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Quick hit from me: here’s a good op-ed in the NYT on health care reform:
One of the major goals of health care reform is to cover the vast numbers of uninsured. But how vast, really, is that pool of people? Who are they? And how important is it to cover all or most of them?
Critics play down the seriousness of the problem by pointing out that the ranks of the uninsured include many people who have chosen to forgo coverage or are only temporarily uninsured: workers who could afford to pay but decline their employers’ coverage; the self-employed who choose not to pay for more expensive individual coverage; healthy young people who prefer not to buy insurance they may never need; people who are changing jobs; poor people who are eligible for Medicaid but have failed to enroll. And then there are the illegal immigrants, a favorite target of critics.
All that is true, to some degree. But the implication — that lack of insurance is no big deal and surely not worth spending a trillion dollars to fix — is not.
No matter how you slice the numbers, there are tens of millions of people without insurance, often for extended periods, and there is good evidence that lack of insurance is harmful to their health.
Scores of well-designed studies have shown that uninsured people are more likely than insured people to die prematurely, to have their cancers diagnosed too late, or to die from heart failure, a heart attack, a stroke or a severe injury. The Institute of Medicine estimated in 2004 that perhaps 18,000 deaths a year among adults could be attributed to lack of insurance…
If nothing is done to slow current trends, the number of people in this country without insurance or with inadequate coverage will continue to spiral upward. That would be a personal tragedy for many and a moral disgrace for the nation. It is also by no means cost-free. Any nation as rich as ours ought to guarantee health coverage for all of its residents.
Don’t worry, I am assured that posts in my absence won’t be all-health-care-all-the-time. :)
[Hopefully this isn't too focused on health-care. I don't wish to be dreary.]
When it comes to highlighting wingnuttery as Metavirus recently did, I’m unfortunately a poor substitute of late. I’ve become desensitized to partisan insanity. When I read that same quote several days ago—”our democracy has never been threatened as much as it is today”—I did not think twice about it. Par for the crazy course, it seemed.
I’m reminded of Jane’s Law:
The devotees of the party in power are smug and arrogant. The devotees of the party out of power are insane.Quite true. I’m sure most of you remember how smug and arrogant the Republican Party was when it held power. But perhaps you don’t also remember left-wing craziness during the effort to reform Social Security. And perhaps you don’t see the arrogance of Democrats today. It may be easier to shrug off your own side’s excess, but it’s there—though I hope not usually to the degree Republicans have been spewing lately.
I don’t plan on digging into this much, however. Partly because it’s yesterday’s news, but mostly because I wish to avoid drowning in weak man arguments. The majority of the partisan blogosphere pretty much runs on weak mans. A progressive will pull some ludicrous position or quote from a conservative to ridicule with her buddies, and vice versa. Subtext being: “of course we have to fight those people—they’re all insane!”. It becomes a snarky, smug, morale-boosting sport. One that in the past I’ve dabbled in often—albeit from my own pox on both your houses perspective.
For more of a policy example, a couple months ago Metavirus joined others mocking Sen. DeMint’s health plan, which apparently offers a subsidy for any American who’s unhappy with their current coverage to go out and buy new care. Yes, it would serve to move us away from employer-based care, but at what cost? As pointless wastes go, it’s right up there with Cash for Clunkers—as if the health-industrial complex deserved a stimulus. The lunacy of funding it with recovered TARP funds for “deficit neutrality” just ices the cake with sweet craziness. (The correct approach, which I advocate, is to fund subsidies by repealing the employer tax credit, and to means-test them with a low-income requirement, ala Wyden-Bennett)
Via the Dish, I see Julian Sanchez wondering about a better way to argue politics:
Consider the way our views normally evolve. We sort of hunker down in our ideological bunkers trying to fend off various attacks and challenges. Sometimes an especially forceful argument will require a modification in the fortifications—and on rare occasions, we’ll even be forced to abandon a position. Which is to say, we learn from other perspectives largely in a defensive mode, through a kind of Darwinian selection of arguments. But what if instead we tried to use the insights available from our own perspectives, not to defeat or convert the other guy, but to give his argument its best form?I would probably find it very difficult to reformulate progressivism or social conservatism in a snarkless, non-derogatory manner. But I get why it would be intellectually edifying to exercise the ability. For my own part, I try to at least read the best of progressive and socon thought. (Matt Yglesias. Ezra Klein. Paul Krugman. Postmodern Conservative. The American Scene. Ross Douthat. Daniel Larison…) It’s useful to know where the smartest people on the other side are coming from if you actually want to have a good faith argument and aim to be more convincing than shrill.
This might sound like giving aid and comfort to the enemy, but even in terms of the Darwinian struggle, there’s value to being able to show how your view trumps even the optimal form of the competition. Think of chess: You can’t see your own best move unless you have some sense of what your opponent’s best response would be. But the more intriguing possibility is that a smart progressive’s good-faith reformulation of libertarianism might be something that the libertarian, too, could recognize as an improvement—and vice versa.
In any event, please don’t interpret my present lack of enthusiasm for wingnut-bashing as a knock on Metavirus’ style. Ridiculing weak opponents is still good fun, and we wouldn’t be here if we didn’t enjoy it
But when he asked for guest bloggers, I jumped at the chance to engage and offer some perspectives I hope are not so easy to ridicule. A little reminder that, hey, not everyone we may disagree with has to be a nut.
For instance, I’m generally against medical egalitarianism. I don’t think adults have a positive right to health-care anymore than I think they have a positive right to food. Life entails work, or relying on the independent charity of others. And as a libertarian I’m theoretically against all initiation of force—including charity by force.
So I found DIA’s post countering the notion of “misplaced medical egalitarianism” to be challenging. How do I draw the line? I definitely support efforts to provide treatment to children in very low-income families, for both moral and equal opportunity reasons. And I’m for emergency services acting as an egalitarian safety net, because few of us can be bothered to make personal arrangements for such catastrophes. This seems an appropriate role for the limited government I support.
But why am I against medical egalitarianism for, say, kidney transplants and cancer surgery? Why not give every patient a lottery number and fund treatment through an equitable tax?
One answer is that “free” health-care is a bad incentive: people are less motivated to live healthily, because someone else will pay for all their problems like obesity and diabetes. (Canada apparently “solves” this with long waiting lines). But this answer is insufficient, because there are also many health problems we have no personal control over, such as genetic predispositions and birth defects.
Another is that, over time, a competitive for-profit health market produces better research, development, and investment in advanced treatments:
Source: Fraser Institute
Another answer might be the problems of regulatory capture and government-by-lobbyists.
My deepest held answer probably boils down to the same reason I oppose most welfare: individualism. People ought to be motivated to succeed for their own sake, and not to bum off the rest of society.
Metavirus recently posted a NYT op-ed arguing that ”any nation as rich as ours ought to guarantee health coverage for all of its residents.”
Well, self-interest is humanity’s most powerful and effective motivator. Let’s deploy it for good rather than ill. I’m pretty sure that’s how we became so freaking rich in the first place.
Maybe we can help the poor out with subsidies, like the Swiss. At the very least, let’s find a way to ensure continuous coverage across periods of temporary unemployment. But guaranteeing the same centralized,
As a contemporary example, Cato argues Cash for Clunkers is among the dumbest ever:
Sane folks should agree these outcomes are outrageously dumb. B-b-but, Obama bragged the program was popular! And truly, it was.
- A few billion dollars worth of wealth was destroyed. About 750,000 cars, many of which could have provided consumer value for many years, were thrown in the trash. Suppose each clunker was worth $3,000 at a guess, that would mean that the government destroyed $2.25 billion of value.
- Low-income families, who tend to buy used cars, were harmed because the clunkers program will push up used car prices.
- Taxpayers were ripped off $3 billion. The government took my money to give to people who will buy new cars that are much nicer than mine!
- The federal bureaucracy has added 1,100 people to handle all the clunker administration. Again, taxpayers are the losers.
- The environment was not helped. See here and here.
- The auto industry received a short-term “sugar high” at the expense of lower future sales when the program is over. The program apparently boosted sales by about 750,000 cars this year, but that probably means that sales over the next few years will be about 750,000 lower. The program probably further damaged the longer-term prospects of auto dealers and automakers by diverting their attention from market fundamentals in the scramble for federal cash.
Offering everyone $100 towards burning an old set of ugly clothes and buying a sleek new replacement might also prove popular, both to consumers and the clothing industry. Huzzah, let’s do it! Regrettably, such popularity does not make it a good idea nor mean that implementing it would make any kind of economic or environmental sense—which it clearly wouldn’t.
This basic problem of economic inefficiency, generalized, is why the majority of other government programs and economic interventions are also really bad ideas. What is politically popular seldom implies economic efficiency. Often, quite the contrary. Political popularity foments fiscal insanity. First you get your Democrats, who want to give every person on Earth a free cake, dog, and pony—plus the choice of a prepaid subscription to either People or The Washington Monthly. This proves popular. Then as a reaction you get your Republicans, who don’t want to pay half a cent toward anything. This also proves popular. Unsurprisingly, voters want to have their cake and not have to pay for it, too. Politicians are happy to pander to both sides. The emerging compromise? Massive deficits—a.k.a. having our children and grandchildren deal with it somewhere down the line.
Yes, Virginia—I don’t mean to scare you with technical phrasing, but politics and government really do suck.
A sufficiently free market, by contrast, implements a method that almost always results in superior efficiency to either political popularity or technocratic fiat. It’s called price signals.
Unfortunately, due to a history of misguided (but politically popular!) government interventions and regulation, the U.S. health-care system does not have price signals. This works out very poorly.
Allow me to paint you an analogy. It would be as if credit cards were issued by “insurance card” companies who agree to provide their customers with “consumption coverage”. You would pay them a pre-arranged monthly “consumption premium”, and in exchange they would “cover”—with just a small co-pay!—any shopping you do with their card, provided it was clear that you “needed” it. Ramen noodles would probably be covered—eat more than you can puke. So would most canned goods. Even many of the cheaper fruits and veggies. But the fine entrée you wanted to serve at your next dinner party? Sorry, your insurance card company doesn’t think you “need” it. Oh, and there would also be limits on things like how much gas you can buy per week or how many drinks you’re allowed at the bar per night. Sound good? Meanwhile, more and better ways would be developed to game and profit off the convoluted system. Retailers would overcharge whatever they could get away with making the “insurance card” companies pay, and consumer demand for more and better purchase coverage would rapidly increase. Thus the monthly cost of these “consumption premiums” would also soar.
The above scenario is basically the status quo of U.S. health-care. Obviously, it sucks. In lieu of price signals, people always want more and better health-care to be provided, just like in the above they always want more “consumption coverage”. When the consumer doesn’t pay for services, markets become dysfunctional. (Also true of some marriages >_>)
So how to reform the system? Apart from those unfortunate Brits—who tragically got the idea during WWII that it would be good for their state to stay in the business of directly providing care—the left’s favored solution tends to be single-payer: a government takeover of health insurance companies, analogous to taking over the odd “insurance card” ones above.
Insurance companies make great villains, but as we saw with Cash for Clunkers and can observe by looking at many other programs—particularly socialized health plans in other countries—they all have their own kinds of problems. These problems are different from the US status quo: better in some ways, worse in others.
For example, one thing other countries’ socialized systems are better at is cost control (.pdf). They use their monopsony power to negotiate lower prices, and they can often be better at saying no to consumers. They say no in more equitable ways, such as long waiting times, and some Canadian towns run regular lotteries to decide which families get a doctor.
Controlling costs would be nice, especially compared to an expensive system like the US status quo. But one thing centralized bureaucratic cost controls also do is reduce the incentive for future private innovation. Why spend your time experimenting with and further developing a new health product if you can’t know whether the health bureau will decide it’s a cheap and effective enough treatment to get it off the ground?
In short, the choice between the U.S. status quo and a single-payer system offers trade-offs. I won’t spill more ink trying to formally pin them all down: it’s a big topic, kind of like going on about the difference between Republicans and Democrats.
At this point someone usually pipes up and wails about the plight of the uninsured poor. But that is not a health-care system problem, it is an income problem. And one of the few ways to directly mitigate an income problem is to provide subsidies to low-income families (some ways are more economically sound than others). Point is, you could implement subsidies and attain universal health insurance coverage in the U.S. without directly changing anything about our health-care delivery system or the insurance companies themselves. It would just be really expensive and balloon either the deficit or tax rates, which is why it shouldn’t be done in isolation.
Happily there’s a reform that would lower costs for everyone while actually increasing innovation: bring back the price signals that are so essential to market efficiency. Here’s how this might be accomplished:
Firstly, repeal any state-level regulation—often called “patients bill of rights”—that require insurance companies to fully cover particular procedures or put an artificial ceiling on deductibles. This would clear the regulatory barriers for health plans that sport low premiums and high deductibles, suitable for catastrophic coverage only. This is how real insurance is supposed to work, like the kind we have for our cars and homes. By contrast, the sort of thing we call “health insurance” today is actually “pre-paid health care”. Just imagine how high your car insurance payments would be if it were required to cover 80% of the cost of oil changes, tire rotation, wiper blades, new tires, regular service, etc.
Secondly, implement something like Health Savings Accounts (HSAs) for all the routine, preventative, non-catastrophic care. Apart from trimming administrative jobs in our bloated health insurance industry, this would free consumers to shop for their own health care (Enter price signals, mission accomplished).
Of course, esteemed Nobel laureates like Paul Krugman shall protest: ”Health care is not a bowl of cherries…or a carton of milk, or a loaf of bread.”
Indeed, shopping for health-care probably sounds like an odd idea to most. But HSAs have been tried right here in America, and the data suggest they work well:
Consumer-driven health (CDH) products [i.e., high-deductible health plans relying on HSAs or Health Reimbursement Arrangements to reimburse for qualified expenses] have been marketed in various forms since the early 2000s. While emerging data is [sic] not entirely conclusive, general directional conclusions can be drawn from the studies published to date. […]Bottom lines: the status quo puts health care rationing in the hands of insurance companies. Single-payer puts rationing in the hands of bureaucrats. A free, CDH market places it in the hands of consumers.
With regard to first-year cost savings, all studies showed a favorable effect on cost in the first year of a CDH plan. CDHplan trends ranged from -4 percent to -15 percent. Coupled with a control population on traditional plans that experienced trends of +8 percent to +9 percent, the total savings generated could be as much as 12 percent to 20 percent in the first year. All studies used some variation of normalization or control groups to account for selection bias.
For savings after the first year, at least two of the studies indicate trend rates lower than traditional PPO plans by approximately 3 percent to 5 percent. If these lower trends can be further validated, it will represent a substantial cost-reduction strategy for employers and employees.
Generally, all of the studies indicated that cost savings did not result from avoidance of appropriate care and that necessary care was received in equal or greater degrees relative to traditional plans. All of the studies reviewed reported a significant increase in preventive services for CDH participants. Three of the studies found that CDH plan participants received recommended care for chronic conditions at the same or higher level than traditional (non-CDH) plan participants. Two studies reported a higher incidence of physicians following evidence-based care protocols.
Which of the three do you prefer?
Contrary to popular belief, those of us on the economic right do not advocate market solutions because we have some arcane faith in mythical powers of the market. We do so because they actually work better—even when they’re politically unpopular.
(At this point someone usually pipes up to rail about how the financial crisis, like, totally discredits the idea of markets being better. Let’s try not to be distracted by this different, macroeconomic topic that has more to do with a combination of poor regulation and lack of understanding the business cycle.)
The mean socially conservative Republican voter is our useful idiot. They don’t understand free market economics any better than the left does, and are liable to show up at your local town halls spouting all sorts of nonsense about government conspiracies to kill more babies. But the socons are willing to vote with us, so we often have to hold our nose and work with them. It’s called fusionism, and it’s been the price to pay for an economic way of doing business that—while superior on the merits—would otherwise be too politically unpopular. See for example the situation in contemporary Europe, which unlike the US has managed to purge socon fervor the old-fashioned way: through a long, tragic history of disastrous war.
I deplore social conservative attacks on personal freedom as much as the next freethinker, and I aim to counter them. But I also deplore the left’s attacks on economic freedom. And I’m aware of the uncomfortable truth: unless I can convince a lot more of my fellow social liberals to cut back on their leftism and support freer markets, a chronic Faustian bargain with socons is necessary to preserve what economic freedoms we have. Without this bargain, the U.S. economy would become more like Europe’s, with the lower efficiency and lowered growth that over the long term is worse for everyone—rich and poor alike. Unless, of course, one is lucky enough to become a politician, bureaucrat, or have a personal connection to the business. Then the European political-economic landscape looks pretty rosy, and one can seek out all sorts of creative ways to gloss over the underlying economic inefficiency.
Check out this exchange at a town hall between Blue Dog Democrat Barron Hill and a member of the audience:
If this isn’t a perfect example of prideful, unapologetic ignorance being held forth as a virtue, I don’t know what is.
“I’m not a Democrat or a Republican,” the man said. “I consider myself a political atheist. But from what I’ve heard about the plan on TV, there’s a lot about it that I disagree with.”
“What part do you not like?” Hill asked.
“Well, just some of the stuff they have been talking about on TV,” the man responded.
“OK, and what was that?” Hill asked.
But the person couldn’t come up with an example of what he disagreed with.
Three cheers for Barney Frank:
Rep. Frank gets a rare two Quotes of the Day out of this:
QUESTION: Why do you continue to support a Nazi policy as Obama has expressly supported this policy? Why are you supporting it? [...]
FRANK: On what planet do you spend most of your time? … You want me to answer the question? Yes. You stand there with a picture of the President defaced to look like Hitler and compare the effort to increase health care to the Nazis. My answer to you is, as I said before, it is a tribute to the First Amendment that this kind of vile, contemptible nonsense is so freely propagated.
“Trying to have a conversation with you would be like arguing with a dining room table.”
Trendy Nouveau Conservateur* David Frum gives us a great run-down of some of the dangerous right-wing scare-mongering going on today:
Here’s Frum’s prescription for what ails us:
The Nazi comparisons from Rush Limbaugh; broadcaster Mark Levin asserting that President Obama is “literally at war with the American people”; former vice presidential candidate Sarah Palin claiming that the president was planning “death panels” to extirpate the aged and disabled; the charges that the president is a fascist, a socialist, a Marxist, an illegitimate Kenyan fraud, that he “harbors a deep resentment of America,” that he feels a “deep-seated hatred of white people,” that his government is preparing concentration camps, that it is operating snitch lines, that it is planning to wipe away American liberties”: All this hysterical and provocative talk invites, incites, and prepares a prefabricated justification for violence…
Here’s Fox News’ Glenn Beck clucking sympathetically that white males are being driven into murderous rage by “political correctness.”
Here again is Beck chuckling as he play-acts the poisoning of Nancy Pelosi.
Just yesterday, the radio host Sean Hannity openly contemplated violence—and primly tut-tutted that if it occurs, the president will have only himself to blame.
It’s not enough for conservatives to repudiate violence, as some are belatedly beginning to do. We have to tone down the militant and accusatory rhetoric. If Barack Obama really were a fascist, really were a Nazi, really did plan death panels to kill the old and infirm, really did contemplate overthrowing the American constitutional republic—if he were those things, somebody should shoot him.If he seems like a lone voice in the wilderness, that’s because he largely is. Wake me up when the sane people take back the Republican Party. A 30-year nap sounds delectable…
But he is not…
The president can be met and bested on the field of reason—but only by people who are themselves reasonable.
* – French for “new conservative”.
They came for new teeth mostly, but also for blood pressure checks, mammograms, immunizations and acupuncture for pain. Neighboring South Los Angeles is a place where health care is scarce, and so when it was offered nearby, word got around.
For the second day in a row, thousands of people lined up on Wednesday — starting after midnight and snaking into the early hours — for free dental, medical and vision services, courtesy of a nonprofit group that more typically provides mobile health care for the rural poor.
Like a giant MASH unit, the floor of the Forum, the arena where Madonna once played four sold-out shows, housed aisle upon aisle of dental chairs, where drilling, cleaning and extracting took place in the open. A few cushions were duct-taped to a folding table in a coat closet, an examining room where Dr. Eugene Taw, a volunteer, saw patients.
When Remote Area Medical, the Tennessee-based organization running the event, decided to try its hand at large urban medical services, its principals thought Los Angeles would be a good place to start. But they were far from prepared for the outpouring of need. Set up for eight days of care, the group was already overwhelmed on the first day after allowing 1,500 people through the door, nearly 500 of whom had still not been served by day’s end and had to return in the wee hours Wednesday morning.
On the other hand, they should all just suck it because some angry, confused seniors are scared of President Darky McBlackerson fiddling with their
government-sponsored socialism Medicare and Megan McArdle is fretting feverishly about a vampire-like public option that would inevitably (she swears!) suck all the blood out of our nubile American Innovation Machine (TM).
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