What kind of mandate should “the right” have supported?

by on June 20, 2012 at 7:02 am in Medicine, Uncategorized | Permalink

The conservatives and libertarians who earlier supported a mandate, ideally, should have been looking for the following qualities in a health care policy:

1. A very small number (one?) of categories for health care coverage and also reimbursement rates.  Mandates for everyone, in other words.  No Medicare, no Medicaid, no separate set of people in an employer-based, tax-subsidized health insurance sector, rather a unified system.  Switzerland comes relatively close to this, and of course some commentators hope ACA will evolve into this (“means-tested vouchers”), though I suspect the scope of the mandate and the cost of the subsidies will prevent this.

2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor.  Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.  We need to accept the principle that sometimes poor people will die just because they are poor.  Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree.  We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.

3. A modest bundle of guaranteed coverage and services.  I am very influenced by David Braybrooke’s book on meeting basic needs.  Yet for me basic needs truly are basic and do not involve cable TV or small probability chances of delaying death from prostate cancer.

4. Price transparency (mandated if need be) and real competition in the health care sector, including freer immigration for doctors, nurses, and other caregivers, and relaxation of medical licensing and encouragement of retail medical clinics, a’la WalMart style.  This helps keep the cost of the mandate to reasonable levels.  Most cost-saving innovation should come through markets.  The man strapped to a gurney, bleeding, while negotiating a price with his doctor is the exception in this sector, not the rule.  In any case the insurance companies can prearrange the price for that one.

5. If you wish to move away from the strictly conservative direction, you could consider price controls on some areas of medicine.  Singapore does them.

6. Always convert dollars of benefits, usually a private good, into dollars of support for medical research and development, a public good.  You will never end up at a margin where this is a bad trade.

7. Society should firmly believe that it is the duty of the government, first and foremost, to protect us against foreign enemies, environmental catastrophes, pandemics, and other existential threats.  History shows that such existential threats are real.  Alleviating individual sufferings through governmental charity can be a useful source of mutual advantage but it should be subordinate to these broader goals.  Furthermore we should be determined to resist the creation of a large class of perpetual beneficiaries who will strangle the government fiscally and pull it away from these more basic duties.

I would think that such a mandate would be a serious policy option, though maybe not a first best choice.  (There are also mixes of single payer backstops and HSAs, as in Singapore, and a variety of provincial systems.)   Yet that is far from the ACA.  We should not “blame” Obama for that difference (it’s not clear what his more utopian preferences might be, though it is clear he could not have passed them), but still it seems to me that observers can support some version of an individual mandate and oppose ACA.

I agree, by the way, with Ezra Klein’s analysis of the “motivated reasoning” of many particular individuals when confronted with ACA a few years ago.  You can think of this post as an “ideal type” analysis which may or may not apply to many actual people.

Andrew' June 20, 2012 at 7:22 am

6. We CAN cure aging, and while funding for “dying with tubes and officious a-holes you don’t know” gets a trillion dollars, fundamental aging research (and most diseases the medical system treats poorly and ultimately fails at are largely aging) gets roughly zero. Treating disease itself is not a public good. The diseased are by definition a minority, even in aggregate, and we don’t really have systems that treat in aggregate. I propose remaking the system so that it does treat in aggregate. Treating aging, which will treat the majority of diseases that can be treated, is a public good.

The Original D June 20, 2012 at 9:58 am

Doesn’t that just offset the timeline of costs? If everyone lives longer through anti-aging techniques, is it not 100% certain they will die of similar causes as today, just a few years later? I suspect the “last 6 months” problem in health care is akin to the “last mile” problem in broadband access: it’s the most expensive.

Andrew' June 20, 2012 at 10:18 am

Think of it this way:

“Doesn’t not dying by lunch today just offset the costs?”

Make sense?

The Original D June 22, 2012 at 8:28 am

I don’t see your point. If I have a massive stroke today I’m going to pay for my care and decline with 2012 dollars at 2012 rates. If current health care costs growth continues, I don’t see how waiting 20 years and paying the 2032 rate is a better option.

Yancey Ward June 20, 2012 at 11:19 am

Depends. Say that extension works this way- you have the health you had 59, but now at 62. You have 3 additional years of productive life to fund that last six months. Now, if instead we take that extension and just make retirement longer, then, yes, you have compounded the problem.

Andrew' June 20, 2012 at 11:33 am

That’s economics. I refer to biology.

Enrique June 20, 2012 at 12:07 pm

Point #6 has to be wrong — there is a point where a marginal dollar of research produces less than a marginal dollar of possible cures or other benefits — it would be better to argue that the marginal benefit may exceed a dollar some time way in the future, or that the possibility that the marginal benefit may exceed marginal cost in the future is high enough to justify the initial investment in research — but why not leave it up to the patent system to produce socially-efficient levels of investment? — why add public spending into the mix?

Orange14 June 20, 2012 at 7:25 am

I’m sure that this will have over 100 comments within the next two hours. Here is my 2 cents on this (and I’ve been studying the issues going all the way back to 1990 when the first Jackson Hole meetings took place. Ultimately the current system will collapse since it doesn’t address the fundamental problem of inflationary heath care costs. This will be addressed regardless of whether we keep a quasi-private sector or public sector approach since the cost/benefit ratio in the US is so out of whack compared to the rest of the world (our outcomes are no better than in countries that have fully socialized medicine). It’s worth pointing out that The Netherlands have an individual mandate AND private sector health insurance for everyone; their costs are 1/2 that of the US with better outcomes so this is a model worth looking at.

The only private sector approach that I think will work in the long run is the Fuchs/Emanuel one proposed about six years ago (see: Zeke Emanuel’s book, “Healthcare Guaranteed: A Simple, Secure Solution for America) where a value added tax is put in place that pays for a an insurance policy for everyone that covers the basics. This also replaces Medicare and Medicaid, so everyone is level in terms of benefits. It also gets all employers off the hook in terms of having to provide health care coverage and should also promote empolyee movement for those who are only staying with an employer for the health care benefit. Extra coverage can be purchased for those who want it and I suspect (as does Zeke) that there will be a significant after market that provides this. HMOs would also be part of this mix as they would still be providing primary care for those who like that option. Of course this is too sensible to be enacted (and Grover Norquist would object because it does raise taxes though the full effect is difficult to judge because of the elimination of Medicare tax and the relief provided to business as they no longer need to pay).

Yancey Ward June 20, 2012 at 11:29 am

Extra coverage can be purchased for those who want it and I suspect (as does Zeke) that there will be a significant after market that provides this. HMOs would also be part of this mix as they would still be providing primary care for those who like that option.

The problem, as I see it, is still going to be the egalitarian objection. Either the “basic package” is going to include all the new treatments that are coming available all the time, and includes an open-ended cost accruement for any individual, or the political opposition will force this on a continual basis since it is “just not fair that means governs the availability of healthcare treatment”.

MD June 20, 2012 at 1:19 pm

I don’t know about that. I’m a liberal, and some kind of “basic package” makes sense to me. What should go in that package would obviously be difficult to determine. For instance, I know someone who is poor and had a child (I know, I know, could have made better life choices), and that child was born with a severe cleft palate. The surguries to fix that probably wouldn’t be considered “basic” but without it, the baby would struggle to survive (because of difficulty eating and drinking) and would have difficulty finding work (because no one would hire someone who looks like that for any job dealing at all with the public). Tough choices, no?

Dan Weber June 20, 2012 at 2:48 pm

You are too rare. I’ve met many liberals who think it’s unconscionable that the rich can have better health care. For that matter, I’ve also met a few conservatives who think that, since they paid into Medicare, they should get 100% of what they (or their doctors) think they want.

For better or worse, we’re going to end up with the rich having better stuff than the rest of us. It’s just a question of how much time and money we waste before we get there.

dan1111 June 20, 2012 at 6:13 pm

“For better or worse, we’re going to end up with the rich having better stuff than the rest of us. It’s just a question of how much time and money we waste before we get there.”

Well put.

uffy June 20, 2012 at 7:28 pm

Why exactly would such a surgery not be considered basic? It’s a fairly routine surgery with very high success rates and an excellent cost-to-benefit ratio.

I do agree that a Medicare-for-all should not be open-ended, but this seems like a fairly awful example of where to close the “end”.

MD June 20, 2012 at 10:15 pm

Hey, I don’t know! I saw the before, and I saw the after, and it looked pretty impressive to me. Anyway, I never can tell what people are going to think around this place.

rb June 27, 2012 at 2:49 pm

“Why exactly would such a surgery not be considered basic?”

It is not basic because the child is poor. Did you not read the original post? “We need to accept” that it the child will die because the child is poor.

“Some of you don’t like the sound of that,” but hey, get over it.

As MD points out, the child should have “made better life choices” by being born to richer parents.

liberalarts June 20, 2012 at 7:30 am

Suppose that you take a sample of Americans who are as slender at the Dutch and look at the cost of medical care for that sample of Americans. I wonder how that would compare to the Dutch costs?

The Original D June 20, 2012 at 10:01 am

I’d be curious to see this, but I’d also be curious to see info about how much extra exercise the Dutch get merely by biking to work instead of driving.

Also, I just got back from Europe and noticed how much smaller the meal sizes are there (at least in Germany, Austria, Czech Republic and Hungary). What could the US do to incent restaurants to use smaller portion sizes?

Urso June 20, 2012 at 10:44 am

This is a very good question. Part of the problem may be that the US is so agriculturally productive that food is, and has been for a long time, very cheap. As a result, restaurants were able to compete on portion size, which they weren’t able to do in Europe (although I do suspect this is changing). This could conceivably result in a kind of “race to the biggest plate” with the end result that everyone’s serving size is bigger. You can see this clearly in the ever-expanding Coke bottle.

Personally I find it insane the idea that a restaurant is expected to serve you enough food to feed you not once, but twice, and people actually get upset if they don’t have any food to take home. I think this may be a generational issue; in my (obviously anecdotal) experience older people are way more concerned with serving size than younger people.

Stephen June 20, 2012 at 11:15 am

But the governments of Europe don’t mandate the smaller portion sizes, right? It’s a preference that restaurants respond to.

Rahul June 20, 2012 at 3:18 pm

Maybe a Germany native will correct me; but from my Germany travels food-portions don’t seem small at all. At least as big as the US unless you go out of the way to choose a salad or some dish with intentional small portions.

stuhlmann June 21, 2012 at 3:17 am

I am an American, who has lived in Germany for most of the last 30 years. German restaurants are like US ones in that some compete on “value” – amount of food for the euro, and some compete on taste or quality. You can get schnitzels (breaded pork cutlet) that barely fit on a platter, covered with a heavy sauce, and accompanied by a heap of french fries. You can also get a lean steak, or even leaner piece of turkey or chicken, of modest size, served with a couple potatoes and a salad. It just depends what you want. I would agree with Rahul that overall, German portions are not small.

The Original D June 22, 2012 at 8:32 am

I was just in Berlin. Perhaps they are similar in size on average, but I certainly did not see anything like what you would get at the Cheesecake Factory or Five Guys Burger and Fries. Plus, in my experience you had to order a soup/salad and bread separately whereas in the US those are often part of the standard meal. Think Olive Garden’s unlimited salad and breadsticks.

The Original D June 22, 2012 at 8:34 am

Oh and Berlin is an extremely bike-friendly city, comparable to my hometown of Boulder, CO.

Orange14 June 20, 2012 at 12:06 pm

LOL, go to Italy! You get lots and lots of food and most restaurants are disappointed if you don’t order four courses (antipasto, pasta dish, main meal, desert). I took a one day cooking class in Florance and we had six courses that we prepared!

Bender Bending Rodriguez June 20, 2012 at 5:46 pm

What could the US do to incent restaurants to use smaller portion sizes?

Make food twice as expensive? American at-home food costs are at least half what they are in European countries. Hell, you can throw food-outside-the-home into American food costs and
it will still be less than what Europeans spend on food at-home.

http://www.dailymarkets.com/economy/2010/07/03/as-share-of-income-americans-have-the-cheapest-food-in-history-and-cheapest-food-on-the-planet/

uffy June 20, 2012 at 7:34 pm

That data you linked to is only about food costs as a percent of income rather than the costs to eat a healthy European-style diet when in America.

Rahul June 20, 2012 at 7:37 am

Isn’t #1 (one category of benefits) at odds with #2 (buy what you can afford)?

About #7. What specific program areas does Tyler see advocate more funding for under the rubric of ” foreign enemies, environmental catastrophes, pandemics, and other existential threats.”

Deflecting asteroids? Preparing for a Chinese invasion? Bird flu research? AIDS? Global Warming?

Orange14 June 20, 2012 at 7:48 am

AIDS/HIV and Bird Flu fall into the pandemic box and warrant funding. What about spending $14.5 B on improving the flood control system in New Orleans to benefit only about 200,000 residents? Is this a good expenditure of money? It’s already been spent and I don’t think the state of Louisiana spent anything to protect their citizens.

derek June 20, 2012 at 10:58 am

No need to look for nonsensical flights of imagination. There was a nasty influenza strain that brought the Ontario health system to it’s knees a few years ago. I don’t remember the details, or even what it was called, but the organization of health care delivery was the problem. The Canadian habit of funnelling all health care provision through the emergency ward essentially created disease vectors. The system was wholly unprepared for a nasty but relatively simple to handle infectious disease. But health care is free, and we are a caring society.

Matthieu June 20, 2012 at 8:24 am

>small probability chances of delaying death from prostate cancer.

You should know better, Prostate cancer is one of the best cured and one of the lowest mortality (since it’s overdiagnosed in older men) . Steve Jobs was the exception. But yes you are right, extend the life for 6 months for a brain cancer is very very expansive and we can ask for what purpose.

Orange14 June 20, 2012 at 8:37 am

Jobs had pancreatic cancer and not prostate cancer.

Matthieu June 20, 2012 at 8:46 am

True, it’s a bad one.

Dan Weber June 20, 2012 at 2:51 pm

Leaving prostate cancer alone is usually the best thing to do.

dan1111 June 20, 2012 at 6:17 pm

“You should know better”–huh? The over-diagnosis and over-treatment of prostate cancer is probably exactly what Tyler was suggesting would not be included in a basic plan.

foosion June 20, 2012 at 8:25 am

I’ll believe libertarians and conservatives are serious when they support a free market in healthcare, including eliminating government enforced monopolies granted to pharma companies and licensing requirements in order to practice medicine.

Fixing some other market failures would help, such as pricing transparency.

Instead, the major effort seems to be to concentrate resources in the best off.

Yancey Ward June 20, 2012 at 11:32 am

And I will take liberals seriously when they start advocating that government funds cover only generic medications.

Other DW June 21, 2012 at 5:44 pm

I’m a liberal (well moderate and left-leaning at any rate) and I agree with this. Only if generic versions are available though.

dan1111 June 20, 2012 at 6:22 pm

You’ll start taking us seriously only when we adopt a reductio ad absurdum of our own position? How generous of you.

Anyway, plenty of conservatives have come up with and are advocating real market-based policies. The reason they can’t actually accomplish it is the same reason the Democrats can’t enact their dream health care schemes: the compromises of politics.

mw June 20, 2012 at 8:30 am

1. this definitely would have been a good move for conservatives, because when the mandate was then declared unconstitutional, there would be nothing left standing, which is of course the stated republican goal.
4. you’re absolutely right that “the man strapped to a gurney, bleeding” is the exception–the *rule* are the people with non-life-threatening illnesses who put off early care to save money and come back five years later to cost the hospitals unnecessary billions in unreimbursed care. there’s your rational consumer. More importantly, as has been said hundreds of times but not internalized by 90% of commentators, our health care is expensive because our doctors are overpaid–changing consumption decisions would make little difference. i would love to see one conservative acknowledge this.
6. this meant to say “into dollars of targeted tax breaks for the wealthy”? (it was addressed to conservatives right?)
7. health care is not a morality play. the ‘class’ of permanently dependent citizens it will create, given our stratospheric cost of health care, would just be “average income and unlucky.”

Orange14 June 20, 2012 at 8:42 am

One final comment on #4 – absent a mandate, we all end up paying for the ER visits of the uninsured person on the gurney. I don’t see how this can be addressed in any other manner absent a mandate (though one could seize the person’s assets for payment). Paul Starr had an interesting proposal that is worth considering. Do away with the mandate but if someone comes in after the the initial policies are issued under a modified ACA, they don’t get guaranteed issue and pre-existing conditions can be used to establish a higher premium base.

careless June 20, 2012 at 9:23 am

We do? I’m sure he’ll be very happy to hear that.

Reality may vary. Also. A person who can’t actually pay is more likely to be under Medicaid, and impervious to the mandate.

Andrew' June 20, 2012 at 9:59 am

You cannot imagine any alternative to a mandate?

Well, you’d better start thinking because it looks like the mandate is gone.

Actual emergency ER is a pittance.

And then there is this crazy idea I like to call “pay your bills.” I know, it’s insane, right?

FooFighter June 20, 2012 at 1:22 pm

I’m going to go ahead and guess that you’re young, healthy, and relatively wealthy, and have never spent much time in the medical system as a consumer or practitioner. Healthcare has bankrupted even the most responsible of individuals.

Point being, ‘pay your bills’ may actually be the irrational choice for many.

DonJon June 28, 2012 at 12:58 am

Fuck paying those that already have it all…. and fuck you.

DonJon June 28, 2012 at 12:59 am

Not true, douchbag… It’s not easy getting on Medicare unless your over 65 or disabled.

Paul Crowley June 20, 2012 at 8:45 am

Even strong supporters of egalitarianism should support you on point 2. Trying to achieve egalitarianism through outrage that the rich can buy more life has very silly outcomes. Better to just tax the rich than indulge in that kind of mucking about.

How do you feel about Hanson’s “Buy health, not health care” proposal? http://hanson.gmu.edu/buyhealth.html

foosion June 20, 2012 at 9:22 am

Supporters of egalitarianism believe there is more popular support for programs that benefit all, e.g., social security and medicare, than programs perceived as welfare.

Many view healthcare as different from a consumer good. Making sure everyone has a Ferrari would be riduculed, making sure people don’t die needless deaths due to lack of funds has a lot of resonance.

Yancey Ward June 20, 2012 at 11:35 am

Defining “needless” is the problem.

DonJon June 28, 2012 at 12:55 am

A good definition would be ‘You.’

angus June 20, 2012 at 9:09 am

Tyler goes behind the whale!

Joe Hobbs - recetas faciles y rapidas June 20, 2012 at 9:42 am

I really concerned about the aging of individuals and their health. In many countries of Latin America, the medical associations do not allow new customers associated with chronic diseases. This is very unfair, especially for big people, many at a certain stage of their lives could not afford a private association and when they can not allow it because you already have a chronic disease.

Sure medical associations serves more young customers will not generally produce any great expense for many years that older clients with chronic illnesses. Sorry for my little English but is an issue that concerns me greatly.

regards,
Joe Hobbs.

Scoop June 20, 2012 at 9:46 am

Can anyone speculate why Rs and Ds did not agree simply to copy Singapore’s system?

Almost no one in any part of the medical industry would have liked it, obviously, but special interest lobbying shouldn’t have been able to sink it. This isn’t farm subsidies, which greatly benefit a few (who will lobby and vote on that topic alone) at very small cost to the general public (who don’t suffer enough to base votes on it). This is the very sort of thing the general public votes on.

And, yes, the public would have been extremely skeptical, if not outright opposed — initially. But, the public would eventually come around because of the massive benefits: cut medical bills by three quarters and the government deficit problem goes away (SS is entirely manageable on its own) and wages that have been stagnant since the 70s rise.

All that needed to happen was the two parties needed to agree to support each other (and stick to that) on an issue that unquestionable would benefit everyone. Why didn’t it happen?

economist1 June 20, 2012 at 5:29 pm

I’m sure Obama would have listened if the Republicans had proposed a Singapore-type system. Currently the Democrats are the only ones with reasonable health-care proposals, which they largely copied from Romney’s plan in Massachusetts. I welcome any Rs that want to put forward serious, center-right proposals like Singapore’s, but I’m not holding my breath. I expect more screaming about death panels.

Ricardo June 20, 2012 at 11:05 pm

Here are the salient features of Singapore’s system from what I can tell:

1. A state-run catastrophic health insurance system called MediShield.
2. It is illegal for private companies to compete with MediShield; they may only offer supplemental health insurance and clients must be enrolled in MediShield before purchasing private supplemental insurance.
3. “Libertarian paternalism”: all salaried employees (whether working for government or private entities) are by default enrolled in MediShield and health savings accounts called Medisave.
4. Income-contingent billing at public hospitals and a system of subsidies for poor Singaporeans in need of medical care called Medifund.

The debate on the public option seems to show that Republicans and many Democrats would never support #1 or #2 and there are powerful special interests opposing such a set of policies. #3 would certainly be opposed by libertarians but since it seems to depend on a state-run option as the default, it wouldn’t be implemented without doing #1 and #2 first.

That leaves #4 and the U.S. has elements of this already in locally-run public hospitals and in Medicaid. I think special interests combine with a sort of right-wing populist rhetoric about “government take-over” of health care and “death panels” to oppose any government expansion in the health care industry. Singaporeans and people in many other developed countries trust their governments a lot more than Americans trust theirs. Until that changes, even something like PPACA is going to be a very difficult sale.

asdf June 20, 2012 at 9:55 am

As a sick individual, I support any policy that means I get guaranteed coverage for any medical expenses above some reasonable out of pocket level (say a few grand a year). How we get there, I don’t care. I know if I had to pay for my own medical care it would be five or six figures annually. Since this would basically mean the end of any reasonable life for me, assuring it doesn’t happen is my top priority.

false seriousness June 27, 2012 at 3:42 pm

“We need to accept the principle that sometimes poor people will die just because they are poor.”

It sounds like Tyler Cowen and the rest of these disgusting libertarians are talking to you. How people don’t howl at the absurdity and amorality of their beliefs, and publically jeer them, I don’t know.

So Much For Subtlety June 20, 2012 at 10:08 am

I would assume that the sensible Right wing alternative would be to start by taking insurance away from companies and return it to individuals. For too long health care has been tied up with your job.

But the sensible solution would be for the Feds to fund the States to implement something like Singapore’s system. Individuals would be encouraged (and if poor, helped) to establish their own health funds. To which their employer could contribute if they wanted. All routine predictable health care costs would have to be met by these. The States would then insure against unexpected and potentially catastrophic conditions. How they did that was up to them. They could have a State-level single payer system or they could open it to tender or to competition. Whatever they wanted. The Federal government would simply provide block grants of money to help them do it.

In fact this system is so obviously better than what America has or what it is likely to get, I don’t see why both sides don’t support it. But then, the obvious is often ignored.

dan1111 June 20, 2012 at 6:30 pm

Also, obvious to you is not the same as obvious to everyone.

Andrew' June 20, 2012 at 10:20 am

How ’bout what I call the “pay your bills like almost every other business” plan?

How did we end up in this “the only thing we can imagine is a pre-pay mandate” world?

Steve June 20, 2012 at 11:24 am

Trying to figure out your line of reasoning here. Do you not believe in insurance in general or just not for health care?

Andrew' June 20, 2012 at 11:36 am

I believe that even in other things that use insurance and you don’t have it you pay your bills.

What I don’t believe in is that we can only imagine some form of mandate as the solution to the screwed up medical insurance market.

Andrew' June 20, 2012 at 11:40 am

Put simply, we can “imagine” the government forcing people to pre-pay, but we cannot imagine the government forcing people to post-pay?

We truly have an imagination deficit.

And to be clear, this is all to band-aid the government rules mandating service providers to provide care.

Again, real emergency ER is a drop in the bucket of the problem the government has created. They’ve turned the ER into a free clinic. Now that is broken and all they can imagine is forcing people who aren’t using a service to pay for those who are.

Andrew' June 20, 2012 at 11:56 am

Oh, and I guess to actually answer your question, no I don’t believe that the principle of “insurance” is right for a large portion of health care.

Wiki: “Insurance is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment.”

It makes a lot of sense for unforeseen catastrophic care. It doesn’t make sense for a lot of stuff for which the “insurance bundle” is really just a payment plan. There are all kinds of alternative payment plan schemes. There is no “risk” in either health maintenance or end-of-life. There is no “risk” for pre-existing conditions.

But we aren’t even talking about an expanded definition of insurance. None of the entitlement programs are insurance even in a wrong sense of the word. Neither is a medical payment mandate. You are paying a system, not even for a promise of access like club dues. You are simply being forced to pay.

What we are really talking about here is inverse insurance. The hospitals possess the risk of unknown loss foisted on them by the government. The government is mandating that we pay the hospital’s premiums.

jmo June 20, 2012 at 11:59 am

“the government forcing people to post-pay?”

When most folks use up the majority of their lifetime health care spending in the last years of life – how the h*ll do you expect the government to get them to post-pay?

Andrew' June 20, 2012 at 12:18 pm

Oh, and I guess to actually answer your question, no I don’t believe that the principle of “insurance” is right for a large portion of health care.

Wiki: “Insurance is a form of risk management primarily used to hedge against the risk of a contingent, uncertain loss. Insurance is defined as the equitable transfer of the risk of a loss, from one entity to another, in exchange for payment.”

It makes a lot of sense for unforeseen catastrophic care. It doesn’t make sense for a lot of stuff for which the “insurance bundle” is really just a payment plan. There are all kinds of alternative payment plan schemes. There is no “risk” in either health maintenance or end-of-life. There is no “risk” for pre-existing conditions.

But we aren’t even talking about an expanded definition of insurance. None of the entitlement programs are insurance even in a wrong sense of the word. Neither is a medical payment mandate. You are paying a system, not even for a promise of access like club dues. You are simply being forced to pay.

What we are really talking about here is inverse insurance. The hospitals possess the risk of unknown loss foisted on them by the government. The government is mandating that we pay the hospital’s premiums.

jmo,
Ask Bill. Seriously.

Steve June 20, 2012 at 1:31 pm

I am not very knowledgeable in this area but my impression is that most people do pay. Since many people go bankrupt due to medical bills (at least in the US) it would seem someone is trying to make them pay but they are unable. So still not entirely clear on your point here.

I agree with you on the lack of risk being included in the health insurance model. And when you think about it health care is not a good match for the insurance model since so many people would be un-insurable (the loss you are insuring against is not uncertain it is certain). I expect it does not make sense from an economic perspective to provide health care to the elderly or younger people who have long term health issues. It seems the reason we discuss health care for the elderly and other undeserving people is more along the lines of “leave no soldier behind”.

mark June 20, 2012 at 12:42 pm

Unfortunately, health insurance is not actuarially priced and there are hardly any risks that are excludable, so it does not fit into a strong insurance paradigm. It is more of an income supplement, really, with the amount of the subsidy a function of one’s medical usage. As structured, it makes little sense.

There are really two ways to go:

1) make it more like insurance with risk adjusted premiums, variable coverages and deductibles, etc. Give premium supplements in various forms to advance governmental goal of broader access.

2) eliminate the insurance middleman and have the government provide universal health care directly a la UK. Let medical service providers and health insurers operate in more of a free market fashion on a smaller scale and it will become a discretionary purchase for persons who wish to avoid the governmental health providers.

eric June 20, 2012 at 10:21 am

I really don’t get #2. No health care reform scheme that has ever been considered has even hinted at attempting to deny wealthier people the ability to purchase additional health care services beyond what’s covered in the (quasi) public scheme. The whole point is to set a floor under what people have access to. Nobody argues for imposing what people should be able to buy on their own.

eric June 20, 2012 at 10:22 am

edit: “Nobody argues for imposing a ceiling on</b? what people should be able to buy on their own.

Finch June 20, 2012 at 10:28 am

Doesn’t Canada do this?

TallDave June 20, 2012 at 1:57 pm

I think it was eventually ruled unconstitutional or something, but yes, private medicine was essentially illegal or made highly impractical by regulation, apparently because direct billing would “limit access” and because it makes the public waiting times even longer.

http://articles.latimes.com/2009/sep/27/nation/na-healthcare-canada27

Finch June 20, 2012 at 2:12 pm

Thank you for the link.

Finch June 20, 2012 at 2:19 pm

I once spoke with a guy whose firm sold health insurance to people who lived in socialist countries and wanted to have access to higher quality medical care. He told me a list of countries they weren’t allowed to do business in, and Canada was on that list. If I recall correctly; it was quite a while ago. He also might have been oversimplifying.

ThomasH June 20, 2012 at 10:50 am

These principles sound pretty close to a typical “liberal” approach. I guess you might get some discussion of what a “minimum” amount of coverage and consequent need for taxation should be. I see no reason ACA cannot evolve in this direction. Of course “the right” (I’ll take the House Republican caucus as an operational definiton of “right”) seems to have no interest in health insurance policy per se, it’s just a matter of how to use the issue to what they consider to be their immediate political advantage.

efp June 20, 2012 at 1:01 pm

Indeed. Most MR readers would probably consider me on the “left,” but I think these points sound far superior to what we have. My basic contention is that any single, coherent approach would be better than the tangled clusterf*ck of a “system” we have now.

Joan June 20, 2012 at 11:05 am

We can afford to provided care that saves people lives, it is the cost of extending the lives of people who can not be saved that we can not afford.

Yancey Ward June 20, 2012 at 11:39 am

“it is the cost of extending the lives of people who can not be saved that we can not afford.”

And we know who these are, how exactly?

FooFighter June 20, 2012 at 1:25 pm

90-year old cancer patients? It happens more often than you’d think.

DonJon June 28, 2012 at 12:48 am

Hey FooFighter, I hope they pull the plug on you as soon as possible… You people are a bunch of fucking assholes talking about who should die. All of you here go fuck yourselves… I hope everyone of you die from some nasty ass bleeding disease. Bunch of fucking trolls.

TallDave June 20, 2012 at 1:47 pm

Approximately 100% of people will eventually die.

msgkings June 20, 2012 at 2:49 pm

Not if Andrew’ gets his wish

Rahul June 20, 2012 at 3:27 pm

If only it were approximately……..

Slocum June 20, 2012 at 11:07 am

No mandate at all — it’s not needed. What’s needed is subsidies so that the cost of *basic* (#3) insurance will not exceed ‘X%’ of family income, where ‘X’ is a higher percentage for higher incomes. Also much higher limits if you’ve been living outside the system and want to buy in. So if you have not been buying insurance until you have an expensive medical problem, then your limit is much higher. For example, if your income is $100K, the normal limit might be 18% of income, but if you haven’t been carrying insurance and want to buy in, your costs might be 30% of income for the first 5 years of coverage — something along those lines. In short, incentives rather than a mandate.

Medicare is untouchable and employer-covered health care likewise, so #1 is a non-starter. Instead equalize employer and individual policy tax-treatment by making individual insurance policies and out-of-pocket medical expenses fully deductible.

Bruce B June 20, 2012 at 11:12 am

Ahh… it is so refreshing to have Tyler clearly state what he thinks are possible solutions rather than trying to figure that out from his oblique and sometimes sarcastic comments on what others write. This was a very good list, but regarding the following statement in #7:

“Furthermore we should be determined to resist the creation of a large class of perpetual beneficiaries who will strangle the government fiscally”

I suspect that creation of a class of beneficiaries here refers to creating dependencies by bestowing benefits. However, these beneficiaries have already been “created” and they will continue to be created – beneficiaries such as:
– people over 65 whose health will inevitably decline at some point and who are generally no longer employable
– people who are part of the growing obese/type II diabetes/not enough exercise demographic
– “ZMP workers” with little or no income
– soldiers who return from battlefields with shattered bodies and minds
etc etc

as these beneficiary populations continue to grow the politically tough question is how many benefits will we decide we can continue to afford bestowing on them?

Greg G June 20, 2012 at 11:45 am

Agreed Bruce. One of the reasons I read this blog is to find out what Tyler thinks about questions like this. I would like to see more of that.

TallDave June 20, 2012 at 11:23 am

Good points:

1. As long as it has markets.

2. Very true. As Kling points out, the main reason U.S. healthcare is expensive is that we give everyone a standard of care no other OECD country provides to anyone. Unfortunately, doctors/hospitals like to have general guidelines/protocols for everyone, and trial lawyers tend to make difference in care untenable.

3. Yes, Kling again.

4. Yes, and in emergencies the patient should be able to point to lower-cost alternatives in post-treatment negotiation.

5. Price controls lead to shortages.

6. Gov’t is very bad at directed R&D, let’s have X-Prizes.

7. Yes.

Orange14 June 20, 2012 at 12:12 pm

How can you write #5 with a straight face? There is no shortage of medical care in the UK or the Scandinavian countries where the most rigid govt supported health care is in place. In everyone of the EU countries pharmaceuticals are price controlled and there is likewise no shortage.

Andrew' June 20, 2012 at 12:22 pm

Orange14

Dude, don’t jump the shark on your second day here.

Why does UK NICE have wait-times as a major initiative?

http://www.guardian.co.uk/society/2012/apr/19/david-cameron-pressure-nhs-waiting-times

And after yesterday’s discussion how sure are you that EU countries don’t have any pharma shortages?

What TD is takling about is economics, the purpose of which (Bill) is so that you don’t have to always know details.

What you are talking about is the nature of a network business like creating drugs, which like video games, the replications of which cost very little. In those businesses, the shortage is like to be in the development phase.

Rahul June 20, 2012 at 12:34 pm

I’m not so sure you really want to point to UK-NHS as a model for a functional health care system.

TallDave June 20, 2012 at 12:37 pm

As Andrew says, you think there aren’t shortages, you haven’t been paying attention.

Stealing pharma IP from the U.S. via monopsony has been a nice model for the rest of the OECD since drug companies will take marginal profits over nothing, but it hasn’t been totally without costs.

Orange14 June 20, 2012 at 2:42 pm

….and pray tell who is responsible for this articulate quote, “There is no reason why, in a society which has reached the general level of wealth ours has, the first kind of security should not be guaranteed to all without endangering general freedom; that is: some minimum of food, shelter and clothing, sufficient to preserve health. Nor is there any reason why the state should not help to organize a comprehensive system of social insurance in providing for those common hazards of life against which few can make adequate provision.”

TallDave June 20, 2012 at 10:16 pm

The key words there are “minimum” and “help” as evidenced by his other articulations in that essay:

Few catch-words have done so much harm as the ideal of a “stabilization” of particular prices or wages, which, while securing the income of some, makes the position of the rest more and more precarious. In England and America special privileges, especially in the form of the “regulation” of competition, the “stabilization” of particular prices and wages, have assumed increasing importance.

It is not those who cry for more “planning” who show the necessary courage, nor those who preach a “New Order,” which is no more than a continuation of the tendencies of the past 40 years; and who can think of nothing better than to imitate Hitler. It is, indeed, those who cry loudest for a planned economy who are most completely under the sway of the ideas which have created this war and most of the evils from which we suffer. The guiding principle in any attempt to create a world of free men must be this: A policy of freedom for the individual is the only truly progressive policy.

Hayek was definitely not suggesting the government should take over a sector of the economy that is today around the size of the entire economy as it existed when he wrote that in the 1940s. He seems to have had in mind something covered nicely by the Social Security disability program, though presumably without the lifetime of leisure for those with a diaper fetish.

Mikey June 28, 2012 at 3:29 am

Guaranteed and sufficient are the key words.

Becky Hargrove June 20, 2012 at 11:40 am

All we need for healthcare is for healthcare practitioners of all kinds to have the right to teach other people how to heal, and for those people to have the right to heal one another.

John David Galt June 20, 2012 at 12:20 pm

Point 7 is hooey. The entire history of the environmental movement is one PHONY existential threat after another, all made up to silence dissent.

Bill June 20, 2012 at 12:24 pm

What’s interesting is that every conservative and libertarian experiment has been tried before.

It’s just that they forgot or don’t want you to remember.

You see, could look at how populations were served or how well they faired before Medicare or even Medicaid.

So, why are there no conservative or libertarian historians telling us about the good ole days?

MD June 20, 2012 at 2:32 pm

I will have you know that I am a fact historian, and the fact is that even with all those scientists making pills, and doctors performing operations, and sanitation workers doing whatever sanitation workers do, and governments meddling in all of it, 100% of people who are alive continue to die. Therefore, government has failed, and if you disagree you must be a high liberal who loves Soviet central planning and denying the existence of AIDS.

dan1111 June 20, 2012 at 6:44 pm

Really? “every conservative and libertarian experiment has been tried before”? I think the burden of proof is on you to show that. How about the ideas listed above? Where have they been tried?

Every conservative health care idea is not equivalent to returning to the status quo of 50 years ago. In fact, I have not heard any proposal to do this. Anyway, healthcare has advanced so much since then that it is probably not a useful comparison for any purpose.

TallDave June 20, 2012 at 10:25 pm

Just think of the billions who could have been saved from starvation if we’d only invented food stamps thousands of years ago, instead of wasting all this time developing better agriculture.

Mathguy June 27, 2012 at 11:36 am

Nice non sequitur there, TallDave.

Adrian Ratnapala June 20, 2012 at 1:11 pm

They say that everyone’s claims about the mandate’s constitutionality is really code for their opinion on political economy. Not mine. In principle I think insurance mandates are a fine policy, but I can’t see how the United States has the right to impose one.

So if I were an American, I would say “No mandate at all” (from the Feds). Just make it a tax.

In fact I am an Australian, and in Oz the Commonewealth has enumerated powers allowing to legislate the provision of health care and pensions. So there my answer is different.

Barkley Rosser June 20, 2012 at 2:56 pm

Item 4 is potentially useful. For a period of time we had a more relaxed policy on allowing physicians to immigrate, but the AMA went after that and it was tightened up under Clinton. Of course, today conservatives would oppose loosening this due to anti-immigrant hysteria, even though it is obviously a free market solution.

And, of course, Milton Friedman famously opposed licensing doctors. I remember hearing of a prof who was accused of being a communist because he was talking about Friedman’s proposal in a classroom. One of the students was the son of his state’s AMA chief, and he ran to daddy to squeal and whine, with Daddy going to the university’s oversight body. One of those cases proving that tenure is a good thing.

Speaking of communists, Ezra Klein does not go far enough. This massive switch by the GOP on the individual mandate is the biggest mass switch in views by a political party in the US since the US Communist Party flip flopped back and forth on Hitler’s Germany as on the one had the Molotov-von Ribbentrop treaty was signed in August, 1939, only to be followed in June, 1941 by Hitler invading the USSR. It is truly astounding how few people are noticing how utterly hypocritical this massive party switch is.

Rahul June 20, 2012 at 3:25 pm

Of course, today conservatives would oppose loosening this due to anti-immigrant hysteria

The US anti-immigration lobby sorely needs a more nuanced position (if that’s not an oxymoron). It ought to be an acceptable position to be anti-illegal-immigrant / anti-anchor-baby / anti-amnesty /anti-refugee etc. while being pro-high-skilled immigration.

The current ham handed immigration approach essentially equates a pediatrician with a dishwasher; and often it is the pediatrician who has to jump more hoops to immigrate!

careless June 21, 2012 at 9:44 am

I’m unfamiliar with this lobby that puts illegals and high-skilled legals in the same box. Could you introduce me to it?

careless June 21, 2012 at 9:42 am

Warning: the voices in your head may not reflect reality.

Jim Green June 20, 2012 at 4:28 pm

I”m 100% disabled [service connected] so all my medical care is provided…throuh the VA…without the slightest cost to me. So my most fortunate circumstance should not influence the present discussion…except to say that the VA’s “one stop shopping center” for healtth care makes enormous sense. I’m 75 years old, and a recent coronary-catherization showed not the slightest obstructions. So just a reasonable degree of preventative health care [no smoking, etc.] has been fruitful.. But I’ll likely expire within 10 years. I’d like to avoid imposing upon “the system” the absurd expenses of the “the last six months”. Better that those precious resources be diverted to the screening of 5000 children for early health issues. At the appropriate time I’d like to call my family together…. for a few last days….and after a kiss and hug from each of them, be able to terminate my life with dignity, and without the risk of my family suffering criminal prosecution, or stigmatism by society.

Bill June 20, 2012 at 4:39 pm

In the long run, we all die. That’s from a famous economist.

You don’t need to be an historian to make that answer.

You did avoid the question of how things were before.

Come on, take up the historic challenge

Bill June 20, 2012 at 4:41 pm

This was in reply to MD above.

MD June 20, 2012 at 5:44 pm

It’s entirely possible I wasn’t being completely serious. (I would be interested to see what would happen to a country that implemented all of McC’s ideas, but I until I see it work for somebody else I shall remain skeptical.)

V June 20, 2012 at 5:10 pm

4. “real competition in the health care sector, including freer immigration for doctors, nurses, and other ” is categorically wrong as increasing the supply of doctors has always and everywhere raised total health care costs.

Unfortunately for Tyler (and every other economist unfamiliar with the sector), the orthodox line of thinking that says more labor results in decreased unit price doesn’t say anything of value in supplier-induced demand markets like HC. Adding hundreds of thousands of physicians will result in substantially more health care (mostly of questionable or even negative value) delivered, increasing total costs to the system for no clear benefit.

The salary of an individual physician might (or might not) decrease but we, as taxpayers, are no better off as the ultimate payor. Furthermore, the examples of prior efforts in this direction (e.g., the foundation of osteopathic schools in the ’70s to increase supply) have been almost consistently negative.

If we want to decrease physician salaries, reduce the price caps Medicare already applies through the CMS reimbursement process. But the only way increasing physicians cuts costs is with strict utilization controls which have never proved workable unfortunately…

Willitts June 20, 2012 at 6:41 pm

The individual mandate was the only part that made economic sense. But it was also the part that most surely violated the Constitution.

Others above have made arguments against the mandate on grounds that you can enforce payment after the fact. In practice, this is most difficult and costly. It’s much easier to ask for and verify insurance than to sue for expenses. Many assets can be protected by irrevocable trusts.

I agree with Andrews definition of insurance, but any true, feasible insurance plan is going to have a first generation with pre existing conditions. There is also a problem with premium pricing. We should all NOT be paying the same premiums since we don’t pose the same risks to the solvency or liquidity of the system. Few politicians will support separate equilibrium pricing if it disadvantages women and minorities.

Orange14 June 20, 2012 at 8:37 pm

So If I read you correctly, a genetic dice roll that leaves you with a pre-existing condition that requires periodic hospitalization and ongoing medication will result in astronomical premiums for you and that this is OK? Anyone who does not have the luxury of employee paid for health insurance can find them self in this situation. I ran into a woman while on holiday in Italy and we got to talking about this and she said that the premium to cover her and her husband (who had lymphoma six years ago but is cancer free right now) is $25000 a year and this is with a fairly high deductible. I don’t know how many posters today have employee-based insurance or are college students under their parent’s plan but think about what it would mean to buy an individual policy if you are not one of the lucky healthy ones.

TallDave June 20, 2012 at 10:28 pm

Under a state system, you will generally be dead instead of broke (or more likely, aborted in the first place, often without your parents even being told you might be viable, though expensive). Remember, this is exactly the sort of extremely expensive, low-return case where the system most benefits from rationing.

Rahul June 21, 2012 at 12:53 am

Is there any evidence that Germany / Scandinavia / UK / Canada etc. abort more casually and liberally than the US, say? Or is this speculation?

TallDave June 21, 2012 at 10:15 am

Yes, quite a bit in fact — non-U.S. are much more likely to abort for birth defects, mainly for cultural reasons. Megan McArdle covered this a couple years ago at the Atlantic.

Another reason this happens is because of the numbers game — other OECD countries usually say if you’re born below a certain weight, you are stillborn, breathing or not. That also means they generally don’t go to great lengths to try to save you, because it doesn’t count against their statistics.

Perversely, this all means they get better infant mortality numbers.

careless June 21, 2012 at 9:48 am

The Constitution is not a perfect work handed down by a god. It can and should be changed to improve it. That it has not been substantially changed in nearly 100 years is a national disgrace.

TallDave June 21, 2012 at 10:16 am

Why bother with all that fuss and bother of ratification when you can just appoint justices to emanate penumbras that do whatever you like?

Barkley Rosser June 21, 2012 at 2:44 pm

Why is it, TD, that almost the only things in anything you post that are factually correct are words like “and”?

So, your link to McArdle fails to report on US data on abortions for defects, although those for Down’s Syndrome are lower than most other countries, if not all.

As for your screed about OECD definitions of live births, this is an old lie that gets repeated in the usual locations where people like you get your “facts.” Here are the OECD countries currently not using the live birth definitions used by the US and the rest: France, Netherlands, Ireland, Czech Republic, Poland.

Oh, and the bottom line on that is of course that indeed the US record on infant mortality is screamingly awful, particularly given the horrendous amounts we spend for our health care and how fevered so many people are here to preserve the old system. Those trying to get around this, and the awful life expectancy numbers as well (50th in the world) are either misrepresenting or just plain outright lying, whether they are doing so consciously or simply out of being delusional and misinformed. Which one are you, TD?

Sorry, but do try to get your facts in better shape before you post here again, TD. You are pretty much rock bottom in credibility among those who regularly post here.

Careless June 21, 2012 at 11:47 pm

But Barkley Rosser doesn’t want to think about how the voices in his head are misleading him,

Ricardo June 21, 2012 at 3:44 am

Health outcomes are the result of a complex interaction of genes, past environment and health history, future lifestyle, and other future environmental factors. If insurance actuaries had their way, they would have pretty good information on genes, past health history and could make decent guesses about your future lifestyle. Especially as medical screening and technology gets more and more advanced, the risk you as a consumer would get to insure away would be an ever smaller range of unpredictability in terms of your health outcomes.

Most people in the real world would not, I think, prefer such a system. There is some justice in charging smokers, drinkers and people with bad diets more for insurance. There is much less justice in charging people more who simply came up short in the genetic lottery or who grew up in a house with lead pipes and a polluting factory nearby.

Insurance for most people means simply being financially protected from unlucky outcomes. Since those outcomes are, in the field of health, a complex mix of past and future factors, some sort of universal insurance that is not priced purely in terms of ex ante actuarial risk seems overwhelmingly preferable.

Matt June 20, 2012 at 8:58 pm

“*We need to accept the principle that sometimes poor people will die just because they are poor.* Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.”

Thanks for articulating this point! I disagree, but it’s the right place to be making the argument – should our system be mega-efficient for all users, or should it provide care to the most number of users. I don’t see this as an ‘economic’ question, per se. (If you want to try on ‘markets fix it’, please read the above, think about the implications, then, don’t.)

Jason June 23, 2012 at 7:08 pm

None of the things listed in #7 are “existential” threats. They are collective action problems. Most people live through their country being taken over (so why involve yourself in war?), most people lived through the 1918 influenza pandemic (so why fund public health?), most people lived through the black death (ditto), most people lived through acid rain (so why price sulfur emissions?) and most people will live through global warming (so why price carbon emissions?). You do these things with government because it makes little sense for an individual to do these things on their own unless most people do them.

I actually see little difference between using market forces to solve acid rain and the ACA: both seek to create functioning markets to price negative externalities and remedy adverse selection. Our military is also a similar solution: most of what the military most obviously defends are the interests of the elite, but defending elite interests can benefit everyone (such as preventing Stalinist communism from taking over). As a serf, I have little interest in helping my lord pay for knights since if his lands are taken away, I’ll likely just be a serf with a different lord. Overall, there are losses collectively, but I don’t want to pay to keep up the knights myself.

I think the people over at crooked timber have a much better idea for the raison d’etre of democratic government: it is a separate “algorithm” to solve difficult problems/optimizations that aren’t solved by markets or direct authority.

Mathguy June 27, 2012 at 11:38 am

@Cowen: “We need to accept the principle that sometimes poor people will die just because they are poor.” If you truly believe stuff like this, I don’t know how you sleep at night. Just sad to see someone casually dismiss the value of a person because they are poor.

DonJon June 28, 2012 at 12:38 am

Mathguy, why are you so nice to this Nazi eugenics promoter?

Irony Abounds June 27, 2012 at 12:54 pm

Easy solution. Move everyone into the Mayo Clinic model and wean the US away from fee for service, at least as the standard care for most Americans. You can do this via a mandate, through a system that rewards both doctors and patients for doing so, or a combination where under Medicaid and Medicare patients are required to use a Mayo Clinic type system if available and others are rewarded for doing so. You get better care at less cost. If the rich want to pay oodles more for extra treatment, fine, let them.

RedKitten June 27, 2012 at 1:17 pm

“As Kling points out, the main reason U.S. healthcare is expensive is that we give everyone a standard of care no other OECD country provides to anyone. Unfortunately, doctors/hospitals like to have general guidelines/protocols for everyone, and trial lawyers tend to make difference in care untenable.”

Yes, damn those doctors and lawyers for not agreeing with TallDave that poor people deserve substandard care, as punishment for their unspeakable crime of being poor!

Gad, you’re repellent…

firebrand June 27, 2012 at 6:36 pm

“We need to accept the principle that sometimes poor people will die just because they are poor.”

Sigh.

Statements like this only prove what kind of person you really are. And it seems like you’re quite the evil s**tbag, Mr. Cowen.

dollared June 27, 2012 at 7:59 pm

“*We need to accept the principle that sometimes poor people will die just because they are poor.* Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.”

We need also to accept the principle that elites that use their privileged positions to deny life essentials the the majority of the population will sometimes be strung up on lampposts. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other good – most importantly, unlimited access to political advertsising and immunity from the banking and securities laws as they existed as recently as 1990 – which in simpler times would lengthen their lives and which the poor enjoy to a lesser degree. We shouldn’t screw up our political institutions by being determined to ensure fair play and due process for rich people and their hired trolls for one very select set of factors which determine political process outcomes.

DonJon June 27, 2012 at 8:56 pm

Maybe you will DIE in the GUTTER of the revolution that is coming! You fucking piece of shit.

DonJon June 27, 2012 at 9:03 pm

This is seriously unreal…. This sounds like Nazi Town… You fucking pieces unnatural troll shit.

DonJon June 27, 2012 at 9:04 pm

This is seriously unreal…. This sounds like Nazi Town…

JohannGreen June 27, 2012 at 9:17 pm

“We need to accept the principle that sometimes poor people will die just because they are poor.”

You might “accept” this as a regrettable, inevitable fact – i.e., because it is impossible to design a workable healthcare system where this isn’t true. (I don’t believe that myself, but someone could make that argument.)

But – unless you’re a complete moral idiot – you don’t “accept” this as a fucking *design principle*. What the hell is wrong with you?

IanG June 27, 2012 at 9:19 pm

Your endorsement, I think it is, of the right-wing argument that everything we do to help the poor hurts them – i.e. “trying to equalize health care consumption hurts the poor” – is a mighty convenient & comfy way to think, but I see no reason why it necessarily has to be true. I also do not think that health-care can be discussed as if it is just another consumer good. If other societies can take care of their people, why can we, the richest country in the world, not do so?

It is only the rapacious, heartless greed of a small minority that could possibly endorse such a cold-blooded distribution of health-care as you have outlined.

I would vastly prefer Medicare for All!

DonJon June 28, 2012 at 12:36 am

“We need to accept the principle that sometimes poor people will die just because they are poor.”

I will accept that Nazi eugenics promoter Tyler Cowan get fucked in the ass with a broom stick and hung up with a meat hook in the blistering sun of Texas and beat continuously by those same poor people he wants us to accept will “just die because they are poor.”

Eli Rabett June 28, 2012 at 4:06 am

The real moral issue here is why should the inherited rich be allowed to waste their money on useless things. Carneige was right, he who dies rich dies disgraced.

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