Socialised health care as feasible utopia

A reasonable question to ask might be, what’s the relationship of utopia to diagnosis?

Both make use of theory and evidence, in counterfactuals. The utopia is an assembly of such counterfactuals; diagnosis is a chain of counterfactuals leading to prognosis and treatment.

The great obstacle to the social democratic vision of cooperation and consensus, it seems to me, is the inevitability of competition, conflict and domination. What use are we to make of competition, conflict and domination? What limits are feasible? What channels serve?

Given that hierarchically organized society will have an elite, should we propose a utopian vision of anarchy, in order to inspire the overthrow of an sclerotic elite? Or a neo-liberal, or libertarian, utopia of “free market” competition, where concentrations of private predatory power are to be regretted ever so sincerely, or celebrated, as taste may allow?

Erik Olin Wright’s Envisioning Feasible Utopias

‘Envisioning Real Utopias’, I think it’s called.

D’oh! Fixed now – JQ

One “real utopia” that I can’t help being excited about is zero-fare public transport.

we could start with a utopian ideal where everyone got all the health care that could benefit them. But that would be utopian in the pejorative sense – the scope for expanding health services is effectively infinite, and the resources available to society are not.

Is this actually true, though? Surely there’s a limit to the amount of healthcare services people can consume, even with no price to pay.
I mean, I am served by the NHS, so I can already get certain sorts of health care completely free, but I don’t spend all my free time down at the GP’s surgery getting my blood pressure monitored and my hearing checked. I’ve got better things to do.

Similarly with Harald’s example (though he’s not saying that it’s not feasible); if you made all the public transport in London free, people are still not going to consume an infinite amount of it.

Yes, but in the realm of politics one would expect the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing.

So, I’m disputing the idea that socialized health care (and particularly with that ‘but it has to be feasible’ caveat) is some sort of “political project of social democracy”. It seems perfectly consistent with any political project of cut-throat capitalism.

(Sorry, I see ajay said the same thing first)

in the realm of politics one would expect the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing.

Well, would one? Why? I can see that Henry Ford would support cheap food; it means he can pay his workers less and still be confident that they’ll be well-fed enough not to faint at the assembly line. But JM Sainsbury won’t want anyone to be selling cheap food, because he won’t be able to make any money; either he’ll have to cut prices or he’ll lose customers.

ISTM that the best you can say is that “one would expect some parts of the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing” – with the exception of those bits of the business elite who are currently making money from providing non-cheap food, clothing, housing and health care. And given the proportion of the economy those four represent, well, that might be getting on for a majority.

“So for any proposal the only issue of which is whether cheap X is desired, the faction opposing cheap X will be outnumbered. It’s never the only issue, of course, but that’s irrelevant.”

It sounds like the old case of concentrated benefits versus dispersed costs. A healthcare lobby, whose supporters benefit immediately and directly from increased costs, can be much more successful at keeping costs high than the larger set of organisations and people that all benefit marginally and less obviously from lower costs. In the political arena, you usually get more bang per buck by lobbying for a specific benefit to you, then a general benefit that you share a little bit in.

ISTM that the best you can say is that “one would expect some parts of the business elite to strongly support a cheaper, socialized basic health care system, as well as wide affordability of basic food, clothing, and housing” – with the exception of those bits of the business elite who are currently making money from providing non-cheap food, clothing, housing and health care

Subsidies, all businesses should be, logically, in favor of government subsidies and other government policies that make the necessities of life affordable for their workers. They can still make money, not to mention charge a lot for organic food and chinchilla coats.

Of course if you own a medical insurance company, the NHS puts you out of business, and that’s a different story; but still, this has to be a very small portion of the business elite acting against the interests of overwhelming majority of it.

…And the National Gallery of Art, which is actually not part of the Smithsonian Institution, though it’s often lumped together with the Smithsonian.

Subsidies can be (and typically are) paid for not by the owners of capital but by workers in higher income category (‘middle class’). Capital gains tax is typically very low (if I am not mistaken, zero in some countries); earned income tax is, typically, high.

Hmm. The OP was about the need for the left to present people with a vision of how life should and could be; the discussion immediately became mired in technocratic details. A neat demonstration of the morass in which we currently are stuck.

the discussion immediately became mired in technocratic details

Well, isn’t it kind of important whether your vision is a real thing (something that goes against the interests of the establishment, to the benefit of the ordinary people), or it’s a sort of pseudo-achievement, beneficial to the establishment, introduced and implemented with no (or minimal) resistance?

To be more explicit, we know that more that one kind of universal health care system DOES work. The point in this discussion is not to get down in the weeds of exactly how they work and which system might be better. The point is to realize that 1) they DO work, and 2) they came to exist in those societies which had a robust vision of the common good which had as a corollary that health care for all is a basic right. So, how do we recapture that kind of vision- which is rapidly being lost even in much of Europe- and generalize it to other social and political institutions, in a way that the average voter can grasp and will desire? The technocratic details can wait, we KNOW those can be worked out.

derrida derider 09.07.11 at 6:31 am

” On the narrow point about health care, there is definitely no ideal – or even good – system extant. Market failure is pervasive, but then so is government failure. ”

First, ‘no ideal system extant’ means absolutely nada. As for good, a number of other countries have a variety of systems which outperform the USA.

Imagine, George W. Bush succumbed to the utopian vision of universal health care when he created the costly new entitlement of prescription drugs in Medicare. But America did not yet know that it couldn’t afford such an entitlement because of the huge tax cut Bush gave the rich. Cynic, though, might say that Bush expanded Medicare to enhance his friends in the pharmaceutical business and to get votes, only to be right.

One must be suspicious of utopian schemes. Generally they are schemed to advance some self-interest.

Americans: if you ever want to make this work, may I suggest that you sell it thus: “Let’s make the health care system more like the VA!”. After all, quite a few of you already have a single-payer system, and it works just fine, despite the massive load thrown at it by demography over the last three decades. HTH.

“Medicare is a single-payer service; I think the VA is more like a single-provider service (it runs its own hospitals etc) along the lines of the NHS. I like the idea though. First say “VA care is for veterans and their spouses and children as long as they shall live”; then extend it to grandchildren (and really, a fairly massive percentage of the US population must have at least one parent or grandparent who’s a veteran, thanks to WW2 and the draft); and then you’re pretty much there, and extending it to cover recent immigrants and their children is just a matter of strategically losing a lawsuit or two.”

Newsletter. Would like to subscribe. etc.

Yeah, Ajay really needs a blog…

I’ve thought that for years now and have told him so (and I know I’m not the only one) but if he did so I’d be afraid that his prolific commenting would diminish at all the blogs he comments at; he’s like a one-man wumao dang army, only with quality.

Fine, so this may be one explanation for the US situation. Plus that the businesses probably sense that current system is advantageous in that by linking health care to employment it creates a sort of serfdom.

Still, I’m afraid I have to insist that this is not a very good example of a utipian dream come true, since it fits reasonably well (as I hope you agree we’ve established) with the dominant socioeconomic system. Wake me up when you manage to expropriate $10-15 trillion from the top 1%.

Regarding the point that health care expenditures can approach infinity quite easily… it is time the non-economists got on board with this, and quickly. Evaluating the costs of health care in the United States this has become overwhelmingly obvious that is not only theoretically possible but actually a real phenomenon in health care provided by well meaning human beings operating relatively open loop that costs in end-of-life care can get quite out of hand. You actually do need death panels to regulate the kinds of end-of-life care that are appropriate in different situations. The UK does this explicitly by evaluating the expected quality life years versus the cost of treatment. Medicare does not and will be an issue that has to be tackled explicitly or implicitly to prevent long term health care costs from growing to the point where the political will to support the cost will no longer exist.

Regarding the point about Ricardo and health care costs, this is both wrong and quite irrelevant to this discussion. He is talking about continuation of the species type of care. There is definitely a question as to whether good prenatal and early life care is cheaper than simply having women try multiple times to get their kids up to an age where they can survive pretty easily without professional assistance, but really that is a minor point. Most of the costs of health care apply to the elderly who are neither necessary for the propagation of the species or productive workers. And the minority who require care just to get through their working years intact are not required either. It is quite reasonable from the capitalists perspective that health care expenditures by the labor class be effectively zero because they receive no professional health care. It has been this way for most of human history. Socialized medicine may not be a bad thing for the capitalist, but it is not part of his agenda! Don’t get distracted by this red herring.

One less visible bit of the health-care question is what else is happening in that area there. We see the accomplishments of medicine as a relatively pure defense against hostile attack from disease etc., but maybe something else is happening there at the same time.
Maybe by taking over almost all our own evolutionary pressures, dismantling them, but not replacing them with anything other than economic versions of predation and response, we’ve not managed to better the system in any but the most immediate, temporary, way.
Also, allowing individual humans to profit from other humans’ miseries, in whatever form, may be ubiquitous and obvious now, but overall it’s a pretty bizarre way to preserve a species.
But maybe preserving the species isn’t really what we’re on about anymore?

” It is also possible that capitalism will enter into a long-term process of intensifying crisis and permanent decline, but in the absence of of a compelling theory of the mechanisms that generate such intensification, this is a purely speculative argument.”
Wright, Envisisioning Utopia, p. 320
Also see pp. 100-3 against the thesis of crisis intensification. Elsewhere in the book Wright claims that a disciplined labor movement could work with the state to ensure full employment. But offers little in the way of analysis of the grave difficulties in getting such an outcome.

#38

Americans: if you ever want to make this work, may I suggest that you sell it thus: “Let’s make the health care system more like the VA!”.

You would think so. But if “Just like Medicare, but for everyone!” wouldn’t fly, I’m not sure the VA (which I think even fewer people are familiar with) is going to sell single payer. Especially, as has been pointed out, since it’s more of a single provider program. It’s bizarre that it is politically impossible to extend the hugely popular single payer system for old people to everyone else.

it’s possible to pour essentially unbounded resources into keeping terminally ill patients alive for a few more days

It’s possible to spend millions of dollars freezing your body after death in the hope that you will be resurrected a few centuries down the line. I understand this is quite popular with the American super-rich. The inference as to what rational people, on the other hand, would choose to do with such resources remains unclear to me.

This question brought to mind Rousseau in his Gov’t of Poland writings, where he considers a similar problem. If I recall, his ‘solution’ was to channel competitiveness to the national, or community’s, glory rather than to the individual’s. In other words, co-opt competition through various mechanisms. So, I wonder if, underlying your question is yet another: can competition be both made to serve the public good and to serve a public that is widely considered, rather than narrowly.

(And naturally a world without motor cars, or even one where Californians don’t have two each when Africans have to walk, is the stuff of utopian dreams…)

only really holds if we assume that businessmen are solely motivated by the desire for aggregate economic growth and aggregate profits

Look, if I’m the owner of GM, whatever I pay for my workers’ medical insurance, and whatever extra I’m paying to my $50K/yr workers, for them to be able to afford their portion of the premium – this either comes out of my pocket directly, or indirectly, by reducing my competitiveness. A half of it is a waste (insurance companies’ profits, inflated doctors/hospital fees, unnecessary procedures), and a bulk of the rest could’ve been paid, under a socialized scheme, by $100K/yr Microsoft employees. Do I really need to be all that enlightened to see it?

Steven, sure, since empirically we don’t observe GM lobbying for a socialized scheme (at least not openly), there’s gotta be something else, some explanation. All I’ve been saying here, from the beginning, is that socialized health care is not, logically, antagonistic to the interests of the elite.

This limit on costs seems to be the real savings between US and UK spending.

One of them, but far from the only one. The US also has doctors who are paid too much, and insurance and hospital executives who are paid far, far too much, and an army of insurance and hospital bureaucrats who shouldn’t be employed at all, and overuse of expensive and dubiously effective treatments apart from the last year of life.

Surely one part of the explanation as to why GM is not lobbying for socialised health schemes is that, as Thatcher famously said, “There’s no such thing a a company: there are only executives.” The interests of the upper executives, as we have seen, are best served by them arranging circumstances where they are grossly overpaid until the company collapses in a screaming heap, when they take their loot and go home; it’s certainly difficult to extract any other drivers from their practice. And this means that their planning timelines are in the order of two to three years, which means that they can afford to disregard any long-term damage to society.

hartal says (at 50): “Elsewhere in the book Wright claims that a disciplined labor movement could work with the state to ensure full employment. But offers little in the way of analysis of the grave difficulties in getting such an outcome”.

In Australia from 1983 to 1996 there was a very deliberate and (to my mind) pretty successful effort at getting “such an outcome”. It was called The Accord. A very brief summary of that adventure by Peter Cook, a Fed. Govt. Minister at that time, is here (Note: .pdf):

http://cep.lse.ac.uk/pubs/download/occasional/OP001.pdf

Maybe Prof. Quiggin, who is also an Australian, could provide more comprehensive references if commenters are interested.

A very brief summary of that adventure by Peter Cook, a Fed. Govt. Minister at that time, is here

He went into politics after failing to become a judge. He didn’t have the Latin, you see.

Steven, sure, since empirically we don’t observe GM lobbying for a socialized scheme (at least not openly), there’s gotta be something else, some explanation. All I’ve been saying here, from the beginning, is that socialized health care is not, logically, antagonistic to the interests of the elite.

Well, way back in the late 40s, Walter Reuther actually made them an offer – join us in a joint campaign for national healthcare, and we’ll let you off putting lifetime health benefits in the contract between the UAW and Detroit. They were willing to essentially sign a blank cheque rather than be seen to agree with the UAW.

Spite and bullshit explain a lot.

Chris: at least some of it must be down to the VA’s homebrew open-source case management software that the NHS wasn’t allowed to use because Bill Gates got at Blair back in 2001.

JQ, high income earners are not compelled to insure with private insurers. We have to pay a slightly higher tax rate (1.5%) if we don’t have private health insurance. But when you do the sums (or at least when I do) you come out ahead paying the tax and saving the premium, for what is a really crappy product (private health insurance). Because if you are seriously ill in Australia, you *really* want to be in a public teaching hospital, not some private set up where they will just send you to the public hospital when things go wrong. And for lots of ‘elective’ things, it’s actually cheaper to pay the doctor and use the public hospital (as I found for gall bladder surgery last year — $380 to the surgeon, no waiting, great public care). Private health insurance, like private schools, is really for signalling wealth, rather than actual utility.
And the Medicare levy is the only bit of my taxes that I actually get to direct to a worthwhile cause (unlike, say, helping the Americans obliterate Afghanistan or Iraq). I positively enjoy paying it every year.

Cheers Sam: it looks like about half of US households have an income which is above the VA ‘thresholds’, although it’s not clear from the VA site whether these refer to individual or household income. On the other hand, I’d imagine that a majority WW2 veterans would have entered the system aged 65 or more, and census data suggests that a far higher proportion of households headed by over-65s have an income below those lines.

I find your initial contention a little confusing:

“Turning to health care, we could start with a utopian ideal where everyone got all the health care that could benefit them. But that would be utopian in the pejorative sense – the scope for expanding health services is effectively infinite, and the resources available to society are not.”

For starters, a finite number of humans cannot exactly consume an infinite amount of health care. Secondly, it hardly benefits someone to be kept alive hooked up to a machine despite being brain dead, which I understand is a rather expensive operation. So I think we can safely say that as long as you include the caveat which you did include, i.e. it benefits them, there’s no way healthcare costs will tend anywhere near infinity.

Anyway, don’t mind me, I’m just disgruntled because the bastard tories are destroying the NHS and giving it away to their rich pals to play with, and no political party has the balls to do anything about it.

This just in from the U.S. Republicans’ first debate: Rick Perry does not believe Social Security should exist.

Also in from the U.S. Republicans’ first debate: Rick Perry is apparently really awesome specifically because he signed orders to get a lot of people killed. 234! Including someone who was never found guilty of murder or even accused of a murder charge (Robert Lee Thompson), someone who was blazingly obviously not mentally fit to stand trial (Kelsey Patterson), and someone whose convictions relied on evidence that was later called into question and found to be deeply faulty, meaning the prosecution’s case could plausibly have been utter bullshit (Cameron Todd Willingham). Those people plus 231 more! It’s a record! I think Rick Perry also holds the elite status of being the very last governor to refuse commutation to a minor. He’s proud of that: he even faced off with the Supreme Court over the right to let juries assert the mental fitness and competence of someone facing the death penalty and overrule professional medical assessments. How courageous. And he, by his own admission in that video clip I just linked, hasn’t ever felt worried about potentially executing the innocent!

Rick Perry is a man proud to grant his approval to executions against the advice of his Texas Board of Pardons and Paroles (his because he has sole authority over the people who comprise the board, as all members are his appointees). So I can say, completely literally, that Rick Perry approves of death panels, but only if those panels almost always approve death.

(Thank you, I needed a chance to say that.) I’ve known Perry was slime for quite a while; no news there. But how the audience responded to his boisterous remarks just knifed me in the fucking chest. Click the link, scroll down to the 71-second video clip from the debate, watch it. Know this man is one of the top contenders for the Republican party’s choice of President, and could quite plausibly receive the support of half the voters in this country, and easily a third of those would’ve applauded in that audience if they had been there on that day. Despair.

It’s feeling like a couple decades from now Restrictions on the state’s right to authorize executions as feasible utopia will be a coherent blog post title.

Pete @37 & OCS @51: While that could perhaps sound reasonable, Sweden is a good counter-example. They had rationing during WW2, but not bombing or a US-style military mobilization. Still, they built a welfare state, despite not having been at war since 1814.

Engels, you don’t seem to care much what kind of utopia it is, just so it’s utopian.

I’m not really sure what this means, but I’m sure it means you’ve won the argument.

Pleased to hear that in Utopia the hard-working and productive classes will be doing the school run in solar-powered 4x4s.

I take JQ’s point to be that “socialised” health care works reasonably well (and demonstrably better than more market-based alternatives) and the basic approach could be extended to other areas. Whether this could work or not can be debated but, in an earlier post, JQ pointed to the need to inspire people with something more than a technocratic recipe for somewhat greater welfare. I don’t see advocacy of a more mixed-economy approach to, say, housing, as meeting this need.

It’s worth reflecting on how we got to social democracy – a seventy-year civil war, sometimes full-on, sometimes simmering, over the restoration, in a different economic setting, of the basics of community provision that had been lost with the changes from agrarian to industrial economies. Social democracy emerged as a response to a challenge. Is more equal access to decent housing the real challenge now?

I’d see the broad range of environmental issues (and the concomitant need to downsize our impacts on the planet with the minimum of distress) as the major challenge. Surely one could come up with a social democratic response to this that would inspire people?

“and, on the other hand, markets perform very badly.”

That really doesn’t sound quite right.

A pure free market, turn up with your chequebook to get treated, works badly, certainly. The US private insurance market has many well known problems too.

However, within the various government backed social insurance schemes ranging from Singapore’s health savings accounts plus catastrophic illness insurance, through to the UK’s near monolithic NHS (both govt financed and directly govt run) with the various Swiss, Sweidish, German, French etc variants in between the performance of markets seems to be rather good.

The French system for example, was regularly said by the WHO to be the finest one in the world (and the evaluation was based on impeccable social democratic measurements, like equity of access, equity of financing etc as well as standards of treatment) and that has competing providers, govt owned, charitable, for profit, even if largely govt financed.

So the statement that markets perform badly in health care would seem to be too broad. Markets in the financing of health care, yes, it does seem that they work badly there. But markets in hte provision, supply of it, well, they seem to work just fine.

Elitist in the sense that the preferred policy option in dealing with these issues is often a call for regressive taxation or a rather blithe attitude about how the “costs of adjustment” might affect blue-collar jobs (combined with a distaste for “dirty” manufacturing), or a tendency to be more interested in Other People’s Poverty than the home-grown variant. Ascetic in the sense of looking down on materialism and consumerism, which rather rankles people who can’t afford to shop at Whole Foods or buy all-hemp clothing and who could use some more material security.

It’s not that there can’t be a green politics that does class well, but at least in the U.S, environmental politics tends to attract an audience that’s whiter, maler, and in some cases richer than even the GOP.