Health Care Policy, Controlling Costs, And Not Admitting What You Want

paulryan

The AHCA, also know as “repeal and replace,” has suffered an embarrassing defeat, and that makes me happy. It’s looking likely that Obamacare is going to survive. For now.

The Republicans are in an interesting position. Most conservative intellectuals seem to think that the goal should be to keep health-care costs down, and to that end, the government shouldn’t be involved beyond trying to make sure everyone has access to low-cost catastrophic care insurance. In their view, it’s good for ordinary health-care expenses to be paid directly by consumers, because otherwise consumers won’t have any incentive to negotiate or shop around for better values, and health care costs inevitably rise.

Liberals, on the other hand, mostly believe that the way to keep health care costs down is through government price controls. These can be “hard” price controls, like some other countries have, in which the government simply tells medical care providers what they can charge. Or it can be the “soft” price controls of a superbuyer – if a government organization (like Medicaid or Medicare) is bvuying health care for millions of Americans, it can use that position of power to negotiate much better prices than consumers can on their own.

What’s interesting is that both parties have incentives to not admit what they want to the public. Republican complaints about the ACA include high co-pays and deductibles – but actually, in their view, having people pay a lot for non-catastrophic medical care is a good thing.

Similarly, very few elected Democrats will talk about “price controls,” because that sounds scary and communist and such, plus they don’t want to piss of the doctors.

Of course, I’m not saying both parties are equally bad – on health care, the GOP is clearly much, much worse. But it’s still an interesting parallel: Neither party dares admit to their voters what price-control policies they actually want.

Anyway, feel free to use this thread for all ACA and AHCA related discussion.

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53 Responses to Health Care Policy, Controlling Costs, And Not Admitting What You Want

  1. 1
    Mookie says:

    Hmm. I agree emphatically that the goal of most politicians is to keep the quiet parts (including messy, necessary details) quiet — some don’t always succeed, of course — but I don’t quite see reality reflected in that second para. Are conservative intellectuals synonymous with GOP here? Are they the ones who wrote and tried to sell this policy? Was it even spun that way, barring the usual caveats of Ryan being inexplicably described by his own party as wonkish?

    As for AHCA itself, I don’t know that I’d characterize its impetus as “price controls”; most policy exists to solve a problem, and I view (perhaps incorrectly) ACA’s existence as the “problem” at hand, not “price control” and certainly nothing so nebulous and positively bogged-down-in-difficult-details as subsidized healthcare.

  2. 2
    MJJ says:

    What’s interesting is that both parties have incentives to not admit what they want to the public. Republican complaints about the ACA include high co-pays and deductibles – but actually, in their view, having people pay a lot for non-catastrophic medical care is a good thing.

    The desire is that people have access to low-cost catastrophic health insurance. The reality for many is that people have access to high-cost catastrophic health insurance. People resent paying a lot for very little.

    The problem with Ryancare is that it dealt with none of things people didn’t like about Obamacare, but it made certain to cut taxes that very few people care terribly about. Typical Chamber of Commerce wing of the GOP stuff.

    I find it hilarious how many liberals are taking credit for killing this bill with their protests, phone calls, etc. Truth is, the Democrats were never going to back this bill anyway, and GOP opposition to the bill came more from the tea party wing than from people who cared what the liberals thought.

    Like her or hate her, Ann Coulter and her ilk are the ones who killed the bill.

    https://twitter.com/AnnCoulter/status/845410191700979712

  3. 3
    AJD says:

    @MJJ, I mean, sure, but the only thing stopping Ryan from changing the bill to appease the tea party wing and passing it that way was that doing so would lose the votes of the Republicans in swing districts who knew that their constituents wouldn’t let them get away with it. So I think it’s not incorrect to say that AHCA was defeated by those constituents calling their representatives against the bill.

  4. 4
    Charles S says:

    There were about as many declared moderates (the Tuesday Group) and ACA supporters (folks who supported the medicaid expansion or who were concerned about opioid addiction treatment programs) who opposed TrumpCare as there were extremists who opposed it for not being evil enough. So it took both Ann Coulter and Indivisible to prevent it from passing.

  5. 5
    Kate says:

    The desire is that people have access to low-cost catastrophic health insurance. The reality for many is that people have access to high-cost catastrophic health insurance. People resent paying a lot for very little.

    Exactly. The way to bring costs down is to provide coverage which prevents catastrophies.

  6. 6
    Sam Cole says:

    Confession. I troll Breitbart sometimes, although I try to be nice.

    The other day, something encouraging happened. Breitbart had an article about Sean Hannity saying that the failure of the AHCA was not Trump’s fault, blah, blah, blah.

    I posted:

    Pay close attention to what Hannity actually said:

    ‘This is not President Trump’s failure. President Trump went above and beyond and did everything in his power to get this bill across the finish line.’

    In other words, Trump did not fail, because Trump tried his hardest to get this crappy bill to pass. Sounds like failure to me.

    I expected to get one or two death threats or to be told that George Soros was paying me. (Does anyone know where I can send my resume?)

    Instead, it was my most upvoted comment ever, and most people agreed with me. (121 upvotes and counting.)

    I realize they oppose the AHCA for a very different reason than I do. But I really hope that’s an encouraging sign for 2018 and 2020.

  7. 7
    MJJ says:

    Exactly. The way to bring costs down is to provide coverage which prevents catastrophies.

    You can argue that, but that is not what the part you quoted was saying. My point was that people are paying for comprehensive health insurance even though they are getting what amounts to catastrophic health insurance. So it is not the same thing the Republicans say they want, which is catastrophic health insurance that has the cost of catastrophic health insurance.

  8. 8
    MJJ says:

    I realize they oppose the AHCA for a very different reason than I do. But I really hope that’s an encouraging sign for 2018 and 2020.

    Maybe. But people thought that the Obamacare-defund shutdown of 2013 was going to destroy the Republicans in 2014 and 2016, or that not passing the Gang of Eight bill would destroy them.

    Honestly, I think most people are not understanding Trump’s strategy on health care. He rushed to get this passed when there were not enough votes.

    My take: he knew this was not going anywhere this year (or maybe even this term) so he wanted to get it done and over with. Put another way, if the bill was going to fail regardless, he would rather spend a week or two on it rather than spend months on it.

    If we assume, as many do, that Ryan is an opponent of Trump and he is trying to use up all of Trump’s time and political capital on taxes and healthcare so as to prevent Trump from getting anything legislative done on immigration or infrastructure, then Trump played this pretty well.

    Remember, the secret to winning at poker or blackjack or any other gambling game that involves skill isn’t about winning every battle. Despite what you see on TV, counting cards does not magically win you every hand, and a good poker player does not magically get straight flushes on every hand. The goal is partially to win slightly more often, and partially to minimize what you bet when you are losing and to maximize it when you are winning.

    Knowing how to cut your losses when you cannot win is a pretty important skill.

  9. 9
    nobody.really says:

    Singaporians pay for much of their own care out of their own pockets, and their major insurance program is designed to cover long-term illnesses and prolonged hospitalizations, not routine care…. The island state has excellent health outcomes while spending, as of 2014, just 5 percent of G.D.P. on health care. (By comparison … the United States spent 17 percent.)

    However, there has never been a major Republican policy proposal that just imitates what Singapore actually does….

    First …. [u]nder their Medisave program, they spend money saved in mandatory health-savings accounts, to which employers contribute as well. Second, their catastrophic insurance doesn’t come from a bevy of competing health insurance companies, but from a government-run single-payer system, MediShield. And then the government maintains a further safety net, Medifund, for patients who can’t cover their bills, while topping off Medisave accounts for poorer, older Singaporeans, and maintaining other supplemental programs as well.

    So the Singaporean structure does not necessarily minimize state involvement or redistribution. It minimizes direct public spending and third-party payments, while maximizing people’s exposure to what treatments actually cost. And the results are … extremely impressive….”

  10. 10
    nobody.really says:

    I agree w/ Amp, although I might express the dynamics differently.

    To begin, let’s acknowledge that there is no uniform view among Republicans. As with so many insurgencies, the insurgents are united only in their desire to overthrow the current order. Thereafter they fall into their own warring factions. Thus, there was no challenge for Republicans to unite people in opposing Obamacare. (Hell, we could probably organize a crowd of people finding fault with Obamacare composed entirely of people on this web page.) The challenge was in identifying a viable substitute. And because that would be a challenge, Republicans have studiously avoided doing so—until now that they’re in charge and can avoid it no longer.

    The health care marketplace is complicated, but here’s its central feature: The nation spends 50% of its healthcare budget on 5% of patients. This has two consequences. First, it’s impractical to expect anyone in that 5% to save enough to pay for her own medical bills; such a person must have some means to socialize the costs. Second, the political constituency supporting these 5% are not sufficiently large that they can’t be outvoted by the rest. Thus, it’s politically viable to sell these 5% down the river if you can make them invisible or persuade the majority that they are being victimized by socialized health care costs.

    Given this context, what do people want?

    Some (libertarians?) want deregulation: Every man for himself. It is unclear to me that these people actually are hiding anything; they are forthright in their lack of compassion. And they are rare.

    Others cringe at this lack of compassion. Thus, what they want is a least-cost means to appear more compassionate. It matters not how much patients suffer, so long as voters have a fig-leaf of deniability. Quite obviously, voters don’t want to be candid about these objectives—even with themselves.

    Other people hate to see suffering—even by people who contributed to their own circumstances (by, for example, failing to buy health insurance)—and thus want government to ensure that everyone has health insurance. This policy has a variety of practical benefits: It reduces administrative costs, because less money is spent by insurers on risk-avoidance. It decouples insurance from employment, making the labor market more efficient—and simply letting people retire rather than keep working to maintain health coverage. But the policy also has two dynamics that they seek to conceal:

    A. The policy promoters want to live in a country in which everyone has health coverage, even if the people being covered would rather have cash to pay for fixing the car or drugs or a college education or whatever. Thus, the relevant recipients of benefits under this policy are the policy promoters rather than the people getting coverage.

    B. Someone has to make the call about what will be covered, and what won’t. Other policies leave this decision to the market: When you run out of money, you die. But if we tie a benefit to the full faith and credit of the US Treasury, then we need some other mechanism to make the call. Thus, we get “death panels”—with all the justified fears of “elitism” this entails.

    Note that insurance companies already have death panels. They decide which types of treatment are deemed “usual and customary.” If you need treatment beyond that, you’re out of luck. Voters may find this harsh when it comes from a private firm, but voters don’t control private firms; when it comes from your own government, voters may be intolerable.

    Clearly other nations with socialized medicine have addressed this problem. I just don’t know how it has been resolved.

  11. 11
    gin-and-whiskey says:

    The problem with the whole thing is that “insurance” is something different that we’re actually discussing.

    The first goal of insurance is to insure against *unexpected* events. Expected events (physicals, dental cleanings, planned pregnancy, etc) are not really “insurance” issues at all, insofar as they have roughly a 100% chance of occurring.

    The other goal of normal insurance is that it is reasonably personalized, so your costs relate well to your expected risk and coverages. Since people vary widely w/r/t their risk profile, this can produce huuuuuge differences in costs. A healthy athletic 35 year old woman with her tubes tied is going to pay MUCH less than a 65 year old man who has had a prior heart attack.

    Right now, we mingle expected and unexpected events. This isn’t a great thing, usually. If you were going to form a group to increase your purchasing power for planned expenses, and maximize efficiency, you wouldn’t choose a modern insurance company. Also, right now we use insurance rates as a redistributive tax, which prevents everyone from knowing what they are really getting. I don’t pay flood insurance or coastal storm insurance or commercial-use insurance. Neither am I obliged to pay extra on my insurance policy to help subsidize the folks who build businesses in coastal flood zones. To the degree that those subsidies exist, they should be taxable, voted on, and set out as a separate line item.

    Same with insurance. If you want to tax folks so that you can provide cheap health care for seniors, tax them. You can provide any benefits you want. At least it will be progressive. But be up front about the amount and type of subsidies. It’s insensible to pretend that Rhonda the Runner should pay a high rate for her insurance so that Sam the Smoker doesn’t have to pay too much for his. Hiding the subsidies in “universal coverage” laws prevents us from intelligently discussing them.

  12. 12
    Ampersand says:

    Two more points about Singapore: one, the government artificially keeps prices low. We could spend much less on health care if we used price controls, too. (And we should!)

    HSAs have nothing to do with it. Health care costs actually went up in Singapore after HSAs were introduced.

    The second thing is that average age in Singapore is lower – in other words, they have fewer old people. That definitely makes health care much cheaper, but it’s not something we can imitate.

  13. 13
    Ampersand says:

    The first goal of insurance is to insure against *unexpected* events. Expected events (physicals, dental cleanings, planned pregnancy, etc) are not really “insurance” issues at all,

    Can you say where this definition comes from? It’s not a universal definition. The first definition that comes up when I google is “a practice or arrangement by which a company or government agency provides a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a premium”; nothing there required it to be unexpected. In fact, one commonplace form of insurance – life insurance – pays out in the case of death, which is certainly an example of something with “roughly a 100% chance of occurring.”

    Similarly, a lot of your comment seems to treat things that are your personal preference or definition as if they are universal truths.

    Nearly all insurance is redistibutive. We take money from the insured people who didn’t get sick this year, or crash their car, or had a fire, and we use the money to pay for the expenses of insured people who did have these things happen to them. Insurance without a redistributive aspect is just a HSA, isn’t it?

  14. 14
    Jake Squid says:

    In fact, one commonplace form of insurance – life insurance – pays out in the case of death, which is certainly an example of something with “roughly a 100% chance of occurring.”

    I don’t think this is a good example. Try getting life insurance at age 92. You’re going to have a tough time finding a company willing to issue you a policy. Also, life insurance premiums (for term or annual renewable term, universal isn’t life insurance in the same sense) rise significantly as you age. Right up to the point where the odds of you dying this year are too high for any insurance company to risk issuing you a policy at any price.

  15. 15
    Ortvin Sarapuu says:

    “And the results are … extremely impressive….”

    The Singaporean system is certainly better than what the USA has right now (even under Obamacare) and probably represents the apex of what’s possible under a broadly conservative philosophy of healthcare.

    But calling it “extremely impressive” is an overstatement and probably speaks of an Americocentric perspective. When compared to comprehensive systems on the European model, Singapore falls well short, and many poor Singaporeans complain about their inability to fund routine treatment and elective surgery.

    From a personal perspective, I have permanent residence in both Singapore and a European country (citizen of neither) and have full healthcare rights in either. I earn a middle class salary in Singapore, and I’m chosing to have my tonsilectomy in Europe, because it is basically free and I’ll get the same standard of care.

    So, in conclusion – Singapore = better than the USA, possibly even good, but not “impressive”, let alone “extremely impressive”.

  16. 16
    nobody.really says:

    The problem with the whole thing is that “insurance” is something different that we’re actually discussing.

    The first goal of insurance is to insure against *unexpected* events. Expected events (physicals, dental cleanings, planned pregnancy, etc) are not really “insurance” issues at all, insofar as they have roughly a 100% chance of occurring.

    I have no specific problem with this statement. If we want to call Obamacare something other than insurance, I’m not hung up on language. Knock yourself out.

    That said, I do find fault with this reasoning. I agree that I want insurance to cover large, unexpected costs. But I have no objection to insurers acting in their own self-interest—even when this involves going beyond covering large, unexpected costs.

    Imagine an insurer agreeing to insure everyone employed by XYZ Corp. The insurer learns that smokers rack up larger health bills. So the insurer starts offering smoking cessation classes. The classes have the effect of getting people to quit smoking, thereby lowering the insurers net costs. “NO!” thunders gin-and-whiskey. “Smoking cessation classes are not coverage for large, unexpected costs, ego an insurer has NO BUSINESS engaging in such practices!”

    Similarly, the insurer notes that some people get pregnant unintentionally, and this leads to higher costs in abortions, or in miscarriage, or in a healthy pregnancy and delivery, or (worst case scenario) in an unhealthy pregnancy, or botched delivery, racking up enormous costs. So the insurer subsidizes birth control, which has the effect of reducing unwanted pregnancies “NO!” thunders gin-and-whiskey. “Birth control is not coverage for large, unexpected costs, ego an insurer has NO BUSINESS engaging in such practices!”

    Etc.

    True, smoking cessation classes, birth control, routine physicals, dental cleaning, etc., are not large, unexpected costs. But they might be cost-effective substitutes–that is, practices that help an insurer avoid large, unexpected costs.

    The other goal of normal insurance is that it is reasonably personalized, so your costs relate well to your expected risk and coverages. Since people vary widely w/r/t their risk profile, this can produce huuuuuge differences in costs. A healthy athletic 35 year old woman with her tubes tied is going to pay MUCH less than a 65 year old man who has had a prior heart attack.

    Right now, we mingle expected and unexpected events. This isn’t a great thing, usually. If you were going to form a group to increase your purchasing power for planned expenses, and maximize efficiency, you wouldn’t choose a modern insurance company. Also, right now we use insurance rates as a redistributive tax, which prevents everyone from knowing what they are really getting. I don’t pay flood insurance or coastal storm insurance or commercial-use insurance. Neither am I obliged to pay extra on my insurance policy to help subsidize the folks who build businesses in coastal flood zones. To the degree that those subsidies exist, they should be taxable, voted on, and set out as a separate line item.

    Same with insurance. If you want to tax folks so that you can provide cheap health care for seniors, tax them. You can provide any benefits you want. At least it will be progressive. But be up front about the amount and type of subsidies. It’s insensible to pretend that Rhonda the Runner should pay a high rate for her insurance so that Sam the Smoker doesn’t have to pay too much for his. Hiding the subsidies in “universal coverage” laws prevents us from intelligently discussing them.

    Here we get into more substantive disagreements.

    1. Yes, private insurers seek to tailor policies to customers to a certain extent. This is in order to poach healthy customers from rival insurers, while discouraging risky customers from buying insurance, thereby encouraging them to go to some other insurer. Indeed, insurance companies incur substantial expense engaging in this kind of screening with the goal of selling insurance to people they think will need it the least, while withholding it from people they think will need it the most. This is explicitly a bugger-thy-neighbor strategy. If they were to achieve their goals perfectly—say, if insurers had crystal balls–insurers would render themselves perfectly useless!

    In the meantime, what becomes of all the people who could not afford insurance because of their risk profiles? Do they magically become costless? Yes—for the private insurers. But not for society.

    And this is precisely why a public insurer should not emulate private insurers. And this is a blessing for public insurers: Precisely because they are NOT seeking to avoid giving coverage to people who need it, they can operate without the costly but socially useless screening exercises.

    2. To wax philosophical for a moment, I lean towards a Rawlsian theory of justice. Imagine we were to design a world into which we would be born, not knowing what station of life we would occupy. Some would be born rich and healthy, some poor and sick. What insurance policies would we design under those circumstances? THAT is the bargain we struck—and now that we’re born on earth, it is our duty to implement THAT bargain.

    Libertarians (and, in truth, most non-Rawlsians) argue that we should renege on this pre-birth bargain, and instead re-write the rules now that some have been born with the risks we would have insured against. It’s as if they anted up at the poker table, got dealt three aces, and now retroactively want to change the rules of the game to increase the ante.

    As you can see, public insurance fits more closely with a Rawlsian worldview, whereas private insurance fits with a libertarian one.

    3. That said, for some purposes we want to distinguish between controllable and uncontrollable risks. If someone can control her behavior to avoid the risk of certain costs, then we might conclude that it’s inefficient to shield that person from those costs. But if they can’t, then it’s just cruel to withhold coverage. The challenge arises in sorting conditions into these two categories, and devising appropriate policies.

    Yeah, that alcoholic brought his afflictions upon himself. But is that alcoholic a Native American, and do certain Native Americans have genetic predispositions to alcoholism? Well, ok, he’s got SOME Native American ancestry. Is that sufficient? And even if he had none, so long as we acknowledge that SOME people can have a genetic predisposition, isn’t that the relevant variable to analyze, rather than ancestry?

    Ok, now here’s a study showing that alcoholism is learned in the home, or correlates with social class. So even if we can’t find a genetic predisposition, can we blame people for their home environments or social class?

    Etc. Where can we draw the line between individual responsibility and social influence? Indeed, determinists argue that we’re entirely a function of our environments—and to try to draw a distinction between the behavior of the individual and the environment is like drawing a distinction between the behavior of a pebble and the rest of the rocks involved in an avalanche.

    And so, even if there is some theoretical justification for withholding coverage for discretionary costs, the effort may not be worth the return. If we’re going to patch up the elbow of the teenager who broke his arm while skateboarding, can we then justify discriminating against the smoker?

    Maybe the better path is to extend coverage—but also fund smoking cessation classes.

  17. 17
    MJJ says:

    #13:

    The issue, Ampersand, is this. If you are going to have 2 checkups a year and you know this, why would you have your insurance pay for it and then have to pay higher premiums rather than just pay the doctor yourself and save on the premium? What is the benefit of paying through a third party who skims a little off the top rather than just paying directly?

    The point of insurance generally is to spread risk around. I buy fire insurance (e.g.) because there is a 1 in 1000 chance that I will have a $200,000 fire damage my house in a year, and it is safer to pay $250 a year and likely never need it than to take the chance I lose big.

    The only reasons not to pay the doctor directly are (1) you belong to a group that negotiates better rates, (2) you want to spread out your payments by in effect prepaying for care, or (3) the real goal is to get someone else to pay for your care, not to insure against risks.

    Nearly all insurance is redistributive. We take money from the insured people who didn’t get sick this year, or crash their car, or had a fire, and we use the money to pay for the expenses of insured people who did have these things happen to them.

    The point is that true insurance is redistributive in an unpredictable and therefore consensual way. That is, people buy insurance because they do not know whether they will be net payers or net payees. When it is redistributive in a predictable way, you have to coerce the people who know they are getting a raw deal to buy.

    Put another way, if everyone in a flood plain buys flood insurance at rates that reflect their level of risk, that is in a sense redistributive in that only those who suffer flood damage will get money back. But no one knows who that will be, and those who are least likely to get flooded are still willing to buy because it won’t cost them as much. But if you start demanding that people who live on flood-proof hills pay at the same rate as those who live right next to the river, even though there is no chance they will have a flood, that is redistributive in a very different way, and people who live in areas with a marginal risk of flooding have little incentive to buy insurance unless you force them to do so.

  18. 18
    Ruchama says:

    The point of insurance paying for yearly physicals is that it saves money in the long run. The physical is relatively cheap, but it can catch problems that could become really expensive if they’re not treated soon. It’s much cheaper to do a yearly blood test and blood pressure, see that someone’s numbers are high, and put them on some medication, than it is to treat that same person for a heart attack a few years later.

  19. 19
    David Simon says:

    Seconding Ruchama. Insurance companies cover routine and preventative care because encouraging it is in their interest. My insurance even reduces my premiums when I get regular checkups.

  20. 20
    Grace Annam says:

    Ampersand:

    …in other words, they have fewer old people. That definitely makes health care much cheaper, but it’s not something we can imitate.

    Not without passing something like the AHCA and letting nature take its course for awhile, anyway…

    Grace

  21. 21
    Ell says:

    Ruchuma sez:

    “The point of insurance paying for yearly physicals is that it saves money in the long run.”
    _______________________

    It sounds good, but probably not. There are lots of links on this if you google “do annual physical exams reduce death rate” or the like.

    https://www.nytimes.com/2015/01/09/opinion/skip-your-annual-physical.html?_r=0

    http://articles.mercola.com/sites/articles/archive/2015/11/04/annual-physicals.aspx

    https://www.washingtonpost.com/national/health-science/annual-physical-exam-is-probably-unnecessary-if-youre-generally-healthy/2013/02/08/2c1e326a-5f2b-11e2-a389-ee565c81c565_story.html?utm_term=.aa64bdf4f379

  22. 22
    Humble Talent says:

    G&W Said:

    The first goal of insurance is to insure against *unexpected* events. Expected events (physicals, dental cleanings, planned pregnancy, etc) are not really “insurance” issues at all,

    Barry Said:

    Can you say where this definition comes from? It’s not a universal definition. The first definition that comes up when I google is “a practice or arrangement by which a company or government agency provides a guarantee of compensation for specified loss, damage, illness, or death in return for payment of a premium”; nothing there required it to be unexpected. In fact, one commonplace form of insurance – life insurance – pays out in the case of death, which is certainly an example of something with “roughly a 100% chance of occurring.”

    It’s not universal, but you’d be hard pressed to find another situation where you could insure against an occurrence that’s already happened. This isn’t like insuring your eventual (uncertainly timed) death, this is trying to sign up for house insurance after your house has already burned down.

  23. 23
    Humble Talent says:

    The only reasons not to pay the doctor directly are (1) you belong to a group that negotiates better rates, (2) you want to spread out your payments by in effect prepaying for care, or (3) the real goal is to get someone else to pay for your care, not to insure against risks.

    Nearly all insurance is redistributive. We take money from the insured people who didn’t get sick this year, or crash their car, or had a fire, and we use the money to pay for the expenses of insured people who did have these things happen to them.

    This is an amazingly good point, by the way, and one I think Liberals struggle with. This is why early Obamacare has some of the cringiest advertising I’ve ever seen aimed primarily at young people: These systems eat the young. They act as a subsidy to certain groups, particularly the elderly and female, at the expense of other groups, mainly the young and male. Now on the male/female dichotomy, there’s a solid arguement that those costs are reproductive in nature, and society has an interest in ensuring the next generation. But I can’t think of any justification to have one of the least secure demographics in America subsidising one of the most secure. It’s the kind of thing I’d think liberals would be against, generally. And I’d love one of ya’ll to explain why you aren’t.

  24. 24
    Jake Squid says:

    But I can’t think of any justification to have one of the least secure demographics in America subsidising one of the most secure. It’s the kind of thing I’d think liberals would be against, generally. And I’d love one of ya’ll to explain why you aren’t.

    Because, deity of your choice or, perhaps, just blind luck or genetics, one day the young will be old and will like to have healthcare at that time.

    Your argument is the same as the argument against social security. Why should I be paying to support the olds? (Note: Your social security taxes don’t pay for your retirement. They pay for those who are currently retired.)

    It’s the quintessential libertarian argument. “Why should I have to pay for anybody else to live/live well?” Pretty much everybody on the left has a different position.

  25. 25
    Humble Talent says:

    And now to the meat. As a Canadian, I maybe have a different outlook than most Americans on this issue. I see the benefits to both systems: Socialist systems have relatively inexpensive, near universal coverage, and Capitalist systems have premium, quick service. I also see the downfalls of both systems: Social systems have horrendous wait times (about 18 months for a hip replacement, right now, my aunt tells me), Capital systems have people fall through the cracks.

    I don’t know whether or not health care is actually a human right. If it is, it’s only because we live in a time where society can actually deliver on it, if it was so inclined. It couldn’t possibly have been even a couple hundred years ago, and then it gets worse moving back from there. I’m grateful to be alive now. Regardless… I don’t really care how it’s done, I would just prefer it be done right. America seems fundamentally unable to have a conversation about healthcare in terms that makes sense… Your electorate so polarised that when you get is an unortunate mismash of incompatible compromises. If you’re going to have an insurance based system, it makes absolutely no sense to cover pre-existing conditions, see my above house fire example… Doing that means that no one will buy insurance until they need it, and at that point you’ll come to absurdities like $10,000 deducatables. On the other hand, if you’re going to have a social system, it makes no sense to peice it out by state, when the whole point of a social system is to take advantage of economies of scale.

    It’s looking likely that Obamacare is going to survive. For now.

    That “For now.” is quite foreboding. I look at the trends: The piling costs, the closing exchanges… It seems almost unavoidable that the current incarnation of the ACA will collapse, and then what happens?

    I roll my eyes slightly at the glee with which some of my progressive friends are treating this latest Trump defeat. On one hand, it was bad legislation, that deserved to die… But on the other hand: You’re still kinda fucked. Trump says he’s going to back off from this issue: That’s not good for anyone. How I interpret this is that is him saying that he’s going to wait until Obamacare starts to freefall collapse, and then he’s going to repeal and replace with something just as bad as what he just tried. And at that point everyone will be dripping for something, anything, to replace the ACA.

  26. 26
    Humble Talent says:

    Your argument is the same as the argument against social security. Why should I be paying to support the olds? (Note: Your social security taxes don’t pay for your retirement. They pay for those who are currently retired.).

    When did the American Dream become “Pay Taxes and Collect Services”?

    What you said is only true because the government poorly conceived, and then absolutely bungled the plan. It wasn’t meant to be that way, whether it was concieved that way, it certainly wasn’t advertised like that. It was: “Save for your retirement,” Not “Collect money we take from your kids,”. We have (basically) the same program up here in Canada, just as poorly managed, called the Canada Pension Fund. The fact that social security payments went into general revenues and spent as opposed to investments and saved for the program is EXACTLY why you have the problems you do now. The fact of the matter is that everyone who paid into social security was robbed. The money is gone, and that should be criminal.

    It’s the quintessential libertarian argument. “Why should I have to pay for anybody else to live/live well?” Pretty much everybody on the left has a different position

  27. 27
    gin-and-whiskey says:

    Ampersand says:
    Can you say where this definition comes from? It’s not a universal definition.

    It is in fact how insurance works, absent tricky controls.

    You can buy life insurance, sure–but that matches my explanation. The first type (which I have) is “term” life and is designed to insure against early/accidental death. Usually it’s cheap and term-limited (to your “safe” years, relatively speaking). The risk of death is low and therefore the payout/premium ratio is high if you, say, buy in your 20s when you have kids. But you can’t easily buy term life which starts when you’re 50 and it’s probably impossible when you’re 70–or if you do, the premiums are super high and the payout/premium goes way, way, down.

    The second type (“whole life”) is a really complex thing that combines insurance and investment, largely as a tax/investment/estate planning tool (insurance is handled differently than other estate stuff.) Few people understand how it works. But if you were to look at how the premiums are set, the yearly premiums do in fact take account of the predicted risk of death at the time of death. If all goes according to plan, and you live to your full life expectancy, the payout/premium ratio can be LESS than one (accounting for interest), because the insurer makes a profit. In many respects, you’re basically signing on to a low-interest security backed by the insurer.

    Nearly all insurance is redistributive. We take money from the insured people who didn’t get sick this year, or crash their car, or had a fire, and we use the money to pay for the expenses of insured people who did have these things happen to them.

    Well, no. That isn’t redistribution. Pooling reflects the reality that a large enough insurer will have a reasonably constant set of random payments. I hope to lose all my payments on my term life policy into the ether, but so long as they accurately reflect my risk they are not redistributive. Redistribution as I was using it reflects a law or policy which is specifically designed to undercharge “high risk” people, and overcharge “low risk” people.

    Insurance without a redistributive aspect is just a HSA, isn’t it?

    No, redistribution and pooling are not requirements of insurance, in any way. (They probably are due to insurance laws, but that’s a different issue.)

    To use an example, if any company wants to sell insurance, from an “is this insurance?” question it is completely irrelevant whether or not they insure anyone else. So long as they can pay you if you have a claim, there is no difference whether they get the money to pay you from “other insureds” or from their own savings. You can bet a Vegas bookie at 1:10 odds that you won’t live until you’re 60, and that is the same thing as life insurance. All of the pooling just increases their apparent stability (so you’ll buy a policy from them) and allows them to do more complex things and make more money.

    This is probably one of the biggest misunderstandings people have about insurance.

    nobody.really says:
    March 27, 2017 at 12:27 pm
    I agree that I want insurance to cover large, unexpected costs. But I have no objection to insurers acting in their own self-interest—even when this involves going beyond covering large, unexpected costs.

    Sure. If they want to do it, there’s no reason to stop them.

    Yes, private insurers seek to tailor policies to customers to a certain extent. This is in order to poach healthy customers from rival insurers, while discouraging risky customers from buying insurance

    Not really. Insurers are happy to insure risky folks: it’s their business. They just want to charge them a ton of money to reflect that risk.

    Indeed, insurance companies incur substantial expense engaging in this kind of screening with the goal of selling insurance to people they think will need it the least, while withholding it from people they think will need it the most.

    They don’t want to “withhold” it. In the commercial world, you can insure just about anything–this is what firms DO. Firms issue high risk policies all the time. They are withholding it because of the regulations which prevent them from charging enough money to account for the risk (or from writing the policies like they want.)
    All the people who want “flat premiums, no pre-existing conditions” are just arguing for vast subsidies for sick people. Insurers obviously want to avoid losing money on those people, so they unsurprisingly try not to sell to them.

    In the meantime, what becomes of all the people who could not afford insurance because of their risk profiles? Do they magically become costless? Yes—for the private insurers. But not for society.

    Correct. But at least we can have an open discussion about what we should or should not pay for, and what it costs, and who gets it. Society can decide how deep and how wide the safety net goes. We don’t have that discussion now because the data is hidden in insurance costs.

    I’m not on the “health care is a human right” bandwagon but I think that our society should provide some minimum level of health care. Right now we can hardly discuss what it is.

    Jake Squid says:
    March 28, 2017 at 7:19 am

    But I can’t think of any justification to have one of the least secure demographics in America subsidizing one of the most secure. It’s the kind of thing I’d think liberals would be against, generally. And I’d love one of ya’ll to explain why you aren’t.

    Because, deity of your choice or, perhaps, just blind luck or genetics, one day the young will be old and will like to have healthcare at that time.

    But this argument is insufficient.

    First of all, it avoids alternatives. For example, you could pay for old people’s health care needs by taxing rich people more (which is actually redistributive) or by trying to capture more of their rich-person funds, instead of taxing young people. I can’t even TELL you how many rich people I know who are determined to game medicare/medicaid/insurance in order to leave as much of their money as possible to their kids… we do not need to allow them to take money out of the system like that.

    You could also pay for the young people’s “future health care needs” by allow them to save and invest the money that they’re currently being overcharged.

    Second of all, it rests on the assumption that overpaying now will guarantee them benefits later, so it’s partly logical. But that is not at all true.

    Your argument is the same as the argument against social security. Why should I be paying to support the olds? (Note: Your social security taxes don’t pay for your retirement. They pay for those who are currently retired.)

    Well, SS is no longer an investment and it is not need-based, and basically any economist will acknowledge that this is a stopgap political fiasco and not a rational “invest now to be part of the solution” kind of thing.

  28. 28
    Ruchama says:

    Capitalist systems have premium, quick service.

    I have no idea where this idea comes from. I recently had to wait six months for an appointment with a rheumatologist. (And this was after being rejected by several other rheumatologists, who either weren’t taking new patients at all, were only taking new pediatric patients, or weren’t taking new patients with my disorder.) I had a similar wait time for an endocrinologist. I think it was three months for an ENT, but my primary care doctor called them and they were able to fit me in earlier, because my ear drums were getting close to popping. I’ve got friends who just moved to the US from Canada, and they were shocked at how long the wait time was for some appointments they needed.

  29. 29
    Jake Squid says:

    I recently had to wait six months for an appointment with a rheumatologist.

    Precisely. It’s not like I can have a hip replacement 2 weeks after going in for a consult.

    Humble Talent:

    What you said is only true because the government poorly conceived, and then absolutely bungled the plan. It wasn’t meant to be that way, whether it was concieved that way, it certainly wasn’t advertised like that.

    It was conceived to operate that way. If it hadn’t been, it would have been decades before anybody received any benefits. See, for example, https://www.ssa.gov/history/briefhistory3.html . You can also look at this pdf from the SSA. It’s very clear. I have never seen anything to suggest that Social Security was designed so that you are paying your own retirement benefits. That’s what a 401(k) is.

    The fact of the matter is that everyone who paid into social security was robbed. The money is gone, and that should be criminal.

    The money is not gone. Look right here. The asset reserves in the Social Security Trust Fund were a mere 2,847,687 million dollars at the end of 2016.

  30. 30
    nobody.really says:

    What you said is only true because the government poorly conceived, and then absolutely bungled the plan. It wasn’t meant to be that way, whether it was conceived that way, it certainly wasn’t advertised like that. It was: “Save for your retirement,” Not “Collect money we take from your kids,”…. The fact that social security payments went into general revenues and spent as opposed to investments and saved for the program is EXACTLY why you have the problems you do now. The fact of the matter is that everyone who paid into social security was robbed. The money is gone, and that should be criminal.

    It’s the quintessential libertarian argument. “Why should I have to pay for anybody else to live/live well?”

    Which illustrates the weaknesses of the quintessential libertarian argument. Plenty of people have paid for *us* to live well—many with their lives. The libertarian argument rests on a heavy foundation of amnesia.

    But let’s imagine that we did just as proposed: Social Security dollars were not “spent” (for government services) but rather were “invested” (in, say, stocks). What would have happened?

    First, demand for stocks would have skyrocketed. This would had driven up prices, and driven down price/earnings ratios.

    Second, the US government would end up owning a much larger share of the “free” market. The government would have been “picking winners and losers,” and voting huge amounts of proxies. Far from a libertarian utopia, this would have created a vast expansion of socialism.

    Third, given the huge increase in demand for stocks, it seems likely that ever more firms would be organized to sell stock. And as we observed in other financial booms where investors are hunting for new investments, we could expect a surge in securities fraud. (Anyone recall Credit Default Swaps?)

    Fourth, to offset the loss of funds that previously financed government, the US government would have had to raise massive funds via some other mechanism. Perhaps it would have vastly increased income taxes—with all the attendant consequences for market transactions. Or perhaps it would have issued vastly more bonds, driving interest rates skyward. Or perhaps it would have simply printed money, supercharging inflation. Or some combination of these strategies.

    On balance, the stimulative effect of government stock purchases would tend to offset the depressive effects of taxing or borrowing, but there would have been substantial dislocations. However, if we relied on simply printing money while also engaging in a buying spree, this would have only amplified the consequences for inflation.

    The net result would have been that government would suddenly become the primary buying in the stock market, just as all kinds of other policies would be implemented to reduce the incentive for private parties to invest in the stock market.

    Me? I kinda prefer the system we’ve got. It has its problems—but at least it doesn’t have THESE problems.

  31. 31
    Humble Talent says:

    I recently had to wait six months for an appointment with a rheumatologist.

    Precisely. It’s not like I can have a hip replacement 2 weeks after going in for a consult.

    We’re kind of talking past eachother… You’re working under the assumption that your system IS a capitalist system. It isn’t. Your system is a giant pile of cobbled together dysfunction.

    Even so, it’s closer to a capitalist system than I have here in Canada, and don’t get me wrong, I wouldn’t trade, but we have a whole lot of snowbirds up here that go down south for the winter and a hip replacement. Your anecdote aside, if this weren’t true, no one would do it.

  32. 32
    Jake Squid says:

    … but we have a whole lot of snowbirds up here that go down south for the winter and a hip replacement. Your anecdote aside, if this weren’t true, no one would do it.

    What was the process for getting the hip replacement? Did they see their surgeon during winter #1 and have the operation during winter #2? Did they see their surgeon in September of Winter #1 and have their operation in March of Winter #1? Did they see their Surgeon on December 1st of Winter #1 and have the operation on December 15th of winter #1?

    I hope you can see how your anecdote fails to address what we’re talking about wrt wait times since it doesn’t tell us anything about the wait times for these snowbirds.

  33. 33
    Elusis says:

    Libertarians (and, in truth, most non-Rawlsians) argue that we should renege on this pre-birth bargain, and instead re-write the rules now that some have been born with the risks we would have insured against. It’s as if they anted up at the poker table, got dealt three aces, and now retroactively want to change the rules of the game to increase the ante.

    This is extremely well-put, nobody.really. My partner is having a debate with his mother about ACA/ACHA and I just suggested this analogy to him (along with your description of a Rawlsian thought experiment).

  34. 34
    Humble Talent says:

    The money is not gone. Look right here. The asset reserves in the Social Security Trust Fund were a mere 2,847,687 million dollars at the end of 2016.

    What do you think that proves? The annual SS expenditures are just under a trillion dollars, the fund is basically hand to mouth.

    I have never seen anything to suggest that Social Security was designed so that you are paying your own retirement benefits.

    https://www.ssa.gov/pubs/EN-05-10070.pdf

    “Many people wonder how we figure their Social Security
    retirement benefit. We base Social Security benefits on your
    lifetime earnings. We adjust or “index” your actual earnings
    to account for changes in average wages since the year the
    earnings were received. Then Social Security calculates your
    average indexed monthly earnings during the 35 years in which
    you earned the most. We apply a formula to these earnings and
    arrive at your basic benefit, or “primary insurance amount.” This
    is how much you would receive at your full retirement age”

    For a second I thought I had horribly misunderstood the social security system, but no… This is very close to the CPP. I find it… unconvincing… to suggest that a system where you pay money into a fund over the course of your life, and then take money out at the time you retire at a rate that increases as you pay more into it is anything but a pension plan. You can find things in the plan that differ from a tranditional pension plan, sure. I’d like to know what you think it is if not a pension plan?

  35. 35
    Humble Talent says:

    What was the process for getting the hip replacement? Did they see their surgeon during winter #1 and have the operation during winter #2? Did they see their surgeon in September of Winter #1 and have their operation in March of Winter #1? Did they see their Surgeon on December 1st of Winter #1 and have the operation on December 15th of winter #1?

    I hope you can see how your anecdote fails to address what we’re talking about wrt wait times since it doesn’t tell us anything about the wait times for these snowbirds.

    You’re being deliberately obtuse, and it’s ugly. If the American system were not markedly faster, no Canadian would ever get a hip replacement in America, because as Canadians we don’t have insurance. The American system is so much faster that there are people willing to pay the entire amount of the proceedure rather than wait and get one for free. I’m not saying you don’t have wait times, I’m saying they don’t compare.

  36. 36
    Jake Squid says:

    For a second I thought I had horribly misunderstood the social security system…

    You do horribly misunderstand it. How benefits are CALCULATED is not the same as how benefits are FUNDED.

  37. 37
    Jake Squid says:

    You’re being deliberately obtuse, and it’s ugly.

    I’ve refrained from being personally insulting to you even through your endless evidence free assertions. I’m done with you.

  38. 38
    gin-and-whiskey says:

    nobody.really said:
    Libertarians (and, in truth, most non-Rawlsians) argue that we should renege on this pre-birth bargain, and instead re-write the rules now that some have been born with the risks we would have insured against. It’s as if they anted up at the poker table, got dealt three aces, and now retroactively want to change the rules of the game to increase the ante.

    That’s a ridiculous accusation.

    First, libertarians don’t and didn’t “renege” or “rewrite,” because they don’t accept the premise in the first place. Neither do they “retroactively” do a damn thing. They merely disagree.

    Moreover, to the degree that libertarian folks are willing to start from a Rawlsian premise for argument’s sake–a position which I would frankly hesitate to adopt if you’re going to continue with that sort of accusation–they tend to reach a different set of conclusions. For example, people often disagree on the acceptable variance in outcomes, or the acceptable minimum, when those are traded off for higher averages. Joe’s idea of a Rawlsian model may be “don’t die early;” Mary’s may be “have a +1% chance of dying early in exchange for a +10% chance of an 10% better life.” Rawls has an interesting approach w/r/t the “imagine you’re a random person” thing but he doesn’t have a moral lock on the preferred results by any means, nor on the economic analysis to support his arguments.

    As you can see, public insurance fits more closely with a Rawlsian worldview, whereas private insurance fits with a libertarian one

    Not at all. If the government was capable of providing limited basic healthcare efficiently then libertarians would probably be OK with it, just as they support other limited basic aspects of government. In theory that’s the sort of thing the government could do. In practice, not so much.

    Moreover, the crucial words for libertarians would be “limited basic” and it seems that for many liberals the idea of health care limits is something which apparently exists only in the abstract. But that won’t work. Republicans are mildly better at it, since they already have the presumption in place that the government is not a rich parent.

  39. 39
    Humble Talent says:

    I’ve refrained from being personally insulting to you even through your endless evidence free assertions. I’m done with you.

    Look Jake, your evidense in this case consisted of denying what I said was true and relying on someone’s anecdote that they waited 6 months for a rheumatologist. Now I’ll admit I didn’t provide links, but quite frankly, neither did you, and Medical Tourism is a well known, common practise.

    http://www.cbc.ca/news/politics/canadian-health-tourists-drop-1.3800729

    http://news.nationalpost.com/news/canada/number-of-canadian-patients-travelling-abroad-for-treatment-increased-by-25-study-finds

    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2231416/

    50,000 Canadians (plus or minus) every year CHOOSE to pay for their proceedures as opposed to getting them for free because the wait times are so horrendous. That doesn’t count people who have accidents while abroad, and while I can’t find the exact number that goes to America specifically, I would be genuinely surprised if the number was less than half.

  40. 40
    Ampersand says:

    A few points on health care:

    1) There is evidence that wait times in Canada are longer than in the US – as long as you don’t include people who are waiting for health care because they can’t afford it. If those waiters were included, I suspect that average wait times in the US would be far longer.

    2) The Fraser Institute is Canada’s version of the Heritage Foundation – a right-wing, libertarian think tank. That doesn’t mean that their study is wrong or unreliable, but it is one thing among many to keep in mind when reading Humble Talent’s links.

    3) According to the Fraser Institute’s report (pdf – executive summary), what part of Canada you look at makes a big difference – the wait times in Quebec and Ontario are very short, but Canada’s average wait time is brought way up by the long waits in places like Newfoundland. It also depends on what procedure you’re looking at. So there’s no simplistic “the US is always faster than Canada, therefore free market health care is better” interpretation that fits with the data.

    4) Also, Canada actually has the longest wait times of any wealthy country in the world. And the US is fast, but Switzerland and the Netherlands are as fast. So, again, it’s hard to conclude that the US’s relatively market-run health care system is the only way to keep wait times down.

    And, again, if we included people who were waiting because they could not afford health care, the US would be doing much, much worse in these comparisons. Also, delays due to insurance complexity are more common in the US, and aren’t included in the usual statistics. This Commonwealth Fund report has more information.

    “In 2013, more than one-third (37%) of U.S. adults went without recommended care, did not see a doctor when they were sick, or failed to fill prescriptions because of costs, compared with as few as 4 percent to 6 percent in the United Kingdom and Sweden.”

    I think that’s a more serious problem than Canadians having long wait times, honestly. (Even though wait times are, I repeat, a real problem.)

    5) How many operations take place a year in Canada? What percentage of that is 25,000-50,000? How many of those are operations on people who had some other reason to be in the US (“snowbirds,” for example?).

    6) From research published in Health Affairs:

    Over the five-year observation period from 1994 to 1998, 2,031 patients identified as Canadians were admitted to hospitals in Michigan; 1,689 to hospitals in New York State; and 825 to hospitals in Washington State. During the same period, annual inpatient admissions to hospitals within the bordering provinces of Ontario, Quebec, and British Columbia averaged about 1 million, 600,000, and 350,000, respectively.12 Thus, Canadian hospitalizations in the three U.S. states represented 2.3 per 1,000 total admissions in the three Canadian provinces. Furthermore, emergency/urgent admissions and admissions related to pregnancy and birth constituted about 80 percent of the stateside admissions. Elective admissions were a small proportion of total cases in all three states: 14 percent in Michigan; 20 percent in New York; and 17 percent in Washington.

    7) 1.4 Million Americans Will Go Abroad for Medical Care This Year. | The Fiscal Times One reason Americans go abroad, according to this article? For reduced wait times. :-p

  41. 41
    Ampersand says:

    If the government was capable of providing limited basic healthcare efficiently then libertarians would probably be OK with it, just as they support other limited basic aspects of government. In theory that’s the sort of thing the government could do. In practice, not so much.

    By almost any measure, every wealthy country in the world does a better job at providing health care, while spending less money per capita on health care, than the US. So this seems like a bewildering statement.

  42. 42
    gin-and-whiskey says:

    BTW, when discussing Canada, remember that it has a very small population of ~1/10 the U.S.. As a result, 50,000 people leaving Canada for medical tourism (1 out of every 740 Canadian citizens!) is roughly equivalent to half a million Americans, which seems like a non-insignificant number, at least to me.

    Ampersand says:
    March 28, 2017 at 4:35 pm

    If the government was capable of providing limited basic healthcare efficiently then libertarians would probably be OK with it, just as they support other limited basic aspects of government. In theory that’s the sort of thing the government could do. In practice, not so much.

    By almost any measure, every wealthy country in the world does a better job at providing health care, while spending less money per capita on health care, than the US. So this seems like a bewildering statement.

    I apologize for being unclear; when I say “the government” I am talking about *OUR* U.S. government, which–as you note–does not seem to have much ability to do it right, at least in this arena. It’s almost certainly the case that *A* government can be set up in which “providing low cost health care” is achievable, depending on how you define it…though it will of course involve other tradeoffs and may not be better overall.

    Also, without getting into enormous details on the numbers, I can’t resist pointing out:

    The Commonwealth Fund is a left-wing health-care version of the Heritage Foundation – and focuses particularly on “society’s most vulnerable, including low-income people, the uninsured, minority Americans, young children, and elderly adults.” That doesn’t mean that their data is wrong or unreliable, but it is one thing among many to keep in mind when reading Amp’s link.

  43. 43
    nobody.really says:

    Libertarians (and, in truth, most non-Rawlsians) argue that we should renege on this pre-birth bargain, and instead re-write the rules now that some have been born with the risks we would have insured against. It’s as if they anted up at the poker table, got dealt three aces, and now retroactively want to change the rules of the game to increase the ante.

    That’s a ridiculous accusation.

    First, libertarians don’t and didn’t “renege” or “rewrite,” because they don’t accept the premise in the first place. Neither do they “retroactively” do a damn thing. They merely disagree.

    That’s a fair statement. Yet I endure objections from libertarians that government is “imposing” policies on them—which is every bit at ridiculous. That is, everything can seem like an “imposition” depending upon what baseline you presume. I find no greater support for the libertarian’s preferred baseline than they find for mine. Ayn Rand styled herself a bold freedom fighter; I style her a welcher. PotAto, Potato.

    Moreover, to the degree that libertarian folks are willing to start from a Rawlsian premise for argument’s sake–a position which I would frankly hesitate to adopt if you’re going to continue with that sort of accusation–they tend to reach a different set of conclusions. For example, people often disagree on the acceptable variance in outcomes, or the acceptable minimum, when those are traded off for higher averages. Joe’s idea of a Rawlsian model may be “don’t die early;” Mary’s may be “have a +1% chance of dying early in exchange for a +10% chance of a 10% better life.” Rawls has an interesting approach w/r/t the “imagine you’re a random person” thing but he doesn’t have a moral lock on the preferred results by any means, nor on the economic analysis to support his arguments.

    This is also a fair critique. Rawls concludes that people, confronted with risk, would tend to adopt a maxamin strategy—that is, maximize the welfare of the people who end up in the worst circumstances, even at the sacrifice of some high-end outcomes. But we can certainly find evidence that people engage in all kinds of behaviors in which they appear to adopt different strategies. For example, people who buy lottery tickets would appear to embrace a profoundly anti-egalitarian, reverse-Robin-Hood ethic of preferring to transfer wealth from the relatively poor to the relatively rich.

    Newer research in behavioral economics—such as relayed in the bestselling Thinking, Fast and Slow by Nobel Laureate Daniel Kahneman—provides explanations for many of these anomalies. Much to the surprise of economists, but no one else, human beings prove to be much more generous, and much less consistent and strategic, than the Rational Actor model would suggest. In short, people generally do favor a maximin strategy when stakes are high and they are not distracted by other circumstances. But that doesn’t mean that every individual person would make that same choice.

    By the same token, libertarian/Enlightenment-minded folk often cite Social Contract Theory as a justification for government. Under this theory, people are presumed to live free in a “state of nature,” but willingly surrender some of their freedom in order to join a collective and thereby gain a modicum of security. Nice theory—but again, the fact that many people might make such a choice doesn’t mean that everyone would do so.

    Nevertheless, government imposes its laws on its citizens, consent or no. If Enlightenment folk can reconcile themselves to this, so can Rawlsians.

    If the government was capable of providing limited basic healthcare efficiently then libertarians would probably be OK with it, just as they support other limited basic aspects of government. In theory that’s the sort of thing the government could do.

    “Nor is there any reason why the state should not assist the individuals in providing for these common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance — where, in short, we deal with genuinely insurable risks — the case for the state’s helping to organize a comprehensive system of social insurance is very strong…. [T]here is no incompatibility in principle between the state’s providing greater security in this way and the preservation of individual freedom. To the same category belongs also the increase of security through the state’s rendering assistance to the victims of such “acts of God” as earthquakes and floods. Wherever communal action can mitigate disasters against which the individual can neither attempt to guard himself nor make provision for the consequences, such communal action should undoubtedly be taken.”

    Friedrich Hayek, The Road to Serfdom, Chap. 9, “Security and Freedom”

    , the crucial words for libertarians would be “limited basic” and it seems that for many liberals the idea of health care limits is something which apparently exists only in the abstract.

    Can you describe “limited basic” care? I’ve hypothesized that various kinds of services are cost-effective substitutes for more expensive (and necessary) care. I grant that people disagree about the cost-effectiveness of various interventions. But other than disagreements about that, how would “limited basic” care differ from the care available under Obamacare?

  44. 44
    Ben Lehman says:

    Could we please define “wealthy country” for the purposes of this conversation?

    The general metric is OECD membership, but that doesn’t seem to be what you’re talking about?

  45. 45
    Ampersand says:

    You’re right, I should have just said “OECD countries,” since as far as I can tell that’s the group that’s easiest to compare the US to (as far as health care goes).

  46. 46
    pillsy says:

    I apologize for being unclear; when I say “the government” I am talking about *OUR* U.S. government, which–as you note–does not seem to have much ability to do it right, at least in this arena.

    This is a perfectly legitimate argument, but it’s also an outlier to how most countries that have healthcare provide it, and perhaps a bit of a straw-man in terms of what most liberals want. If we somehow had the option for an NHS-style healthcare system, I’d have a ton of doubts, but it’s politically untenable and something that even Bernie Sanders doesn’t argue for.

    The liberal “fantasy”, if you will, tends to be “Medicare for All”, and Medicare for Old Folks, while distinctly imperfect, works OK. There are also a ton of very decent multi-payer systems in the world, with varying degrees of “patient contribution” at the point of care. Some of these are likely to be more “conservative friendly” than a single-payer system, but the GOP’s recent decision that insurance mandates are the devil really constrains their ability to offer anything at all that would work well enough to be popular.

  47. 47
    Ampersand says:

    Ell, thanks, that’s really interesting.

    I’d nit-pick a little; Ruchama was still correct in saying that the point (which I think means “purpose”) of annual physicals is to save money in the long run. That is, as far as I can, the intention. It just happens to be that the intention is based on an incorrect belief.

    If evidence shows that annual physicals don’t actually help people or save money, then yes, we should do away with them.

  48. 48
    pillsy says:

    Could we please define “wealthy country” for the purposes of this conversation?

    I’d include the US, Canada, non-former-Soviet Bloc Europe (or Turkey), Japan, South Korea, Taiwan, Australia, New Zealand, and Israel.

    I may have missed a couple. I’m excluding Brunei, UAE, et c., mostly because I don’t know a damn thing about their healthcare systems.

  49. 49
    Harlequin says:

    I also think Ruchama is correct if you replace “yearly physical” with “appropriate preventative care”–which may be more or less rare than an annual physical depending on risk level.

    There are a lot of devils in the detail of defining “appropriate,” of course.

  50. 50
    gin-and-whiskey says:

    An interesting article and counterpoint:

    https://www.adamsmith.org/blog/us-healthcare-most-people-dont-know-what-theyre-talking-about

    Obviously this seems to be from a fairly conservative perspective.

    it did lead me to dig into the details of this Commonwealth Fund report, though. Interesting stuff.

    To some degree it seems like there’s some double counting going on:

    For example, you have a health care standard which is “Primary care physicians receive the information needed to manage a patient’s care within 2 days after they were discharged from the hospital.” This falls under the larger category of “coordinated care.”

    But we consider this relevant only because experts think that this has an effect on actual health outcomes. IOW, there’s no benefit per se from satisfying the above question, unless it produces some measured result in outcomes….and those outcomes are already measured.

    So it seems honest to promote rankings that “the U.S. has XXX health care problem (high rate of death)” and to explain that possible causes include the Coordinate Care measures discussed above.

    But it seems dishonest to promote low rankings on both measures without specifically explaining that they are causally linked. (Or if Coordinated Care is unrelated to other health care measures, then it’s meaningless anyway.) That creates the implication that the U.S. did worse than reality.

    But no matter what, it’s always fun to read the reports.

  51. 51
    Ampersand says:

    G&W, the US is third-best of all the countries measured in the report by the “pcp get info within two days” measure. So if you’re correct that there’s double-counting going on there which distorts results, wouldn’t that raise the US’s standing, creating the implication that “the US did [better] than reality”?

  52. 52
    nobody.really says:

    But no matter what, it’s always fun to read the reports.

    Uh … ok.

    In case you missed it, the baseball season has started again. Half the teams are still undefeated. Just sayin’….

  53. 53
    gin-and-whiskey says:

    Honestly I have no idea. I don’t know enough about the details of how Commonwealth calculates its rankings and I haven’t the time to dig into them in depth. I happened to remember that one. The U.S. is ranked 6th for “coordinated care” overall.

    Either way, though, the argument stands: it wouldn’t be any better if it artificially inflates the results.

    It’s just that these measures are wonky.

    To use another example, the U.S. does badly on an “equity” score, which is judged by differences in how above- and below-average income folks “rate their access to care.” (Oddly enough, it is NOT judged on an objective measure of how good or accessible the care actually is. I have no idea why; perhaps we can’t measure it well.)

    But it’s statistically clear that improvement in the top portion (which has no negative effect on anyone and may well drive overall innovation) will reduce a country’s “equity” score, even if the health care system has actually improved.

    IOW, things like the overall averages and means and SD serve to objectively lay out what the situation is. Things like the “equity” score serve to impose a hidden value judgment–in this case, the judgment that it’s basically a bad thing for people to better themselves unless they pull everyone else up as well.

    And even the equity score itself is complex. For example, poor people tend to use hospital ERs for non-emergent matters. But when that happens they are more likely to get get triaged to the bottom of the line, to get treated brusquely by the folks who believe the ER should be limited to emergencies; to get duplicative “so you say this is emergent” tests; to be denied medications for fear of enabling drug-seeking; and so on.

    So do you have a lot of lines for many factors? Do you have one line fot “are you poor and do you use the ER for primary care?” And so on.

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