Sitting this one out
By Thoreau
I’m sitting out the healthcare policy debate. I will, however, explain why this libertarian plans to sit out a debate on what is potentially the most significant change in domestic policy since the 1930’s.
The American people have spent decades with a system of healthcare that is hardly free-market but certainly does have several layers of private businesses involved: Your employer that purchases a plan, the health insurer that purchases the care, the company that hires the doctor or runs the hospital or whatever (the independent practicioner is becoming rarer and rarer, although group practices admittedly vary quite significantly in size, with specialty practices often being smaller), and any number of pharmaceutical companies and device manufacturers and other suppliers that provide the pills and machines and whatever else. Now, as a libertarian I can point to any number of ways in which this system is hardly free-market, I can point to regulations and guilds and things in the tax code and subsidies and more subsidies and still more subsidies. Be that as it may, I know that none of these arguments will be convincing.
If the only reason these arguments weren’t convincing was that mere mortals were too benighted to understand the superiority of a truly free market, then I would sit here and snark at you. However, I have no illusion that the immediate and drastic scaling back of state involvement would deliver a system that is significantly superior to the status quo in the short term. Economies and societies are more complicated than that. Free market solutions happen through a process of evolution (Hayek would be glad to argue in favor of that proposition) and evolution can be messy.
Moreover, many large players in the private sector have spent decades being fine with state involvement in healthcare as long as it is structured to favor their interests. A free market needs raw materials, and our private sector is currently short on them. Large players in the private sector have spent decades working to discredit the healthcare system that we have (not to be confused with an ideal healthcare system in a textbook written by a free market economist) and no amount of recitation from economics textbooks will do anything to restore credibility. Credibility is a bit more complicated than that in the real world. Otherwise, we would be ruled by Ph.D. economists. (And thankfully, we aren’t.)
Does that mean I think the government solution will be better than a process of market evolution? Almost certainly not. It is, however, possible (even if unlikely) that the government solution will be better than the status quo. Laugh if you will, my fellow libertarians, but nowhere is it written that one heavily-regulated system is automatically better than another just by virtue of being a status quo system that some big (and politically connected) businesses happen to like. The state can deliver flawed systems with flaws of varying degree, and while I have no great confidence in the state’s competence I also have no sound basis on which to conclude that any and every regulated system will work out in practice to be worse than the status quo. We must wait and see before claiming the pyrrhic victory of being right about the suckitude of the new system.
I will say that I am actually confident that the system will continue to deliver high-tech medical pills and medical devices. The military-industrial complex, for all of its many flaws, has spent decades delivering technological wizardry. Even as we speak, our fine President continues a bipartisan policy of sending flying killer robots to shoot up rural Pakistan. Back in the 1980’s, we thought that flying killer robots were sci-fi nonsense, but now the Terminator is governor and Hunter-Killers are real. These technological breakthroughs will not be delivered with maximum efficiency, but that doesn’t happen now either. Moreover, do not confuse technological breakthroughs with efficient delivery of care. Magic pills are one type of innovation, and better delivery of care is another. It is not as glitzy, just as more efficient ground operations are less glitzy than flying killer robots, but it is important. So, if you are looking for a gloomy prediction to hang on to, if you need that consolation, predict fewer innovations in the less flashy areas.
Finally, I must salute liberals for their likely political victory: Jim wrote last year that while we libertarians were viewing the 2008 election as a chance to repudiate 8 years of bad policy on civil liberties, liberals were looking at this as the healthcare election. If a healthcare bill is delivered, and if it resembles some rough outline of what you were hoping for (at least on paper, we’ll leave aside for now what happens in practice) then you will have gotten far more than the GOP base (by which I mean rank and file voters, not the wealthy elite) got after 2000. I remember 2000. I remember the base talking about Bush’s religiosity and something about federalism and rumors about abortion. (Indeed, I remember people in 2000 who voted for Gore precisely because they believed that the GOP base would prevail on abortion if Bush won.) Well, it’s 2009, there was no drastic devolution of power to the states (quite the contrary, one of Bush’s first domestic policy initiatives was greater federal oversight of k-12 education), and abortion clinics are still open. The GOP base was played for chumps on domestic policy. If you get healthcare, you can claim a greater domestic political victory than your opposite numbers got. Only time will tell if the policy lives up to your expectations, but at least I will salute you for fighting a more successful batttle than your opposite numbers.
EDIT: I can already anticipate the slings and arrows that will soon be coming from at least one commenter. All I can say is that I am not conceding the battle on some ideal, platonic level of ideas. I continue to believe that free market economics provides better guidance (not to be confused with ideal end-games) than most alternative systems of ideas. However, I know when a battle is lost, I know why it is lost, and I know that credibility is about more than intellectual superiority. So I’m sitting out, which is different from saying that the other side is right.
Comment by bob —
August 16, 2009 @ 1:21 am
Musing over the relative merits of free markets and state intervention in heath insurance without ever referring to the concept of market failure is… weird. A window into the libertarian thought process, or an idiosyncratic oversight?
Comment by Thoreau —
August 16, 2009 @ 1:52 am
Oversight implies an unintentional omission from what was mean to be an exhaustive discussioon. Calling it a window into my thought process implies that I’m trying to display my every thought on this. I don’t feel the need to discuss every angle of an issue when explaining why I’m sitting it out. If I did discuss every angle, I wouldn’t really be sitting it out, would I?
Anyway, the great thing for people who want to explain why libertarians suck is that you get to beat us up for what we didn’t say after you’re done beating us up for what we did say. Have fun!
Comment by Kevin Carson —
August 16, 2009 @ 2:52 am
It would probably be easier to implement genuine free market reform of the British National Health Service than of our present corporatist system. All you’d have to do is turn each hospital and clinic into a stakeholder cooperative, and it would be privatized–presto changeo. And it would be a lot easier to sell that on some sort of cooperativist grounds than it would be to dismantle the professiona licensing cartels and drug patents in this country, eliminate barriers to lodge practice, the licensing requirement to “show need” for a hospital, etc.
Statism isn’t any less statist because the privileged class is nominally “private.”
Comment by bob —
August 16, 2009 @ 2:58 am
Fair enough that you’re under no obligation to be comprehensive in a post like this. And I’m really not trying to pick a fight.
Still, I don’t think it’s right to dismiss market failures as some sort of tangential angle of the issue under consideration–they’re basically the whole game. And I think the result of ignoring them is that you get your thinking on the issue badly wrong. If you start from the position of “free markets best”, “regulated markets second best”, than, sure, swapping one set of regulations for another is not obviously good or bad and so stay on the sidelines. But markets fail and regulated markets can do better than free markets. So the types of regulations on health insurance being being proposed might improve market outcomes, and depending on how you evaluate it, that might bring you off the fence.
Put another way: Did libertarians stop believing in adverse selection at some point?
Or more seriously: It is not at all obvious to me why, e.g., community rating regulations aren’t something a libertarian could love.
Comment by Ceri B. —
August 16, 2009 @ 6:08 am
The case for market freedom in this case would certainly be easier to make without things like recission turning up wherever insurers have a free hand.
The problem for me is that I don’t think any legislation likely to pass at this point will move things in the direction of effective state involvement for the material betterment of a significant number of citizens. Instead, it seems by far most likely to me that we’ll get something in the spirit of the financial sector bailout and the Medicare “reform” under Bush – vast handouts to favored businesses, maybe some improvement for some people at large, and a lot of screwing over with reduced accountability and increased power.
I’ll get active again if I think there’s any chance at seriously curtailing existing insurers’ power, which I think is actually a prerequisite for both what Thoreau would like and what I’d like. But mandates are really awfully for people in need, and while there may well be some constraints on corporate behavior around the edges, I see insurers getting a whole lot more money and a lot of ways to use it against the public interest. Any public’s interest broader than that of their largest shareholders.
Comment by JDC —
August 16, 2009 @ 6:53 am
bob is completely right on this one. And your comment in 2 strikes me as disingenuous. bob’s not “beating” you for things you didn’t say. He’s pointing out there’s an elephant in the room and you haven’t even acknowledged its existence. To me, your post has a “I have discovered a truly remarkable free-market health care system which this blog post is too small to contain” air about it.
You write “However, I have no illusion that the immediate and drastic scaling back of state involvement would deliver a system that is significantly superior to the status quo in the short term.” I infer from this that you do believe that a “drastic scaling back of state involvement” would offer significant improvements in the long run. If my inference is in error, I apologise. But at a minimum I’m very curious as to what you think about market failure and health care.
You go on to write “It is, however, possible (even if unlikely) that the government solution will be better than the status quo.” Why unlikely? I guess it all comes down to what you mean by “better”. But to me this reads like a reflexive dismissal rather than anything resembling an argument. (I may well be blaming you for an appalling piece on Radio 4 yesterday with some joker from Cato talking bollocks about health care. Sorry about that.) Hell, I’d think libertarians of a certain stripe (which I don’t take to be you) would love a direct NHS transplant since it consumes far less tax money on a GDP% basis than what the US already spends before non-tax expenditures.
Finally, and just to rub it in for no good reason, I have to note that the first thing I think of when I read the phrase “evolution can be messy” is Rumsfeld’s “Freedom is untidy.” Just sayin’.
Comment by Seth Flannel —
August 16, 2009 @ 7:40 am
I think a more interesting omission is the word ‘Medicare’. Up to now Medicare is the largest state intrusion into the wide world of health care, and arguably the most necessary if one of your goals is longer lifespans and better health outcomes for the over-65 group. I’d love to hear an idea for “market evolution” to a system that would 1) reduce this intrusion, 2) not make insurance costs for the non-elderly skyrocket as the elderly are reintroduced to the risk pool and 3) not be disastrous for the health of the non-rich elderly.
.
(2 and 3 are making me think of Cocoon run backwards; healthy, happy old people are dumped in a pool and turn feeble and cranky. Of course, Wilford Brimley haunts my dreams, so it might not be as obvious to most people.)
Comment by Glen Raphael —
August 16, 2009 @ 10:25 am
Bob, JDC: Thoreau also didn’t refer to the concept of government failure or public choice theory more generally. The fact that there exist some hypothetical or actual inefficiencies associated with market provision of a good doesn’t even weakly imply government is likely to do better unless you have discovered some truly remarkable regulatory system which this blog post is too small to contain which is likely to, on net, make the overall provision of medicine significantly more efficient than the market outcome. Just as a hypothetically efficient market system would need to deal with problems related to adverse selection and externality, a hypothetically efficient government system would need to deal with problems such as rent-seeking and regulatory capture.
The US health care system has achieved demosclerosis; it’s so complicated and there are so many restrictions on what is politically feasible that any actual reform amounts to poking a monster with a stick and hoping nothing too terrible happens as a result.
Maybe things will get better – the monster will leave – or maybe they will get worse – the monster will eat more of us after being provoked. Both the monster and the stick-making process are so complex that the only way to know whether we’ll be better off after A meets B is to try it and see.
Comment by The Angry Optimist —
August 16, 2009 @ 10:32 am
you’ll get what you deserve.
unfortunately, you’re going to drag the rest of us down with you.
“All that is necessary for the triumph of evil is that good men do nothing”
Comment by dhex —
August 16, 2009 @ 10:36 am
Instead, it seems by far most likely to me that we’ll get something in the spirit of the financial sector bailout and the Medicare “reform” under Bush – vast handouts to favored businesses, maybe some improvement for some people at large, and a lot of screwing over with reduced accountability and increased power.
judging from what meetings i’ve sat in on and dispatches from ny state healthcare groups, this is more or less the expectation.
Comment by bob —
August 16, 2009 @ 10:58 am
Bob, JDC: Thoreau also didn’t refer to the concept of government failure or public choice theory more generally.
Sure, and I understand those concepts are in the background here.
But I think their omission only contributes to what makes the argument in the post so weird. There is a strain of libertarian thinking that I follow–I think it is frequently mistaken, but I follow it–that goes: markets fail, but so do governments, so call it a wash and leave markets unregulated. This argument at least aknowledges that the free market outcome might not be so hot, it just argues that government can’t improve on it.
This isn’t the logic I take the post to reflect, though. This post seems to follow a line of thinking that is more along the lines of: an unregulated market for health insurance would work well, but in this fallen world it isn’t one of the options on the menu.
But maybe I’m misunderstanding.
Comment by Glen Raphael —
August 16, 2009 @ 11:45 am
Bob asks: Did libertarians stop believing in adverse selection at some point?
One answer to that as applied to the current heath system is here. Upshot: in practice it doesn’t see to be a very big problem. Quote: “you do not gut rehab the US health system to solve the problems of a tiny fraction of one percent of the population; you find a way to deal with the problems of those people.”
(Note that Megan is arguing in a very different context from Thoreau. She hasn’t decided to sit this one out; she’s determined to go down swinging in opposition to the current reform trend; she thinks it will make things worse for the masses more than it helps the few, especially if you count future masses. Thoreau seems to be withholding judgment on that question.)
Comment by The Angry Optimist —
August 16, 2009 @ 11:48 am
one thing is for sure: government-run health care will cause more pain and death than thoreau’s hobby-horses of the Iraq War and torture.
But, you know, it’s some old people and the retarded, so that doesn’t matter, right?
Comment by All Your Summer Songs —
August 16, 2009 @ 11:56 am
Shop at Whole Foods!
Put more money in the CEO’s pocket, such that he will more quickly be able to instigate his coup d’ Rand, starting with the GREAT State of Texas, & install a Libertarian Paradise*.
*& actually, quite a bit like Coolio’s paradise of the gangsta variety, but with even more reefer.
Comment by Thoreau —
August 16, 2009 @ 1:08 pm
Show me a winnable battle here and I’ll take to the field.
Fuck you.
To everyone else:
I don’t think that 100% unregulated medicine is likely to deliver very good results. Any satisfactory system is likely to have some government involvement. Tell you what, I’ll put it in all caps and bold so you can stop beating up on somebody who just offered to cede the field.
I DON’T THINK THAT 100% UNREGULATED MEDICINE IS LIKELY TO DELIVER VERY GOOD RESULTS. ANY SATISFACTORY SYSTEM IS LIKELY TO HAVE SOME GOVERNMENT INVOLVEMENT.
Anything else you want me to say before my ceding of the debate is satisfactory?
I do think that there are ways to improve healthcare that involve less government rather than more. However, the case for fewer regulations and reduced government involvement (even just in limited aspects) has been discredited in practice by decades of a system that is hardly free market but heavy on private sector actors. The battle of free markets vs. government intervention is not won by the interventionists but rather lost by the free market side. It isn’t a matter of something that is pure in theory being unfit for this fallen world. It’s a matter of actions and proposals being discredited by poor practices.
If that isn’t sufficiently reality-based for you, then consider yourself added to the list of recipients of the “fuck you” I directed at TAO above.
Comment by Thoreau —
August 16, 2009 @ 1:15 pm
To those confused on whether I believe in absolute, hard-core, scorched-earth-if-necessary 100% state-free end games, I invite you to re-read something I put above:
Also, on whether the reforms will be superior to the status quo, I said that I consider it highly unlikely, because I am skeptical of politicians’ ability to get something right, but the ultimate proof of the pudding is in the tasting.
Finally, I salute our Blue readers for what is likely to be a greater victory for your side (at least in the short term) than the GOP base got on domestic policy in the first 8 months of 2001. You are clearly a more formidable adversary than the GOP base.
Comment by Jim Henley —
August 16, 2009 @ 1:20 pm
And the mechanism by which this would occur would be?
Comment by Neel Krishnaswami —
August 16, 2009 @ 1:37 pm
There are excellent, simple policies. The Brad de Long plan is one. It goes like this: Mandatory health savings accounts for everyone — say, 10% of income — out of which people buy health care. Anything you don’t spend gets returned to you after 12 months. The government picks up the tab, up to some max (e.g. 100K per year), whenever the HSA runs dry.
The point is that people will spend their own money on care, which is a necessary pre-req for price competition. But, the income percentage cap on how much they can be forced to spend means that poor people don’t locked out of the health care system, either.
Health care for the elderly is not an insurable risk. Insurance only turns a profit when adverse outcomes don’t happen most of the time. But old people entirely predictably get sick — it’s part of what being old means. Paying for health care for old people is a transfer payment, pure and simple, and it’s best to explicitly treat it as one, rather than trying to shoehorn it into the insurance market.
Comment by Neel Krishnaswami —
August 16, 2009 @ 1:38 pm
I should add that the problem with this plan is getting there from here. I have no idea how anything like this could get through Congress.
Comment by Thoreau —
August 16, 2009 @ 1:41 pm
Neel,
I like that. It has a progressive element, it treats transfer payments like, well, transfer payments, but it keeps incentives for competition without putting the government in charge of the whole thing.
I also have no idea how to get there, and since I believe that arguments against more government and in favor of market competition have lost credibility with the public as far as healthcare goes, I’m sitting out.
Comment by The Angry Optimist —
August 16, 2009 @ 1:41 pm
I expect you’ll salute the Reds for Iraq soon. Hey, what a victory!
Start Here.
Comment by Thoreau —
August 16, 2009 @ 1:42 pm
The Iraq War was sold to the base by the leaders. It was not something that the base demanded during the campaign. There’s a difference.
Comment by bob —
August 16, 2009 @ 1:43 pm
I read that, but honestly couldn’t make heads or tails of it. I don’t know what it means to think of “free market economics” as a “system of ideas”. Partly as a result, the distinction you are trying to draw between “guidance” and “end games” is not really all that clear.
Comment by radish —
August 16, 2009 @ 1:44 pm
Sure. If you’re aiming for, or away from, any predetermined outcomes, then you need regulation. Period. There’s no point setting up an unregulated market as a way to identify a locally “efficient” distribution of resources, and then — if it turns out that the scheme involves putting the old folks out on the floes — turning around and say “oh, noes, we didn’t want that!” You need to apply artificial constraints (the regulatory scheme) and you need to also provide activation energy if you happen to be aiming for something that’s difficult to get to from here.
But talking about market failures is a two-edged sword. Before you can talk about market failures you need to identify outcomes that are undesirable and constitute “failure,” and the problem is that you cannot make an exhaustive list of the outcomes that you want to avoid.
So there’s also no point pretending that you, as an intelligent but not omniscient/omnipotent designer, can prevent outcomes that you consider undesirable simply by placing artificial constraints on an evolutionary (aka free market) process. Evolution, once unleashed, will always be looking for maximally efficient local equilibria, whether or not you consider those equilibria acceptable. It will always be able to find outcomes which obey the rules that you set for it, but which you did not anticipate and may not find acceptable.
This isn’t an argument for or against anarchism or statism or any other political view. It’s just the way the world works, and if anything it’s an argument for highly adaptive, red-queen-friendly regulatory regimes. Rust never sleeps and neither does natural selection.
Comment by Thoreau —
August 16, 2009 @ 1:46 pm
Some people define libertarianism as a destination, a utopia we must reach. To me, libertarianism is more useful as a set of ideas to guide you when choosing between alternatives. It’s a guide to change on the margin, rather than a prescription for some ideal end-game.
Comment by bob —
August 16, 2009 @ 1:50 pm
Got it. Thanks.
Comment by The Angry Optimist —
August 16, 2009 @ 1:56 pm
you’re still saluting a party for effecting a takeover of a large amount of power. Shame on you.
Comment by Thoreau —
August 16, 2009 @ 1:59 pm
I’m acknowledging the acumen of a strong adversary, TAO.
Comment by radish —
August 16, 2009 @ 2:05 pm
I guess I should clarify that this is relevant because as a libertarian you might well think of the “market failure” problem as inherently unsolvable and therefore not worth mentioning.
If you anticipate that the observer (the polity) will come up with a set of rules that’s at least comprehensive, if not exhaustive, such that whatever market/state hybrid system you create will not manage to find an undesirable outcome that obeys all the rules you set up for it, then you might take bob’s view.
If you anticipate the opposite — that the system will figure out a way to fuck you over while obeying the rules that you set for it (and here we’re not even getting into whether failures of enforcement and capture scenarios constitute market failures or regulatory failures) then you should indeed take Thoreau’s view. That’s not naive libertarianism, it’s cynical libertarianism. Weird to some perhaps, but certainly not disingenuous.
Comment by The Angry Optimist —
August 16, 2009 @ 2:12 pm
Sorry, but s”ceding the field” before there is even a readable or debatable proposition on the table tells me that government healthcare doesn’t really bother you all that much.
Comment by Thoreau —
August 16, 2009 @ 2:15 pm
TAO, you can think whatever you want to think about what you think bothers me, but I see the momentum, I see what the public is upset about, and I don’t see a victory scenario.
Comment by Meth Channel —
August 16, 2009 @ 2:19 pm
Gotta run so I don’t have time to dig out the de Long plan, but don’t the over-65 crowd currently served by Medicare not have much in the way of income, plus a frequent need of more than 100K of care in a single year? So the government will still pay for everything above what 10% of their meager incomes can. I’m not necessarily opposed to this, but it’s not clear to me how this is a system more pleasing to team libertarian.
Comment by The Angry Optimist —
August 16, 2009 @ 2:20 pm
there have been plenty of alternative proposals fronted already – you don’t see any way to add to the debate because you don’t want to. Like I said, if this were a 100-troop invasion into Micronesia, you’d be all over this for days. But takeover a 2 trillion dollar industry? Nothing but shrugs and faux-world-weariness.
Comment by Thoreau —
August 16, 2009 @ 2:34 pm
If there is an avenue to fight in, it is in offering alternative proposals. The problems with taking up that fight are:
1) I don’t think that any case involving the phrases “less government”, “free market”, or “private sector” will carry weight with the public. Since that’s a lot of my rhetorical arsenal, I’m already going into the fight weakened.
2) What you’re left with, then, is making the cases for these alternative plans (e.g. the DeLong plan) with wonkish arguments on the details. I’m not a healthcare wonk, I can’t explain or argue for details and dissect their consequences. So I’m going into that fight even weaker.
3) Frankly, any alternative that is credible with the public, even one that has some element of free markets or other phrases that I won’t utter in the public debate, will be unsatisfactory to a principled libertarian, so arguing it on this blog just opens up my right flank while I’m making a weak case against my left flank.
4) Fuck you, I reserve the right to criticize foreign meddling irrespective of which domestic policy fights I think I can win.
Comment by The Angry Optimist —
August 16, 2009 @ 2:40 pm
Dude, likewise. I reserve the right to call you on your selection of easy targets – it’s so simple to be against torture and war; not so simple when the other side is selling a government takeover couched in puppies and rainbows, is it?
As to your 3, Mackey’s alternative in the WSJ was, while not satisfactory, leaps-and-bounds better than anything else.
And I don’t buy that you’re not smart enough to grab onto the “wonkery”, either. This stuff actually isn’t that hard.
Comment by The Angry Optimist —
August 16, 2009 @ 2:43 pm
And, for what it’s worth, it appears that the dumb opposition is working. So just imagine what a smart guy like yourself could do…
Comment by bob —
August 16, 2009 @ 3:02 pm
Says the guy who is under the impression that Medicare is a program for snuffing out the elderly. As demonstrated in the careful empirical work on excess death of Bastiat.
Comment by The Angry Optimist —
August 16, 2009 @ 3:09 pm
bob, I never said either of those things. Failure to be able to understand a basic argument without having everything spelled out for you is the sign of narrow mind.
Comment by bob —
August 16, 2009 @ 3:16 pm
angry optimist, sorry, I figured based on:
that we were cool with hyperbole.
Comment by The Angry Optimist —
August 16, 2009 @ 3:18 pm
fwiw, there will be no “mechanism”, no “panels” – it will never be so officious or formal. It will a bureaucrat in an office looking at a government-printed chart and writing “denied” on a form. And the “little person” at the other end will die, with no chance for recourse other than “voting” – a process that yields us a 95% retention rate and a fourth branch wholly unaccountable to the people. It will be “you might have bankrupted yourself trying to save your preemie child, but that’s no longer an option. We have to stop care in the neonatal ICU”. And, to try to cover their ass, the government will change the standards.
Nothing so crass or formal as “death panels” or mechanisms – just the soft but deadly touch of government, killing people before their time.
Comment by joe from Lowell —
August 16, 2009 @ 3:43 pm
There are not enough fuck yous in the world for this shitbag.
fuck you.
40,000 people died in this country last year because they didn’t have health insurance. And the year before. And the year before.
That’s evil. Your taxes going up a teeny weeny little bit to stop that from happening isn’t evil, you shit.
That doesn’t even get to the matter of recision, which kills tens of thousands more. Recision, which happens right now, is the process of insurance companies dropping people when they get sick. It is exactly a bureaucrat in an office checking “denied” on a form.
The fact that it happens much, much more frequently in corporate offices than it would in government offices isn’t important though, because just as money spent on war isn’t real money, people murdered by spreadsheets run by for-profit corporations aren’t really dead.
Comment by joe from Lowell —
August 16, 2009 @ 3:56 pm
The great irony in all of this is that the only system that denies people medical care based on their productivity is the free market.
Comment by joe from Lowell —
August 16, 2009 @ 3:57 pm
If you were more productive, you would have been able to afford that operation.
But it’s ok – you’re productive enough to afford some Tylenol with Codeine. Nighty-night.
Comment by Neel Krishnaswami —
August 16, 2009 @ 4:05 pm
First question: more or less. This is why health care for old people can be viewed as a pure transfer payment.
Second question: no. Very, very few people need to spend more than 100K per year, and it’s few enough that you could discard the cap without really affecting total expenditures. The sorts of events that require very expensive care (e.g. organ transplants, trauma from car accidents, etc.) are random enough that an insurance model is feasible for them.
The need for health care is extremely fat-tailed. The bottom fifty percent of the population accounts for 3% of spending. The top 5% account for almost 50% of spending. The top 1% account for 22% of health care spending. In 2002, you needed to spend $11K to enter the top 5%, and to spend $35K to enter the top 1%.
This kind of distribution is really hard to summarize with averages, though, since you really want fine discrimination at the top. (Remember that one person care cost a million bucks costs as much as 30 people who needed 35K — which is to say, organ transplants.) Unfortunately, the spend of the top 1% is as fine as I can easily find online.
Comment by I, Kahn O'Clast —
August 16, 2009 @ 4:14 pm
TAO: What you describe is different from the current system when an insurer denies a claim how?
Comment by I, Kahn O'Clast —
August 16, 2009 @ 4:14 pm
Oh, @ 40
Comment by joe from Lowell —
August 16, 2009 @ 4:32 pm
Can I answer? The incentive structure in the private insurance market is such that denying as many claims as possible and spending below a projected budget is rewarded with bonuses and promotions.
While the incentive structure in government offices is such that failing to spend the office’s budget is punished, and rewards and promotions are decided based on either total resources spent, or (the more likely candidate in this case) outcomes.
When, exactly, did conservatives start believing that bureaucrats in government offices are penny pinchers, always striving to come in under budget, like private-sector bureaucrats?
Comment by The Angry Optimist —
August 16, 2009 @ 4:57 pm
Just to get it clear in my head, how often are lawsuits successfully prosecuted against the government as opposed to private actors?
Comment by joe from Lowell —
August 16, 2009 @ 5:09 pm
Not often enough to prevent the deaths-by-spreadsheet that everyone else in the country seems to know about.
Comment by Joshua Holmes —
August 16, 2009 @ 5:41 pm
A good public health system isn’t likely to involve much more government than we’ve already got in the health system. If it’s well-run, it’s likely to produce results at least as good. Obviously, I oppose both the system we have and a well-run pubic system on libertarian grounds, but if two choices are basically equally libertarian, I’ll take the better outcomes.
However, I don’t think we’re getting a well-run system. We’re getting the system as it stands, subsidized around the edges, with all the usual suspects ponying up to the table. The efficiencies, cost savings, better outcomes, etc. that liberals are promising simply aren’t unlikely, while even more massive deficits are very likely.
Comment by joe from Lowell —
August 16, 2009 @ 5:56 pm
It irritates me to see people shedding crocodile tears about people who will, allegedly, be denied care by a government bureaucrat who doesn’t want to spend the money on them, when these same people don’t give a crap about people, not allegedly, who have been denied care because a private-sector bureaucrat doesn’t want to spend the money on them.
But what really makes my blood boil is the utter indifference of these tear-shedders to people who don’t get health care because no one would ever even consider spending money on them, because they have no health care coverage whatsoever.
Comment by The Angry Optimist —
August 16, 2009 @ 6:09 pm
where did I say anything about not giving a “crap”?
oh, because I don’t want to force people into paying for other people, that means I don’t care?
Comment by joe from Lowell —
August 16, 2009 @ 6:14 pm
Yes.
When the options are “He doesn’t get care,” and “ZOMG, the force!” – as they are in the real world – then arguing “ZOMG, the force!” is an argument for denying people care.
It is active support for people not getting medical care.
Yes, it is. I don’t care about your heart; I care about what actually happens to people. I’m sure on Angry Optimist Rainbow Puppy Island, everybody would get good medical care without ZOMG teh force, but I don’t really care what happens on Angry Optimist Rainbow Puppy Island.
I care whether people in the actual United States do, or do not, get health care, and the motivations of those determined to defeat the effort to give it to them interest me only in an academic sense.
Comment by joe from Lowell —
August 16, 2009 @ 6:16 pm
Your utter silence, in the midst of your howling about how much you care about people who’d be denied coverage by the bureaucrat in your head, was deafening.
Comment by The Angry Optimist —
August 16, 2009 @ 6:17 pm
Right. I guess you don’t care about drug addicts, since you don’t want to force them to quit drugs.
ALL the people who have died from drug overdoses…joe doesn’t care!
Sorry, but your rank emotionalism is not enough to justify government intervention. Screw your “appeals” to emotion.
Was your opposition to the Iraq War meaning that you were opposed to “helping” the Iraqis?
Comment by The Angry Optimist —
August 16, 2009 @ 6:20 pm
Ah, playing at mindreading again, eh joe?
Good job, little Kreskin.
Comment by joe from Lowell —
August 16, 2009 @ 6:23 pm
I fully support public funding for addiction counseling, which is the actual analog to supporting public funding for health care.
We are actually talking about human lives here. My emotions about those human lives aren’t the argument; it’s those lives themselves.
Once again, I fully supported American funding to support Iraqis seeking to resist the Saddam government, which is the actual analogue to public funding for health care.
I’ve never written a single word about forcing people to accept any medical treatments they didn’t want, which would be the appropriate analogue to forcing people to quit drugs, or invading Iraq.
Comment by joe from Lowell —
August 16, 2009 @ 6:24 pm
I trust that, if you had an argument to rebut what I’ve written, you’d have made it.
All I’m getting is a whimpering sound.
But I’ll say it again: I don’t give a crap what’s in your heart.
Comment by joe from Lowell —
August 16, 2009 @ 6:27 pm
…
Apparently, “rank emotionalism” – we’re using the very special TAO definition of “appealing to the cost in human lives” is wholly unacceptable as an argument for changing something that is actually costing thousands upon thousands of human lives, but is a valid argument when the lost lives in question are invented out of thin air.
Comment by joe from Lowell —
August 16, 2009 @ 6:32 pm
And finally, “The only thing it takes for evil to triumph is for good men to do nothing.”
It is evil to allow people to die from a lack of access to medical care, and all it takes for evil to triumph is for good men to do nothing to help them get it.
Comment by Dand82 —
August 16, 2009 @ 6:32 pm
This is what really angers me about supporters of the current bill, you make it sound as though anyone who was a different idea about how to reform healthcare wants people to die. I happen to favor tax payer funded medical saving accounts for people with low income as well as a generous negative income so that they can buy catastrophic coverage. I am likely to oppose any bill the democrats propose but that doesn’t mean I want to do nothing.
Comment by joe from Lowell —
August 16, 2009 @ 6:55 pm
Help! I’m dangling off the cliff! My harness broke! Throw me that rope!
You know, I don’t support throwing you that rope – on principle, you understand – but I would support putting a large mattress below you, to break your fall. If there was a mattress.
I’m slipping! Help!
Sigh, if only there was a mattress. Please understand, I don’t support letting you plunge to your death, I’m just opposed to ropes. Oh, if only I had a mattress!
Aaaaaaaaaaaaaaaaaaaaaaaaaaa………..!!!!!!! *splat*
Fin
I believe you when you say you support helping people via government-funded MSAs. Seen any?
Believe you me, Dand82, this health care bill isn’t my dream solution, either. But there is no mattress. We are faced with a yes/no question about helping the poor and uninsured. Let’s do the most important thing – cover them – and then come back and see if we can do it better. I can’t abide by holding them hostage in an effort to get my ideal bill.
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August 16, 2009 @ 7:22 pm
[...] going to make like our old friend Thoreau and sit this one out. There really is no point. You’re going to get what you [...]
Comment by All Your Summer Songs —
August 16, 2009 @ 7:48 pm
High-strung bunch, here, huh? I think we all need to sit back & take some Tussin. & if you’ve run out, add water, shake — presto, more Tussin.
Comment by Mona —
August 16, 2009 @ 8:20 pm
Dand82 offers my notion of the optimal solution, but it is nowhere on the table. That being true, what is to be done about a health care situation that has long been not free market, but rather, a worker benefit in which the health care recipient has no choice but what the employer offers? There has been no portability (COBRA is short-term and for most, an expensive joke).
We all die, and need to be treated humanely when that is upon us. As others have pointed out, that is a welfare entitlement for most, and not part of a level risk pool. Unless some plan such as Dand82’s were effected that accounted for elderly (or even catastrophic illness in the young). But that is not even being considered.
Comment by Dand82 —
August 16, 2009 @ 8:39 pm
Well, I’m not a congressman so it’s not like my opposition has any effect. One thing I don’t get is why the US left is so insistent on Single Payer. For me and I describe myself as libertarian with some liberal leanings the German Healthcare system would be more than acceptable but most liberals would reject it because it’s not Single Payer.
Comment by The Angry Optimist —
August 16, 2009 @ 8:59 pm
the accident of your birth does not entitle you to the labors of others. To think otherwise is to be a shortsighted spoiled brat.
Comment by The Angry Optimist —
August 16, 2009 @ 9:05 pm
ZOMG do something before moar people DIE!
Health care supporters are just like war/torture supporters.
“Let’s do the most important thing – protect the nation – then come back and worry about civil liberties.”
Awesome.
Comment by Jim Henley —
August 16, 2009 @ 9:54 pm
TAO, I’m going to leave aside your self-contradictions on the issue of what kind of tears to cry over which kind of deaders. Your initial claim was that increasing the number of people covered by government-funded health insurance – teh public opshun – would lead bureaucrats to kill old people and the retarded. When asked to provide a causal mechanism how this would happen you punted. (When I advert to Bastiat I take the trouble to explain exactly which part relates to my argument and how.)
So, explain: “old people” have been the purview of government bureauctats for decades in the United States. Teh Public Opshun would not increase the government’s sway over geezer health care. And say what you will about Medicare, during the four decades of the program, the life spans of the elderly have increased as have the range of treatment options, pretty much all of which Medicare covers. So how will providing government-funded health insurance to people who are not the elderly lead the bureaucrats who already oversee care of the elderly to start snuffing their charges all of a sudden.
As to the retarded, where do they come in?
Comment by Thoreau —
August 16, 2009 @ 10:15 pm
Step 1: Expand government control over health care provided to somebody other than the elderly.
Step 2: ????
Step 3: Soylent Green!
Comment by Jim Henley —
August 16, 2009 @ 10:18 pm
I have to say, I think the retarded would make tastier food products than the elderly, being younger and more tender.
Comment by von Laue —
August 16, 2009 @ 10:20 pm
As shithouse as the tone of this thread is — the leet-speak, encyclopedia-dramatica internet-jive sarcasm it seems to have infected all factions with is an order of magnitude more fucking terrible and unfunny. It makes me wish I were uninsured-poor/guvmint-bureaucrat murdered, so there was no possibility of ever reading a sarcastic !!11! again.
Comment by Thoreau —
August 16, 2009 @ 10:22 pm
Silly Jim, that’s what Irish babies are for.
Comment by Macbeth Annal —
August 16, 2009 @ 10:30 pm
I appreciate NK’s response. For the uninitiated the Brad de Long plan is here. From an outcomes perspective, it seems pretty good (if there’s some help for the poor paying into it); from a political perspective, it’s adorably delusional – I don’t know whether raising people’s taxes for the HSA is more unlikely than getting rid of the insurance companies, but the plan is labeled at the top “An Unrealistic, Impractical, Utopian Plan”. Again, for libertarians it doesn’t seem to be an improvement on the status quo or any of the eleventy-twelve plans currently circulating. Not being a libertarian, this doesn’t bother me. Probably my last comment on this issue since I am out of rhymes for “panel”.
Comment by joe from Lowell —
August 17, 2009 @ 9:36 am
You gotta love someone who thinks that the fact that a proposal would save human lives is a reason to oppose is.
Except, of course, for the war and torture being based upon a completely false threat, and “health care supporters” wanting to address one that actually exists.
What a sad, bitter little man you are. “Hey, that guy wants to help people! Fuck him, that makes me feel bad about myself! Down with helping people!”
Comment by joe from Lowell —
August 17, 2009 @ 9:38 am
Step 4: Accuse those who aren’t convinced of trafficking in fear.
Comment by joe from Lowell —
August 17, 2009 @ 9:40 am
…
Hypocrite.
Comment by The Angry Optimist —
August 17, 2009 @ 10:22 am
I am not advocating for government intervention with the same arguments that Patriot Act supporters used.
Saying I am a “hypocrite” is failing to grasp the distinction between force and voluntary action. I know you don’t appreciate the difference, but I didn’t expect to be so bombastic in your ignorance.
Comment by fishbane —
August 17, 2009 @ 10:37 am
TAO is more fun when it is being a jackass over at Patterico’s digs. Here its knee-jerk jackassery against actual reasonable people is just annoying, the brave 101st fightin’ keyboarder fronting more tired than an insomniac mom with new triplets, and bullshit appeals to reason after hyperventilating about other people’s choices in policy discussions, well, the sort of thing that might be precious in a four year old, briefly.
Comment by The Angry Optimist —
August 17, 2009 @ 10:52 am
I am glad to say that I am waving a bloody shirt here. Frankly, I think given the number of bloody shirts manufactured by government action, I have history on my side.
Comment by Not Today —
August 17, 2009 @ 12:22 pm
I have not read all the comments so I dont know if this was mentioned.
Here in California we have State Subsidized Workers Compensation. Well obviously with the state in the business of providing workers comp insurance all other companies have left that market right? Wrong. In fact it has helped many companies that are able to provide better service than the state.
I see the same deal with healthcare. Major companies wont leave. They will provide supplemental insurance and individual plans for those not interested in government run plans.
My only hope is that the final bill sees a “default” plan that kicks in for anyone not on another plan. I would also hope for some sort of healthcare tax rebate for those paying for their own plans (yeah right!). At the end of the day, this wont eliminate business or competition, but it will ensure many more americans the ability to be on healthcare.
This is from a Conservative Libertarian…
Comment by fishbane —
August 17, 2009 @ 12:38 pm
I am glad to say that I am waving a bloody shirt here.
And we all tremble beneath the incredible glory of your fearless comment posting prowess. Pick me up some Mountain Dew on your cheetos run, kay?
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August 17, 2009 @ 2:02 pm
[...] a libertarian, is sitting out the health care debate, but makes a great point in a Nixon-to-China sorta [...]
Comment by Spartacus —
August 17, 2009 @ 2:41 pm
Not Today,
I’ve frequently mentioned the CA Workers Comp market as an example of a public option in the insurance market. I’ve also frequently cited Singapore and the Netherlands as providing public options. But those who oppose the current proposals seem completely incapable of reconciling these public/private insurance markets with their ideological opposition to the currently proposed public option.
For this reason, I really do believe that for those opposed to reform it’s really an ideological value; it’s not about (1) achieving universal coverage, (2) reducing the cost of insurance for those who are already insured, and (3) achieving better value for the money this country does spend on healthcare.
Comment by Mike —
August 17, 2009 @ 7:02 pm
Every competent and sane economist recognizes that the free market does not work in health care. But libertarians are neither competent nor sane.
Comment by joe from Lowell —
August 18, 2009 @ 2:51 pm
Ah, I see. When you condemned appeals to the well-being of human beings in political argumentation, you were referring only to people who don’t agree with you on policy and ideology. It’s ok for people arguing for your preferred politics to argue that way, but not anyone else.
That’s what makes you a hypocrite.
Comment by joe from Lowell —
August 18, 2009 @ 2:53 pm
You know what would be a useful difference to appreciate? The difference between “misunderstand” and “disagree with.”
Every time I disagree with your argument, not matter how detailed my demolition, you pretend that I just don’t understand it.
Your argument is childishly simplistic. I don’t fail to understand it. I fail to respect it. Appreciate that difference.
Comment by joe from Lowell —
August 18, 2009 @ 2:56 pm
…
Comment by Kevin Carson —
August 19, 2009 @ 12:36 pm
I posted the following comment on Libertarian Alliance Forum, in response to Sean Gabb’s essay here:
http://libertarianalliance.wordpress.com/2009/08/17/a-libertarian-perspective-on-the-national-health-service/
I’d like to get from the present system to a free market: no drug
patents, no licensing cartels, no requirement to “show need” to build
a hospital, no FDA, etc. But moving straight from one to the other is
a bit like starting with a sedan and trying to turn it into a
motorcycle by taking off two of the wheels. There will be statist
stages in the middle.
And frankly, I’d find it easier to implement a genuine free market
reform of the NHS by simply devolving control of hospitals and clinics
to the neighborhood or town level and turning them into stakeholder
cooperatives run by patients and staff (Rothbard’s model for
privatizing state industry). The American system isn’t a bit more
“free market” just because the entities composing it are nominally
“private sector.” A system is no less statist when the ruling class
consists of nominally “private” businesses. When the actual
functioning amounts to privilege and exploitation by the political
means, carrying out such functions by nominally “private” actors just
adds another layer of useless eaters to be fed to the ruling class.
I’m not even sure that Obama’s plan represents a significant increase
in statism; to the extent that his new insurance regulations are
secondary qualifications on the use of primary grants of power by
state-privileged entities, they may actually be net reductions in
statism. The most statist aspect of it is the proposed “public
option.” And since it is to be funded by internal revenues, and
consist of voluntary membership, it’s hard for me to get too bent out
of shape about it. Its primary function is to provide low-price
competition against state-privileged entities whose privileges Obama
refuses, as part of the deal from the outset, to remove.
So if I’m to choose between forms of statism, I prefer the one that
weighs less heavily on my neck and that of anyone else who works for a
living. If we’re going to have a corporate state, I’d prefer one that
has a little welfare for poor people mixed in with all the welfare for
the rich.