I was struck that Arnold Kling recently admitted:
My preference would be market-oriented health reform and the creation of real health insurance, which is bought by individuals and covers only insurable events (unexpected high expenses). But if it comes down to a choice, I’d rather have socialized health insurance with a robust private-sector job market than hang on to a private health insurance industry with a shriveled private-sector job market.
Of course, we could easily have health reform that keeps employer-provided health insurance and even makes matters worse. Odds are, that’s where we are headed.
Kling’s rank-order seems to be: Libertarian solution to healthcare > Socialist/welfare-state solution to healthcare > Current system and its descendants.
Is this a common sentiment among libertarians? That they would prefer the genuine socialism in healthcare to the current system? And how about liberals, would they prefer a genuinely libertarian solution to the current system? As I have noted before it seems that both the Left and the Right agree that the current system is not very good. As I note below even Republicans agree that there is a strong moral aspect in healthcare. If you ban discrimination against those with preexisting conditions then the incentive is to sign up for a low premium high deductible plan, and simply “upgrade” when you’d prefer a higher premium but lower deductible plan. Great market for consumers, if you can call it that….
razib,
Kling is reductive–to be insurable, an occurrence must be also be truly fortuitous and of estimable value (discrete) without verging on systemic. Mesothelioma and Asbestosis were not insurable events. An oil refinery blowing up or releasing oil into the gulf of Mexico is insurable as are fraternity members curbstomping an outsider at a party, a bus broker recommending a shitty coach service and many many more.
the non-health insurance market I am most familiar with (property & casualty) has a special section for the most hazardous commercial and recreational activities ongoing but also have an appetite for low hazard business and manage to price both in such a way that contractors in a very down economy are still able to buy it.
This is why I am so doubtful that any kind of scheme can provide the most acceptable outcomes to the most people–when I look at high hazard stuff, my first thought is not, “aha, generous terms and very little premium.” It’s, “we could lose our shirts, but if it’s well-run it’s a good bet not to blow up. This is worth serious premium for the coverage they should reasonably expect if a savvy buyer of insurance.”
of course, i’m looking at experienced professionals who are accustomed to closely reading insurance contracts and are familiar with general industry attitudes and how they changed over time. Even in Kling’s (and my) ideal free-market, I sincerely doubt that any future generation of health-insurance-buyer will know which carrier offers specifically what and for what price.
I routinely see the retail (faces you see on billboards off highways) agents who sell our policies fundamentally misunderstand and egregiously misrepresent the scope and degree of coverage afforded by them and the reason they continue to do so is that people tend to blame the evil insurance company for denying the claim than their agent who bought a cheap policy without the relevant coverages, or even the wholesale broker who made the transaction possible.
it’s rather hopeless.
Liberal here.
My rank order (using your not-exactly-dispassionate terminology):
Socialist/welfare-state solution to healthcare > Libertarian solution to healthcare > Current system and its descendants
I wonder if we might make progress in the debate by separating the idea of insurance (insurance against catastrophic costs) from regular everyday predictable costs. It might make it more obvious to people what they are buying. Perhaps they could even be provided by different providers?
A worthwhile article from David Goldhill in the Atlantic:
http://www.theatlantic.com/doc/200909/health-care
He winds up at largely libertarian conclusions, but does so from a liberal concern for providing a safety net.
Nayagan:
Ron White, one of the 4 or 5 resident philosophers on Jeff Foxwothy’s
“Blue-Collar Comedy” (on Comedy Central) sums it up best (and most succinctly): “You can’t fix stupid!”
Since all insurance consists in promises to allay one or another untoward effect contingent on future events, it is unsurprising that fraud and half-truth feature regularly on both sides of the contracts.
It would be fitting for government to enroll all t
You are arguing pins on the heads of needles. Obama is promoting a bill that almost no Congressmen have read. If you want to debate reality, read the bill (hint: it isn’t really written yet) and debate that.
The Obama plan will be friendly to trial lawyers and unfriendly to doctors and biomedical corps. Expensive political payback euphemistically described as healthcare legislation — in the grand tradition of bank bailouts and overhaul of auto manufacture. And just wait until Cap N Trade hits the economy.
Reality is a beech.
Is this a common sentiment among libertarians?
At least for me, no. My preferences are:
Libertarian solution to healthcare > Current system and its descendants > Socialist/welfare-state solution to healthcare
Yeah, I would prefer straight-out socialism to the current mess. I get irate over anyone characterizing this as a “free market”. It’s a government-regulated guild system that is a travesty of a market. All it does is give capitalism a bad name when people think that this represents a freedom-oriented solution.
Straight-out socialism is the straight-out worst option. Putting aside the question of utility (on which it’s rather weak), a socialist system nationalizes your body. Every conceivable act becomes government business, as it can be tied to health. In essence, you become government property, an asset or a liability to be managed. Oh, it’ll be dressed up in pretty lies, but that essential truth will be forever operable. The only way out is to have enough pull to bend or downright break the rules. Our system has its problems but it’s reformable. A socialist system would full on crash before we could return to sanity.
Health care is simply not a good area for the application of pure free market principles, as it is unreasonable to expect consumers to understand which “products” they want. Empirical evidence, in the form of the health care systems of other countries, suggests that a mixture of socialist and true free-market systems is best: a high socialist “floor” providing preventive and emergency care as well as cost-effective interventions, and a high free-market “ceiling” provided by private insurance companies.
Condition isn’t covered by the QALY (quality adjusted life years) criteria? Then the taxpayer won’t foot the bill, and you’d best have a private policy. Because all demonstrably cost-effective interventions are provided, waste and inefficiency are minimized, but the availability of private insurance for those with the resources to afford it preserves the element of choice. I find myself perpetually amazed that this clearly superior hybrid option is ignored in favor of the “pure” libertarian or socialist systems.
Preferred ranking: Hybrid > socialist > libertarian > current
That said, it is difficult to evaluate the pure libertarian case, as few if any examples exist. The closest system may be the highly regulated Switzerland, with costs nearly as high as in the US.
It’s also unreasonable to expect consumers to understand how their cars work, or how to construct a motherboard from scratch, would that make those products into a viable candidate for nationalization?
Explain to me in what way any “cost-effective intervention” could somehow be considered consistent with supporting a free-(lack of intervention)-market without landing ourselves right back into the crapy mixed/corporatist situation that we have today. Deregulation of the healthcare industry would open up a plethora of opportunities for competition. In return the quality products/services would go up as the cost goes down and perhaps then, you won’t even need insurance for care. It’s only when a handful of insurance companies get in bed with the government that they’re able to stamp out competitors with the help of big brothers regulations and form stagnant, wasteful, monopolies. Competition is the driving force behind progress, and that can only occur where there is a market for it. Even Ted-nationalize the healthcare industry while getting treated for your brain tumor at a distinguished private hospital-Kennedy would agree with that.
@Miles White
Miles,
How does understanding the underlying physics, much less how to build one from scratch, have any bearing on one’s choice of product? Presumably when buying a car you have a list of criteria – mileage, features, reliability, reviews, feel of the test-drive – and choose based on how well each model fits your conception of your needs. In healthcare, your need is simple: “Stay healthy”. Whether or not a given treatment will help you meet that need is more than the consumer can be expected to judge. Ultimately, most people are forced to trust their doctor, who is already overworked and may have competing financial interests. Want to shop for doctors? Go ahead, but where I live most practitioners already have significant waiting lists.
To clarify, “intervention” referred to a treatment, not a market intervention. Apologies for the confusion. I never claimed it was consistent; the free-market approach would apply only to treatments not proven cost-effective under QALY criteria. A pure, completely deregulated libertarian approach has never been tested; I would love for some country to try it, but I’d rather it not be mine. Surely the conservative position is to adopt the best proven model rather than embarking upon a radical experiment from first principles? In this particular case, that means copying France. Such is life.
And how about liberals, would they prefer a genuinely libertarian solution to the current system?
If the “genuinely libertarian solution” involves people whose need for healthcare exceeds their economic productivity being left to die in the streets, then no, they would not. A lot of that already happens under the current system but at least there are *some* attempts to prevent it (e.g. Medicaid).
The inability of libertarian principles to come up with a solution that doesn’t kill those people has a lot to do with the unpopularity of libertarian principles, I think.
Poor people, by definition, have little or nothing to offer the market (possibly some low-market-value labor, but if their health is sufficiently bad, perhaps not even that); therefore the market has little or nothing to offer them. TANSTAAFL. But the reality of human psychology is that very few people are willing to accept such a ruthless death sentence on people who have generally done nothing to deserve it.
P.S. The example of Stephen Hawking was dishonestly raised in the US health-care debate as someone who might be adversely affected by health-care reform — dishonestly because Hawking is British and has been covered by the UK’s single-payer system since childhood. But imagine someone in the US with the same medical condition as Hawking, but who isn’t also a genius academic. How do you write an insurance policy for that person? This illustrates the limitations of the insurance approach to health care — and also the market approach. There’s just no way such a person can afford his or her own health care.
Liberal here.
I guess I’d go “Socialist” -> “Libertarian” -> Current. I guess. The devil is in the details. I see systems around the world that function better than the current system. Most, if not all, are more socialistic than ours. I hear what sound to me like pie-in-the-sky Libertarian solutions. I have a Libertarian streak in me, and I’d actually very much like to believe that we could reform the current system in a Libertarian style (aka tear the thing down, especially employer-based health insurance) and end up in a better place. The current system is a Rube Goldberg machine. The Baucus bill is garbage that might actually make things worse.
But, much like Chris above, that new system needs to provide at least a basic level of care for the poor. I’d prefer a socialized system for all with private policies available to cover stuff the government doesn’t, which would allow people with more money to get more healthcare (and all that entails) while not leaving the poor the ER or the gutter. A two-tiered system, if you will.
I see Libertarians calling for total deregulation of healthcare, including stuff like Doctor certification. Barriers to entry! Bad! Yes, there is a cost there – this probably does reduce the supply of physicians (and we do appear to have a problem with primary care physicians). The flipside is that we do want to prevent quackery, do we not? Ah, but in a real free market, the quacks will lose business! Yeah, sure. After they’ve killed how many people? How will they lose? Lawsuits against them? I thought Tort Reform was all the rage…
This just doesn’t compute to me. The assumption that everyone should become a healthcare expert (and I do mean an expert, as opposed to taking some reasonable steps to educate oneself about a condition you may have) and be able to steer clear of charlatans, be able to bargain for the appropriate price of a service (oh, say, a liver transplant?)… I’m sorry, but I don’t buy it.
I’m intrigued by the HAA. Does that fall under “libertarian” reform or “socialism?”
fwiw. when i say “libertarian” or “socialist” i don’t necessarily really mean the extreme visions, e.g., people dying if they can’t pay vs. an NHS like service. there are certainly people who would wish that the laws which require emergency room care to be given to people in need regardless of ability to pay be repealed. but that’s really a nonstarter.
I see Libertarians calling for total deregulation of healthcare, including stuff like Doctor certification. Barriers to entry! Bad! Yes, there is a cost there – this probably does reduce the supply of physicians (and we do appear to have a problem with primary care physicians). The flipside is that we do want to prevent quackery, do we not? Ah, but in a real free market, the quacks will lose business! Yeah, sure. After they’ve killed how many people? How will they lose? Lawsuits against them? I thought Tort Reform was all the rage…
This just doesn’t compute to me. The assumption that everyone should
so i don’t think this is an either/or. for example, loosening licensing or introducing grades of license would probably do a lot to increase access by increasing labor supply. i think we’re at one extreme, so there’s probably a lot of plausible slack in the system.
@David Hume
Fair enough, but you understand my concern. Perhaps it’s just the way people sometimes communicate (or don’t) on the ‘net, but I haven’t seen much nuance to the deregulation argument before. Plus, not being an expert on the current licensing setup, I don’t really have the knowledge base to have an intelligent discussion re: small tweaks to that setup.
People do realize you can get private medical care even in England, right? It’s not the Soviet Union! (…Erm, where you could also get private medical care, even if it was not official. But anyway.)
A truly libertarian solition would be great: the unregulated quacks could kill off all the credible idiots. Better than an Obama Death Panel, by my troth!
More seriously, as a liberal (which does not mean a socialist) I favour a mixed solution: strong nationalized healthcare with plenty of room for those who can afford it to pay for above-standard care options (including things such as treatment choice, etc.). I don’t see a libertarian option as even on the table because I just don’t think it would work.
@outeast: Why would lack of workability prevent it from being on the table? Abstinence-only education was not only put on the table but actually enacted, despite being totally and predictably unworkable. There are many other examples.