thoughts on socialized medicine


Erik Kain

Erik writes about video games at Forbes and politics at Mother Jones. He's the contributor of The League though he hasn't written much here lately. He can be found occasionally composing 140 character cultural analysis on Twitter.

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53 Responses

  1. Avatar Kyle Cupp says:

    Good thoughts, E.D. While I’m undecided on the best way forward, I get irritated at knee-jerk reactions to the idea of universal healthcare that treat the idea as if it were one type of system that we absolutely had to incorporate in all its parts if we decided to switch to it. As you rightly point out, we can take what works well in other programs. And there are many of them! We don’t have switch to any one system. We can build our own with a mind to limit its foreseen negative effects.

    I also agree that we need to ask ourselves fundamental questions about healthcare. What kind of good is it? A public good? A private good? Is it a good that a for-profit system can provide for adequately?Report

  2. Avatar Jaybird says:

    Part of the problem is that health care is a positive good.

    If you have disease X, there is always one more treatment, one more specialist, one more prescription, one more operation, one more *SOMETHING* that could be attempted… well, that can lead to the question of “who gets to decide when we tell the person that, no, you don’t get to try one more thing?”

    And, given that we do not have an unlimited number of health care dollars to spend, there will, eventually, be something to say “nope, sorry, we are going to stop now”.

    Under the system we have, the rich can always buy one more treatment, see one more specialist, get one more prescription… and the poor get boned. Or those well-connected enough to get a good job with good insurance can mostly get stuff covered… while the poor get boned.

    A two-tiered system seems preferable, insofar as it will help the poor get boned less… but, eventually, the question will come up for why it’s fair that Mr. Rockefeller can afford a $100,000 perscription but it’s not available to the bottom tier. I thought this was America! How come the rich can afford one more treatment, one more specialist, one more prescription when the poor children (The Children!) cannot?

    And we’ll be back in the same place.Report

  3. Avatar mike farmer says:

    While, of course, I’d prefer private solutions, if government did provide these services, it would be wise to relax licensure laws which protect physicians and allow P.A.s to provide some of these services.

    “I know that the accepted argument amongst pro-business types is that competition drives down prices and makes goods more available. But it certainly hasn’t with health care. Costs are sky-rocketing, and largely because we’ve taken an area of society that was never meant to be a for-profit industry, and we’ve turned it into one, and in the process we’ve created a lot of unnecessary supply and demand, waste, etc.”

    I think this fails to take into consideration the incredible amount of government intervention into healthcare through the years which makes any assessment of free market forces useless. It’s like if I interfered with my assistant’s work all day, making changes, telling her she can do this, but no that, that but not this, then blaming her for whatever she was working on not working. She’s good at what she does, so if I leave her alone, she gets it done.Report

  4. Arrggh (I’m sorry if this comment seems testy – I’m just ornery today)! Look, I’m in favor of a number of single-payer options (as I detailed here:, but a lot of these arguments miss the boat in terms of understanding free market arguments about health care.

    1. What Jaybird and Mike Farmer said.

    2. No free market advocate (whether pro or anti-business – and can we stop treating free market and pro-business as synonyms?) worth his salt would defend the existing system (Republican pols and talking heads, yes; honest advocates of the free market, no). And that is in large part because the legal regime is set up in a way that totally perverts the market – insurance providers’ customers aren’t patients, they’re employers.

    3. As has been pointed out time and again, what we call health insurance really isn’t “insurance.” Insurance is something that exists as a hedge against disaster – it is, by its very nature, equivalent to gambling on whether or not you will suffer a disaster, except that the losses if you avoid disaster are tolerable, whereas the losses if disaster occured and you lacked insurance would not be tolerable. But it’s supposed to be a losing gamble. In the case of health insurance, though, we’ve decided that it shouldn’t just be a hedge against disaster, it should be the primary vehicle through which everyday care should be provided. This is, to be blunt, idiotic – we are quite literally paying our insurance companies to decide whether or not we should pay doctors for services we ask the doctor to provide….and if the insurance company decides that we shouldn’t pay for those services, we still have to pay for them out of money that we haven’t provided the insurance company in trust. On top of that, add the fact that the insurance company has little incentive to care whether you are satisfied with the way it decides to spend your money. Shockingly, this all results in absurdly high costs and poor service!

    4. Ultimately, there may be a good argument for completely government-based insurance, if we agree (as increasingly seems to be the case) that health care is a public good worth paying for collectively (to be distinguished from completely socialized medicine). Indeed, the US government, for all its bureaucratic problems, seems to do a fairly competent job when it acts more or less like an insurance company – the FDIC usually gets high marks, and as I understand it, doctors give much higher marks to Medicare and Medicaid than employer-based insurers.

    5. That said, this makes no sense to me: “Costs are sky-rocketing, and largely because we’ve taken an area of society that was never meant to be a for-profit industry, and we’ve turned it into one, and in the process we’ve created a lot of unnecessary supply and demand, waste, etc.” Meant by whom? Is there a time-honored history of doctors being in the exclusive control of the sovereign? Should we expect doctors to work for free or at cost, since anything above that would be “for-profit”? If there is already “unnecessary demand,” wouldn’t nominally free health care services create even more unnecessary demand?

    6. I’m not sure why you think that the only thing standing in the way of socialized medicine is naked ideology and partisanship. This assumes that there aren’t any honest arguments against it beyond simply “longer lines.” You cite the German example, but ignore the Swiss one. Additionally, while it is fine to look at other countries for ideas, we shouldn’t assume that what works or appears to work there would work here – whatever they’ve implemented was implemented in the context of their existing laws, strictures, and customs, not to mention the things that may not appear to “work” to us, but may play a significant but unsung role in why something else “works.” Conversely, whatever we implement will be implemented against the backdrop of our existing laws, strictures, and customs. It will also have tradeoffs that need to be closely evaluated – whatever flaws exist in our current system, we shouldn’t pretend for an instant that there are no things that we already do well that could be hurt.

    7 Finally, Arnold Kling’s proposal ( makes a ton of sense and strikes me as something that would fit well against the backdrop of our existing norms and institutions.Report

  5. Avatar E.D. Kain says:

    #2 – Fair enough. The system is certainly distorted – though I fail to see how a “pure” free market solution would provide the necessary benefits either.

    #3 – Agreed. The system as it stands is awful, and #4, again, agreed.

    #5 – Of course doctors shouldn’t work for free – I was speaking more to the overall industry that has built up around health care, which is largely an example of public/private corporate statism gone bad. As you know I’m not a fan of such partnerships. Perhaps a purely free market system would be better, but probably not. Perhaps a purely government run solution would be better, perhaps not. But the system now is one in which subsidies, poor regulations, and especially the disconnect between consumer and provider (vis a vis employer based insurance) creates terrible results – and indeed supply and demand that are unnecessary. Look at the drift toward “specialists” and away from family doctors. That is largely unnecessary, wasteful, expensive etc. But it is more profitable for health care providers, and so we have profit-driven waste. That’s what I was driving out here.

    And by the way, some of the anarcho-open-source-mutualist stuff I’ve read on this makes lots of sense. The reason I tend toward socialization over that sort of approach is purely pragmatic and not at all ideological. I just don’t think there’s a snowballs chance in Hades that it would ever work in the real world, while in theory it sounds very promising. (in fact, much of my current stance on health care reform is based on what I view as the pragmatic, not necessarily best solution…)

    6 – of course there are smart arguments against this. But I’m not seeing any coming from people making the decisions, or from the mainstream voices on the matter. Which is too bad.

    7 – Thanks, I’ll take a look.

    And Mark, you’re always ornery. I’ve resigned myself to it! 😉Report

    • Re: 2 – As you say in your last comment a “pure” free market solution isn’t available. But we can certainly move towards a “purer” free market solution. Specifically, I think a two-tiered system similar to what Jaybird described and to what I described in my old post would make a lot of sense – expand SCHIP, Medicare and Medicaid significantly, but for everyone else find a way of transitioning from employer-based insurance (which is heavily incentivized by various gov’t policies) to individual insurance that would presumably have higher deductibles, but significantly lower premiums. Bottom line, though: get rid of the perversions!

      Re: 5 – Like I said, I’m mostly on board with government provided insurance, but I have to insist that the laws of supply and demand still hold valid even if you do that, and even if you make doctors government employees. You might be suspicious of profits but the fact is that allowing individual doctors to set their own prices provides an extremely important signalling device about what society needs/demands more of, even if we might not like the results. The shift towards specialization may or may not be lamentable, but it tells us something about where the demand currently is. Of course, that demand might (actually, would probably) change under a different insurance regime of any sort.Report

      • Avatar E.D. Kain says:

        Hmmm. So how to combine a strong public safety net with a purer free market? Smart means-testing plus a move toward deregulation?

        I’m in favor of putting an end to patents altogether in the drug business. Or severely limiting their use. More competition in the medical equipment, pharmaceutical, and other health-care related industries would certainly provide lower costs. I’m in favor of competition along these lines. I’m in favor of cooperatives to increase the buying power of small businesses and individuals. But I think a strong public option needs to exist alongside these or we will find ourselves in a continually devolving health crisis.Report

        • Exactly (without expressing an opinion one way or another on patent law changes).Report

        • Avatar Kyle says:

          I really wish I had a better understanding of the healthcare industry in general because maybe this is a stupid question but isn’t part of the reason why Americans pay so much for pharmaceuticals is because we’re paying for exorbitant R&D costs and subsidizing losses the companies incur abroad? In which case, lowering costs would be good for American consumers (British and Japanese as well)but not necessarily for the industry upon which the consumers are reliant.

          What you’re suggesting, fewer government controls, more competition, and lower costs, sounds very much like what the goals of airline deregulation were. Which, worked. Disastrously for the airlines, horribly for the environment, and, as it turns out, going from general profitability to marginal profitability placed enormous pressure on airlines to adopt unsafe procedures to save money.

          Now I don’t know how germane or useless that example was but I guess I’d like to know more about how cutting costs will affect the overall research, development, and production of pharmaceuticals. The production of quality and helpful drugs being at least as important as their affordability.Report

  6. Avatar E.D. Kain says:

    Okay – I like what Kling has to say to some degree – except this:

    If I were a Republican, I would support a public health insurance plan that provides real health insurance. That is, it would have low premiums, but extremely high deductibles and co-payments–beyond anything we see today. People on the plan would, on average, pay more than 50 percent of their health expenses out of pocket. Only people at the very high end of expenses would get insurance payments. Even their co-oayments would not drop to zero.

    I may be missing something but while 50% of most health care costs might be affordable to some degree for some people, what about if I get in a car accident and need surgery that runs say, $20,000? I’m supposed to buy insurance and still pay $10,000 out of pocket? That would destroy me.

    I think that “reducing” health care use is important, but not in the sense that Kling is talking about. I think getting “gatekeepers” involved in the health care practice is important – actual primary care, low-cost general practitioners, even nurse practitioners, who handle most health care needs, who are there also to educate, immunize, etc. and to really put priority into prevention and health. The reason costs have gone so high is, quite frankly, the abundance of tests, specialists, etc. among other things.Report

    • Avatar Mark says:

      I think you are justifiably suspicious of any health care plan presented at the Cato Institute. Kling is still trying to drown the government in the bathtub, so to speak.

      The “spinach” of health care reform, as Kling so oddly refers to it as, should be to improve health outcomes, presumably by actually bothering to cover the entire country. This is not “dessert” – it’s always amazing to me that so-called “Libertarians” think that their own “right” to pay lower taxes trumps their neighbor’s right to be alive.Report

  7. Avatar E.D. Kain says:

    Oh – and “free market” vs “pro business” while I understand your distinction, the fact remains that supposed free markets simply don’t exist and I don’t see them coming into existence any time soon. When politicians and business types talk about free markets they are simply referring to agendas that will enrich them, not truly free the markets up in the way that I know you define free market capitalism (in its anarchical sense). So in theory I tend to agree with you on a lot of that, but in practice I see time and again this theory fail…Report

  8. Avatar Kyle says:

    Good post E.D. I have some more thinking to do on the subject but the idea of providing community focused/based preventative health care services is an attractive one.

    but I do think that when it comes to health care, pretty much everything else – including political ideology – needs to take a back seat.

    Is it possible (in philosophical not realistic terms) to sunder a discussion of healthcare solutions from politics/political ideology. Ideology seems to inform (for some) and dominate (for many) not only views on the scope and urgency of the problem itself but also the entire breadth of solutions.

    So isn’t saying that you can have a healthcare discussion/solution without political ideology kind of like saying you can judge without any influence of personal experience/identity?

    i.e. aspirational but ultimately unattainable.

    I agree the healthcare debate is entirely too partisan but even if you were to strip partisanship from the debate, I think you’d still have legitimate ideological disagreements.

    we’ve taken an area of society that was never meant to be a for-profit industry, and we’ve turned it into one,

    Is this true? Maybe this is just a facet of my growing up in the West, but it seems to me that American history is rife with examples of distinctly for-profit miracle cures, wonder tonics, and surgical fads.

    Although I agree that profit should be a secondary concern of medicine, I’m not sure that our present system is some sort of historical aberration, but I don’t know much about American medical history so your thoughts on the matter would be appreciated.Report

  9. Avatar Jaybird says:

    Have they ever measured which countries are most responsible for most of the newest, bleeding edgingest treatments?

    I’m tempted to suggest that the difference between new tech developed by the US compared to the new tech developed by Canada is disproportionate to, say, our relative populations or GDPs.

    I don’t know though. Is there anyone with stats out there to disabuse me of my suspicions?Report

    • Avatar Mark says:

      It doesn’t make much sense to compare the US to Canada. Canada is a small enough place that minimal investment (or lack thereof) can make the difference between having no industry in a particular area and having one that is so large as to be completely out-of-proportion with the size of the rest of the economy. For example, Canada was once the 2nd-largest car manufacturer in the world. But Canada also has no domestic manufacturers of airport bomb screeners, for example, which posed some difficulties recently. If you want to compare the US to another country, you need to look at Japan, or maybe Germany and France. Canada is just too small – I kid you not when I say that I know my Member of Parliament, and I could call him up anytime.Report

  10. Avatar E.D. Kain says:

    I’m not sure that matters so much. For one thing, there should be no constraints on the development of new technology just because medical providers are using a government insurance plan. Nobody is saying we should socialize the developers of medical technology. And beyond that I’m pretty sure that Sweden, Canada, and Japan all have pretty outstanding tech industries. But I’ll have to dig.Report

    • Avatar Jaybird says:

      Well, here’s my intuition. Let’s see if it makes any sense.

      There is a drug that is going to come out in 2027. It is called Cabrotilerolperin (it’ll be advertised as “Cabro”). It is, truly, a miracle drug.

      It reduces high blood pressure and has only one negative side effect: it increases the output of hair follicles. A fairly hairless guy becomes a hairy guy. A hairy guy becomes Robin Williams. Women who take this drug, sadly, grow goatees… but what can you do? It reduces high blood pressure. They can get that laser removal done, anyway.

      Now, as a person who suffers from high blood pressure, I ask:

      Am I entitled to this drug? Do I have a right to get it for free (or at negligible cost)?

      This drug does not exist. I am not and *CANNOT* be entitled to it. It’s absurd to believe so.

      Here’s my intuition: its creation does not change the amount of entitlement I have to this drug. It remains “none at all”.Report

      • Avatar E.D. Kain says:

        Same go for antibiotics? I don’t know, jaybird. The point is not that people are entitled to each and every drug. The point is that as a society we are obligated to some degree to the general welfare of our populace, including, and perhaps especially, the health of our populace. Indeed, providing said drug free or at negligible cost might save money in the long run, so whether or not it is specifically something we are “entitled” to may be beside the point in a purely pragmatic sense.Report

        • Avatar Jaybird says:

          “Same go for antibiotics?”

          I don’t see how it wouldn’t go for antibiotics. Are you entitled to Penicilin X (the “X” is for EXTREME!!!!)? It hasn’t been created yet. Are you entitled to it?

          How about (treatment)? How about access to (new and wonderful machine)?

          Does my obligation (as a society!) extend to give these things (that we agree that I am not entitled to) to someone who might die without it?

          If I am not entitled to (prescription) or (treatment) or access to (new and wonderful machine), can we agree that we, as a society, are not obligated to provide these things?

          Can we then discuss whether (extant drug) or (extant treatment) or access to (extant machine) is similar to the above in any meaningful sense?

          Or is that outside of the scope of what we’re talking about?Report

          • Avatar E.D. Kain says:

            So are we coming up to the tension that exists between both obligation and entitlement as well as society vs. individual? To my mind society (as composed by individuals) exists to provide entitlements (including general welfare, defense, etc.) out of a sense of shared benefit and obligation. Does this mean that we are entitled to every extant or conceivable treatment? No. Does it mean that we (I know you hate that word) as a society (again!) need to determine as best we can what treatments need to be applied to create a better, more ordered civilization? I would say, yes. That is why we have 40 hour work weeks, or programs to provide children with free education or free health care. Is a child “entitled” to an education. I don’t know. Is there some universal rule to follow when determining this? Or are we bound by our own flawed system – which is still better than doing nothing or relying on some utopian sense of the perfected individual…Report

            • Avatar Jaybird says:

              I am of the opinion that we have a golden goose that gives eggs so golden as to provide us with a country where one would hope one would end up (assuming a veil of ignorance, of course)… in addition, I believe that we are a country that develops the tech upon which other countries adopt at cost (analagous to the “free rider” problem, maybe?) and the idea that we, as a society, have an obligation to provide stuff that didn’t even exist X years ago will result in the death of the goose.

              But, hey. At least we’ll have free health care.Report

              • Avatar Kyle Cupp says:

                I don’t think we can accurately speak of an absolute entitlement to medicine M or procedure P, for reasons that you indicate, but if we as a society have the capacity to provide for one another using medicine M or procedure P, and can do so without killing the “golden goose,” as you say, then I’d say we have an obligation to do so. As Spiderman says, with power comes responsibility.Report

              • Avatar Jaybird says:

                I do not own medicine M. I do not know how to apply procedure P. I cannot give treatment T. I do not have a wonderful machine WM to provide access to.

                To say that I am (or you are) entitled to these things that others have strikes me as me giving away someone else’s stuff.

                Even if we have a vote on it first.Report

              • Avatar E.D. Kain says:

                Yes well, perhaps that “someone else” lives within the same country as you, and perhaps they share in all the benefits of living in said country – roads, a first rate military, police and prisons, etc. Maybe if they don’t like helping to provide for their neighbor’s sick children they should “go Galt” and buy an island somewhere to revel in their selfishness.Report

              • Avatar Jaybird says:

                Which is the flip side of the argument that if you want to live in a nice society with nice people who want to give you free health care, you can move to Denmark and have little wine and cheese parties with all of the other expats over there enjoying their free Tylenol.

                (Aside: I cannot believe the tendency of flag wavers to resort to “love it or leave it” whenever anyone disagrees on how stuff ought to be done.)Report

      • Avatar Creon Critic says:

        Am I entitled to this drug?

        Depends on what theory of rights you’re using. As someone who favors the interest-based theory of rights, I beleive an entitlement is generated by your interest in obtaining the medicine. High interest in the medicine means a high obligation for provision. So, maybe blood pressure medicine doesn’t fall into this category (depends on how much oa a miracle drug it is I suppose), but anti-retrovirals for HIV/AIDS treatment do. For instance, the South African Supreme Court has a pretty developed jurisprudence on economic and social rights and their consequences for the state (For a breif overview, see Comparative approaches to econ and social rights protection). Specifically dealing with the anti-retroviral example is their case, Minister of Health v Treatment Action Campaign. Economic and social rights are made justiciable because the Court recognizes certain boundaries, like reasonableness and progressive realization – but these boundaries do not vitiate the underlying right (One caveat, I come at these matters from an understanding human rights angle, I’m not a lawyer).

        Or there’s the Rawls route. Not knowing how healthy you’ll be, which society would you rather live in: A society that recognizes and works towards the realization of economic and social rights à la the South African Constitution, or a society that says tough cookies, no medicine for you (not even the miracle ones? not even when medicine provision is reasonable given the resources of the society?)?

        Also, rights aside, what kind of good is public health? Is it a Rawlsian primary good, “a things which a rational man wants whatever else he wants”? Is public health a public good?Report

        • Avatar Jaybird says:

          The very idea that “a things which a rational man wants whatever else he wants” has any necessary overlap with “rights” is astounding to me.

          For one thing, you see the (No True) Scotsman’s thumb on the scale right there. I mean, is (sex act) something that a rational man wants whatever else he wants? Of *COURSE* it is!!

          That doesn’t make it a “right”. It’s absurd to think so.

          “Not knowing how healthy you’ll be, which society would you rather live in:”

          Just because I *WANT* something does not make me *ENTITLED* to it… which means that I am not *OBLIGED* to provide it to others.

          I mean, any rational man would agree with that.Report

          • Avatar Creon Critic says:

            I’m not arguing a mere desire, or “want”, generates a right, I’m arguing a sufficient interest generates a right. This frames the discussion around what the interest means to the individual. Does the interest have “the requisite sort of importance to justify the imposition of duties on others variously to respect, protect, and promote that interest” (Thomas Pogge, here)? How widely shared is the interest? What capabilities are denied if the interest goes unmet (the capability approach)?

            My interest in satisfying my sweet tooth – fail. My interest in being literate – pass. My interest in not dying of some wholly treatable illness (especially in a society with the resources to provide prevention/treatment) – pass.

            I take your point about putting my thumb on the scale – this is a theory of rights that is fairly inclusive when compared to its competitor, will/choice theory; and Rawls’ concept of “primary goods” is particularly compatible with the interest-based theory of rights. Overall, people are constructed as needing a lot (positive and negative rights) to have autonomy/human dignity – Rawls’ account of self-respect for example.

            I notice you deftly avoided saying which society you’d prefer to live in. I’m particularly curious as to what advantages the alternate society (South Africa vs. tough cookies) has – low taxes? Strongly constructed notions of private property, notions of the individual? Highly profitable pharmaceutical companies?

            Glenn Loury remarks (on a totally different subject, but his point applies to this discussion),

            The most challenging problems of social policy in the modern world are never merely technical. In order properly to decide how we should govern ourselves, we must take up questions of social ethics and human values. What manner of people are we Americans? What vision would we affirm, and what example would we set, before the rest of the world? What kind of society would we bequeath to our children? How shall we live? Inevitably, queries such as these lurk just beneath the surface of the great policy debates of the day.


            • Avatar Jaybird says:

              “I notice you deftly avoided saying which society you’d prefer to live in.”

              I’d prefer to live in a city where the chicks are as hot as in Las Vegas, the jobs are as stable as on K Street, the food is as good as NYC, the rent is as cheap as Duluth, and the weed is as plentiful as Vancouver.

              For the life of me, I don’t see how my personal preferences relate to any discussion of rights.Report

              • Avatar EngineerScotty says:

                That gets to the underlying theory, I suppose, of natural rights vs social contract–if you assert that rights arise from nature and are (or should be) inviolate–and that this doesn’t depend on any sort of cultural context, it wouldn’t matter where you live. Further, if you believe, as I kinda suspect, that being taxed for the benefit of someone else (or having a product you manufacture price-controlled, etc) is a violation of your rights, but being excluded from lifesaving medical care (based on an inability to pay for it) is not; then I suspect that you would not like South Africa in this case.
                Of course, many of us disagree with you on either a) the existence of natural rights, or b) what they ought to be. I, for one, find your position–at least at the extreme–obnoxious. Where to draw the line is a difficult question, of course, but let me ask you this. Were you to get hit by a car, paramedics will come to your aid. The fire department and police, in most jurisdictions, will not charge you for this service; depending on where in the US you are, you may or may not have to pay for an ambulance ride. Your tax dollars, of course, pay for the police and paramedics.
                Are your rights infringed by this arrangement? If so, what other arrangement would you propose?Report

              • Avatar Jaybird says:

                Ah, the social contract.

                I do not mind the idea of a social contract (I *LOVE* contracts!). I just wish I had more say in what it said and on the terms under which it changed. It also would have been nice to have been asked to sign.

                When it comes to paying for police officers to help when I get hit by a car (or when you do), of *COURSE* I don’t mind that particularly. (Is it a violation of rights? I don’t mind the idea of public servants whose job it is to keep the peace… in theory. I’m not too crazy about those who shoot puppies during drug raids on the wrong house.)

                But we aren’t talking about accident services, are we?

                We’re talking about whether we ought to modify the social contract so that it will henceforth include Socialized Medicine… up to and including my responsibility for your replacement (body part) after a lifetime of your (bad habit)… and, more to the point, discussing “well, we pay when you get hit by a car… now we’re just haggling over whether we pay when I need (replacement body part)!”

                (And when I say “I don’t think that we should change our social contract”, I can usually expect to be told a variant of “love it or leave it”.)Report

              • Avatar Creon Critic says:

                I’d prefer to live in a city where the chicks are as hot as in Las Vegas, the jobs are as stable as on K Street, the food is as good as NYC, the rent is as cheap as Duluth, and the weed is as plentiful as Vancouver.

                Ah but would you say that is you were a gay, itinerant, non-foodie, with lots of money, and against smoking pot? Reflective equilibrium clears stuff like this up every time.Report

              • Avatar Jaybird says:

                I’m sure I would prefer different things if I were a different person.

                I know for a fact that my preferences at age 21 were *COMPLETELY* different than they are 15 years later… and I know that 15 years from now, I will likely have new and different preferences.

                Hell, I will probably have different preferences tomorrow.

                This is why I find “preferences” to be far, far different from “Rights”.Report

  11. Avatar Kathie Brown says:

    Arnold Kling’s suggestions may strike some as fitting “well against the backdrop of our existing norms and institutions” but the question might be which “norms and institutions”? Our income and income distribution norms? The present piecemeal system of price negotiations between medical institutions and multiple insurance plans and companies? Our unequal treatment of primary care providers vis a vis specialist providers? The cost of prescription drugs and the subsequent pressure by insurers to turn mail-order drugs into a new profit center for themselves (and, by the way, weaken local pharmacists)? The use of emergency rooms as family physicians by poorer Americans, in part because they can’t afford an ongoing relationship with a family physician?
    One of the “norms” of our current system is the astounding difference between what you as an individual pay for a medical service and what your insurance company pays. So do Mr. Kling and Mark imagine that we will ALL be paying negotiated rates (and who would be that single negotiator because now there are as many as their are insurers?) so that we could pay 50 percent of our medical costs — because paying 50 per cent of non-negotiated rates is beyond most Americans’ abilities. Although preventative care to keep us as healthy as possible is prudent, we would need incentives beyond prudence to convince many people to pay for that care out of their own pockets when they’re feeling healthy.
    This effort to design health care reform by playing up the “insurance” analogy will not reduce the inequity and uneven access that motivates folks like me to change our current norms and institutions. The need for medical services cannot be easily budgeted for like deciding how big a mortgage one can handle or how much to spend for a car. I’m sure Mr. Kling is thinking about at least the $5000 deductible now common in the individual insurance market (that’s per person or $10,000 per family) on top of the $4200 yearly premium. Many of his friends may have incomes that elastic but many of mine don’t. Like E.D., I think it makes more sense to involve the government at the lower end of the scale, where most people spend their health care dollars in good times, and achieve higher general levels of health as a common good. Then construct a catastrophic insurance market for the really expensive interventions that far fewer people suffer. What I don’t know how to address are mid-range situations like my recent broken femur, that billed at over $75,000 but for which my providers were paid closer to $30,000. And my income is not elastic enough to handle even that $30,000.Report

  12. Avatar greginak says:

    In regards to paying/entitlement to the newest tech. That is somewhat of red herring, since it is basic, preventative care that can often do the most to extend life. If we can prevent HBP or diabetes then we have less need for the highest tech.

    Also the government pays for a lot of basic medical and bio research because profit making companies want to pay for what will put money in their pockets. The gov can still fund oodles of basic research and even when we improve our healthcare there will still be plenty of money to be made.

    One of data points about other countries that have some sort of universal coverage, whether socialized or not, is that many have equal or better life expectancies. So it seems like we can cover everybody without a piling up dead bodies.

    Mr. Kling, feh. It is easy to pile up tens of thousands of dollars in one stay in the hospital. My son was in the hospital years ago and we had bills in the hundreds of thousands. One basic facet of a sensible health care system is that people shouldn’t go broke or bankrupt if they actually need care.Report

  13. Avatar richard says:

    “I’m in favor of putting an end to patents altogether in the drug business. Or severely limiting their use.” e.d. kain. Why would any company pour hundreds of millions into research and development to produce a drug with no patent protection. i can’t think of a surer way to kill innovation and stifle competition than to do away with patent protection. Among the top twenty pharmaceutical firms world wide the U.S. has ten. Sweden Canada and the U.K. have one among the top twenty between the three of them, and that one is a British firm. Draw your own conclusions on how much innovation in this field comes from these three countries. and ask yourself why the U.S. companies dominate. “I’ve read recently that health results in areas where most of the medicine was provided by general practitioners (family doctors) rather than by a host of specialists were actually much better – longer life expectancy, lower costs, and so forth.” E.D. Kain. Jesus that’s a pretty bold statement could you point me to these studies. I’m not saying its a bad system or concept but i am dubious of your overall claim of superiority. Finally I have been on cobra, company plans((ppo and hmo) and I have been without insurance. i have tremondous empathy for those who are not covered. I have a chronically ill daughter who requires monthly medications which cost close to a $1000 a month. I do not know what the best solution is. as a conservative i have doubts about single payer. as a person with compassion there is no excuse for anyone in our country to be without medical recourse. i have been there and it is hell and I live in fear of losing my insurance again and being unable to pay for my daughter’s healthcare.Report

  14. Avatar mike farmer says:

    Of one thing I’m certain — when we begin taking the individual and his/her mind for granted and acting as if they’re pliable, functioning part’s of “society” to be engineered to the benefit of some mysterious “greater good” by government planners, we’re becoming as delusional as Stalinist flunkies.Report

    • Avatar Mark says:

      That’s bizarre. Our advantage in electronics innovation, for one, owes itself to the enormous government expenditure in the defense industry over five decades. Has there ever been a larger government-planned effort directed at the nation’s “greater good”?Report

    • Avatar E.D. Kain says:

      I don’t think that health care qualifies as “social engineering” but that’s just me.Report

  15. Avatar mike farmer says:

    You can depend on the defense industry for the future — I choose to place my confidence elsewhere. But the real point is that if you create a situation where there is a brain drain, even billions spent on government research will not produce very good results. When you follow the development of ideas, it’s usually a handful of individuals who have worked diligently, and who have special talents, who led the research to incredible results — these types of discoveries can’t be commanded to happen. Russia spent billions, but with very few original breakthroughs — it’s not so much the research that can be bought, it’s the environment where free minds are allowed to take the research to higher levels — it’s the motivation to do these things. You can get results from the point of a gun, but they aren’t the best results, and they usuually lead to to the wrong types of use. The defense industry could never envision what their research would develop into in the, relatively, free market. There’s a tendency to just play the game, unless there’s freedom of expression and the right to own the fruits of labor.Report

    • Avatar Mark says:

      I don’t think you understand the motivation of scientists and engineers who work in R&D. They’re not in it for money or fame – if they were, they would have long ago jumped to far more profitable careers in sales or finance. In particular, there’s no money in basic research with a five-year (or longer) outlook – that’s why various federal agencies fund it. It is hardly a failure of imagination that defense contractors didn’t foresee federal deregulation of the airwaves 40 years in the future.

      It’s convenient to assume that everyone engages in profit-seeking behavior. But it’s just not the case – doctors, in particular, are obsessed with finding the specialty that most interests them, and they will often switch residencies mid-stream, at a massive financial penalty.

      I also find your concerns very chauvinist – Japan and Korea beat the US in all kinds of high-tech industries, and they certainly don’t offer their workers the kinds of financial incentives you assume are required to spur innovation.Report

  16. Avatar E.D. Kain says:

    Jaybird (from above):

    (Aside: I cannot believe the tendency of flag wavers to resort to “love it or leave it” whenever anyone disagrees on how stuff ought to be done.)

    I certainly was not saying you (or anyone) should leave if they don’t want to pay taxes or whatever – I was saying “good luck with that.” Or, rather, good luck finding a society that you’d want to live in that doesn’t find itself further and further obligated to providing social services for the more disenfranchised. You’re not going to find such a utopia because it doesn’t exist…Report

    • Avatar Jaybird says:

      So, in the future, when we discuss inequality… it’s cool to just say something like “you want to make the world fair? Good luck with that.”?

      I’m down.Report

      • Avatar E.D. Kain says:

        Sure. I recognize that the world will never be “fair” and that such a goal is inherently flawed. That is hardly the central thrust of my arguments in any case. I’m arguing for safety nets because I think they will make the entire societal structure – the edifice itself – more sturdy.Report

  17. Avatar mike farmer says:

    Mark, we’ll have to agree to disagree — George Gilder has probably done more research than anyone tracing the developments of technological advances — it’s really very enlightening to see the chain of events and read about the players and what they put into their accomplishments. The reward — the fruits of labor — are not always measured in money, which I didn’t claim.Report

    • Avatar Mark says:

      Ah yes, George Gilder, Time Magazine’s “Male Chauvinist Pig of the Year”, 1978, who claims that information theory disproves evolution. Have you purchased your tinfoil hat from him yet?Report

  18. Avatar richard says:

    “Sure, if we choose not to fund them…..” how do you fund a ponzi scheme?Report