Live by the flaming sword of true religious spirit technicality, die by the technicality

by John Holbo on February 4, 2013

Dave Weigel calls this, from Yuval Levin, the ‘best riposte’ to the new HHS regulations. I must say: if this is the best they can do …

Levin’s objection is that HHS is just looking for a way in which they can say that, technically, we’re not doing this thing people say infringes their religious liberty. HHS is hereby neglecting to address the larger spiritual issue of religious freedom. But the original complaint about the contraception mandate was that technically you can be made out to be making us do this thing. Technical hitch calls for technical fix. It ain’t pretty, but what were you expecting from a lawyerly work-around?

The Obama administration was not motivated, originally, by animus to religious freedom. The goal wasn’t to humiliate Catholics. It isn’t the case that no one gave a damn about contraception, one way or the other, except as a convenient device to force religious believers to do things against their conscience, for the sheer sake of forcing them to do things against their conscience. The purported insult to religion, such as it was, was an accident, due to the kludgy quality of employer-provided healthcare. It isn’t like the Obama folks only went for employer-provided healthcare because they could see that this set-up was ripe for forcing employers into a posture of religious self-humiliation. Letting the private sector run things is a concession to those who want the private sector to stay powerful, not a sop to those who want to throw Christians to the lions, like in the good old days.

Now, courtesy of HHS, we have a fresh kludge to slap onto that more time-honored kludge of employer-provided health insurance. Can anything look less like an insult to religious liberty? Yet, bizarrely, Levin objects that all the change does is make a conceptual change that “makes the rule less insulting”, by substituting IRS definitions for other stuff. Somehow removing the unintended insult, which was the only injury, is adding insult to injury.

Why bang on about the true spirit of religious liberty when there is, patently, no threat to that, just a technical bump on the road to somewhere else: healthcare ends everyone agrees are permissible, in principle [UPDATE: legally permissible. I had assumed it was clear enough that this was the relevant sense of permission, but comments have shown me the need to be clearer.] Those who sincerely care about religious freedom should be happy to see healthcare clear the bump and be on its way.

Unless, of course, they are just looking to take offense. And this is precisely what Levin implies that proponents of religious freedom should not do. (At least it looks to me like he is implying this.)

Religious liberty is an older and more profound kind of liberty than we are used to thinking about in our politics now. It’s not freedom from constraint, but recognition of a constraint higher than even the law. It’s not “the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life” but the right to answer to what you are persuaded is the evident and inflexible reality of existence, of meaning, of the universe, and of the mystery of human life. It’s not the right to do what you want; it is the right to do what you must.

The more truth there is in this thought, the less appropriate it is to be on a lawyerly hair-trigger for every last little technical sense in which someone might be construed as having trod on your little toe, where religion is concerned. Civil life should be not lived, permanently, at the very cliff’s edge of civil disobedience. Isn’t that Levin’s point?

It is therefore incumbent upon the government of a free society to seek for ways to allow people to live within the strictures of their consciences, because it is not possible for people to live otherwise.

How can it not be likewise incumbent on religious believers, in a free society, to see if there is some way to live within the legal strictures of that society, arrived at by people who may not share all of their specific religious beliefs? (Isn’t it obvious that this cuts both ways, if it cuts either way?)

This is particularly obvious with regards to the sorts of institutions that are in question. Faith-based institutions that are part of civil society and semi-entangled in government, in a technical sense – hospitals and schools and so forth. The government should try to make fixes to its rules, to accommodate religious sensibilities. And believers should try, in turn, to be willing to accommodate this need to operate by means of technical accommodations. How else could the whole thing possibly work? Unless the rule is just: whatever religious believers want, they get, even if it tramples on the freedoms of non-believers not to get that particular, religion-driven result? But that can’t be right.

Why be a sore winner? You got your technical fix to your technical hitch. K-Lo acts as if the fact that the fix is 80-pages long (“enjoy!”), and written by a lot of people who are on the other side of aisle, politically, shows how inconsiderate they all are of the religious sensibilities of folks like her. But surely it shows the opposite: those people are obliged to take the religious sensibilities of folks like K-Lo at face value, even if they suspect (as would be quite reasonable, under the circumstances) that she is making exaggerated faces, for effect. “Enjoy!” is a double-edged sword, after all. I’m sure these folks had more fun things to do with their day than write an 80-page thing that did the same thing, basically, as the other thing did before they added the 80-page thing.

{ 88 comments }

1

Random Lurker 02.04.13 at 11:39 am

“It is therefore incumbent upon the government of a free society to seek for ways to allow people to live within the strictures of their consciences, because it is not possible for people to live otherwise.”

I believe that freedom of religion is not a form of freedom from the state, but a form of freedom of believers of something from believers of other things. Thus for example the problem of a legislation that forces Catholic employers to pay for contraceptives is the problem of the beliefs of those employers VS the beliefs of their employees who might be pro choice and expect that the health insurance they have the right to under the law covers contraceptives.
If the government gives too much to the “Catholics”, it infringes on the religious freedom of the “non Catholics” (I use those terms for short).
The government is only the refree here, not one of the players.
It is funny how the religious freedom of, for example, us atheists is not seen as relevant as the religious freedom of “believers”.

2

rf 02.04.13 at 12:20 pm

There’s also a story linked to on Dershowitz’s wiki entry of a time ten years ago in Harvard when, faced with a BDS campaign on campus, he ended up calling a meeting and debating ‘an empty chair’ ..

“The Harvard Law School professor had publicly challenged Winthrop House Master Paul D. Hanson to a debate over the Israel divestment petition that Hanson signed last spring. Last night, saying Hanson had turned down his offer, Dershowitz staged a solo debate in the Winthrop Junior Common Room.
Standing beside a chair with a copy of the petition taped to it, he said students and professors who had signed the petition were anti-semitic and knew “basically nothing about the Middle East.”
“Your House master is a bigot and you ought to know that,” he told the crowd of about 200 students. “Everyone else who signed that petition is also a bigot.”

Which makes his behaviour now particularly brazen..

3

rf 02.04.13 at 12:21 pm

Sorry, wrong thread..

4

The Modesto Kid 02.04.13 at 1:20 pm

@Random Lurker: Clearly it is because atheism is freely chosen, whereas religiosity is forced upon one (“it is not possible for people to live otherwise”)

5

Glen Tomkins 02.04.13 at 1:33 pm

“Unless the rule is just: whatever religious believers want, they get, even if it tramples on the freedoms of non-believers not to get that particular, religion-driven result? But that can’t be right.”

That is the rule that they live by and want forced on the rest of us. I’m not sure the rest of the post was necessary.

6

Left Coast Bernard 02.04.13 at 1:36 pm

The new health care law does not infringe on Catholics’ religious liberties. The law does not require priests and nuns to use birth control. They are at liberty to use it or not in accordance with their beliefs.

The issue, as your blog post considers, is the Catholics’ assertion that the laws they obey are superior to those of civil society. This is a dispute 20 centuries old. The Catholic Church wishes to impose their harmful and foolish beliefs on non-Catholics because the Church believes that its law is superior to civil law.

Health insurance that an employer arranges for employees is part of the remuneration of the employees, belongs to the employees, and the employees use it as they see fit.

This fight is not about Catholic dollars going to pay for birth control. Policies that include birth control cost insurers less than those that don’t because having babies is more expensive than not having babies. The Church ought to be demanding refunds from insurers who provide no-copayment coverage for reproductive health. The Church would be paying negative dollars for this coverage.

7

Random Lurker 02.04.13 at 2:01 pm

@Left Coast Bernard

“This is a dispute 20 centuries old. The Catholic Church wishes to impose their harmful and foolish beliefs on non-Catholics because the Church believes that its law is superior to civil law.”

I disagree with this formulation.
In ancient societies, the distinction of “civil law” vs. “religious law” didn’t really exist; for example, the kings were supposed to be kings because of the “will of God”.
Even in the fight between the emperor and the pope about the investitures during the middle ages, the emperor’s theory was that his role was given directly by God and not from the pope, so his role was still a religious one; the various “protestant” kings that went against the pope also believed (or at least asserted) that they were kings by God’s will, and that the Roman Church was a sort of false church, not that their rule was “civil” and that “religious law” was unimportant.

Speaking of the Catholic Church as if it was the only bad repressive religious institution that existed from AD 0 to date seems very much a straw man to me.

Also, “civil law” is supposed (by most people) to be morally just to some degree, but from the point of view of a believer “morally just” means “more or less in line whith the absolute moral truths that I believe in”.

8

SamChevre 02.04.13 at 2:22 pm

healthcare ends everyone agrees are permissible, in principle

This is the core of the issue. Catholics DON’T agree that the end of providing contraception is part of healthcare, or is permissible in principle.

9

Uncle Kvetch 02.04.13 at 2:33 pm

Catholics DON’T agree that the end of providing contraception is part of healthcare, or is permissible in principle.

And yet over 90% of them use contraception. How does that work?

10

John Holbo 02.04.13 at 2:36 pm

“Catholics DON’T agree that the end of providing contraception is part of healthcare, or is permissible in principle.”

Sorry, Sam, but it’s not legally controversial that the government could mandate contraception provision as part of a government healthcare program. It’s only controversial whether they can do it in this employer-provided, hence employer-mandated way. So while it may be true – is true, I take it – that Catholic teaching forbids contraception, hence probably denies that it is a legitimate part of healthcare, religious freedom does not entail the right to impose one’s religious beliefs on others who may not share them. So Catholics can’t really think they have the right forcibly to impose Catholic religious teachings on the nation, on religious liberty grounds. Nor are they actually arguing this. They have to restrict their argument to the rather technical provision about who can be made to provide what. My point is that a restricted technical argument is one that invites a restricted, technical response, not a sweeping spiritual one.

11

Steve LaBonne 02.04.13 at 2:40 pm

And yet over 90% of them use contraception. How does that work?

It works by people like SamChevre telling the baldfaced lie that “elderly pedophiles in skirts plus a small minority of wingnut churchgoers” = “Catholics”. This is also the same way some people convinced themselves that Obama was going to suffer a large decline in his “Catholic vote”.

And that’s before even getting into the lie that “religious freedom” means making non-believers in your religion live by its supposed tenets.

12

wembley 02.04.13 at 2:54 pm

It’s not the right to do what you want; it is the right to do what you must.

Ew.

13

RSA 02.04.13 at 3:11 pm

What seems incongruous to me, as a non-believer, is that Catholic teachings are full of technicalities and mechanisms for working around them. The Code of Canon Law for receiving communion, for example, reads like a legal document.

14

Ben Alpers 02.04.13 at 3:12 pm

Some additional notes:

1) It’s not just Catholics, but Evangelical Protestants, like the owners of Hobby Lobby, who’ve been leading this fight, despite Evangelicals’ not opposing contraception as a matter of dogma.

2) Lurking in the background of this discussion is the propertarian assumption that employers ought to be able to control the lives of their employees. In this sense, the kluge of employer-provided healthcare is a feature, not a bug, for those screaming about “religious liberty.” To a great extent, they believe that their religious liberty includes the right to dictate their employees’ behavior.

3) Discussions of church dogma and legal niceties are just window dressing on yet another argument about controlling female sexuality.

15

James 02.04.13 at 3:20 pm

It could also be seen that a nation trying to bring health care costs under control would do well not to anger an organization that provides a good portion of that nations healthcare.

16

Steve LaBonne 02.04.13 at 3:25 pm

It could also be seen that a nation trying to bring health care costs under control would do well not to anger an organization that provides a good portion of that nations healthcare.

That can and should change, since that same entity refuses to provide certain categories of health care to those humans who are deemed by it to have inferior rights because they happen to possess vaginas, and thereby makes itself a menace to public health.

17

bianca steele 02.04.13 at 3:26 pm

Religious liberty is an older and more profound kind of liberty than we are used to thinking about in our politics now. It’s not freedom from constraint, but recognition of a constraint higher than even the law.

This part caught my eye too, but I don’t get your response to it. Isn’t Levin just saying “I obey 613 laws and you only obey 612, so it’s logically impossible that I could be breaking any of your laws”? To make sense, he has to be saying that they’re the same laws, that he believes secular people have pretty much all the beliefs as “religious people” (kind of a broad category, but it seems to be his category), and secular people and secular laws are just kind of benighted in some way and won’t or can’t obey the law, but should realize deep-down that they owe a debt and some real respect for people who do. And religious freedom would mean the benighted people are prevented by law from interfering with the good people, I suppose.

For Levin to be saying life should be lived on a hair trigger of civil disobedience would have to mean religious and secular law were totally incompatible, and religious freedom meant they were not only allowed to have their areas where they withdrew from the secular world, and to engage in a certain amount of persuasion that secular people didn’t mind, but really to go beyond that (and not just to talk about how nice it would be if they were allowed to go beyond that, kind of thing). This would be really peculiar, I’d think.

18

MPAVictoria 02.04.13 at 3:26 pm

“3) Discussions of church dogma and legal niceties are just window dressing on yet another argument about controlling female sexuality.”

You really could have just posted this. In fact every article, blog post and comment about this issue could simply be replaced with a link to a website containing nothing but the above comment.

19

Tim Worstall 02.04.13 at 3:34 pm

“Catholics DON’T agree that the end of providing contraception is part of healthcare, or is permissible in principle.”

Leaving that aside, why would anyone at all want to provide contraception through an insurance mechanism? Or vaccinations, or annual doctor visits or anything else that doesn’t involve a pooling of risks?

Why use insurance of all things to pay for what just about everybody is going to use? Just doesn’t make sense. Even (shudder) a single payer system would be better for such things.

20

Holden Pattern 02.04.13 at 3:45 pm

Leaving that aside, why would anyone at all want to provide contraception through an insurance mechanism? Or vaccinations, or annual doctor visits or anything else that doesn’t involve a pooling of risks?

This is a daft question. The answer is because the insurer pools the demand and therefore can bargain with the provider for lower prices, reducing the cost for everyone within the plan. Further, because these prophylactic measures are cheap relative to the expense of the thing they prevent (for everyone: insurer, individual, employee, employee’s family, society across the board), everyone ought to want the insurer to bargain the price of these things down, and therefore increase the consumption of these things.

21

JanieM 02.04.13 at 4:06 pm

I was raised Catholic. If the Church had had its way, I would never have known I exist.

This endless nitpicky quibbling about the rules for employer-provided health insurance is the purest smokescreen, the holding action that the Catholic Church has been forced into because it was actually given a hard push backward on this issue in the sixties and seventies with Griswold and its aftermath. Before that, the Church had spent about eighty years implacably fighting against the mere legalization of birth control. (Great book on the history: Liberty and Sexuality, by David Garrow. It’s a doorstopper and a pageturner at the same time. The first eighty percent of it is about the long campaign to make contraception legal. The rest is interesting too. :)

I don’t believe for a second that the bottom line of this fight is that the Church doesn’t want to pay for contraception for its employees. I don’t even believe that the bottom line is that it wants to force its employees not to use contraception, no matter who pays. The bottom line isn’t about its employees at all, it’s about all of us. Sad to say, the fight is never over. Too bad, you’d think we had better things to do.

22

Trader Joe 02.04.13 at 4:27 pm

I find that many religious people who get worked up about items such as this (and many others, usually involving holiday decorations) are at a complete loss as to what the First Amendment actually says. So many are taught the short hand version that “The first amendment establishes a separation between church and state” that they believe it limitation greater than the Amendment actually provides.

The First Amendment says “Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof”

Clearly neither the ACA nor anything put out by HHS establishes a religion, so the only possible objection is free exercise. Free exercise, in this context and according to Catholic dogma would be to respect life and not use birth control – paying for insurance coverage cannot be construed as preventing free exercise of a religious belief, its the prefunding of costs expected to be borne by the payor. Insurance dollars are fungible – they don’t know what they are paying for.

Healthcare coverage provides a myriad of things that one religion or another might find objectionable including transplants, blood transfusion and many others….there is no free exercise restriction. Paying for the availability of coverage is far different than actually using it. Most religions don’t advocate drug use, yet no one objects to insurance dollars going for morphine.

It would be the equivalent of saying I’m not paying taxes as a pacifist because some portion of the money goes to defense or I’m Islamic and some portion goes to pay interest….the free speech to think so is protected, but that doesn’t guarantee the success of the argument.

The problem, as the religious orders well know, is that their employees will use the coverage if its available since many are private paying already (the 90% often cited). The church wants an out to say, in effect, ‘we didn’t facilitate the hand of the devil.’ The HHS has seemed to give them that as much as they think they can, its now up to the theoreticians and the church’s clever lawyers to decide if they wish to accept the olive branch or pursue an argument they can’t really win.

23

Billikin 02.04.13 at 4:38 pm

What about the religious liberty of the employees? Aren’t they the ones who really bear the cost of their insurance? The employer is a middleman. Why shouldn’t the religious liberty of the employees be paramount?

24

Billikin 02.04.13 at 4:46 pm

Holden Pattern: “The answer is because the insurer pools the demand and therefore can bargain with the provider for lower prices, reducing the cost for everyone within the plan.”

That last phrase does not follow. Health insurance companies play the middle against both sides. They do not necessarily pass savings on to their customers.

25

Holden Pattern 02.04.13 at 4:52 pm

That last phrase does not follow. Health insurance companies play the middle against both sides. They do not necessarily pass savings on to their customers.

My wife would be surprised to hear that, given the cost of her birth control with and without insurance. I would also be surprised to hear that, given the cost of lab tests with and without insurance and the cost for my annual visits to the doctor with and without insurance (hint: “copay” is less than the bill), and the cost of my semi-annual dentist visits with and without insurance.

Sure, in theory, the insurer might take all of that difference, but in practice, part of what the insurer offers is negotiated rates with providers relative to the uninsured rate. That said, given the patchwork trainwreck that is American health care, those rates are all over the damn place, and it’s very hard to know what anything actually costs.

26

Glen Tomkins 02.04.13 at 4:59 pm

Rendering unto Caesar

Levin is a US ctiizen. Has he ever paid any taxes to the US? Are we to imagine that nothing else the US spends money on, and that he has therefore made himself responsible for by paying his taxes, has ever bothered his conscience? Until this bit about religious organizations being forced to provide insurance that includes contraception, he was a 100% booster of everything the US has ever done in his tax-paying lifetime? I’m not going to even bother looking up any more of his writings for a refutation out of his own mouth. He writes for NR. Those people make a career out of being morally outraged at things the US spends money on.

Just to confine the discussion to contraception, Levin has for decades helped finance the contraception that the US provides via military medicine, VA medicine and the Indian Health Service, to name only the sources of the direct provision of govt-funded health care. Unless he’s writing from a jail cell, we have to assume that he’s somehow squared his conscience with that. He just needs to ditto whatever reasoning or revelation has already squared him with rendering unto Caesar, and he will be fully squared with this insurance regulation.

Even if you don’t follow any of these religions, it is useful to have some familiarity with them, because you can bet that any sleazeball religious argument you’re likely to run into has already been thoroughly debunked by non-sleazeball religion. I have yet to hear argument one from an atheist that wasn’t stolen from some centuries old refutation of heresy.

Not that Levin’s little essay deserves any refutation. It displays a pathetic lack of seriousness about its claims, because he passes up the same issue in the obviously stronger form in which it would strike anyone of conscience — the matter of supporting with taxes a govt that we all believe does at least some grossly evil things — in favor of faux outrage over a legal footnote. He’s straining at gnats and swallowing camels.

27

mud man 02.04.13 at 5:05 pm

@bianca steele #17

Anyone who acts from principle rather than law is faced with the possibility of being self-required to an act of civil disobedience. Of course principle arises from other stances than deistic. I would take the ideal point of secular law to be a minimally-principled set of constraints that allow acts of civil disobedience or difference, such as divisive speech and unusual personal habits, to be maximally tolerated. But clearly that isn’t what the bishops and their fellow-travelers are after; rather than living out their own values (ie, advocating against contraception by example, speech, demonstration) they are seeking a secular framework that protects them from the consequences of acting out their faith. That’s the very opposite of what I take to be the Christian message: Jesus didn’t bargain with Caiaphas or Herod. That is, with Religion OR State.

28

bianca steele 02.04.13 at 5:20 pm

@mud man on “principle” as opposed to “law”

As it happens, I’d been considering replying to Holbo’s @10 on this, because I don’t see the difference between principle and law in the sense you’re suggesting. I think there’s no such thing as secular law, as it happens, that is derived solely from first principles, or from empiricism, or anything like that. Secular law is an evolutionary development from Western Christian traditions, not completely incompatible with present-day religious traditions, but not identical with them or dependent on them either.

In liberalism, presumably, all these traditions, including an independent secular tradition, get to duke it out in various ways, to determine what substantive law will be.

29

Glen Tomkins 02.04.13 at 5:36 pm

@24,

Once upon a time, there actually was a “usual and customary” price that providers of medical services charged patients who paid out of pocket. Back when paying out of pocket was the dominant pattern of paying for medical care, that usual and customary price would be kept down by market forces, by competition. This was so much the case that when medical insurance first entered the picture, it would pay this price, because it didn’t need to do anything else to get a good, market-disciplined, price.

Now that third party payment is the dominant form of paying for medical care, the usual account is that folks paying out of pocket don’t have the market power to hold any such usual and customary prices down. But even if you accept the current system of paying for medical care at face value, and accept the idea that third party payers bargain down prices, you wouldn’t say that the uninsured rate is in any way any sort of natural, unbargained price. Providers jack it up as an afterthought, without any concern for the increased market share they might gain by offering even this small market competitive prices. Why do providers ignore even a small market? They are under pressrue to maximize proifits, and this market is, after all, growing, as more people cannot afford insurance anymore.

Well, providers ignore the market for the uninsured for the same reason the insurers don’t really conform to your ideal of agents using their market power to negotiate low prices. Wellpointe has more benificiaries than the whole Canadian health care system, yet it fails to use that market power to do what Canada does, negotiate low prices from Big Pharma. It doesn’t do what Canada does because, unlike Canada, Wellpointe and Big Pharma are parts of one big cartel. One hand washes the other, and all hands belong to the cartel.

Letting your wife have her birth control pills at anything near the price of production (pennies per pill) plus overhead and some profit margin, would mess up the monopoly pricing they are allowed to inflict on all of us, insured and uninsured alike. They would get more market share among the uninsured by passing on some of the huge savings they could realize if they actually did negotiate with Big Pharma, but that would kill the sweet deal they have going overall. That they let prices go so far up for the uninsured is just the incentive they leave in the system to get you to buy into their more profitable racket and become one of their “beneficiaries”.

30

Tim Worstall 02.04.13 at 5:45 pm

@ 20. What @28 says plus. Did you not note my last line?

“Even (shudder) a single payer system would be better for such things.”

I am continually astonished at how the US health care system is so entirely screwed up that it’s not only worse than a good health care system (say, Singapore’s, about the same quality at under half the price via a very large dose of market forces plus the necessary government style catastrophic insurance) it’s actually worse in some ways (some mind, not all) than a single payer/single provider system like the NHS.

31

Holden Pattern 02.04.13 at 6:01 pm

@28 & 29: Yes, the market is completely effing broken, and operates effectively as a private system of taxation for the benefit of a few large companies.

I would vastly prefer a single payer system (Medicare for all!) or even a Swiss-style system (sound, heavily regulated basic insurance at a regulated price, offered to all without exception). Returning to an unmediated out-of-pocket market system would of course ration good healthcare even more aggressively than we already do, because the technology is so much better (and more expensive) than it was when medical insurance was first introduced. (And I’m guessing that poor people typically died a lot faster and a lot uglier than rich people even then.)

But the question was “why on earth would you use insurance for these routine preventive measures?”. And the answer is, “given the trainwreck we have, it reduces costs overall relative to what they would be given the trainwreck“.

If you want to start with “let’s ignore the current entirely broken system and see what other systems actually work better”, that’s a different discussion entirely, and most important, a conversation we are not allowed to have in any serious way in the United States because anyone that tries to have it is promptly relegated to the shouting-on-streetcorners fringe.

32

Glen Tomkins 02.04.13 at 6:09 pm

@29,

Welcome to Adam Smith’s vision of hell. I’m not sure what he would have made of Socialism, but we know where he stood on crony capitalism. He wrote a whole book against it. He practically invented the whole discipline of Economics to mobilize opinion against crony capitalism. And we’re soaking in it! Well, marinading, more likely.

I don’t know the details, which is an essential feature of any good and competent cartel, but I have to assume from what the beast does, that cartel is what it is. Be not astonished at the workings of an entrenched cartel, and the wonders of monopoly pricing. We’re lucky it doesn’t do much, much worse, because nothing is restraining it.

Personally, I think a NHS would work best in the US. Countries like France that manage well with a retained layer of private insurers, never went through a phase in which the beast was allowed to get a taste for raw profit. I don’t think that we’ll get our insurers back to being satified with a vegan diet, we’ll just have to kill them off.

But if we’re not going to do that, if we’re not going Socialist because we insist on a market solution, well, then we need to run actual free markets in medical services. Breaking up the cartel should be the solution pushed for by free market enthusiasts. What we have instead of free market enthusiasts is a set of boosters of crony capitalism. They are intent on strengthening the cartel, not breaking it up. So things will either get much more astonishingly worse, or we’ll end up going Socialist. Capitalism doesn’t seem to have any champions left to fight for a market solution.

33

Harold 02.04.13 at 6:27 pm

As the interpreter and custodian of Divine law, received through revelation, the Church can claim to override temporal authority.

As I understood it, the Church traditionally recognized a hierarchy of four kinds of law:
Eternal law
Divine law
Natural law
and Positive (or man-made) law.

Eternal law applies to God and is identical to the mind of God, while Divine law applies to humans and is promulgated through revelation. Natural law is implanted in human nature by God and is known through reason. Positive law is subject to change from time to time and place to place. Law concerns the common good and it is essential to the nature of law that it be promulgated (preferably by writing).

http://people.wku.edu/jan.garrett/302/aquinlaw.htm

[Thomas] Aquinas describes law as “a certain rule and measure of acts whereby man is induced to act or is restrained from acting.” (q90, a1) Because the rule and measure of human actions is reason, law has an essential relation to reason; in the first place to divine reason; in the second place to human reason, when it acts correctly, i.e., in accordance with the purpose or final cause implanted in it by God.

Law is directed by its nature to the good, and especially to the universal or common good. (q90, a3) It is addressed not primarily to private persons but to the whole people meeting in common or to persons who have charge of the community as a whole.

Promulgation–i.e., the application of the law to those to whom it is applied and the communication of this law to them–is essential to the nature of the law. The natural law is promulgated by God: “God has instilled it into human minds so as to be known by them naturally.” Divine and human laws can be promulgated by word of mouth or, even better, by writing.

34

Steve LaBonne 02.04.13 at 9:27 pm

Harold, I’m not sure what your point is, but the attitude a secular society must take to all of that was already well stated by mud man @27.

35

SamChevre 02.04.13 at 10:18 pm

He just needs to ditto whatever reasoning or revelation has already squared him with rendering unto Caesar, and he will be fully squared with this insurance regulation.

That’s not how it works, in almost any of the principled arguments. There’s a very substantial difference between “what government can spend tax money on” and “what government can rightly order people to do.” This distinction is rather well-established and generally accepted.

Letting your wife have her birth control pills at anything near the price of production (pennies per pill) plus overhead and some profit margin, would mess up the monopoly pricing they are allowed to inflict on all of us, insured and uninsured alike.

Actually, a substantial number of contraceptives are available at pennies per pill (13 pennies or so, to be exact.) (Look at Wal-Mart’s $4/$10 dollar prescription list.)

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Consumatopia 02.04.13 at 10:47 pm

Leaving that aside, why would anyone at all want to provide contraception through an insurance mechanism? Or vaccinations, or annual doctor visits or anything else that doesn’t involve a pooling of risks?

If contraception and vaccination decrease the risks that the insurer is covering, it would make sense for the insurer to let the patient have them at reduced cost.

37

Harold 02.04.13 at 11:35 pm

@34, I agree with Mudman’s point, insofar as I understand it. My point is simply to show how, as I understand it, the Church traditionally has argued that its law (revelation) transcends civil law.

The Church is probably right that there are over-riding (or under-girding) principles that local laws have to (or ought to) follow, but the argument that the Catholic employer is “forced” to pay for legal contraception or abortion seems to me a sophistry. The insurance is part of the employees’ compensation and the employer has no right to tell the employee what he or she can do with his salary, even if what is chosen is a sin in the employers’ eyes, such as spending it on gambling, drink, or contraception, or hair dye. That goes double if the employee is not a Catholic. It is a slippery slope.

Contraception has to be covered by insurance because in many cases you need a doctor’s prescription in order to buy it; and it is often prohibitively overpriced.

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Mitchell Rowe 02.04.13 at 11:53 pm

“If contraception and vaccination decrease the risks that the insurer is covering, it would make sense for the insurer to let the patient have them at reduced cost.”

Shhh you are interrupting the right wing talking points. Don’t you know that single payer is horrible! Which is why it is so popular in Canada. Everyone hates it!

39

faustusnotes 02.05.13 at 12:27 am

Tim @19:

Leaving that aside, why would anyone at all want to provide contraception through an insurance mechanism? Or vaccinations, or annual doctor visits or anything else that doesn’t involve a pooling of risks?

Don’t you sometimes write policy for some kind of bunch of fringe loonies in the UK political scene? If so, I would suggest that you steer well clear of healthcare, because this one sentence shows such an insane level of ignorance of basic healthcare financing and economics that it is breathtaking.

Vaccinations, for example, prevent illness. You know, the stuff that health insurance companies have to pay for. Thus, rational health insurers support the cost of vaccinations if it will reduce serious illness or improve health within a given cost-effectiveness framework. There are studies on which vaccinations it is worth supporting, and which are not worth supporting. You may be vaguely aware of the debate about the cost-effectiveness of breast screening. I suggest you do some reading about cost-effectiveness analysis, NICE, and the role of universal health coverage (UHC) in promoting public health.

40

DrDick 02.05.13 at 12:34 am

It is also the case that the regulations as originally written exempted purely religious organizations. What is being protested here is a provision which prohibits religious affiliated secular organizations (hospitals, social service agencies, and the like) from discriminating against those employees who do not share their religious views.

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Gene O'Grady 02.05.13 at 3:58 am

If the Catholic reaction of Montini and Wojtyla had really been concerned about a constraint higher than the law they would not have produced in Humanae Vitae a document clearly based on backroom deal cutting at the expense of the discussions of the Vatican Council and the relevant experts on the commission. But then they also wouldn’t support pedophilia, would they? Which is why I am personally convinced that Wojtyla did not believe in God.

By the way, the current formulation “every sex act should be open to the transmission of life” is a lot younger than I am.

42

Glen Tomkins 02.05.13 at 5:35 am

“There’s a very substantial difference between “what government can spend tax money on” and “what government can rightly order people to do.” This distinction is rather well-established and generally accepted.”

Well, except that paying taxes isn’t optional. It’s something govt orders people to do, on pain of going to prison if they don’t. And then the proceeds of that taxation are used for thousands of purposes, at least some of which just about all of us are likely to find morally objectionable. That was the whole point of springing the question on Jesus about whether it was morally permissible to pay taxes to the Roman regime. Of course that regime did all sorts of horrible things with that money, to include the occupation of Judea. Because tax money is fundamental to the very existence of govt, including its means of coercion, paying for whatever horrible things the govt does is the fundamental submission without which all other submission to “what govt can order people to do” is irrelevant, because there is no govt to force submission until people bring it into being by rendering their money unto Caesar.

Being compelled to pay taxes to support whichever items one finds morally objectionable in the govt budget strikes me as an actual assault on the conscience. If people imagine that contraception is some moral horror, then there actually is some moral challenge on them to object to paying taxes to support it, which US taxpayers do via all of the direct govt health services. US taxpaywers who do not currently reside in jail must have squared themselves with that challenge somehow, but there actually is a real conflict to it, as opposed to the purely symbolic nonsense that Levin is all fired up about.

The administration actually went so far as to arrange that the coverage be provided by insurers at no cost to these conscientious objectors to contraception, so that they don’t have to pay to support this moral abomination. But that’s not good enough. The objectors are still forced to live in a world in which such arrangements are made to circumvent their concerns, rather than what they obviously think is the only acceptable solution, that the rest of us stop including contraception in health care coverage. To Levin, the very circumvention is a fresh insult, a fresh act of defiance of their religious convictions, because those convictions of theirs require obedience even from people who don’t share them, not the setting up of some artifice that lets them off the hook of direct support for the moral horror, but lets the horror continue.

That’s what outrages Levin, that this religious belief is being appeased, and not obeyed. Religious belief is not free until it is free to command the rest of us, is what Levin certainly seems to believe.

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Hidden Heart 02.05.13 at 5:47 am

These are the questions for Protestants who now claim that many or all kinds of birth control are tantamount to abortion, but whose institutions pretty much all covered a lot of contraception until current political fights:

#1. Either you were in gross error for many years, or you are now. By what signs and logic are you sure that it was then and not now?

#2. If it was then, then for many years you took money from parishioners, students, staff., etc, and used it in part to pay for what you have been calling the holocaust of abortion since that was manufactured as a political issue in the ’70s. What steps of atonement have you taken toward those whom you defrauded for that evil purpose?

#3. What steps of prudence have you taken to ensure that you won’t fall into that habit of sin-supporting fraud again?

44

Tim Worstall 02.05.13 at 9:05 am

“Don’t you sometimes write policy for some kind of bunch of fringe loonies in the UK political scene? If so, I would suggest that you steer well clear of healthcare, because this one sentence shows such an insane level of ignorance of basic healthcare financing and economics that it is breathtaking. “

Eh?

The economics of healthcare financing depend rather on the difference between insurance and assurance. The former being the pooling of risks over unlikely but expensive events, the latter being a method of financing likely events.

It’s very definitely a mistake to use the insurance method to pay for things that are in fact assurance. Assurance can be financed in a number of ways. With health care, possibly through health care accounts say. That’s one method. Another method is simply that they’re tax financed for all. Either would be better than using the insurance model.

There really is no point at all in cycling insurance premiums through a profit making company in order to pay for something that all or near all are going to use.

It’s not me that has an “insane level of ignorance” about the economics or financing of health care.

45

faustusnotes 02.05.13 at 12:39 pm

Tim, if these things aren’t covered by insurance, people don’t use them. As soon as a vaccination is scheduled in a single-payer system, rates of use sky-rocket. For common childhood diseases like measles, coverage needs to be above 90% – this doesn’t happen if people have to pay for it themselves. Do you know how much Gardasil costs on the private market?

Also the distinction between insurance and assurance is vague and dubious in a health financing context. Vaccination protects the unvaccinated as well as the vaccinated, preventing maternal mortality protects infants, and so on. Is it assurance or insurance when my insurance company funding you to get a vaccination protects my children? I’d say that’s risk-pooling.

As for using health accounts for these things – why should I, a man, draw on my health account to get routine testing for a disease (chlamydia) that only adversely affects women? This kind of atomized thinking doesn’t work against infectious diseases.

There are lots of other issues too because quality healthcare depends on systems, not individuals. Public health activities serve to reduce the cost of healthcare for all through broad measures – or to improve the health of all through small increases in costs. That type of shared activity works only through insurance systems – which is why single payer systems support vaccinations. That you don’t understand this is … disappointing.

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Tim Worstall 02.05.13 at 1:21 pm

“Tim, if these things aren’t covered by insurance, people don’t use them. As soon as a vaccination is scheduled in a single-payer system, rates of use sky-rocket. “

Err, yes, that’s exactly my argument. That a single payer system for something like vaccines is a lot better than using an insurance system.

Did you actually read what I wrote?

“Why use insurance of all things to pay for what just about everybody is going to use? Just doesn’t make sense. Even (shudder) a single payer system would be better for such things.”

47

faustusnotes 02.05.13 at 1:39 pm

Tim, if you don’t have a single payer system, the insurance system has to cover the things that a single payer system would have. A single payer system is just a big insurer. Unless you’re confusing “single payer” with “NHS”?

(For example now in Japan the single payer system doesn’t cover ART for people with HIV before they hit a CD4 count of 350, even though earlier ART coverage reduces infection and thus will reduce the future disease costs for the system. This is your “insurance shouldn’t cover preventive medicine” argument being used by a single payer system).

If you don’t have a single payer system, you have to achieve the benefits of herd immunity through the insurance system. If you don’t, then the insurance companies will have to pay measles-related costs (for example), and premiums will/may go up.

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Consumatopia 02.05.13 at 7:01 pm

The economics of healthcare financing depend rather on the difference between insurance and assurance. The former being the pooling of risks over unlikely but expensive events, the latter being a method of financing likely events.

It still can make sense for the insurance company to pay for things that make the unlikely but expensive events less likely. If we had a completely unregulated health insurance market, assuming health insurance was still a sustainable business model despite adverse selection, why wouldn’t health insurance companies give a discount to vaccinated customers?

I’m certainly not denying that other systems would be better, and it’s not clear that contraception is a good example of this, but there’s nothing inherently absurd about insurance companies supplying, subsidizing, or rewarding preventative treatments.

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Katherine 02.05.13 at 7:05 pm

HH @ 43,

The short version is that they’ve always been at war with Eurasia.

For a longer version, I can recommend Slacktivist posts on this subject, such as:

http://www.patheos.com/blogs/slacktivist/2013/01/10/memory-vs-hobby-lobby-evangelicals-and-contraception-and-why-denny-burk-is-not-a-conservative/

50

Trader Joe 02.05.13 at 8:32 pm

In Theory
Single pay – Birth control is free, it is smart and healthy so I avail myself of it

Insurance model – Birth control has a $25 co-pay, but babies have a $500 co-pay I’ll be smart and thrifty and use birth control

Private pay – I cannot afford a baby so I will make the smart choice and pay for birth control out of my health savings account.

In reality
Single pay – Birth control is free, abortions are free, babies are free – guess it doesn’t matter what I do. Being pregnant sucks so I’ll use birth control.

Insurance model – The co-pay is $25, but if I get them from Canada or use generics I can get by for just $10 – why should I pay for marketing? How bad can the side effects be anyway?

Private pay – I was running a little short this month and forgot my scrip, but these condoms are ribbed and only cost $1, hope it doesn’t break.

I’m not particularly for or against any particular choice among these, I just always find it interesting that the “theory” of how people will behave under any healthcare system tends to differ rather greatly from what real people do when faced with real decisions.

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Uncle Kvetch 02.05.13 at 9:05 pm

I just always find it interesting that the “theory” of how people will behave under any healthcare system tends to differ rather greatly from what real people do when faced with real decisions.

I find it even more interesting when a (presumably) male commenter makes sweeping generalizations about what goes on in the minds of millions of women he knows absolutely nothing about, other than the health insurance regime of the country they happen to live in.

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Anderson 02.05.13 at 9:08 pm

“would do well not to anger an organization that provides a good portion of that nations healthcare”

Ha! The Catholic hospital in my town bends over backwards to dump indigent patients on the local university hospital. I’ve seen their tax returns – they are making money hand over fist.

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Trader Joe 02.05.13 at 9:20 pm

Uncle
Once again you have trouble differentiating between tongue in cheek and head in ground. Is it a requirement that all posts be taken literally?

My “sweeping generalizations” are no less sweeping than the various suggestions that a single pay system would achieve some outcome X or an insurance pay system doesn’t accomplish Y.

I have had the good (or bad) fortune to experience all three of those choices in my lifetime. Private pay, single pay and insurance pay all have their virtues and all have their problems – my point is that people will respond to each of these systems in their own way regardless of what economic theory tells us people will do.

Lastly I think birth control is a topic sufficiently well understood that neither males nor females have a monopoly on how to think about it. I suppose I could have used colonoscopies for my example but I didn’t think I had enough understanding of butt holes.

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Hector_St_Clare 02.05.13 at 9:22 pm

Re: If the Catholic reaction of Montini and Wojtyla had really been concerned about a constraint higher than the law they would not have produced in Humanae Vitae a document clearly based on backroom deal cutting at the expense of the discussions of the Vatican Council and the relevant experts on the commission.

I’m not sure what parts of the document reflect ‘backroom deal cutting’. The document doesn’t strike me as a compromise: it was a maximalist rejection of any form of artificial contraception, while endorsing natural family planning.

I’m also not sure why Paul VI was under any obligation to *agree* with the majority vote of the commision. He appointed them to express their expert opinions, and he ended up disagreeing with the majority. They were there in an advisory capacity, not a decisive one.

I don’t agree with Paul VI’s pronouncement on chemical birth control, but it wasn’t an obviously silly or immoral one, and he certainly had every right to make it, if you accept his claims to authority (which Roman Catholics do, sort of by definition).

Re: It’s not “the right to define one’s own concept of existence, of meaning, of the universe, and of the mystery of human life” but the right to answer to what you are persuaded is the evident and inflexible reality of existence, of meaning, of the universe, and of the mystery of human life. It’s not the right to do what you want; it is the right to do what you must.

Yes, exactly.

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Random Lurler 02.06.13 at 12:09 am

@65
I’ll reiterate in a stronger form what I wrote in 1:
I don’t think freedom of religion is the rightto do something, I think it was initially
conceived as the negative right to not be persecuted for your religious beliefs, as was very common for a long time.
The modern view of freedom of religion is imho a modern distortion.

56

faustusnotes 02.06.13 at 12:25 am

Trader Joe, they’re not ” suggestions that a single pay system would achieve some outcome X .” There are lots of single payer systems in the world, and we know what happens in them.

One thing that definitely does not happen in general, is free contraception.

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Pete 02.06.13 at 10:22 am

@56 free contraception is definitely a feature of the UK single payer system. It’s also the logical choice for a single payer system – at the very least, free condoms are cheaper than treating STDs.

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Tim Worstall 02.06.13 at 10:26 am

“but there’s nothing inherently absurd about insurance companies supplying, subsidizing, or rewarding preventative treatments.”

Sure, given where the US is now it’s sensible that they do. But given that the stated aim was to reform the system so as to make it better perhaps worth considering what would be the best way to provide such preventative treatments.

As which point cycling money through an insurance company for things which really aren’t insurance seems a bit odd.

“One thing that definitely does not happen in general, is free contraception.”

Strangely, the one I know about, the NHS, has exactly this. And free vaccinations.

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Trader Joe 02.06.13 at 12:26 pm

Faustnotes @56
My experience, as others have commented, is with the NHS where contraception was free along with quite a bit of other stuff…a pretty good system in which to be fairly healthy or moderately sick. If that’s not a common feature of other Single Pay programs, my error. Its such an obvious thing to do I assumed it was more widespread.

You’re clearly quite knowledgeable on this topic, your post @47 highlighted a very particular nuance of the Japanese system – I’d have said that these nuances go exactly to my point. Each system is a little different and while there are some generalizations, the way in which each populace has responded to them, or maybe more accurately learned to interact with them, isn’t a given. Again, from what I know, there is a lot of suboptimal choice occuring unless the program is both generous and well funded. Perhaps your experience has been different.

From my observations Canada’s system seems quite robust, then again the size of their population and the relative wealth of the nation facilitates a generous program that is also very well funded (although even that program went through some deep cuts several years ago). Other nations, such as Spain, seem chronically underfunded and while they do well with what they have its not about to become a medical tourism destination.

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Random Lurker 02.06.13 at 3:18 pm

“Unless you’re confusing “single payer” with “NHS”?” (faustusnotes 47)

Maybe I’m stupid, but it seems to me that there is some misunderstanding:

- faustusnotes uses “single payer” for systems where the government pays private hospitals etc. for delivering health services (as, if I understand correctly, happens in Canada and Japan?) and “NHS” for systems where most hospitals etc. are actually statal (as in UK and Italy, i.e. doctors etc. are actually “public servants”).

- Trader Joe and Tim Worstall use “single payer” for both and actually treat the UK NHS as the prototipical “single payer”.

It seems a dialogue of the deaf.

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Steve LaBonne 02.06.13 at 3:32 pm

Lurker, it’s important for them to obfuscate the difference, because the NHS system is by far the most efficient (the UK attains good i.e average-for-developed-countries outcomes with well below average expenditures). Private interests have been trying to dismantle it in the UK since its inception and have successfully prevented other countries from emulating it.

Single-payer systems are next best, of course. The systems with heavy private involvement in financing as well as care provision (even excluding the pathological US case) are the most expensive without providing any clear benefits in return for the additional cost.

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MPAVictoria 02.06.13 at 4:33 pm

” Private interests have been trying to dismantle it in the UK since its inception and have successfully prevented other countries from emulating it.”

So much this. Conservatives have been trying to wreck everything good about the welfare state for the last 30 years. It is truly insane.

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Tim Worstall 02.06.13 at 8:17 pm

Err, no.

“”Trader Joe and Tim Worstall use “single payer” for both and actually treat the UK NHS as the prototipical “single payer”.”

The distinction here is between “single payer” and “single provider”. The NHS (absent the 10% of the health care market which is private provision) is both.

I’m entirely happy with the idea of single payer for, say, public health measures. And I’d put contraception in there along with things like vaccines. And I’m absolutely happy with the idea of there being a single payer (ie, tax financed system) for scraping people up off the roads, for catastrophic care etc.

The single provider part of any of it I’m a great deal less enamoured of. You know, like the French, Danish, Swedish etc systems manage to have a largely single payer system but not a single provider one.

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Steve LaBonne 02.06.13 at 9:14 pm

Who the hell cares what you’re happy or unhappy about? The real world of cross-national comparisons offers a natural experiment, one which shows that you’re wrong.

65

Steve LaBonne 02.06.13 at 9:15 pm

Also, this thread has established that you have very poorly thought-out notions as to what aspects of health care critically affect public health.

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faustusnotes 02.07.13 at 2:16 am

Random Lurker@60, my question was whether Tim W is assuming that the only single payer system in existence is the NHS – he seemed to be conflating the two. For the purposes of this discussion I’m happy to treat the NHS as a “single payer” system, though obviously it’s also a single provider (as Tim W observes). I think the insurance/assurance issue Tim raises is largely unaffected by whether the insurer is also a provider. The NHS is not the only or even the prototypical single payer system, it’s just one of a wide and diverse range of ways in which the challenge of universal health coverage (UHC) is achieved.

Pete@57, no single payer system (including the NHS) that I’m aware of provides free or subsidized condoms, which are the only contraceptive that prevents STIs. Quite a few subsidize oral contraceptive pills (OCP) which do not prevent STIs. In any case there is little evidence that subsidized condoms would be a cost-effective way to prevent STIs, which is probably why no one does it. Most single payer systems rely on the free distribution of condoms to high-risk groups through certain outlets, but you can’t e.g. walk into a chemist in the UK, flash your NHS number and get a box of good quality PVC condoms off the shelf for a knockdown rate.

Steve LaBonne, international comparisons aren’t a good way to judge but there is little evidence that the NHS is the best of the UHC systems. Japan pays less and gets more; Australia pays just a little better and gets much more. The NHS is definitely not inefficient, its primary health care model is completely broken and its care quality is poor. It also fails to achieve on measures of health inequality, which is why 20-40% of the population is suffering from life expectancies below those of many middle-income nations. At least part of the reason for this is the merging of provider and payer in one organization, but it’s also to do with the deadweight that is the average UK GP, and a legacy of underfunding which means that the NHS has terrible infrastructure (I blame Thatcher!) Certainly if the NHS were funded properly and the primary care system reformed, it would be a very high performing system. But that doesn’t mean that the model itself is the best, which is why the middle-income countries moving to UHC (places like Ghana, Vietnam, Thailand) are not emulating it.

Tim W at 58, the purpose of health insurance is to enable the purchaser of insurance to be able to buy the drugs they need to protect and improve their health. Vaccinations and OCP are a drug. Do you get it? There are a lot of private insurers (and some single payer systems) that don’t cover childbirth – but they will have to cover the medical emergencies arising from childbirth. Can you see how it might be in their interests to enable women to space out their births and have full control over when they have children? By lowering the risk of associated medical emergencies, they lower their costs and thus control premiums, through reducing the amount of risk that is pooled. The purpose of a risk-pooling system is not just to enable everyone to share risk, but to reduce the amount of risk that is shared. This is hardly unique to health insurance!

I really hope that you aren’t responsible for developing health policy at that fringe party you hang around with, if your entire understanding of health financing is a couple of anecdotes from the NHS, and a misconception about how insurance companies work …

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Steve LaBonne 02.07.13 at 1:35 pm

Faustus, your whole “analysis” is completely contradicted by your own admission: “Certainly if the NHS were funded properly and the primary care system reformed, it would be a very high performing system.” Given years of underfunding and neoliberal “reform”, it’s remarkable it still works even as well as it does. That in fact makes it clear that it is a highly robust and efficient model. (Also, the situation in Japan has far more warts than you appear to realize).

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faustusnotes 02.07.13 at 2:06 pm

My analysis isn’t contradicted by that admission. That is my analysis. The NHS would be high performing if certain reforms happened. A key reform is the primary care system – but that’s not going to happen. Instead they’re moving towards this insane clinical commissioning model that is just never going to work. And in my view the best reform of the NHS’s primary care system would be to force it into an Australian-style private market, operating on a fee-for-service basis. Then GPs might consider being open past 5pm, providing a service other than “referral.”

There’s something else going on in the NHS though, something creepy and dark, that I think is related to the lack of a provider/purchaser split. Have you been following this? Of course, the conservative government’s solution is to introduce performance-based pay for nurses (what next, tips?) but the problem here is fundamental and systemic, and often talked about in the UK – finding a new way to cut nurses’ pay isn’t going to fix it. The phenomenon of elderly patients starving in hospital is very common, for example. I think this is at least partly linked to the fact that the people who provide the service also pay for it, so there is no incentive to reform these problems, and the inspectors have to turn a blind eye to the problems because there is no alternative. There is also no spare capacity in the NHS, so it’s not possible to refuse to pay for services from a hospital that is basically killing its patients. Serious reform of the purchaser-provider system is needed, and that is going to involve private agencies.

I’m aware of the warts in the Japanese system. I presented one up above. Every system has warts. But you wanted to present data, and the data you refer to tells us that the NHS doesn’t perform exceptionally well at its funding level, it performs very poorly on equality measures, and other countries (including Japan) perform better on every measure for less or very little more. You presented the data: you address it. And particularly, if you can, address the inequality issue. Healthcare is free in the UK, but the inequality in health outcomes between the top 20% and the bottom 20% of the income scale is almost the same as the inequality between white Australians and Aboriginal Australians. Can you explain that?

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faustusnotes 02.07.13 at 2:08 pm

And I would like to add, talk of “best” or “worst” with UHC systems is largely irrelevant. Countries get the UHC that they can afford and that is politically feasible, and it doesn’t really matter what the details are because the most important thing is getting UHC. All the rest is bells and whistles.

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Steve LaBonne 02.07.13 at 2:19 pm

Have you been following this?

Yes, and it’s a result of underfunding combined with perverse neoliberal incentives that shouldn’t exist in the system as it was intended to function. (Similar things happen all the time in the US system- the range of quality is huge and very badly correlated with price. There are definitely plenty of very bad hospitals with excessive mortality.) You’re still not making your point.

Countries get the UHC that they can afford and that is politically feasible, and it doesn’t really matter what the details are because the most important thing is getting UHC.

On the contrary, if the quality of care is going to be sustained given the demographics of the advanced countries, it matters very much how cost-efficient, and thus affordable, it is. Not many countries are going to be able to sustain a French, German or Swiss level of expenditure in the coming decades, probably not even all 3 of those countries.

I’m actually fine with a single-payer system with private providers, but I think it’s very hard to argue logically that, ceteris paribus, it’s as inherently efficient as a public-provider system. Still, for a lot of countries it would be a significant gain in efficiency.

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faustusnotes 02.07.13 at 2:59 pm

it’s a result of underfunding combined with perverse neoliberal incentives that shouldn’t exist in the system as it was intended to function

Name one neoliberal incentive in the NHS. I can think of Foundation Trusts, and that is a dubious example at best.

On the contrary, if the quality of care is going to be sustained given the demographics of the advanced countries, it matters very much how cost-efficient, and thus affordable, it is

Did I not say that countries “get the UHC they an afford”? And what is this shit about “advanced countries”? Is that where your Marxism gets you?

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Steve LaBonne 02.07.13 at 3:05 pm

Name one neoliberal incentive in the NHS.

Are you serious?

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faustusnotes 02.07.13 at 3:25 pm

I don’t think that report says what you think it says, Steve. Unless any time the words “choice” and “responsibility” appear they are automatically neoliberal… also, how did any of New Labour’s “market reforms” (ha!) address the fact that the person providing the service was also meant to be regulating the provision of the service?

also, you haven’t addressed the NHS’s inequality failings. Waiting …

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Katherine 02.07.13 at 3:27 pm

you can’t e.g. walk into a chemist in the UK, flash your NHS number and get a box of good quality PVC condoms off the shelf for a knockdown rate.

You may not be able to go to a chemist and do that, but you can walk into a Family Planning/Sexual Health Clinic and walk away with free condoms under the right circumstances. Be young or vulnerable and they’re virtually throwing them at you. At the age of 19 I walked out of just such a place with an armful for nowt.

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Katherine 02.07.13 at 3:32 pm

Then GPs might consider being open past 5pm, providing a service other than “referral.”

Honestly, where do you live? I’ve lived in two entirely different (geographically and deomgraphically) ares of the UK just recently, and both my GP surgeries opened past 5pm, and both did surgeries on Saturday mornings. I know anecdote isn’t evidence, but you seem to be throwing out the worst generalisations you can think of without backing it up.

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Katherine 02.07.13 at 3:33 pm

The phenomenon of elderly patients starving in hospital is very common, for example.

And there’s another one! Care to offer any evidence for that assertion?

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Steve LaBonne 02.07.13 at 3:38 pm

The report lists plenty of the reforms you claim don’t exist; I’m not going to get into a long quibbling contest about the analysis so that you can just backpedal some more. And NHS, especially in its crippled state, is supposed to be able to overcome all by itself the far greater inequality of British society?Evidently you’re the health care equivalent of a US corporate school “reformer”.

Anyway, it’s all academic, because I don’t think it will ever be politically viable to establish an NHS-style system in any other country, and even in its original home it has proved all too politically vulnerable. In the US, almost anything but what we have now would be a major improvement, including even the highly bureaucratic yet expensive Swiss system.

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Barry 02.07.13 at 5:42 pm

Katherine 02.07.13 at 3:32 pm

“I know anecdote isn’t evidence, but you seem to be throwing out the worst generalisations you can think of without backing it up.”

Katherine, the word you might be looking for is ‘liar’.

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faustusnotes 02.08.13 at 2:02 am

Katherine, your three points in order:

@74: I don’t think the targeted distribution of condoms to high-risk groups is what Pete meant at comment 57. I pointed out the difference between free access to condoms and a condom promotion program in the sentence before the one you copied and pasted. No one is denying that the NHS distributes free condoms, but most countries do that. There is a big difference, however, between free access to condoms at a chemist and targeted health promotion programs.

@75: you caught me out. Core opening hours under the GP contract are 9am – 6:30pm Monday to Friday. If a GP opens for an extra 30 minutes a day they will be paid an extra pound per registered patient (for the average GP, that would be about 3500 pounds a year I guess). This isn’t exactly making GPs particularly accessible, is it? And in fact it turns out that in poorer areas, less GPs offer extended hours.

Incidentally, that linked article gives a hint at one of the big problems in the primary care system in the UK: you have to register with a GP, can’t just go to any; and GPs are paid according to how many patients they have registered, not the number of services they provide, or the quality (which is why QOF was introduced). Reform that – force GPs to be paid for work done rather than patients accrued – and you will see a sudden flourishing of after-hours services.

@76: I linked above to a report where this is a key issue. It’s actually quite widely reported on in the British tabloid press, and it’s a common enough concern that in her opinion piece today Polly Toynbee addresses it explicitly, when talking about high quality service:

As for care, patients with dementia have red water jugs and trays, so everyone knows they can’t help themselves: at mealtimes nurses stand in each bay, ensuring everyone is helped to eat and drink.

I guess this means Barry thinks that Polly Toynbee is a liar too, right, Barry?

This is pretty much exactly what happened to my grandfather, and my grandmother and parents credit his starvation (and the terrible cold of his unheated hospital room) with his death. They eventually withdrew him from the hospital he was staying in because he was losing so much weight (which may have been the real reason for his death – or maybe he was just old and frail). I don’t know if there is a link, but a hospital is not providing quality care when family members have to stay at the patient’s bedside just to ensure that he isn’t shivering and starving.

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faustusnotes 02.08.13 at 2:14 am

Steve, the report you linked to lists foundation trusts, patient choice, and payment by results. If you think that giving patients the choice to attend any hospital, and reorganizing the way money is distributed around a monopoly service provider, are “neo-liberal reforms” then the phrase “neo-liberal” has been drained of all meaning. The fact remains that the NHS is almost entirely government run, remains a combined commissioner/provider system with no separation between them, and has a series of archaic systems in primary and secondary care that have proven remarkably resistant to change. How can the system be described as “vulnerable to change” when patients still – after 50 years – can’t attend a GP freely, but have to register first? When even the reviled Thatcher couldn’t introduce free choice of hospitals for patients? When hospitals were block funded – regardless of results or patient numbers – up until 2006?

It’s a nice narrative, but the reality is that the NHS has been remarkably resistant to change, and remains largely free of neo-liberal influences. The Tories may change that if they have enough time – and certainly won’t change it for the better – but let’s not over-egg the pudding here.

Re: inequality, if you hunt around the King’s Fund’s website a bit you’ll find all sorts of stuff about how GPs and hospitals in poorer areas provide poorer service. It’s all well and good to blame inequality on society as a whole but we know that in the UK GPs are a barrier to access to care for poorer patients: they take longer to refer such patients, they are less accessible, they are more likely to be single-handed surgeries, and they don’t score better on QOF indicators even though they are designated for special assistance in the poorest (“Spearhead”) areas. Healthcare is free in the UK, and yet poor people’s health gap has failed to improve over at least the past 10 years and probably longer. You can’t blame all of that on the rest of society. At some point the NHS has to cop some blame.

Part of the reason that the health reform debate in the USA is so stagnant (only a small part, I’ll grant you) is that a lot of reformers on the left seem to think that the only option is a fully private market or the NHS. This means that the wide range of acceptable UHC systems between the two have been largely ignored in the debate. IMO Obamacare is way too focused on the private end of that spectrum, but if people pushing for reform had focused less on NHS-style systems and more on something from Australia, Germany or Japan, they might have achieved some traction in the debate and pulled the reforms a little more left-ward. But I guess that’s a debate for another day …

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Niall McAuley 02.08.13 at 8:40 am

faustusnotes @ #79: you caught me out.

You mispelled lying.

It’s actually quite widely reported on in the British tabloid press

You mispelled a pack of lies.

Hope this helps!

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faustusnotes 02.08.13 at 9:20 am

Yes Niall, the Care Quality Commission are a pack of liars.

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Niall McAuley 02.08.13 at 11:02 am

There is a considerable difference between your statement:The phenomenon of elderly patients starving in hospital is very common, for example. and even the Torygraph’s story: Problems include patients not being given the help they need to eat, meaning they struggle to eat or are physically unable to eat meals, patients being interrupted during their meals, and having their food taken away before they can finish.

The difference is that the Torygraph is hostile to the NHS and painting the hospitals in the worst possible light given the reports findings, while you are just lying.

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faustusnotes 02.08.13 at 2:18 pm

Niall, why don’t you check out the Patient Association’s CARE campaign. One of the four targets of the campaign is adequate nutrition. The page has a video reporting on the experiences of people in hospitals, and assistance with feeding is prominent in their concerns. The Health Service Journal reported on highly critical views of nutrition policy in hospitals, (though you have to register to view the article). Here is a case of 38 patients who starved in one hospital – 33 of whom died.

It’s an interesting phenomenon. There is a major scandal engulfing the NHS right now – 1200 needless deaths over 5 years in one hospital – in which failure to feed patients plays a major part. I have referenced that, along with a CQC report on failure to feed. My own grandfather was a victim of this phenomenon. It’s trivial to find more examples of same (as I’ve presented here), including a survey from Britain’s premier journal for people working in the NHS. Yet I am the liar?

In exchange, a series of anecdotes and/or assertions have been presented. At the same time on this same blog, John Quiggin is holding another discussion about the inability of right-wingers to deal with reality. Are there any similarities to be found here? I’m not holding my breath waiting for my interlocutors to join the dots.

And the real irony is that I’m not opposed to the NHS. As part of this discussion I’ve made clear that I think it could do better, but that if it were better funded and the primary care system reformed it would be an excellent system. Yet somehow, I’m being compared unfavourably with the Daily Telegraph and called a liar. What gives?

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Niall McAuley 02.08.13 at 2:45 pm

Before I even click on those links, I know they will not support your mad lie: The phenomenon of elderly patients starving in hospital is very common, for example.

So, clicky clicky…

CARE stands for:

C – communicate with compassion
A – assist with toileting, ensuring dignity
R – relieve pain effectively
E – encourage adequate nutrition

Note that nutrition issues come after going to the toilet, hardly likely if they thought starvation was common.

The case of 38 people who starved actually features 1 (one) man who starved to death, and is, of course, headline news with massive compensation paid, not evidence that starvation is “very common”.

So what gives? You are telling lies.

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faustusnotes 02.08.13 at 2:51 pm

You didn’t watch the accounts on the CARE website, obviously. You are also ignoring the other links – HSJ, who knew it was an enemy of the NHS? – and ignoring my own personal experience to boot. You then manage to rank the CARE campaign principles so that food is below toilet – against the intentions of the Patient Association, of course – in order to trivialise nutrition (“It’s less than shit!”)

Your whole shtick comes across as completely lacking in humanity.

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Niall McAuley 02.08.13 at 3:02 pm

It’s a common tactic: throw up loads of links and pretend they support your argument, most people won’t click through.

From the CARE website which you linked above, front page intro: Our campaign is based on the four most frequent concerns that we receive from patients, their relatives and carers, regarding poor patient care. These include, patients not being helped to go the toilet; not given sufficient pain relief; not given sufficient nutritional intake; and communication is inadequate (e.g. call bells are ignored).

So, that ranking comes from them, not me.

I did not register with HSJ to read the article you cite because an article which “reports on highly critical views of nutrition policy in hospitals” does not support your assertion that starvation is common, so why would I?

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faustusnotes 02.08.13 at 3:14 pm

You’re still coming across as extremely cold. The CARE campaign doesn’t specify an order for its four priorities, and if you watch the videos, you’ll see this very clearly. Suggesting otherwise (as you insist on doing) isn’t helping your case.

You didn’t bother registering for the HSJ site? Such a shame, you might actually learn something about how people connected to the NHS are highly critical of it, and want to change it. But that isn’t your interest, is it? Laughing at people who care is your business, and business is good.

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