance of survival? Can they purchase effective, but expensive medical services that are unavailable through the NHS?

More to the point, if so, do posters here approve of that freedom?

(If I sound harsh on my favoured system (Canadian), let me note that I believe that it is the responsibility of anyone who argues for a position to know and be able to articulate exactly what the trade-offs and costs of that position are. To argue *any* side of the medical systems debate and claim not to be endangering one group or another is ignorant at best and disingenuous at worst. Admittedly, such honesty is not a luxury that politicians advocating for a health-care policy can afford.)

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Salient 09.03.09 at 3:03 pm

Have you considered the possibility of switching employeers? I think most folks would find that a bit easier than say switching nationalities.

Who said I wanted to switch nationalities? That makes no sense. Are you saying that by advocating for a public health care option, I am becoming un-American? It’s a strange comment.

Why not give people a choice?

Because healthy people tend not to “choose” insurance until after they get sick. Basically, people want health care as a right, not health insurance vs. catastrophe. If we really insist on this stupid insurance-based system for paying for health care, then we probably have to write some correspondingly stupid rules that require people to sign up before they fall ill. Frankly, I’d rather just have health care coverage for all — Medicare for all.

Also, what choice? Health care is not the kind of thing one chooses. One should never have to choose between treating a gall bladder infection and treating these weird sores appearing on one’s forearm, or even have to choose between buying a semester’s textbooks and having one’s impacted wisdom teeth removed. One might reasonably have to choose between buying an LCD TV and buying materials to build a deck out behind the house.

And as an aside, the idea that one can “choose one’s doctor” or “choose one’s hospital” is utterly alien to me. I’ve never had a “choice” in my life for which doctor to see, any more than my students really had much “choice” in me as an instructor (what are they going to do, delay their own graduation until I teach something else? Some choice.)

Doctors of a given specialty, like most service providers, are basically fungible, in that they are all nearly equally capable of providing the same thing, and are all trying to provide the same thing: treatment. I’ve never known anyone who got to meet with a committee of doctors as if on interview, and “choose” their favorite to serve them. I’ve never even known anyone who actually goes through the list of treatment providers the company hands you and googles each doctor’s name to see which one is “best” — seriously, does nobody else run into the situation where every doctor on the list can’t see patients until April 2011, so you pick the one doctor who can see you this year? Really?

Of course, I’ve never understood the idea of having a “primary care physician” either — I suspect that most folks my age don’t comprehend this quickly-becoming-antiquated idea, by the way. You make an appointment to go to the clinic, whoever is on duty will be your physician that day. They check your charts, ask what’s up. I gather that some folks used to just go in to their primary care doctor twice a year, just because?

Personally, I find the idea that we should hold as our highest priority “choice” in health care to be appalling:

Choice, sense 1. You choose to get, or not get, care. (Those without enough money are forced to choose no.)
Choice, sense 2. You choose who provides care to you. (This inevitably comes at the expense of lots of people not getting any care at all.)

Both bother me. Of course, if we could accomplish choice sense 2 without the expense of preventing people from getting any non-emergency health care at all, I’d be happiest with that. But full access to the public good of health care comes first.

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scarn 09.03.09 at 3:05 pm

Someguy,

“The Republican plan would replace SCHIP and Medicaid with the credits and exchange.”

Yeah, somehow I missed that. That’s quite a big difference from the Dems. I’m open to this idea so long as the market is national and not regulated state by state, and the form of the subsidy is in direct payment to the recipient, like a pre-loaded bank account or some such. I think that most people on the left (myself included) have a gut fear of this for two reasons.
1. What happens if the individual purchasing care wastes their credit? How do we ensure that wasting credit is next to impossible? Can we even do that?
2. How can I trust Coburn to be telling me the truth when he is a shady Republican? Ok, maybe that’s a bit toungue in cheek but this stuff is complicated, I’m certainly no expert, so it’s tough to make allowance for the fact that the opposition might have a good idea.

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Salient 09.03.09 at 3:10 pm

Also.

Why wasn’t say SCHIP set up that way?

Because kids usually don’t have jobs.

I hope that question was sarcastic. The idea that kids should have to pay for their health care is just unbelievable. (And of course, kids can’t be held responsible for what their parents do or don’t do, so you can’t just say the parents pay for it — the whole point of SCHIP was to provide health care to kids whose parents cannot afford it.)

Also, for the record, my sister (who lost her job and has been struggling to find similarly-paying employment) is “on” SCHIP (for her daughter / my niece) and so defending the appropriateness of the program is quite personal for me. It’s basically the only reason my niece has a decent, low-pain, happyish life at age 5.

So please, no callousness about how my sister should have foreseen she would be laid off years later and should have aborted my niece, or should have never started a family with her husband without such foresight, or whatever. (Yes, I get such comments all the time, as does she. Please don’t add to them.)

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Salient 09.03.09 at 3:14 pm

We can provide whatever redistribution is needed in the form of vouchers or tax credits or debit cards or whatever.

Hmm. Ok, so the idea is, provide vouchers and debit cards to the kids so they can go buy health care. Single-payer sounds simpler and easier to manage. A public option sounds simpler and easier to manage.

And my nascent indirect experience helping someone get signed up for the welfare redistribution system indicates to me that… well… for one thing… the idea that we’ll sort it all out with a tax credit… ain’t going to work unless we agree to raise taxes on others, to offset. Would you agree to FDR-level tax rates and pre-WWII proportion of military spending?

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someguy 09.03.09 at 3:18 pm

Salient,

You said,

“Umm, right now I’m stuck living in the health-care house my employer provides. It’s not a terribly good health care plan—it does not cover any preventative care or maintenance/follow-up care, and the coinsurance for even non-catastrophic care is prohibitively expensive—but I don’t have much of a choice. I am very much stuck within the system provided by my employer.”

Why not switch jobs? You really aren’t that stuck you can switch jobs.

But with a national health care system the only way to switch health care plans is to switch nationalities.

“Because healthy people tend not to “choose” insurance until after they get sick. Basically, people want health care as a right, not health insurance vs. catastrophe. If we really insist on this stupid insurance-based system for paying for health care, then we probably have to write some correspondingly stupid rules that require people to sign up before they fall ill. Frankly, I’d rather just have health care coverage for all—Medicare for all.”

“Choice, sense 1. You choose to get, or not get, care. (Those without enough money are forced to choose no.)
Choice, sense 2. You choose who provides care to you. (This inevitably comes at the expense of lots of people not getting any care at all.)

Both bother me. Of course, if we could accomplish choice sense 2 without the expense of preventing people from getting any non-emergency health care at all, I’d be happiest with that. But full access to the public good of health care comes first.”

Surely vouchers can fix both problems and people can still choose. Folks are unlikely to throw a 5K voucher in the garbage.

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scarn 09.03.09 at 3:19 pm

Salient, I think what Someguy means when he talks about building a consumer market for SCHIP and medicare/aid is this:

The government provides the recipient of the subsidy with money in the form of a tax credit or a direct payment. The recipient then can act like a consumer with that money. They can shop for the lowest price for their treatment, and for the best “customer service”, in this case meaning quality. Because the recipient is now a consumer and providers have to compete for business, costs come down and quality goes up, and hopefully the state spends way less on subsidies because costs have come down. I don’t think he means that your sister would have to pay for her own care – that would defeat the purpose of SCHIP, and also be extremely cruel.

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Phil 09.03.09 at 3:22 pm

the idea that one can “choose one’s doctor” or “choose one’s hospital” is utterly alien to me

Amen to that. They’ve been trying to push this bright shiny idea over here for about the last decade, and it doesn’t make any more sense now than it did to begin with. (“Do you want the good doctor or the lousy one?” isn’t a choice. “Do you want to be treated now by a lousy doctor or in three months by a good one?” is a choice, but not one people should have to make – let alone one that should be designed into a system.)

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someguy 09.03.09 at 3:38 pm

Salient,

I asked why SCHIP wasn’t setup as avoucher program. Why not provide those who need it with a voucher = to the per person cost of SCHIP? That person could choose to enroll in SCHIP or private insurance.

I certainly want adequate health care for everyone including your niece.

173

JMW 09.03.09 at 3:39 pm

Albert Jensen seems to have left the building, but at the risk of calling him back:

His (main) problem is that — mercifully — he misunderstands how any doctor would act in a situation where he or she was capable of providing help to someone who needed it. If someone walks into an emergency room with an appendix about to burst, that appendix is going to be taken out, whether Albert Jensen likes it or not. If the patient can’t pay, the appendix is still coming out. At that point, somebody is paying for it. I’m not stupid enough to claim any special knowledge about an incredibly complicated issue, but this is the crux of the health-care debate as far as I can see, on the practical rather than philosophical level: Given that emergencies are going to require our resources anyway, and that more neglect leads to more emergencies, what’s the most affordable and efficient way around the problem?

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dsquared 09.03.09 at 3:41 pm

But with a national health care system the only way to switch health care plans is to switch nationalities.

or fill in the coupon on one of the BUPA or Aviva advertisements in the newspapers, you can do that too.

175

someguy 09.03.09 at 3:42 pm

Salient,

“Hmm. Ok, so the idea is, provide vouchers and debit cards to the kids so they can go buy health care. Single-payer sounds simpler and easier to manage. A public option sounds simpler and easier to manage.”

A voucher program does not need to be complicated. Social Security is a pretty efficient program. A check in the mail. A voucher program could work the same way. A voucher in the mail.

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Antoni Jaume 09.03.09 at 3:48 pm

Roac, Eric Frank Russell tale you probably think is “Then there were none”, look at
http://www.abelard.org/e-f-russell.htm

I, too, read it around my thirteen years, however I thought that such a society would never work for long before finishing to read it.

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Alex 09.03.09 at 4:00 pm

Who gives a shit about “building a customer market this exchange that”? All very minor. Until universal coverage achieved, the jargon buzzword bingo is a distraction. That’s why it exists.

I see we have one of the Voucher People here…

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Ceri B. 09.03.09 at 4:11 pm

Someguy: Collective bargaining. It’s weird the way a lot of people seem to have forgotten ever learning about the economies of scale when it comes to something like health care. It is cheaper to set up one good system and tend to the needs of a million people than it is to try to make a million separate arrangements. Furthermore, there’s the division of labor, which I always understood to be fundamental to business. 10 people working full-time at it can get better deals for a million people than a million people floundering around on their own. In addition, when there are people who can and do specialize in this, it’s an obvious waste of comparative advantage to make everyone’s well-being depend on something they’re not expert in and can’t become expert in.

There are of course solutions to all these issues, but at some point they converge on a system where professionals arrange the best deals they can for as many people as possible and do so with an eye toward maximizing return on spending and quality of overall outcome rather than profit for providers…and that’s single-payer of some sort.

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nick s 09.03.09 at 4:12 pm

I’ve never known anyone who got to meet with a committee of doctors as if on interview, and “choose” their favorite to serve them.

I think you miss the subtext here: “choosing a doctor” actually means “choosing the kind of patients you want to share a waiting room with” and “choosing a hospital” means “choosing the kind of people you want in the rooms on either side”.

The tacit segregation of healthcare in the US really needs to be seen to be believed.

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scarn 09.03.09 at 4:15 pm

Who gives a shit about “building a customer market this exchange that”? All very minor. Until universal coverage achieved, the jargon buzzword bingo is a distraction. That’s why it exists.

Apparantly, President Obama & several Senators do. This is one way the Democratic bill might go. There is no reason that I can see why you can’t use a credit system to implement universal coverage (though I am open to hearing what those criticisms might be). The Dems are not going to propose to do this in exchange for the Medicare we already have, but they might very well do it in conjunction with a co-op/insurance pool or a public option. Either would be an improvement over our current system.

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Uncle Kvetch 09.03.09 at 4:29 pm

Why not switch jobs? You really aren’t that stuck you can switch jobs.

Right, you can always change jobs. And your new job may or may not offer a better health plan. And if it turns out that it doesn’t–well, change jobs again. It’s not like there’s a shortage of jobs out there.

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Salient 09.03.09 at 5:10 pm

Why not provide those who need it with a voucher = to the per person cost of SCHIP? That person could choose to enroll in SCHIP or private insurance.

Because SCHIP doesn’t have a fixed cost per person. When more people sign up, the cost per person decreases.

Also, I see a multiple-step dance here.

(1) Step One. Arrange for a voucher-paid-for public plan for healthcare for all. Make the purchase of health insurance mandatory (an individual mandate). But that doesn’t matter because everyone gets a voucher for 100% the cost, right?

(2) Insurance companies start to offer some bogus plan that provides hardly anything, for the exact cost of the voucher, and they give you some kind of “discount” at Walgreens for half the voucher amount, or some such weird benefit that can be used when perfectly healthy. Healthy people buy the non-health-care option with their voucher, leaving the public plan with less resources and more cost per person (because only the sick participate).

(3) Now, Step Two. Whittle down the amount of the voucher, or restrict who gets a voucher based on income and then whittle down the maximum income for which you get a voucher. Fewer and fewer people are getting help paying the health care bill that is now mandatory.

(4) Profit! Because the individual mandate holds, insurance companies are guaranteed that every human being will be a customer, and they can offer bogus plans that only cover toenail damage / “premium” plans that cost way more than the voucher and are equivalent to the kind of plan most people currently have, i.e. are sucky.

Also, I believe we should live in a society in which we care for each other, at least enough to support social systems that can protect/benefit/serve everybody. To be clear, I want some of my tax dollars paying for other people’s health care, and I want people to want this.

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Salient 09.03.09 at 5:12 pm

Right, you can always change jobs. And your new job may or may not offer a better health plan. And if it turns out that it doesn’t—well, change jobs again. It’s not like there’s a shortage of jobs out there.

And since one health care company provides the same services to all employers in this state, changing jobs literally would leave me with the same plan. I mean, if we informally consider State of residence to be one’s nationality, I literally do have to change “nationality” and move to a different state where there is some actual availability of alternatives.

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Salient 09.03.09 at 5:13 pm

And since one health care company provides the same services to all employers in this state,

Where by “all” I mean “more than 88%” if we’re going to be technical…

185

Phlinn 09.03.09 at 5:17 pm

You have claimed that she is indifferent to the poor though. “Philosophically, there just isn’t a case to be made against reform unless it’s this simple one: if you don’t have any money, you shouldn’t be entitled to any medicine. McArdle is very indignant when people accuse her of indifference to the fate of the poor, but – honestly – if it isn’t that, then it’s nothing. At the philosophical level.” This is an insulting statement, and it’s wrong, in ways that should be obvious to you. You should not be surprised that she was upset by it. You have misidentified the conclusion, that an entitlement to medicine is wrong, with an argument, and then proceeded to claim that non-argument is the only one that can be made. Hell, rich people aren’t entitled to medicine either, but they have greater ability to pay, so you aren’t even stating the conclusion in any sort of accurate sense.

It is possible, even likely, for someone to care about the fates of poor people, but to nonetheless be philosophically opposed to entitlement programs in general, or to some particular type of program, or to specific programs. Enslaving doctors for example (over the top to illustrate the point) would be an unethical solution. Going more general, many utilitarian libertarians think most entitlements are counter productive in the long term. Nothing about that line of thought indicates indifference.

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scarn 09.03.09 at 5:21 pm

Insurance companies start to offer some bogus plan that provides hardly anything, for the exact cost of the voucher, and they give you some kind of “discount” at Walgreens for half the voucher amount, or some such weird benefit that can be used when perfectly healthy. Healthy people buy the non-health-care option with their voucher, leaving the public plan with less resources and more cost per person (because only the sick participate).

This is EXACTLY what would happen if you don’t have a regulatory body that oversees what can and cannot be offered by an insurance company. As I understand it, Dems who support this kind of a system want to create a government administered panel at the national level. Repubs want an independent non-profit panel that is not government run. I think a non-governmental panel would be a patsy for the insurance industry.

187

someguy 09.03.09 at 5:29 pm

dsquared,

Yea if you enough extra money lying around that you can afford to buy 2 health care plans for everyone in your family.

188

scarn 09.03.09 at 5:37 pm

Yea if you enough extra money lying around that you can afford to buy 2 health care plans for everyone in your family.

Of course, nobody needs two healthcare plans, given that everyone is already provided with one that is fair and effective….

189

someguy 09.03.09 at 5:39 pm

Salient,

“And since one health care company provides the same services to all employers in this state, changing jobs literally would leave me with the same plan. I mean, if we informally consider State of residence to be one’s nationality, I literally do have to change “nationality” and move to a different state where there is some actual availability of alternatives.”

You have only one health insurance provider and every business uses that one provider in your state and that they only provide one insurance option?

I find that very hard to believe. What state do you live in?

Also, again just to be clear, I want tax dollars to provide adequate health care for everyone. We are just talking about the best way of providing that care.

190

jonathan 09.03.09 at 5:40 pm

I, too believe in a society where we should care for each other but this, i think requires equally that the individual must care for society.
The single payer system is not cost effective. In Canada, where the population is about 35 million people, the cost of a single payer system has gone from about $96 billion in 1996 to around $167 billion in 2008 with no noticeable improvement in access to patinet care.
This does not mean that we should discontinue it, nor that we should not continue to try to improve efficiency, but if a single payer system is introduced in the US the escalation of costs is going to be huge.
If any health care system is to work in terms of care delivery and containment of costs, and I would argue that so far no system has done this, the individual must be responsible for the maintenence of their own health. This means following the simple rules of a healthy diet, exercise, and stopping smoking, as well as being prepared to use the simple home remedies that are effective for minor problems.
All health providers are potentially injurious to your health, and a service that is apparently “free” is always abused.
If there was an easy solution to the effective provision of universal health care it would have been worked out by now hence the debate. We can only continue to try to find the solution.

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Substance McGravitas 09.03.09 at 5:44 pm

If any health care system is to work in terms of care delivery and containment of costs, and I would argue that so far no system has done this, the individual must be responsible for the maintenence of their own health. This means following the simple rules of a healthy diet, exercise, and stopping smoking, as well as being prepared to use the simple home remedies that are effective for minor problems.

Also, NO GOING OUTSIDE.

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someguy 09.03.09 at 5:45 pm

Ceri B.,

If what you think is true you should have no objection to vouchers. Any govt plan will on it’s own out perform the priovate plans and we will be left with just the govt plan.

But what if just maybe some people want to make a different choice?

193

someguy 09.03.09 at 5:46 pm

Salient,

Regulations and competition seems to work pretty well for the auto insurance market.

194

Substance McGravitas 09.03.09 at 5:49 pm

Regulations and competition seems to work pretty well for the auto insurance market.

Every car on the road has adequate insurance?

195

Dan S. 09.03.09 at 5:49 pm

Sam C. – oh, I agree. I was just a) wandering off topic b) assuming everyone would somehow know I see as that as a flaw/incompleteness in our (possible) moral intuitions & c) figuring that any engagement with Jensen was pointless and that this was much shinier/interesting.

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scarn 09.03.09 at 5:56 pm

Any govt plan will on it’s own out perform the priovate plans and we will be left with just the govt plan.

I see this claim made all the time and I don’t buy it. Why do you believe that this is the case? In point of fact, the public option legislation that I’ve seen (as I understand it) puts an income limit on the public plan – only people with low incomes can join. Also, Obama’s argument that Fedex and UPS are quite profitable while competing with the USPS seems applicable. TPM is reporting that Obama is going to drop the public option anyways…

197

someguy 09.03.09 at 6:21 pm

scarn,

“Ceri B.,

If what you think is true you should have no objection to vouchers. Any govt plan will on it’s own out perform the priovate plans and we will be left with just the govt plan.”

you = If what Ceri B thinks is true.

I don’t think that at all. I don’t think a govt plan is even needed. I don’t think a govt plan could compete. But I am more than happy to give it try depending on how it is implemented. I am sure hard core public choice folks are sadly shaking their heads at my stupidity but I don’t mind all that much.

198

someguy 09.03.09 at 6:25 pm

Substance McGravitas,

“Every car on the road has adequate insurance?”

We don’t provide vouchers for car insurance. Makes a difference.

The point is that private industry isn’t some monster that continually provides worthless auto insurance to a beguiled public while gleefully carrying the sacks of money to the bank.

Instead you wreck your car and you get a check.

199

scarn 09.03.09 at 6:27 pm

someguy, if by “you = If what Ceri B thinks is true.” you mean I should also have no objection to vouchers, well, I really don’t have any strong objection to vouchers. I think I misread your earlier comment to Ceri B to read that any public plan would outperform all other private plans on the market, something which I think is unlikely.

200

Ceri B. 09.03.09 at 6:47 pm

Someguy, my objection to vouchers is two-fold.

First, the circumstances of life are such that a lot of people cannot, in practical terms, make really good decisions about their medical care. They get hit by surprises – this has been a lot on my mind lately, since I learned this summer that I have hypertension so high my doctor was genuinely surprised I hadn’t already had a stroke, plus diabetes, plus some other stuff. It takes a lot of expertise to overcome natural human deficiencies in risk evaluations and get a plan that will deal with this kind of thing and not fail just when it’s needed most.

It’s possible to design a system to work around all that, but I’d rather put the effort into designing a system in which people simply have access to a good baseline of care in the first place without having to do it all.

Second, in practice, it seems like voucher schemes keep ending up being the toys of people who want to abolish public support for whatever it is altogether. This isn’t a matter of fate or philosophical necessity, but of history: in the US, forces hostile to public service use vouchers as a tool of leverage, and it’s something voucher advocates who don’t want to abolish the public service have to deal with, showing that they’re aware of how these things get used and abused and suggesting ways of keeping it from happening again.

201

someguy 09.03.09 at 7:55 pm

Ceri B. ,

Sorry about your health.

On para 2 –

I think if we hand people a voucher they can pretty much handle it on their own. Especially since there would be some kind of regulatory body. We could default to a plan or set of plans. IE I get a voucher in the mail. I throw it out. The default is I am enrolled in the govt plan. Any difference can come out of my taxes.

On para 3 –

You have it completely backwards. Look at education. Dear heavens a few tiny programs hand out a voucher that is 60% of the public voucher[implied]. Private school enrolle parents are happier, you get at least the same educational results, it costs 60% less, and the competition might improve public school performance. The public sector fights tooth and claw to take that away from the few low income families that qualify.

You really have very little to worry about look at Medicare or SS.

202

roac 09.03.09 at 8:11 pm

Antoni at 175 — yeah, that was it. Thanks. And congratulations on being smarter than me at age 13.

203

nick s 09.03.09 at 8:27 pm

I find that very hard to believe. What state do you live in?

It’s an exaggeration to say that one insurer has the entire state in its, though living in one of the ten states where BCBS has over 70% of the market (and its nearest competitor making up most of the rest) probably makes it feel that way.

But “oh, just switch jobs!” is no more than an exhortation to dine on brioche in best Megan Antoinette fashion.

204

JM 09.03.09 at 9:29 pm

Since McArdle was surprised, by a poster on her own site no less, at the costs of the health insurance programs she was pontificating on, and since she was nailed for making up not only making up numbers but inventing impossible scenarios on healthcare reform in order to defend corruption, I have to wonder why anyone bothers arguing with the childishness, naivete, and unadulterated ignorance that is libertarianism.

Unless, like me, they’re just plain sadistic and enjoy kicking stupid people around?

205

Ryan W> 09.03.09 at 9:31 pm

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).

Granted, academia is better at putting information into the public domain ( a public good. ) But outside of that it seems that this scenario you propose involves (assuming an R&D shortfall occurrs) removing an effective method for bringing drugs to market and replacing it with a likely more costly one. There’s a reason medical treatment rates are so much better in the US than in Europe. In other words, we’d be taking something out of the hands of private developers only to bring it back at, likely greater, public expense. That sounds like failure.

zic – And on the other end of the process, safety is evaluated by FDA. Government investments straddles both ends of the r&d process.

Granted, the NIH is one of the best run government agencies and has done some good work.
But the FDA is more of a barrier than a helpful party. Kindof like how you and the police officer
cooperate at driving; You drive, and he gives you speeding tickets if you go too fast. He’s certainly not
helping you plan your route or paying for gas.

Anyone who really believes reform will strangle innovation ought to pay more attention to our education system, the real feeder for new, improved, and innovative

You’ve just recapitulated what Megan said, then asserted she’s denying it. Her argument was; academia helps develop new targets, but
private enterprise plays a big role in bringing drugs to market. Which dovetails with her point that without market reimbursement, you’ll have less drugs brought to market.

Salient –“I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”—from the Hippocratic Oath

There’s nothing in that quote that supports your point. If you can give some citation of some ancient text describing how the Hippocratic oath, specifically, compelled a physician to give treatment I’ll reconsider my belief that you’ve invented this obligation out of whole cloth.

206

Cryptic ned 09.03.09 at 10:07 pm

It’s not like there’s a shortage of jobs out there.

For whom?

207

roac 09.03.09 at 10:47 pm

medical treatment rates are . . . much better in the US than in Europe

What does this mean, and where is the evidence for it?

208

Salient 09.04.09 at 12:09 am

I find that very hard to believe. What state do you live in?

My state’s not the only one, so I’ll link to a mention of a different state that has 88% of the market dominated by one insurer:

http://hcfan.3cdn.net/506443f324f1bbc60c_99m6bxwf0.pdf

209

Salient 09.04.09 at 12:18 am

Salient -“I will apply dietic measures for the benefit of the sick according to my ability and judgment; I will keep them from harm and injustice.”—from the Hippocratic Oath

There’s nothing in that quote that supports your point.

Umm. They used different words for “provide medical care to” than you or I would, of course. I know that “apply dietic measures” is not, like, common parlance, but neither is it completely incomprehensible as translating to “provide medical care to” (the “diet” they’re talking about includes medicines intended to treat illness).

Unless you think they were preoccupied with weight loss plans in the 18th century?

If it helps, an alternate translation is: I will prescribe regimens for the good of my patients according to my ability and my judgment.

A modern version, which is also pretty clear, is here.

210

soru 09.04.09 at 12:31 am

The point is that private industry isn’t some monster that continually provides worthless auto insurance to a beguiled public while gleefully carrying the sacks of money to the bank.

Instead you wreck your car and you get a check.

That’s kind of the key point to understand: why the health insurance market doesn’t work that way, why it _is_ actually a monster providing worthless insurance to a deluded public while carrying sacks etc.

As the auto example makes clear, it’s not inherent in capitalism or anything. It’s just the case that certain business models are going to be dominated by fraud and not-quite-fraud, such that an individual company that hypothetically tried to do the right thing would go under and probably be taken over (or sued by its shareholders for negligence in failing to deny treatment).

Maybe, somewhere out there is a company that has a legitimate, working and safe way of making a penis naturally bigger. It’s just they can’t understand why their email marketing scheme for an excellent and cheap product has such a low response rate…

Maybe, somewhere out there, there is a health insurance company that actually intends to pay for long-term chronic care for all of its customers who happen to get sick. They just don’t understand why they can’t compete with those who spend the money on marketing and lobbyists instead…

Understanding the failings of a particular business model doesn’t require abandoning any free market principles, it just requires a minimum ability to look at the world and ask ‘how well does this actually work in practise, given actual human beings and institutions, not ideological robots with perfect information?’.

From there, having made that observation, you can move onto adjusting the theory to account for it. Maybe it’s a matter of the fact you pay in advance, typically by decades. Hardly anything else in the market economy works that way, so it not obvious why any general theory of market behaviour would apply.

211

John Emerson 09.04.09 at 12:59 am

If soc*alism gives you and erection lasting more than four hours, see your physician.

(You wish! Never happens. But dream on.)

Dead thread, but I’ve never seen why all the cost of innovation (granting McMegan all her fake facts) should be dumped on American citizens while the citizens of other more democratic countries get cheaper drugs.

I also don’t think that American citizens should be the mule of globalization or cannon fodder for the new world order either. Let the rest of the world pull their share of the load.

It’s sort of odd to see McMegan pushing that kind of Peter-Singer-ish internationalist consequentialist altruism, which goes entirely against various of the dimestore principles that she wants us to believe that she holds dear.

212

someguy 09.04.09 at 1:25 am

soru,

Penis enlargement ads aren’t actually done by the insurance industry.

“From there, having made that observation, you can move onto adjusting the theory to account for it. Maybe it’s a matter of the fact you pay in advance, typically by decades. Hardly anything else in the market economy works that way, so it not obvious why any general theory of market behaviour would apply.”

You mean like life insurance?

Most Americans with private insurance would have no idea what you are talking about. They make their co-pay and get taken care of. I want that for everyone.

213

someguy 09.04.09 at 1:55 am

Nick S,

Good link. I am pretty sure market concentration doesn’t = no competition but good link. Has some persuasive power. Thanks.

Anyway, exchanges and/or allowing individuals and companies to purchase insurance across state lines very directly addresses such situations.

Even accepting this or that market failure doesn’t mean the solution = nationalization = best.

214

A Pedant 09.04.09 at 3:55 am

Well, at least she’s learned how to spell “Philosophical”.

215

James Wimberley 09.04.09 at 10:21 am

Is anybody still out there? I’m going back to dsquared’s nugget in #132 (an actual fact that got lost and strayed into the dorm) that Glaxo doesn’t actually find the USA more profitable than its other (evil socialist) markets.

Hypotheses:
1. Evil healthcare socialism reduces distribution costs. Nah, these are chickenfeed.
2. USA has very high regulatory and admin costs. Nah, ditto.
3. EHCS constraints marketing expenditure for all participants. What’s the point of flying the board of the Rochdale Primary Health Care Trust to Cancun? They aren’t allowed to take such perks, and take their pharmaceutical decisions from NICE. To the extent that drug marketing is a zero-sum arms race, all the corporations benefit if it’s forcibly cut back. Bribing NICE would be cost-effective but it’s horribly risky : high risk of failure, discovery and even jail.
Any 4?

216

belle le triste 09.04.09 at 11:50 am

Penis enlargement ads aren’t actually done by the insurance industry. (Citation needed.)

217

derek 09.04.09 at 1:19 pm

Yea if you enough extra money lying around that you can afford to buy 2 health care plans for everyone in your family.

It costs less to both get private health care and pay your taxes in Britain, than it costs to get only private health care in America.

218

Bloix 09.04.09 at 2:14 pm

Oh, and about those drug companies who simply must keep their profits up or else we’ll all die-
http://online.wsj.com/article/BT-CO-20090902-707834.html

I wonder if McArdle will argue that the past deaths from Bextra were an unfortunate necessity in order to preserve Pfizer’s ability to prevent untold future deaths.

219

soru 09.04.09 at 2:49 pm

‘You mean like life insurance?’

Life insurance has benefits that are defined at the time of purchase, not left ultimately to the discretion of someone on a profit-oriented bonus scheme in 40 years time. So it’s more like buying a TV than it is buying health insurance.

If life insurance worked comparably to health insurance, it would be defined as ‘we’ll give your children and loved ones sufficient money to complete their education and overcome any difficulties they may suffer in consequence of you not being there for them’. Where each word in the above has a footnote referring to a boilerplate definition that amounts to ‘we’ll decide what this word means when you are dead’.

Does anyone think that would work out?

I suspect the countries where private health insurance does work, it is not so much because of the detail of the law, but mainly because they are not as ideologically capitalist as the USA, don’t have profit sharing schemes and stock options, do have unions and employment law. So the profit motive isn’t enough to induce managers to improve the company bottom line by denying care.

220

someguy 09.04.09 at 3:40 pm

James Wimberley,

Just guessing. Something to do with corporate tax laws in each location? Looks like UK and US corporate rates are similar but maybe it has something to do with the details? IE do all your R&D on your US ledger and get a tax duduction.

221

Dingbat 09.04.09 at 4:02 pm

Most of the rest of the world simply has no idea why you are getting your knickers in a knot over public health care. Works alright here in Australia, a mix of public and private. Could be better, but such is life. The rich still get better health care than the poor, which won’t satisfy the ideological purists on either side but nothing ever will.

This Obama as Hitler and Death Panel stuff is seriously freaky – entertaining to be sure, compelling and fascinating that what would be the fringes of debate here is so central in your country. Good luck and take it easy.

222

urgs 09.04.09 at 7:45 pm

Transfer pricing fraud (libertarianish: Tax competition) is pretty big with R&D, so the numbers from the pharma companies are a bit fuzzy.

223

nick s 09.04.09 at 10:05 pm

exchanges and/or allowing individuals and companies to purchase insurance across state lines very directly addresses such situations.

Unless one or two states become the regulatory equivalent of South Dakota w/r/t credit cards. Which happens quite a lot in the US. And is BCBS of State X really going to “compete” with BCBS of State Y?

224

Charlie 09.04.09 at 11:47 pm

… she thinks there is a real possibility that the pharmaceutical industry, as presently constituted, will come up with an immortality drug in time for her to benefit from it, and reducing the industry’s profit margins will lessen or destroy that prospect. In comparison, nothing else matters at all.

Just noticed this. Yes, I think you have it right.

225

Cranky Observer 09.05.09 at 3:44 am

> Doctors of a given specialty, like most service providers, are basically
> fungible, in that they are all nearly equally capable of providing the
> same thing, and are all trying to provide the same thing: treatment.
> […]
>Of course, I’ve never understood the idea of having a “primary care
> physician” either—I suspect that most folks my age don’t comprehend
> this quickly-becoming-antiquated idea, by the way. You make an
> appointment to go to the clinic, whoever is on duty will be your
> physician that day. They check your charts, ask what’s up. I gather
> that some folks used to just go in to their primary care doctor
> twice a year, just because?

Um, if you are younger than 30 (35 if you are lucky) in the US or Western Europe, the odds are very good that you will experience no serious medical problem, and thus any walk-in doctor can give you equivalent care for the occasional strep throat. Once you pass 30-35-40 and serious things start to go wrong (and you start to get symptoms of things which could be serious even though they often turn out not to be), then it helps quite a bit to have a doctor who you see regularly and who is familiar with your chart and treatments (because she wrote and ordered them, respectively). Although I am good with masses of technical detail myself I was surprised at how much my adult medicine primary care doctor was able to remember from visit to vist and how positively it affected my care.

Cranky

Then he got sick of dealing with insurance companies and managing a small business, and went back to academic research…

226

James Wimberley 09.05.09 at 9:14 am

someguy (#220)and urg (#222): yup, I’ll buy tax fiddles as a partial explanation – though they count against American exceptionalism, don’t they?
The subthread is interesting, because based on dd’s smuggled-in actual facts, so I’ll try to rescue and continue it chez Mark Kleiman. Comments are back!

227

Mr Duncan 09.05.09 at 6:15 pm

Jonathan, going from $96bn to $167bn in 12 years is a 4.72% annual growth rate. By comparison, Canada’s GDP grew 5.44% ($837bn to $1580bn, IMF, April 2008) over the same period. So you’re saying that medicare spending in 2008 takes up a smaller portion of GDP than it did in 1996. Sounds like a good thing to me.

228

Cryptic Ned 09.06.09 at 12:28 am

This Obama as Hitler and Death Panel stuff is seriously freaky – entertaining to be sure, compelling and fascinating that what would be the fringes of debate here is so central in your country.

Why isn’t it central in every country? There are certainly high percentages of credulous reactionaries/fascists in every country, and the media in most countries is run by huge corporations.

229

soru 09.06.09 at 2:41 pm

@228: Generally speaking, the stronger and nastier a political system, the more it actually imposes on people’s live and forces them to do what it wants, the more vehement it’s defenders get. It’s basic Stockholm syndrome: you don’t want to be small and weak, so just adopt the perspective of those who are screwing you, and then the more powerful they are, the better you feel.

Take an international incident where, say, some plane maybe crossed a border but noone really has solid information on what happened. It is a law of internet politics that the number of posts strongly backing the position of either side will be, adjusting for demographics, proportional to the amount the political system of that country was reducing life expectancy in comparison with its international peers.

You can see examples across the net from Russia to Iran: look at the thread on this site last years war in Georgia. If North Koreans were allowed onto the internet, every forum would be full of praise for the Dear Leader and denunciations of those attempting to undermine his rule.

Thing is, Americans, when compared to pretty much any other first world countries, have much less personal freedom, are much more bullied and intimidated and threatened by larger powers.

Consequently, there is much more visible, stronger and emotional support for the american political system.

230

Salient 09.07.09 at 8:52 pm

soru, that’s a fascinating generalization that I’m going to need to give more thought to.

Cranky, point taken. I agree there is usefulness in seeing the same doctor over and over again. That given, getting to see the same person you saw last time isn’t the same thing as getting your #1 pick for doctor to serve you from some comprehensive list of practitioners. It’s exactly that idea of “choice” that I find most weird, though I didn’t successfully articulate that in the earlier comment.

I am beginning to suspect that desire for choice derives from some unspoken vague xenophobia of the form “only want to get treated by white people who don’t speak in unbearable accents and make me feel funny.”

It never ceases to amaze me when I hear someone around here complain of having had to see “an Indian doctor” (with the nationality spoken exactly as I would intone the word incompetent). I don’t hear it so much from colleagues, but from students / people around the community / et cetera, and they invariably complain “I couldn’t understand a thing s/he said.” By now, though, this really should have ceased to amaze me…

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