In the Department of a Broken Clock Being Right Twice a Day
The argument for[regulations of personal choices] is that the state has an interest in a healthy workforce: If you’re poor, and you get lung cancer, you’ll be filling up hospital rooms at public expense. If that’s true, then the state arguably has a greater interest in you continuing to smoke and dying young: The ever-aging population of the Western world will be the biggest burden on state resources in the coming decades.
But in the broader picture it might be truer still to say that the individual, unlike the state, therefore has an interest in stopping and reversing the government annexation of health care – because that argument can be used to justify almost any restraint on freedom – and, in the end, you may not get the health care, anyway. Under Britain’s National Health Service, smokers in Manchester have been denied treatment for heart disease, and the obese in Suffolk are refused hip and knee replacements. Patricia Hewitt, the health secretary, says that it’s appropriate to decline treatment on the basis of “lifestyle choices.” Today, it’s smokers and the obese. But, if a gay guy has condom-less sex with multiple partners, why should his “lifestyle choices” get a pass? Health care costs can be used to justify anything.
Now, I am not such a doctrinaire libertarian that I think the state has no role to play in healthcare; a system in which 46 million Americans are uninsured is untenable. But what is to be done about that, making the right policy choice, is critically important, and I’d rather see, say, Cato directing reform than most liberal thinkers on the matter. A situation in which the federal government has a direct stake in every choice we make is a truly scary proposition.
Comment by BruceB —
June 17, 2007 @ 3:36 pm
This is, at first look, a reasonable fear. Do you find it justified by the evidence from countries that do have national health care? I’d be particularly interested in a look at Taiwan, which made the shift to national coverage in 1995 and never seems to get mentioned in libertarian discussion of the subject. (That is to say, I never seem to notice it being mentioned. If it has been studied from a libertarian perspective, I’ve missed it and would gladly check out references.)
It seems, I must say, that this concern when tested against the actual policies of nations with national coverage boils down to “There’s something uniquely vilely intrusive about Americans which would make it work taht way here.” I’m sort of prepared to believe that some days, given that we are commited to uniquely vile policies on military spending and such…but then the question would be, “What else is part of this national pathology? What ideas do I think valuable and worthwhile that end up actually helping to make it worse?”
Comment by Mona —
June 17, 2007 @ 3:48 pm
Bruce, I honestly know nothing about Taiwan’s healthcare syem and whether libertarians have studied it. But I know that in the U.S. seatbelt and helmet laws, and smoking and trans-fat bans, are just the tip of the iceberg, and have already been defended on the “need” to reduce healthcare costs.
We have a strong Calvinist streak in this nation, that afflicts both left and right. Give the federal govt a stake in your personal choices, and I think we will see the War on Drugs on steroids.
Comment by Glen —
June 17, 2007 @ 5:48 pm
A good point, one that I make to liberal supporters of socialized medicine whenever I can. One gripe: don’t buy the “46 million uninsured” factoid without a huge grain of salt. That’s a snapshot figure, which includes many people uninsured for only (say) a month at a time, as they transition from one job to another or from school to the workplace. It also includes people who don’t really need to insure because they can afford to self-insure (i.e., rich people). Less reassuringly, it includes lots of young people with relatively low health risks who choose to go without. How many of those 46 million are chronically uninsured and unable to afford it? I really don’t know, but it’s definitely a smaller number.
Comment by Matt Weiner —
June 17, 2007 @ 6:23 pm
zuzu points out in LGM comments that the tobacco lawsuits already have a public health ground. Also that your private insurance company can in principle exert similar coercive pressures by threatening to drop your insurance, which may not seem like coercion in a libertarian framework but certainly does to us liberals. These folks couldn’t just go get themselves a different carrier.
Comment by Mona —
June 17, 2007 @ 6:31 pm
Glen: Uh-huh. But then they end up stuck in the “pre-existing condition” prohibition on coverage. People stay in sh*t jobs when, say, a kid has developed leukemia because they can’t go anywhere else. And god hep them if they lose that job.
The system we evolved is an artifact from a time when insurance as an employment benefit, when John Doe stayed with Acme Widgets in Peoria for life, made some sense.
It doesn’t make sense now.
Comment by Mona —
June 17, 2007 @ 7:06 pm
All of which is bad. No smoker since at least the 60s has not known the risks. Adults should be free to assume their own risks. But private insurance companies absolutely should be allowed to charge higher premiums for smokers, those who drink exccessivey etc. That isn’t coercion, it is holding people responsible for their choices but not denying them any opportunity to redress it.
Really, where does it stop? At charging parents who feed “too much” fat to their kids so they may burden the state 50 years hence?
Comment by Chet —
June 17, 2007 @ 7:09 pm
It all sounds so chilling. But in the real world, every major insurance company is effectively doing this already: they deny benefits to all sorts of people all the time. It’s difficult to take seriously the cries of state paternalism, from people who sit stil for large corporate paternalism (yes yes, it’s really just looking to their bottom line, but the effect is the same).
As a friend once said about The Economist magazine:
They never met a large public bureacracy they liked, and they never met a large private bureaucracy they couldn’t find an excuse for.
Comment by Barry —
June 17, 2007 @ 7:26 pm
Mona: “No smoker since at least the 60s has not known the risks. ”
Are the tobacco shills still denying those risks? Just from a standpoint of punishing fraud, there’s ground for stripping every tobacco shill of every penny that they’ve got.
Comment by Andromeda —
June 17, 2007 @ 7:39 pm
Man, I originally read that as “promiscuous hot sex also carries health consequences.” I’m afraid I was pretty disappointed once I realized my error.
Comment by Thoreau —
June 17, 2007 @ 7:41 pm
Are the tobacco shills still denying those risks? Just from a standpoint of punishing fraud, there’s ground for stripping every tobacco shill of every penny that they’ve got.
Who actually believes them?
I say no harm, no foul.
Comment by Mona —
June 17, 2007 @ 7:48 pm
Yes, but Barry, nobody believed it. The surgeon general said otherwise. Both of my parents smoked in the 60s, and both told me not to, telling me it caused cancer and other lung problems. One of the few things Hitler got right was to find ironclad evidence that smoking causes disease. This is not a new revelation.
Comment by Chet Scoville —
June 17, 2007 @ 8:17 pm
If you’re poor, and you get lung cancer, you’ll be filling up hospital rooms at public expense.
But that’s exactly what happens now in the United States, even without universal coverage. Besides, Steyn knows better (and lies, as he often does, about what he knows). He’s from Canada, where what the government provides is health insurance and a set of minimum standards for care. It does not make individual decisions in patient care; that’s what doctors and hospitals do. And Canada has never outlawed smoking, or any of the other things he’s talking about.
Can we please stop talking about universal health care as if it were theoretical? It’s the norm everywhere in the civilized world — except the United States — and has been for decades.
Comment by Quiddity —
June 17, 2007 @ 9:55 pm
Don’t smokers die sooner and therefore are less of a drain of Social Security funds? The answer is yes. So where was the campaign to promote cigs? That’s the logic Steyn is peddling, so why didn’t the state’s “stake in one’s personal choices” result in real-world policy implementation?
The simple answer might be that the country as a whole is not interested in having the state get involved with personal choices. And so single-payer might function without meddling in personal affairs.
There are so many issues that are raised when the state gets involved. What about two people who have genetic factors that increase the possibility that their child will be born with a disability? Will they be prevented from procreation? Forced to have an abortion? Etc.
Comment by BruceB —
June 17, 2007 @ 10:51 pm
I’m, um, interested in the argument that because goverment authorities took a stance contrary to the one held by private enterprise on a controversy over the possible risks of a personal pleasure, the public is to blame for favoring the private claim over the public one, and the promulgators of the (knowingly, as has been well documented by now) false private claim bear no responsibility. I would have expected to see that argument, well, on blogs other than this one.
I’m not sure it gets any better if we say that it only applies in cases where we personally agree with the factual truth of the public claim. It sounds like license to commit unlimited private fraud so long as Big Brother contradicts it somewhere along the line.
Comment by Wild Pegasus —
June 18, 2007 @ 12:20 am
But in the real world, every major insurance company is effectively doing this already: they deny benefits to all sorts of people all the time.
Problem is, you can tell the insurance company to fuck off and pay for it yourself, if you’re so inclined. And the insurance company gets not one cent more of your cash. When the state runs the medical industry, either the choice to pay someone to do it anyway will be illegal, or you won’t be able to tell your insurer to fuck off, that they’re not getting any more of your premiums.
“Fuck off” is liberty.
- Josh
Comment by BruceB —
June 18, 2007 @ 12:47 am
Yes, and since when is liberty a virtue automatically superior to every other consideration, like justice? Even anarcho-capitalist approaches to justice do propose to curtail the liberty of criminals, and to some degree of others – David Friedman doesn’t claim that there’s no impact on liberty from the sort of system he advocates, only that it would be a better overall set of tradeoffs. There are plenty of situations in which we curtail liberty and do so willingly, not because we like curtailing liberty for its own sake because we regard the tradeoffs as worthwhile.
“X is liberty” isn’t the end of an argument for anyone except a solipsist or a psychopath. It may well be that the particular tradeoffs aren’t a good deal – that it is, for instance, morally desirable for the US to have a quality of health more like the Third World than any of our economic peers, and to have this grossly substandard care at substantially higher cost, because the possibility of better is worth more than the actual achievement of better on more curtailing terms. But this is not proven by your assertion.
Comment by BruceB —
June 18, 2007 @ 12:52 am
(Footnote to my last: It’s possible to construct a definition of “liberty” which excludes all stuff we want to call wrong-doing, so that jailing someone isn’t actually an infringement of liberty if they are guilty of a crime we consider worthy of jail. This is crap, and I’m assuming that everyone here is sharper than that, but the mysteries of the drive-by remind me that it’d be good to clarify.)
Comment by Alex —
June 18, 2007 @ 4:30 am
This is frankly just a honkin’ great strawman. For a start, I don’t rate the freedom to go bankrupt through medical expenses terribly highly. And, well, the popular perception of the US is that it’s much more censorious with regard to medicine and public health than the UK. Didn’t California turn on public smoking, what, 15 years before we did?
Steyn is also trying to argue simultaneously that the state would want to both ban smoking and encourage it. It is a common low-intellectual quality argument against smoking bans that “oh well, I’m going to die young and save everyone money”. Oh no you’re not! You’re going to die young after months of incredibly expensive chemo!
I can imagine that the argument might hold for banning public smoking (although see my first point), but the other way round is both antic and irrelevant. If you’re a libertarian, you WANT the government to let people smoke, right?
Comment by Alex —
June 18, 2007 @ 4:33 am
PS, Steyn’s examples are lies – the Mancunian smokers and Suffolk fatties have been asked to stop smoking and/or lose weight if they want their smoking- and obesity-related diseases treated, not denied healthcare a priori. I doubt there are that many doctors in the US who would jump at the idea of chopping lung tumours out of someone who promises to keep smoking the coffin nails.
Comment by ajay —
June 18, 2007 @ 5:17 am
A situation in which the federal government has a direct stake in every choice we make is a truly scary proposition.
Flaw in the logic here.
Mona’s argument is, as far as I can tell, that if the government funds your health care, than it has a financial incentive to prevent you from doing things that would make you get sick, thus costing money.
But the government already has a financial interest in your continued health; the long-term sick can’t work and so can’t pay income tax.
Comment by John Spragge —
June 18, 2007 @ 6:49 am
Possible libertarian solutions:
1) Deregulate medicine completely — anyone who wants to can provide care, prescribe drugs, etc. The state only intervenes to prevent fraud or coercion.
2) End the professional monopoly. Regulate doctors and hospitals the way governments regulate pilots and airlines: by setting objective standards for competence and experience, backed by no-nonsense testing and recording requirements. Anyone who can find qualified pilots can start an airline; anyone who can hire instructors and find an airstrip can start a flight school. And none of the existing pilots or airlines have any say in who gets into the market.
Note, however that nobody actually does that, and you should probably look into the results before you try the experiment.
Comment by Thoreau —
June 18, 2007 @ 7:34 am
Bruce-
That’s an interesting point you raise: If somewhere along the line Big Brother says “This is dangerous” then a business is off the hook. Taken to its logical conclusion, this could have all sorts of troubling implications.
However, I’m not sure that we need to take it that far, at least not if our main goal is to draw conclusions about tobacco. In general, I say no harm, no foul. If no reasonable person actually believes it, then nobody can say “Oh, they tricked me! How was I supposed to know?” That might not let the tobacco companies off the hook for all of their lies, but it certainly sets an expiration date (we can quibble over the exact year later) past which nobody can say “How was I supposed to know?” And with tobacco, I think we can all agree that at some point the tobacco shills lost all credibility.
As a comparison, do you think that “faith healers” or psychics or people like that should be liable for fraud? I say no, because any reasonable person should know that what is being sold is at best either entertainment or an outlet for emotions, not a physical cure or accurate prediction or whatever.
Comment by BruceB —
June 18, 2007 @ 7:52 am
By the way, the best readily available study I know of how unregulated medicine actually did work in the US, before World War I, is in John Barry’s The Great Influenza. The picture is complex, with something to make statists and anarchists alike uncomfortable and thinking “well, let’s not do that again”. It’s been rattling around a lot in my head lately, not leading to any real solutions, but to some interesting questions.
Thoreau, with the cigarette companies we have a simpler question: they committed deliberate fraud. See the stuff Tim Lambert’s been linking to lately about the role of tobacco companies in promulgating lies about the harm from restricting the use of DDT, quite calculatedly as a setup for an attack on efforts to deal with tobacco’s risks, for instance.
What I would consider honest error is much trickier, but I also think it’s a much smaller problem overall. The big-scale suffering is almost never accidental – just about always there are people at the top who were informed and chose the course that put others in harm’s way anyway.
Comment by Matt Weiner —
June 18, 2007 @ 8:11 am
Problem is, you can tell the insurance company to fuck off and pay for it yourself, if you’re so inclined. And the insurance company gets not one cent more of your cash.
I touched on this to my previous comment, but if you’re trying to convince liberals as opposed to preaching to libertarians this is not going to fly at all. If you tell the insurance company to fuck off, then you’re likely to have no insurance coverage again ever. (Mona recognized this with her “pre-existing condition” comment.) This means that you’re in a position where an illness, or a new illness, can bankrupt you. From a libertarian perspective, it may not be coercive when a private entity denies someone insurance coverage, but from a liberal perspective it is. (Especially because most people are restricted to one or two insurance carriers unless they change their jobs.)
Furthermore, it won’t always be true that the patient can pay for the procedure herself (which is an option in the UK too). Sometimes she can’t afford it. Liberals like me see raising taxes so that some people can obtain necessary medical procedures and thus continue to live (or that they can change jobs without worrying about losing their insurance forever) as increasing liberty, not decreasing it.
[This isn't directed at Mona, who's condemned our current system, but at Josh, who seems to be defending the private insurance system as OK from the libertarian point of view.]
Comment by b-psycho —
June 18, 2007 @ 10:21 am
It’s not that the government would have an incentive to micromanage personal habits to keep down costs — since when have politicians ever sincerely cared how much was being spent? More accurately, it’s that people naturally tend to want a say in how their money is used on other people. If someone is indirectly paying their neighbors medical bills, then they’ll demand the right to guide their choices in a way that will lighten the load.
People in favor of single-payer tend to assume that no one would want that kind of control, even though that’s the one criticism of activist government that even the biggest statist understands: “…but I don’t have a say in where that money goes!”. I strongly doubt the political will exists to respond to people who would twist that into an excuse for controlling personal behavior with “eh, shove it”.
This isn’t to say I don’t see a problem though. I’d personally lean the direction John Spragge suggested in addressing it, starting with medication: wipe out the drug patent regime.
Comment by b-psycho —
June 18, 2007 @ 10:26 am
Also, in the short term, I’d say that it should be a lot easier to get group rates for health insurance. Make it so rather than that being attached to a big employer anyone who wants to form an insurance group buy-in can do so. Only reason I can think of for that to not be commonplace already would be some law preventing it, correct me if I’m wrong though.
Comment by Dave W. —
June 18, 2007 @ 11:43 am
No smoker since at least the 60s has not known the risks.
Thank you government mandated labelling!
(If you ever have a spare minute, check out a graph of US smoking rates over the years and look at the impact the labelling requirement had — astounding.)
Comment by just sayin —
June 19, 2007 @ 1:43 pm
Not exactly true. The system we evolved is an artifact of WWII-era wage and price controls. Because the controls didn’t extend to fringe benefits, medical insurance spread as an end-run raise in a tight labor market. After the war, the large number of people with apparently free medical care significantly reduced political support for the kind of universal health regimes put in place in most other industrialized countries.