By a thousand cuts.

Alfie suffers from a rare neurological disease that doctors at the hospital have been unable to treat. Alfie’s parents want to take him to a hospital in Italy that has offered to provide care and treatment and to do their best to combat the medical condition, but doctors at Alder Hey Children’s Hospital in London say Alfie’s condition is too far gone and they want to pull his life support and end his life.

I’ll be honest with you, I find myself growing numb to these stories. Not because it doesn’t matter, or because it doesn’t affect me, or that I agree with the court’s decision—it’s that it’s too horrible to fathom. I’ve lost a child to circumstances no one could control (congenital heart defects), and my heart and mind recoil in horror and revulsion at the thought of bureaucracy deciding she wasn’t worth fighting for. We were able to try everything our insurance allowed, we had the best surgeons and care, and we had nearly three years with her. But would a bureaucrat have deemed her life worth prolonging, especially with the uncertainty of a favorable outcome?

By a thousand cuts.

Image by CG Hughes By a thousand cuts.

What do we become when we cease valuing life as a society? Iceland has a 100% abortion rate for Down Syndrome babies. (America isn’t much better: ours is somewhere like 90%.) The Netherlands has practiced infant euthanasia for some time. I’ve read dispassionate arguments stating that infanticide has been practiced throughout human history and is therefore more commonplace than our delicate, modern sensibilities allow, to which I’d counter that the rise of Judaism and Judeo-Christianity readjusted humanity’s baser nature, focusing on the preservation of life, regardless of its imperfections and inherent difficulties. And one only has to give the bulk of humanity’s literature and history a cursory glance to see that valuing life is normal, human behavior.

What isn’t normal is allowing government to control who lives and dies outside of the criminal justice system (which is actually an oversimplification on my part for the purposes of brevity). But we can look at the UK as a model for what not to do, as the British people have been slowly conditioned with each new iteration of the Nanny State, inoculated against governing themselves. Ceding control of the well-being of one’s children to the government seems counter-intuitive initially, but when you take into consideration the infantilization of adults in Western culture—adolescence that extends into one’s 30’s, the insidious idea that one must sacrifice liberty for safety—giving up our children to our betters seems only natural.

Children of the state

And then, suddenly, you can’t homeschool your children without breaking the law (Germany), or take your terminally ill child to specialists in another country. The helplessness these parents must feel breaks my heart. This is what civil libertarians warn against when the push for socialized (“universal”) healthcare results in monstrosities like Obamacare, which was always meant to fail and leave us no option but single-payer healthcare. Single-payer, government-mandated healthcare is handing the faceless bureaucracy unfettered access to your most intimate information, with which they can then do anything, including decide whether you live or die. Whether you “deserve” that liver transplant for your congenital liver disorder when it seems you may have had a few drinks over the course of your life. Whether your child, severely ill and yet still alive—still the possessor of your heart and soul—should be allowed to continue breathing.

All of the criticism directed at “corporations” for treating people like numbers on a spreadsheet becomes reality on a national scale, except when government is the sole provider of healthcare (or education, or whatever), the consumer has nowhere to turn for better options. At least not anywhere the average person can afford. With corporations, competition keeps overreach in check. With government holding a monopoly, we’re at the mercy of the leviathan.

And so are our children.


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111 thoughts on “By a thousand cuts.

  1. Reads:

    to which I’d counter that the rise of Judaism and Judeo-Christianity readjusted humanity’s baser nature, focusing on the preservation of life, regardless of its imperfections and inherent difficulties.

    Thinks about all the killing in the 19th and 20th centuries.
    LOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOLOL.

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      • Okay, sure. The paragraph I took the quote from was ridiculous to me. Sure, plenty of people value life, though most are pretty choosy about which lives they value. In the context of an article complaining about abortions while not acknowledging the very real problems of medical insurance that are driving the push for single payer systems, it seemed a facile point. Let’s discuss children dying because of lack of care or our too high infant mortality rate and lack of prenatal care. Or that we have to fight to keep birth control available and covered by insurance. Of course, the author has no obligation to discuss these subjects; it’s her article. I thought laughter more civil than saying it was a stupid point.

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        • Neither of those things are particularly civil (though I would argue that laughing at someone is rarely more civil than telling them they said something stupid) – but the stuff in the middle of this comment here is extremely valid and important.

          That’s why we push for substantive comments rather than ridicule.

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    • It’s interesting that so many latched onto this particular point, considering it was a throwaway line when I wrote it, as I was using these two religions as examples, not definitive sources. Many religions advocate the sanctity of life and yet have bloody things done in their names. I’m thinking of Islam as a modern example. I assume that judging Judeo-Christianity for past crimes is fine, but Islam–and here I must announce that I do not judge all Muslims by the outliers–has a very recent history of bloodshed, and yet I’m told it’s a religion of peace. This particular piece is about valuing life and resisting the urge to cede our rights to government, and yet we’re talking about the Crusades. It seems… odd.

      PS–I would also argue that one can be an atheist and still value life. This isn’t about God, it’s about humanity.

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  2. Hello April! So glad to have you writing for us.

    Your perspective here will surely challenge many of our regular readers. I’ll take this occasion to remind everyone that it’s good to be challenged that way, and it’s even better to meet that challenge on the merits.

    That goes for a new author, too, of course — what do you think of Medicare, April? In Medicare, we have a government-run, single-payer (or close to it) medical system providing largely for a population that has a much higher-than-baseline number of vulnerable participants. Like all systems of providing health care, it confronts the reality that there is most demand than supply and finds ways to ration out who gets what; if you’re on Medicare you may not get the treatment you seek in a given situation. Medicare is likely to deny payment for that liver transplant to the 90-year-old, for instance. That would suggest that it is the Leviathan that you caution against — and it’s as politically popular as a religious icon.

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    • My parents are on Medicare, and have begun to fear rationing as they get older. No system is perfect, and obviously any system with finite resources will have to make executive decisions. I also believe that programs like Medicare are important for those who may not have the benefit of retirement plans or family to support them. I think what has made me uncomfortable about these rare but sensational cases in the UK and elsewhere is the willingness of the average person to cede their rights as parents to the state. They seem genuinely shocked that they’ve empowered, by their representatives or their direct votes, the govt to even consider preventing them from seeking alternatives to the national system. End of life decisions are fraught with emotion, and making clear-headed decisions is next to impossible. In this case, and in the Charlie Gard case last year, the children in question were undeniably terminal. But who does it benefit to deny their parents the opportunity to seek what treatment they can elsewhere, if they are using private funding?

      When we start using words like “burden” to describe people, and we start justifying ending lives based on their perceived “worth” to the collective–well, where do we draw the line? And do we allow the govt to take over the decision-making process?

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      • These are very good questions, and as described elsewhere here, the first difficulty is in deciding who the stakeholders are who have a legitimate interest in the child.

        Would anyone here disagree that there are multiple stakeholders, starting with a) the parents, b) the doctors, c) whoever is paying, and d) the state in its role as advocate for the child itself?
        And those are in no particular order, since the facts of the case vary wildly.

        Then yes, balancing expected outcomes against the odds of a good outcome, the pain and suffering involved, and against our limited resources can be a maddening question.

        I think this is a case where assertions of “rights” ends up being unhelpful since all of the stakeholders have rights, and yet in the end, someone’s interest or desire will not be satisfied.

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      • But who does it benefit to deny their parents the opportunity to seek what treatment they can elsewhere, if they are using private funding?

        It depends. We’re deep into medical horror cases, adventures in medical ethics, and perhaps answer shopping by the parents. The situation might look like…

        Doctor #1 thinks it’s in the patient’s best interest to let him die, that further treatment at best results in Terri Schiavo and at worst results in a not-brainless-Terri with someone permanently trapped inside there suffering. Doctor #1 thinks Doctor #2 is unethical as all hell and is just trying to keep the patient alive for Doctor #2’s cash flow.

        Doctor #2 claims to think Doctor #1 is wrong and there’s a chance the patient will have some quality of life. He claims his technology is better.

        Doctor #3 thinks both of them are correct and notes “1% is ‘a chance'”.

        (Note I don’t know the details of this situation, but medical horror cases depend on stuff that doesn’t go well into the news).

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  3. This the same christianity that massacred eastern Christians because they “looked funny” during the crusades?
    This Memento Mori Christianity?
    That says it’s appropriate to tell children folktales about the Protagonist (a small child) dying of Freezing To Death, and that that’s a GREAT MORAL ENDING??

    Obamacare was created by Max Baucus, who was bought and owned by the insurance companies. I assure you it was not “created to fail.” (Although the Republicans failing to put some money into the kitty might have had something to do with some of the problems…).

    And yes, congratulations, you’ve managed to argue that You’d Rather Have Every Woman who’s Ever had a C-Section have to disclose it twenty years later (as a pre-existing condition) to get insurance, or get denied later, after giving payments in (that aren’t refunded), rather than Obamacare. Or Single Payer.

    And you just said that JudeoChristianity didn’t punish those who chose life? Actively rewarded it?

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  4. On a different note:
    I’d really rather we not talk about “normal, human behavior” as contextualized by millenia of history.
    Do you think we ought to model our society after those with a mean IQ in the 60’s?

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    • I would also rather that’s not how we look at society, as trying to emulate the past.

      However, I don’t think trying to model our society based on who had the highest IQs is going to work especially well either. People with high IQs are not more wise or more moral than the rest of the world. (I’d say than the rest of us, but, uh… I am one of those people. I just don’t think it counts for much.)

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      • Your response is to something I wasn’t saying.
        Societies where the mean IQ is closer to 100 are more wise than those with the mean IQ closer to 60.
        But this is seeing Wisdom as the opposite of the People of Chelm.
        Not so easily fooled.

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  5. End-of-life situations are always wrenching, without clear and obvious solutions. And doubly so when they involve children.

    If it seems unjust to allow a state to decide to withhold treatment, then we need to put forward an idea that would be considered just.

    Transferring that power to an insurance company? Transferring that power to the market, based on whoever can pay?
    Who is the rightful stakeholder who gets to decide when treatment ends?

    Even religion itself doesn’t offer a definitive answer.
    Most major faith traditions hold that we should embrace life, but also, accept the inevitability of death.

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  6. Lots to think about in your piece, April! Thanks for writing it.
    I bristle mightily at the idea of someone preventing me from seeking care for my child. I really hate these stories. I understand that some of the medical community think there is no hope, but what skin do they have in the game?
    You are getting some heat here, and I do not personally agree with all your points, but thank you for some perspectives to mull over.

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  7. We were able to try everything our insurance allowed, we had the best surgeons and care, and we had nearly three years with her. But would a bureaucrat have deemed her life worth prolonging, especially with the uncertainty of a favorable outcome?

    Are you noticing the thing I’m noticing? Your daughter’s life and medical options were already at the mercy of a bureaucrat, just a corporate one rather than a government one.

    Also worth noting – you were able to try everything your insurance allowed and your doctors thought advisable. There comes a point where any doctor should recognise that further treatment would just amount to medical torture without any chance of helping.

    I have no way of knowing whether Alfie’s doctors made that call before or after an American insurance functionary would have – but it really does seem like it should be a doctor’s call to make, not an insurance bureaucrat’s.

    One indicator: when someone is cut off of treatment by the NHS in the UK it makes international news. When someone is cut off from treatment by their corporate insurer in the US, does it even make statewide news? When someone is cut off from treatment before it even started because they lack corporate insurance, does it make local news?

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    • The issue with Alfie, and Charlie Gard, isn’t that the state refused to do it or refused to pay for it. It’s that they stepped in to prevent anybody else from provisioning it, either. This isn’t like an insurance company denying payment. Would be more like an insurance company denying to pay for it and then prohibiting you from paying for it yourself.

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      • It’s that they stepped in to prevent anybody else from provisioning it

        That’s a fair point – and also a point that’s largely orthogonal to single-payer vs private insurance.

        That I think is well illustrated by the fact that the state preventing people seeking other care is pretty much unique to the UK, while single payer health care of one form or another is common to the entire first world other than the US.

        “We didn’t do this thing the UK has done that led to the cases of Alfie and Charlie Gard” probably has a valid argument behind it, but confusing “that thing” with single payer state funded health care does not.

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          • This is key. It’s important that a single payer system not view it’s own unwillingness to pay for a treatment as somehow a failing that precludes others seeking that treatment through other means.

            I look at the VA system I use. The VA often refuses to pay for things I want (they didn’t pay for my knee stem cell regen therapy, even though the knee injury is service connected), but they have no problem letting me find alternate ways to pay for it, and will happily support my efforts to get it done in whatever way I need.

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            • Yea, that’s a weird part of the British system, that it seems to permit an overriding of private efforts. I get the pain and suffering argument but ultimately I’d give the parents and doctors final deference over the state. One thing to keep in mind is that I believe nearly all UK providers are contracted with the NHS and thus de facto government employees. Seems like there are times where that might create some real ethical challenges.

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            • but they have no problem letting me find alternate ways to pay for it, and will happily support my efforts to get it done

              The NHS would not block YOU in YOUR efforts to seek alternative treatments (*). The Charlie Gard case was never about that, about blocking Charlie’s own efforts. It was about whether the actions the parents wanted done to Charlie were, not just not in his best interest, but went beyond that, into the being harmful to Charlie realm.

              As a society we have acknowledged that sometimes parents harm their children, and that they can harm them even when acting out of love (for instance, gay reparative therapy, because engaging homosexual acts will sunder them from Eternal life). In those cases, society, even ours, has agreed that it is proper to interfere to protect the child from possible harm.

              Was Charlie being harmed by the well intentioned but very likely useless efforts of his parents? That was the question presented to the judges. Charlie was not the property of his parents, but a separate human being that had his own personal rights. But, unlike Oscar, he couldn’t tell us what he wanted done.

              The argument was never money, that the NHS wanted to save a couple thousand pounds. It was whether further treatment was causing Charlie sufferings with little or no hope. There were people of good will in both sides, and none, neither parents nor doctors nor guardians nor judges could truly say “this IS what Charlie wants”.

              (*) Though if you go private on a particular issue, it creates a sort of prexisting condition and they might deny further treatment of the same issue once you go private, but that’s orthogonal to this discussion.

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        • It’s not unique to the UK though, or foreign to the US.

          For instance, there have been a number of stories about pharmacists in the US who won’t fill prescriptions for a ‘morning after’ pill because of their religious beliefs – and not only refuse to fill them, but refuse to return the script to allow the patient to go elsewhere.

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          • Which they are usually not supposed to be able to do, even where they can decline to fill the prescription. My wife, a physician with the training to perform abortions but no desire to, doesn’t have to perform abortions but has been required to refer her to someone who will. I don’t recall where the courts came down on all of this.

            There was a big case in Texas where the family of a pregnant, brain-dead woman wanted her taken off life support and the hospital (a) wouldn’t do it and (b) wouldn’t allow her to be transferred somewhere else to do it. That’s the most comparable case I am aware of. I believe the courts sided with the family.

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            • As far as I know, based on the cases where women undergoing dangerous miscarriages were denied treatment, and not transfered or even informed of the option, the courts have dismissed cases brought against the hospitals. In all the cases I know of those were Catholic hospitals where the guidelines basically said the woman had to be just shy of becoming another Savita Halappanavar before the doctor could do anything. And in most states they face no liability even if the woman were to die because of that directive.

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    • Whether or not you care more about a corporate official or a government official determining who gets care or not seems to really depend on your politics. A person with one sit of politics will see one as more just and natural than the other.

      As to somebody being cut off by corporate insurers, there have been stories of weird and unjust cases in the pre-ACA era but they were rare. People getting cut off by NHS are more newsworthy because a lot of very wealthy people opposed to socialized medicine can use them as propaganda. Pro-government healthcare forces can do the same for people cut off by private insurance but have fewer resources.

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  8. At some point, within any system without infinite resources, care has to be decided on by somebody. This is true for our system and for the NHS and everything in between.

    Single payer is severable from the kinds of decisions that we see where care is being denied by the courts despite the provisions being present. What’s interesting to me is how a lot of people don’t want to sever it and say that you can have single payer without having the state step in like this. Maybe the goal is, to some extent, both.

    In most of the cases I hear about, the situation is pretty hopeless. I’m less familiar with this case, but I did write about the Charlie Gard affair. Charlie almost certainly couldn’t have been saved (especially after intervention wasn’t immediate), but I am extraordinarily reluctant to see the courts act against on the theoretical behalf of the child, and to be honest tend to be defensive of those who embrace the idea.

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    • I understand being distrustful of the state when it comes to making decisions like these, but it’s also pretty difficult for me to trust parents completely enough to object to the state ever stepping in. Indeed, it’s depressingly easy to find parents making medical (or perhaps “medical”) decisions on behalf of their children that the vast majority of us would regard as perverse and cruel.

      And it’s not that controversial to believe that children have rights of their own, and the state has a responsibility to step in and defend those rights even from their own parents.

      We’re left to draw the line somewhere, and it is, at least, not obvious why the UK court systems are drawing the line in the wrong place in this case, or that of Charlie Gard.

      And I’m always left with the question of what happens if we turn it around. What if Gard’s (or Alfie’s) parents had decided that they did not want to prolong the lives (and in their minds, needless suffering) of their child, and the courts ruled in the opposite direction, compelling them to have their child treated?

      Would that be OK?

      If it’s not OK, what precisely is the problem with the way the scenario has played out in reality?

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      • I’m enough of a radical on this that I struggle with the Jehova’s Witnesses cases. I come down on the site of the state, but even that is a little difficult for me.

        I don’t know that I mistrust the state ever stepping in, but doctors wanting and being willing to try treatment suggests that it is ambiguous enough – we’re dealing with unknowns, differences of medical opinion, etc – that it ought to be a parental decision.

        To flip me, you would probably need to convince me that they are acting in bad faith, or are quacks.

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        • Agree with this. I understand the ethical dilemma, the hospital saying “we are not to do harm, and we feel prolonging treatment does harm”. OK, fine. But if the second hospital says “you know, we think there’s more to try and we are willing”… it seems to me that the second hospital is relieving the first of its ethical dilemma. Now, if it was something more clearly harmful I can see the first hospital putting a stop to it. But to give a ridiculous example, I mean something like, “let us take this patient. We think cutting off limbs one at a time without anesthesia might wake him up.”
          I’m being intentionally absurd here, but it would take a lot to convince me that the hospital willing to take him and treat him should not be allowed, if the parents want to try and have the resources.

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  9. I agree with Chip and Will. Until we have a system with infinite resources, there are always going to be gut-wrentching decisions like this.

    The issue in the UK is that they have a different take on the rights of children than we do in the United States seemingly and sometimes the state will step in and enforce the rights of children. As I understand it, the UK government deemed stepping in important to prevent Alfie and Gard from additional suffering. Losing a child is always going to be painful and horrible but at some point, you need to consider the life of the child and the pain that they are experiencing as a person.

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  10. I also fail to see how this is an argument against “free” healthcare as the big issue in the United States is still that people are going bankrupt because of lacking medical insurance and getting huge bills and/or they put off medical treatment because of a lack of healthcare.

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    • There’s also an idealized view of the market in play. Payers are largely in bed with the government already and the market is so distorted they aren’t really subject to the kind of accountability the OP implies. Like, if your insurance fails you on a massive scale its not like you can just walk across the street and get another plan that will take care of things. In a lot of cases you either go bankrupt or die.

      I have a lot of criticisms of the ACA but one thing the Obama administration didn’t get enough credit for was enforcing minimum claim fills. The stories about companies just throwing out every third claim without looking at it have some truth to them.

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      • I think the real hardcore healthcare market advocates want to get rid of health insurance period. They believe the only way to have a real healthcare market with prices as low as possible is to have everybody pay costs out of pocket or through credit like they would other services.

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        • I guess I can’t say there’s no chance that would work but it’s never going to happen. Healthcare is an extremely heavily regulated industry and there are political reasons that will probably always be the case. It’s a big mishmash of public and private interests and authorities. The big flaw in our system is less that there are public components of it and more that the structure is incoherent. People fall through the cracks, markets are distorted, entrenched interests defend inefficiencies that benefit them, and on and on.

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        • That’s absurd. The whole reason for insurance is when ordinary or most people can’t afford the costs on their own but they can through pooling resources. The idea is that maybe you are paying for five or ten or even fifteen years without taking out but eventually you get to use the pool of resources.

          Would these hardcore types reject auto insurance, property insurance? Almost certainly not.

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          • It is absurd. The hardcore would argue that insurance artificially inflates prices though. A real market would force the medical industry to charge what things really cost rather than get inflated payments through insurance. It would also encourage people to shop around for better deals than go to one place.

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            • Its absurd in its very conception, that healthcare is a consumer item like a toaster.

              Healthcare is that odd thing that no one really wants, but when they need it, there is no substitute, and no option of leaving the marketplace.

              I’m of the opinion that insurance is almost as poor a way to deliver healthcare as the marketplace, since unlike fires or accidents, the need for healthcare is actually highly predictable.

              Almost all healthcare is consumed by a small number of people, mostly the elderly in their last couple years of life.
              Scary-but-unlikely events like juvenile leukemia or auto accidents don’t consume much of the total healthcare pie.

              Mostly its us, all of us, when we get old, we get sick in extremely predictable ways.
              And unless someone is extremely wealthy, almost no one can actually pay for their healthcare when they are elderly because it occurs at the very time when we are least likely to be producing wealth.

              And we of conservative disposition can’t even look back to the Golden Age when everything worked, because until recently, the medical treatment for most geriatric illness was a warm blanket and seat by the fire, followed by a pine box.

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              • It depends on how broadly you define insurance. There’s really no way anyone other than the very wealthy can enjoy the benefits of modern medicine without some sort of cost sharing. That’s all insurance really is, public or private. Part of the problem we have is that we’ve created a bunch of artificially small and patch work cost sharing groups then on top of that pay the government as an insurer of last resort.

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              • I’m of the opinion that insurance is almost as poor a way to deliver healthcare as the marketplace, since unlike fires or accidents, the need for healthcare is actually highly predictable.

                Having systematic private insurance really doesn’t make a whole bunch of sense.

                Like, why do we have car insurance? We seem to have accepted that the way the system works is if you are at fault in a car accident, you should pay slightly more money for the next few years while operating a car, and if someone else is at fault in a car accident, your car and person should be made whole.

                So…why not just do that? Increase the fines on traffic violations and let them be paid over time, increase taxes to mirror the fact that more expensive cars are more expensive to insure, and use that money to cover damages? Why this weird indirect system of car insurance, which has a lot of oddities…for example, if you cause a car accident, you can essentially get out of paying for it by not driving for a while.

                Same with all sorts of ‘common’ insurance.

                Now, there’s plenty of insurance that it doesn’t apply to. Home owner’s, for example. A lot of people do not bother to get that, and it’s worth different amounts. We don’t particularly agree that people ‘should’ have stolen or destroyed stuff replaced.

                But this lack of sense of doing it as insurance also applies to health insurance.

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                • How much to charge for insurance is a complex pricing problem.

                  Why should we think the solution to every complex economic pricing problem is “have the gov price things appropriately”? Has that worked out well in other situations?

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                  • That’s trivially true, but far from universal. Ideal Markets break under lots of conditions, creating all kind of situations where the market mechanisms produce results that as a society we deem unacceptable: natural monopolies, public goods, externalities, are examples of things markets can’t price “correctly”.

                    Health care is one such situation: you are dangerously sick, you need health care at any price or you will die. Health care violates one of the rules of the efficient market mechanism, that there’s a price that the demand is unwilling to pay and will withdraw from the market.

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                    • Health care violates one of the rules of the efficient market mechanism, that there’s a price that the demand is unwilling to pay and will withdraw from the market.

                      Food. Water. Shelter. Education.

                      The alternative to food is different food. The alternative to some doctor should be some other doctor.

                      The HC market is broken because of regulatory capture, i.e. we basically don’t have a market since there are no prices published. We also have issues with 3rd party pays, and some other issues.

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                      • What would a functioning health care market even look like?

                        You can’t choose to enter or exit the marketplace, you can’t decide if you do or don’t want the product, you have no control over what product you want.

                        Again, the vast majority of anyone’ health care will occur in those last couple years when you are unable to work, and yet need critical amounts of healthcare far beyond any individual’s ability to pay.

                        There isn’t any market to be created here because there aren’t any choices.

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                        • What would a functioning health care market even look like?

                          Force all HC providers to publish prices and thus compete on price.

                          There are dozens of places in town that do X-Rays, I have NO WAY to figure out which is cheapest. My kids have needed 3-5 x-rays in the last dozen years or so, every time I’ve had hours (or even days) to plan ahead.

                          There’s hundreds of examples of this sort of thing. Think about a true emergency where I need an ambulance right now. That’s multiple thousands of dollars in expense, and if the prices were published my kid could make an app which would call the cheapest ambulance (within X minutes) rather than one at random.

                          , the vast majority of anyone’ health care will occur in those last couple years when you are unable to work, and yet need critical amounts of healthcare far beyond any individual’s ability to pay.

                          And my expectation is you could get more HC if it were cheaper. Society is poorly served by pretending we can write blank checks and fix this problem.

                          And it’s important to spell out just how PAINFUL “cheaper” would be. Our HC system is shockingly inefficient, hundreds of thousands of people would lose their well paying jobs if it became more efficient. This is why the political class is ill suited to fix this and markets are.

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                    • This is true for urgent life saving care. But that isn’t the only kind of medical care and people can & do behave as if a market exists if things aren’t critical.

                      Some people behave that way even when it is about life saving treatment.

                      Perhaps this is the problem, that we tend to want all medical care to be desperately necessary, when only a certain segment of it is. Even when we talk about senior care, how much is life saving as opposed to just the most expedient way to make a person comfortable?

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                      • Even when we talk about senior care, how much is life saving as opposed to just the most expedient way to make a person comfortable?

                        And who is to make the decision?
                        Would you allow someone (not your next of kin, and sometimes not even them) to decide that your life is just not worth the cost of saving it, the most you are worth paying is just making you comfortable until you expire?

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                        • I’m not talking about hospice or anything. Rather, I’m talking about treatment A to handle an age related medical condition, which has side effects that require treatment B, which can cause other things that require treatment C; except condition A is a lifestyle thing, or condition B is something that is handled remarkably well with a daily pot brownie, etc.

                          I think about the advice my grandparents and my parents get from doctors and I get the feeling that the doctors have a bit of ‘treat ’em and street ’em’, because it’s stuff medicare covers and they are overworked and don’t have the time or energy to do better.

                          How much of the cost elder care is due to these kinds of inefficiencies, because no one is thinking about the cost of the non-emergency stuff?

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                      • Perhaps this is the problem, that we tend to want all medical care to be desperately necessary, when only a certain segment of it is.

                        Your knee treatments, the ones the VA didn’t want to pay for, were not desperately necessary. You can live a long life with a limp, or, if God so wills, on a wheelchair. You just personally didn’t like that option and decided to pursue medical care that was in no way desperately necessary. To do so, you accessed a pool of money paid by people like me, who rarely meet my own yearly deductible (*).

                        Given that, even though I enjoy your posts, I don’t know you, you are not my kin, etc., this, too, is socialized medicine. It’s just one in which we have farmed out paying for health care to a private oligopoly

                        (*) You are welcome, btw, I’m glad you don’t have to limp or be in a wheelchair

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                        • It’s not clear to me whether he accessed a pool or paid for it (or otherwise raised the funds for it) himself.

                          Whether his knee surgery or not, though, there are examples of medical care taken care of outside of insurance pools (including government ones): Lasik, cosmetics, and in much of the country fertility treatment.

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                          • It’s not clear to me whether he accessed a pool or paid for it (or otherwise raised the funds for it) himself.

                            Fair enough. It’s not clear to me either.

                            It’s clear, though, in April’s OP that she did access a pool of funds into which I, or many others in a similar position as me, have paid into so that funds were available so her family “were able to try everything our insurance allowed, we had the best surgeons and care…”

                            So I think my point still stands

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                        • I paid for the treatment out of pocket. Insurance paid nothing. All they did due was demand the doctor reduce the bill to contractually obligated rates (his practice was part of a larger system). So I got about a third of the cost back as a refund.

                          I did use my HSA/FSA to pay for part of it, which was handy. Of course, it was only part of it, because our government seems to be allergic to the idea of letting people save larger amounts of money for uncovered medical expenses.

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                    • Health care is priced correctly, meaning that the correct price for old sick people is beyond what any honest person can pay.

                      “Priced correctly” isn’t the phrase I’d use considering the absurd levels of overhead, defensive medicine, price gouging, bureaucracy, regulatory capture, and general lack of competition that we’re enjoying in the HC system.

                      It’s true that the old and sick will be more expensive than the healthy, and people will die no matter where we draw the line and no matter what resources we bring to bear. However I’d argue society as a whole would be much better served if HC were MUCH cheaper and part of that would be facing up to death and enabling markets.

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                      • In order for the assertion that “enabling markets will make healthcare cheaper” to be persuasive, you would need to describe how these markets work.

                        Especially given the following constraints-
                        That the buyer of healthcare has no freedom to refuse the product and;
                        That the seller has no freedom to withhold the product for nonpayment;

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                          • You are talking abut “Cheaper” while I am talking about “universal”.

                            I am asserting that there is no market mechanism that can deliver healthcare based on the twin premises I described above, that everyone who needs it gets it, regardless of ability to pay.

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                            • I am asserting that there is no market mechanism that can deliver healthcare based on the twin premises I described above, that everyone who needs it gets it, regardless of ability to pay.

                              True, but there’s no government alternative which gets everyone everything they need.

                              Governments which make noises about delivering HC on your twin premises find other ways to ration care, often by not allowing certain treatments or even research, or by whatever-you-want-to-call-it when you need to bribe the doctor to actually see him.

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                                • So the choice is how we ration, whether by price, or some other mechanism.

                                  Agreed.

                                  Long term imho we’re never going to do a pure market and just let people die. From a certain theoretical standpoint we SHOULD, because we’re staring at a multi-product always-shifting demand/supply thing that markets balance well and the gov handles poorly. But we’re not going to do that because it’s too easy for a politician to point to the crying eyes of the relatives of someone who is dying and claim he’ll make that better.

                                  But the problem in front of us is we have the worst of all worlds. Very expensive care (which means it’s not efficient) which is also not especially good. We also have the possibility of breaking budgets, banks, and pensions because of health care costs.

                                  Increasing efficiency in a system is something markets do very well via price signals and command+control systems do very poorly. Hundreds of thousands of people need to be fired because they’re not adding value to the HC system, this is an absurd amount of political pain and also something the gov doesn’t handle well.

                                  IMHO the big problem seems to be a total lack of price signals in the system. This seems to be something we could actually fix.

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                • @james-k
                  We’re not talking about the government ‘setting prices’, we’re talking about the government just doing something.

                  And not only is it absurdly common for the government to punish people, via fines, for harm they cause to others, they already do it for car accidents. Likewise, they already charge people to operate cars.

                  I am merely suggesting raising those amounts to the approximate price of current car insurance and the approximate price car insurance goes up after an accident. And generally using that money to cover damages to their cars by drivers who were not at fault in car accidents. (And I guess covering injuries to not-at-fault people, although honestly at some point we all just need health insurance to cover that.)

                  We don’t need to ‘set prices’ at all…in fact, it might be a good idea if the prices were ‘too high’, and more money was collect than needed. Just like _now_, because none of the money collected from drivers in car accidents, nor the money collected from car registration, is currently used to pay for said car accidents.

                  It’s kinda weird how I keep proposing we stop using certain insurance and replace it with the government doing things, and get responses about the price of insurance. Guys, the entire premise is that it wouldn’t really be insurance. It’s a revenue stream for the government that should, on average, cover the expenses. If it collects _too much_ money, the government presumably would use it elsewhere, or at least borrow it for elsewhere, and if it collects too little, the government could borrow for it while it raised rates.

                  You know, basically like social security, which is called insurance but really isn’t.(1) It collected so much extra money over the past few decades the government started borrowing from it. (Except, of course, this would be a year-to-year thing, so wouldn’t be facing the demographic problem that SSI is.)

                  And, again, before anyone claims private industry could be more efficient, I point out the government literally already collects money at all the places I suggested it collects that money (I just suggest collecting more), and we also explicitly have a system to determine fault in car accidents, called a ‘traffic court’. Having another party do all those things on top of what the government does cannot be more efficient.

                  1) I find myself baffled that something that has a well-defined payout that happened repeatedly, starting a certain date, can be called ‘insurance’ by anyone rational.

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                  • And, having the market decide the largest amount of the penalty (How much rates go up.) makes the penalty entirely based on calculated ‘chance of causing future accident’.

                    But a) is that actually what we should be basing the punishment of people off of, and b) is a driving record any good at showing that anyway?

                    I mean, let’s think about a hypothetical driver, Frank, that falls asleep while driving due to driving while extremely tired.

                    In one case, Frank coasts to a stop in the middle of the road, the car behind him pulls up and calls the police, and the police wake Frank up. In another, Frank drives off the road and hit a telephone pole. In another, Frank crosses the center line and hit another car.

                    Now, we certainly should punish Frank for that. Driving while that tired is dangerous.

                    Likewise, in theory, it is likely to cause accidents in the future, so, in theory, the car insurance people would raise Frank’s rates.

                    However, the car insurance people really don’t have any idea Frank fell asleep. Those three different outcomes, on a driving record, look different. (I’m not even sure the first would end up on a driving record?(1)) Depending on what randomly happened after Frank fell asleep, he might be punished an almost trivial amount, or punished harshly.

                    However, in a world where it’s the job of the judge to figure out how much Frank is going to be paying, the judge does have all the facts, and Frank can even dispute things. For example, if instead of being tired, it was some sort of interaction of medication he knows not to take anymore.

                    As it is now, Frank would probably not have to pay a fine, but the insurance company has already decided to raise his rates…and that might even be correct, financially. From their POV Frank is more likely, statistically, to get in another car accident…but we don’t generally need a system where people are punished for hypothetical things they might do wrong in the future if we can instead just punish them for actual wrongs they really did.

                    1) Interesting fact: While trying to figure out what someone would be charged with for just falling asleep but not hitting anything while driving, I discovered that, the way the laws used to be written, occasionally people charged with car accidents because they fell asleep could win in court because the law generally requires people to be conscious to commit a crime. Unconscious people not only couldn’t have intent, they couldn’t be negligent either. It sounds like the laws have mostly been rewritten to require people to affirmatively keep control of their vehicle while operating it, though.

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                    • Last I checked, insurance companies request and get all police records with regard to traffic tickets and incidents, so they would know what happened.

                      Internally, they may not care when it comes to adjusting rates, but they know.

                      As an aside, all this money the government is going to get to act as insurer, is it going into a separate fund, or just the general highway fund? What happens when they spend it all building some new bridges, or bailing out the DOT pension fund, and then they get a 50 car pile-up and have nothing in the kitty to pay for damages?

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                      • Last I checked, insurance companies request and get all police records with regard to traffic tickets and incidents, so they would know what happened.

                        Yeah, that wasn’t the greatest example.

                        The point I was trying to make, but couldn’t come up with a scenario for, is that, when people are punished via higher insurance premiums, they are punished for ‘calculated risk of causing the insurance company to make payouts in the future’.

                        We…don’t generally calculate punishment that way. It’s not only a tad silly to base punishment solely off ‘reimbursement of damages’ instead of societal impact and risk, but it’s really weird to base punishment off ‘calculated future crime’ to start with. Also, insurance companies often oddly forgive certain offenses, at least the first few times, because those offenses are not likely to lead to costs. Meanwhile, other things are greatly punished.

                        In the end, we have a system of ‘punishment via increased insurance premiums’ that, if you look at it from a distance and squint, seems to approximate ‘punishment via fines’, but does not actually operate how we’d ethically and legally set up any such system.

                        And, yes, we have a real system of fines for those things, also, but those are a smaller proportion of what the insurance changes can cost. So it’s like 25% of a real legal system and 75% of this third party thing tacked on.

                        As an aside, all this money the government is going to get to act as insurer, is it going into a separate fund, or just the general highway fund? What happens when they spend it all building some new bridges, or bailing out the DOT pension fund, and then they get a 50 car pile-up and have nothing in the kitty to pay for damages?

                        As weird and hypocritical as it sounds, I suggest they…get insurance.

                        Or, more specifically, reinsurance. For people who do not know, reinsurance is just insurance for statistically unlikely insurance payouts.

                        So the state should get an insurance policy for if the state finds themselves paying more than a certain total a year in claims.

                        As nice side effect, this would result in an insurance company looking over the state’s calculations of the money flow and either saying ‘Yeah, you’re going to spend about this much, and your likelihood of going over this higher amount is only 1% a year, and we’ll insure that possiblity for $X.’, or saying ‘Your math is stupid, you have a 20% chance of going over each year, and we won’t insure you’, at which point the state might need to reevaluate some estimations.

                        Now, as for where the all the money comes from and goes…if the state calculate that, say, claims will average costing them $600 a person a year, and they have reinsurance to cover if people cost them over $1000 a person, that a reasonable point to set attempted collection would be maybe $800 a person. So, on average, they get an extra $200 a person (Or even more!) they can pull out each year and use for general funds, but they have a moderately low probability of that money not being there or even having to put some money back in, but only up to $200 a person.

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                          • Oscar Gordon: But insurance rates going up isn’t a punishment, and isn’t intended to be.It’s merely an adjustment for the increased actuarial risk.


                            DavidTC, are you suggesting we do away with auto insurance, handle damages caused by cars via taxes and have that be independent of the risks created by the drivers?

                            I’m having a hard time figuring out what you want the end goal to be here and why.

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                            • DavidTC, are you suggesting we do away with auto insurance, handle damages caused by cars via taxes and have that be independent of the risks created by the drivers?

                              Handle damages caused by cars via taxes _and larger driving penalties_. (Large enough that we also have to have a system to split them across years. Basically exactly like how your insurance goes up for a few years when you are in a car accident.)

                              And I’m not really proposing that. I’m just pointing out that the system makes more sense than the current auto insurance.

                              Because, and this was sorta my overall point, we have decided, as a society, that we do not want people to be utterly ruined by things outside their control. Like their car being damaged, or them being injured, in a car accident caused by someone who cannot pay that.

                              Medically, we first decided to make sure that people could not die from lack of medical treatment, and then we decided we didn’t want people to incur medical bills they cannot pay.

                              We decided that. Some people might disagree, but that’s not the discussion I’m trying to have here. Start with the premise we are going to do that…and my point is that how we are doing that makes no sense.

                              Because we have decided the way around that is to basically demand everyone have insurance from private parties, which is a pretty nonsensical solution to that.

                              We already had a solution to that: We have the government collect the money, and the government makes the payouts.

                              We used it to solve the ‘old people who cannot support themselves’ problem, for the most obvious example. It’s called social security.

                              Inserting a third party into this is a new nonsensical twist, especially because, as this sort of thing is pretty monopolistic and hard to understand (If we let anyone sell anything and call it insurance, no one would understand they didn’t have good insurance until they needed it.), we have to regulate the hell out of it. Likewise, it’s hard to see what sort of ‘power of the market’ is supposed to show up in…processing money from one point to another.

                              But no one bothers answering the question ‘If we’re going to set all the rules ourselves for different sorts of insurance, and require everyone to have it…why aren’t we just running it ourselves? Why are we not only having a third party take a cut, but having to spend time and effort regulating said third party?’

                              Especially in regard to cars, which, I remind everyone, we already have to interact with the government repeatedly about.

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                              • We have the government collect the money, and the government makes the payouts.

                                This assumes that the government is even remotely as cost (or otherwise) efficient as the private parties when it comes to handling these transactions. You’d have to make that case, and I think you’d have a lot of work ahead of you to make that case.

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                                • There’s a lot of information out there on this but it can be challenging to interpret. To get a basic sense of how it would work you can compare traditional Medicare which is totally government run to Part C which is administered by private insurers. Part C as we know it now started in 1997, but for a lot of its life was less efficient at handling administrative costs than the government. In the last several years Part C appears to have closed the gap, but people are now raising questions about whether thats happening at the expense of quality.

                                  I’m really agnostic on the private vs. public administration but this is one area where the state-as-payer isn’t totally unreasonable. You might even say that a lot of box checking bureaucracy and mailing out checks plays to the government’s strengths.

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                                  • Fair point. I have to keep in mind that I am used to the VA, which is government as provider and sometimes payer, whereas government as payer only is different.

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                                • Actually, while I could make that case, as ImDB says…I don’t have to make it here.

                                  Because the government _already_ collects money, every year, from anyone who operates a car.

                                  And the government _already_ collects money from basically everyone who causes a car accident.

                                  Presumably collecting a larger amount of money would not alter the existing overhead.

                                  This is, incidentally, why I keep calling this system ‘dumbass’. It would be one thing if there was some entirely private insurance system of operating cars and that was all that existed. It could be argued that such a private system is doing as well as the government could do. I mean, that argument would be wrong, but it could logically make sense.

                                  But there is already a huge amount of ‘car owner’ interaction with state governments. And this interaction is at almost every point that a car insurance company needs to interact with people: Registering ownership, collecting base payments, keeping track of accidents, collecting additional premiums depending on risk, determining fault in accidents, etc. Seriously, the mirroring is so throrough that half of what the insurance company does is just ‘get documents from the government’.

                                  The only part of the private insurance system that doesn’t directly mirror something the government is already doing is paying claims. That’s it.

                                  The entire rest of the system is already happening and would not need any additional overhead.

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                              • DavidTC, are you suggesting we do away with auto insurance, handle damages caused by cars via taxes and have that be independent of the risks created by the drivers?

                                Handle damages caused by cars via taxes _and larger driving penalties_. (Large enough that we also have a system to split them across years. Basically exactly like how your insurance goes up for a few years when you are in a car accident.)

                                So you’re apparently good with pricing auto insurance by risk brought to the general pool of society, i.e. “exactly like how your insurance goes up…”. This implies you’re not trying to fix a market failure.

                                I’m just pointing out that the system makes more sense than the current auto insurance.

                                Unless it’s unrealistic to expect the gov to supply the same level of efficiency, competition, freedom of choice, setting/responding to price signalling correctly, while also resisting the political temptation to meddle, reward political favorites, spend the money inappropriately, etc. If that is unrealistic then the current system makes perfect sense.

                                And what you’re really trying to suggest is we get rid of medical insurance companies entirely (where we do have a market failure). It’s possible to put together a gov take over plan on paper which creates huge efficiency gains. On paper.

                                However “huge efficiency gains” mean “throw hundreds of thousands of people out of work”, and I see no way politicians can reasonably be expected to inflict that kind of pain on themselves. What we would see from the political system is throwing money at all parts of the system while leaving the insurance industry (and the hoards of bureaucrats who only exist to deal with their rivals) intact.

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                                • This implies you’re not trying to fix a market failure.

                                  I’m not really ‘trying’ to do anything there. I don’t expect anyone to do anything about this. I’m just pointing out that there’s not really any reason to have a (liability) car insurance market at all.

                                  It’s worth pointing out that many places in the world do not have private systems, like half of Canada, and various states have government-operate insurance that good drivers with low income can get, which is cheaper than normal insurance. (And, no, it’s not subsided out of taxes, it pays its own way.)

                                  There’s some sort of hypothetical rational for trying to have ‘market innovation’ in health insurance, because if health insurance companies can somehow innovate a way to make their customers less sick, everyone’s better off. (Sadly, they have ‘innovate’ this by removing sick customers as their customers, or not getting the customers in the first place…but in theory they do try to make their customers more healthy.)

                                  But there’s almost no hypothetical way car insurance companies can make people better drivers. For a while, they experimented with GPS car tracking stuff, aka ‘paying people to be better drivers’, but ran into two problems…one, everyone hates it, and two, it turns out that speeding (Which is about all those can detect) isn’t particularly indicative of ‘future cost of customers’, so the discount given was almost imperceptible. Drivers who are repeatedly in accidents tend to either have crap reflexes, are overly aggressive, or often do things that make them distracted. Or more than one of those. Not because they speed.

                                  Unless it’s unrealistic to expect the gov to supply the same level of efficiency

                                  As shown by every government-run car insurance program, they are more efficient, because it literally is just moving money around and the government is pretty good at that.

                                  competition

                                  Competition isn’t some magical good in and of itself, it’s only a good because it _does_ those other things you listed.

                                  freedom of choice

                                  Ah, yes, the freedom of choice in liability car insurance. It’s vitally important that people be allowed to…erm, allowed to pick the policy that exactly conforms to state law, because there are literally no options there.

                                  setting/responding to price signalling correctly

                                  Setting the price correctly only matters in regard to actual goods or services that need to be rationed. Car insurance is not one of those things.

                                  If the government wants to system to be self-sufficient aka, ‘Post Office rules’, it needs to collect approximately as much money as it distributes. But it doesn’t have to set the system up like that, and systems like that are pretty easy to set prices in anyway….just raise prices until they meet cost.

                                  while also resisting the political temptation to meddle,

                                  Meddle in…people’s driving behavior? They’re doing that already, and we mostly seem okay with it. Not really sure what you’re talking about.

                                  reward political favorites

                                  …reward political favorites? Via _car insurance payouts_? If the government operating at that level of fraud, then honestly writing bogus paychecks would be easier.

                                  If anything, the current system makes it easier to reward political favorites, as in, government often have contracts to purchase commercial auto insurance for their vehicles, which means they can award contracts to cronies. (You would think they all self-insure, but apparently not.)

                                  spend the money inappropriately,

                                  …didn’t we just cover this?

                                  We actually have a quite a few government-operated insurance claims systems, at state and Federal, and I’m not aware of any _government_ misbehavior there. Obviously, a system to cause fraud is needed, just like any insurance system, but that’s all.

                                  However “huge efficiency gains” mean “throw hundreds of thousands of people out of work”, and I see no way politicians can reasonably be expected to inflict that kind of pain on themselves.

                                  LOL. Seriously, I had to laugh out loud at this from someone who normally takes the conservative side.

                                  You are correct there. I’ve been pointing this out forever, that ‘making things more efficient’ often just means ‘removing some labor from the equation’, and thus automatically pretending ‘more efficiency’ it is good for the economy is somewhat dubious.

                                  But it’s sorta weird seeing you suggest we need to ‘keep all those make-work jobs in auto insurance’.

                                  What we would see from the political system is throwing money at all parts of the system while leaving the insurance industry (and the hoards of bureaucrats who only exist to deal with their rivals) intact.

                                  Hey, I’m not saying it’s something that anyone should spend any political capital on trying to change. I’m just pointing at it because mandatory private car insurance was a dumbass system to have invented, and we have a habit of creating such dumbass systems, by law, to purely move money around, when if we were operating sanely we’d just have the government do that. I’m not saying ‘The Democrats need to get on this!’….no one needs to worry about it, the system works well enough. It’s just needlessly silly.

                                  And BTW, if we’re talking about _practical_ reasons not to do it, there is another real objection to changing this besides ‘people out of work’:

                                  This proposal would weaken car insurance companies (They’d still exist because of collision insurance, but that’s all.), and car insurance companies are very big lobbyists at the state level in favor of stricter driving laws, and safety regulations in cars at the national level, and stuff like ‘requiring driver’s ed to get a license back after a suspension’.

                                  With less money being thrown at legislators by car insurance companies, those legislators would start bowing to pressure to weaken said laws, resulting more car accidents. Especially with safety regulations, which has a counter-lobby in the car manufacturing industry.

                                  But in my mind, this…is not really a very good defense of the current setup. ‘Our politics is so broken that it has to support a bunch of private companies to keep us from democratically removing safety laws we don’t like and killing ourselves in car accidents’.

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                                  • Dark Matter: freedom of choice

                                    DavidTC: Ah, yes, the freedom of choice in liability car insurance. It’s vitally important that people be allowed to…erm, allowed to pick the policy that exactly conforms to state law, because there are literally no options there.

                                    Yes, this exactly. Choice in this context puts brutal downward pressure on overhead. If a company has an army of bureaucrats, they had better be adding to the bottom line productively because shifting their cost onto the consumer is a challenge.

                                    This is why (depending on your state) the car insurance industry has fewer “make work” jobs than the health insurance industry which is famous for its armies of bureaucrats fighting with other armies and adding no value to HC.

                                    Dark Matter: setting/responding to price signalling correctly

                                    DavidTC: Setting the price correctly only matters in regard to actual goods or services that need to be rationed. Car insurance is not one of those things.

                                    Money and Risk are the resources to balance here. Price insurance too high and no one will buy, price it too low and you can’t make a profit. Not only are these problems for the company, they’re also problems for the consumer. Paying too much for car insurance means you can’t buy other things.

                                    The State doesn’t remove this issue but it does obfuscate it because it’s removed from price signals.

                                    DavidTC: If the government wants to system to be self-sufficient aka, ‘Post Office rules’….just raise prices until they meet cost.

                                    Problematic companies can be shut down, the State can not. Companies find it easier to have bad (or simply wrong) behavior adjusted than the State. States frequently can’t “just raise prices” because of various political issues and/or cross linking of incomes.

                                    Dark Matter: while also resisting the political temptation to meddle, and reward political favorites

                                    DavidTC: Not really sure what you’re talking about…. If the government operating at that level of fraud, then honestly writing bogus paychecks would be easier.

                                    In my state the local super city has problems with crime and various other things which make auto insurance very expensive. Elements of the gov occasionally try to “make it fair”, i.e. pass laws which force the entire state to have one uniform auto-insurance rate, which really translates into the rest of the state subsidizing that city’s problems and risk pool.

                                    My insurance rates are supposed to reflect the risk I bring to the pool. If I’m paying more so some politician can curry favor with people who elected him that’s a problem.

                                    Similarly “meddle” can mean “charge less for insurance than the risk pool would demand”, i.e. Florida’s Hurricane insurance which will at some point have a hurricane break the bank and be a mess for the taxpayers.

                                    Or “meddle” can mean “use this income stream for something other than it’s express purpose”, i.e. Puerto Rico’s treatment of its power grid which also has long term problems (which they’re currently enjoying).

                                    Having pots (or streams) of money around invites misuse by the political class.

                                    Especially with safety regulations, which has a counter-lobby in the car manufacturing industry.

                                    We got rid of the motorcycle helmet law a few years back, it seems to be an actual desire among people who ride them.

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                          • Weirdly enough, car insurance companies are moving to a “number of claims” model for some reason. (I suspect the reason is “profit”).

                            My adjuster noted that they were changing their setup, and that I should not use their roadside assistance program (which I freaking pay for) because a “tow” or “tire change” counts as a claim, and my rates will be based not just on total damages, but number of claims.

                            Same for using them to repair dinged windows.

                            So I can have a spotless driving record, but my rates will go up because I had two flats in a six month period, and used the roadside assistance I pay extra for to have it fixed or towed.

                            (In fall fairness, the adjuster had called specifically to warn her customers, and to suggest they drop the company’s roadside assistance in favor of something like AAA, so clearly she wasn’t real thrilled with it either).

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  11. I would in general agree that taking a child to a different country for treatment should be the parents’ decision. However, IIRC the British hospital and physicians were not simply being heartless bureaucrats here (if they were, they’d have just had the parents sign papers releasing them and the national healthcare system of responsibility). They fought the move in court because they believed that the move and further attempts to prolong life would in fact only prolong suffering and therefore cooperating in that would violate their oath to ‘do no harm’. So, as mother, I have sympathy for the parents. But as someone who watched her grandmother forced against her wishes to suffer through end stage cancer (because the “pro-life” state we lived in forbid even DNRs back then), I also have some sympathy for healthcare providers willing to take heat rather than cooperate in extending suffering in the name of extending ‘life’.

    I have to say I am curious that you seem to be both “pro-life” and libertarian. To me, because of my experiences with how dictatorial “pro-life” politicians can be, that seems that really tough circle to square. In fact, my primary objection to single-payer in this country is that I fear what would happen if they gained enough power to really dictate both obstetric and end-of-life decisions.

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  12. April,

    First, welcome!

    Second, thank you for sharing your experiences and your perspective. I don’t know that I agree with the conclusions you’ve reached and/or are approaching, but you’ve given good food for thought.

    What I’m wrestling with most is this passage:
    “Ceding control of the well-being of one’s children to the government seems counter-intuitive initially, but when you take into consideration the infantilization of adults in Western culture—adolescence that extends into one’s 30’s, the insidious idea that one must sacrifice liberty for safety—giving up our children to our betters seems only natural.”

    While I’m tickled a bit by your apt description of the infantilization of adults, I think you miss the mark in noting “the insidious idea that one must sacrifice liberty for safety.”

    The extent to which we invite, allow, or demand government step into the realm of child rearing is not because we ask or require adults to sacrifice some of their liberty for theirsafety; it is because we ask or require adults to sacrifice some of their liberty for their children’s safety.

    This doesn’t necessarily make the case that all such sacrifices are warranted or that government knows all. But it does change the calculus quite dramatically.

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  13. Dude, this was a great essay.

    The government finds itself in a weird situation where its morality has to be utilitarian from a bird’s eye view and it governs people who are some mix of egoists, deontologists, and virtue ethicists.

    It can point to the egoists and say “SEE??? SEE HOW MUCH WE’RE NEEDED???”

    And then it goes on to stomp all over the deontologists and v.e.’s that didn’t need the help.

    And it’s probably going to get worse when all of the people who remember other ways to have done it start dying off.

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  14. I think there’s a conflation here of the British system with universal coverage more generally. Doing something like the NHS in the US would be terrible and a recipe for failure but that’s hardly our only choice. You can still get to universal coverage without all financing and service being provided by the state. Medicare Part C is an example of how we already do this.

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  15. I’ve read dispassionate arguments stating that infanticide has been practiced throughout human history and is therefore more commonplace than our delicate, modern sensibilities allow, to which I’d counter that the rise of Judaism and Judeo-Christianity readjusted humanity’s baser nature, focusing on the preservation of life, regardless of its imperfections and inherent difficulties.

    I this this passage has already gotten a lot of criticism, but to be blunt, it deserves even more.

    Even setting aside the violence that was pretty explicitly prompted by Christianity (the Crusades and the like), culturally Christian countries hardly set an inspiring example even after wars of religion became a thing of the past.

    Nor is it clear why this appeal strengthens your argument that we need not be bound by the ethical standards of past eras.

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  16. I’m sure parents of children suffering from whatever dread, almost 100% fatal, condition are well-read in the latest research surrounding treatment of said condition. Is it communicated to the interested parent how much of a chance any treatment might have?

    I haven’t been party to the end of any child’s life, but I have witnessed a few deaths of older people. In 2 of those cases not one doctor had the balls to tell anyone that any further care was pointless, even though it was plain that the end had been reached. There’s entirely too much CYA in the practice of medicine in America, and it ends up costing both money and agony, neither of which falls into the realm of “first, do no harm”.

    There really is no easy solution to end-of-life stuff. At a time calling for rational decision making, those making the decisions are most likely to be the least rational.

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    • “I’m sure parents of children suffering from whatever dread, almost 100% fatal, condition are well-read in the latest research surrounding treatment of said condition.”

      I don’t think this is true at all.

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      • Sometimes it is, sometimes it isn’t, in my experience. I’ve definitely known parents who were extremely well-read about their child’s nearly-certainly-fatal condition.

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        • For some folks, the very understandable desperation and despair can lead them down all sorts of roads. Look at the many parents of children with serious or incurable diseases that have turned to homeopathy or other forms of pseudoscience in hopes of a cure. Others may take a less-is-more approach in terms of understanding the disease, opting to focus on the child him/herself and letting the professionals and experts do what professionals and experts do.

          And, as points out, many do in fact become subject matter experts.

          I cast no aspersions on any of these people. I can only imagine what they are experiencing. Even looking at more milder situations — children I know personally with ADHD or even my own son with some mild needs — not all parents involved have dived deeply into understanding what is going on for their child. It’s just not the route that makes sense for everyone. And that’s okay. But it does mean we can’t necessarily assume parents are well-informed on what afflicts their child or the best course(s) of treatment.

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  17. An uncomfortable article because death is uncomfortable and this makes us face that. Thank you April, and welcome.

    I think in the past we were not as oriented towards life as you suggest, we just had fewer tools and much of the ugliness of the past is excised from memory and history. The murder rate has gone down from historical norms, not up. Our rates of genocide and war have also gone down.

    As you point out, if we want a publically funded medical system, then yes, allowing the gov to control who lives and who dies is part of the package. This means the supporters of socialized medicine need to get real comfortable with withholding care from sick people (which will be labeled killing them), and I don’t think they are. They also need to get comfortable with letting people die who could have saved from expensive treatments.

    In every society, in every income bracket, in every part of the world, the death rate holds steady at 100%. We don’t get to decide “if”, just “when” and “how much money”. At some point someone needs to decide how much money is spent. Often we make that choice long before via the quality of our insurance.

    As for Alfie… there are two issues. First, “who pays”? Is Italy going to put him on Italy’s public health system, or are they just going to send the bill to London? Second, it takes a lot for me to think the State knows better than parents, but the Doctors here claim think the parents are going to have their kid die by inches.

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    • Second, it takes a lot for me to think the State knows better than parents, but the Doctors here claim think the parents are going to have their kid die by inches.

      Honestly, from looking at what the doctors have said, he already is dead. He’s got some unexplained neurological issue that is destroying his brain tissue, and it’s already destroyed most of the brain at this point.

      Reading up on this is sorta creepy. First he doesn’t seem to be making progress like normal babies, then he becomes unresponsive, has seizures for a bit, and then the seizures stop, which normally would be a good thing but here happened basically because there wasn’t enough brain left to have seizures.

      Even if there was some miracle ‘cure’ that somehow stopped the still-completely-unknown disease destroying the brain (Which there is not, not even in Italy), there’s not enough of the brain left for him to ever be considered alive.

      He’s already well past ‘brain dead’ at this point, and while in _some_ cases a miracle may be hoped for for ‘brain dead’ people, a hope the brain might recover and wake up ‘somehow’…Alfie doesn’t have much of a brain left to ‘wake up’, and people can’t regrow brains.

      And as there isn’t a cure, and in fact doctors are still utterly baffled by what is going on, he’s only going to get ‘worse’.

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      • 1st, , Thank you for the detail.

        2nd, :Ouch: Medical Horror indeed.

        3rd, My take away from this is the parents answer shopped around and found someone willing to keep their son’s corpse “alive”.

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        • We are at the point where, if we hook almost any body up to a machine fast enough, we can keep it ‘operating’ forever.

          So, back when this became possible, we already made the hard call of when we _can_ consider people dead enough to be okay with pulling life support. (Answer: When their brain isn’t working.)

          But we never really decided ‘No, past a certain point, we aren’t going to pretend this person is alive even if the people in charge of medical decisions want to‘.

          Should we make that decision? On one hand, it’s pretty creepy to keep dead people alive, and it’s often clear that the people making the decisions are living in some sort of fantasy. (There’s a reason the first stage of grief is denial.)

          OTOH, medical care is inherently personal, and who we let make those decisions is personal, and maybe the state has no business overriding it.

          On the third hand…this wasn’t some adult who decided ‘Under all circumstances, keep my body functioning even after my brain is dead’, or even picked someone to make medical decisions that thought that way. Maybe _adults_ have a right to do that. But this is a small child, and it’s generally considered acceptable for the state to demand parents provide specific medical care for children even if they don’t want to…or forbid them from providing known harmful ‘medical care’.

          On the fourth hand…this actually isn’t a child, really. Not anymore. [Edit: Rereading that, I can see it might imply the case took so long he grew up, whereas I actually meant he’s not a ‘living child’ anymore, because he’s dead.] And the care doesn’t seem ‘harmful’….although that appears to be the origin of what the hospital is trying to do. The hospital put in the request to disconnect Alfie a while back, when he might have hypothetically been suffering. However, the case has been drawn out so long that it seems unlikely there could possibly be any suffering now.

          Regardless of where we, as society, eventually come to on this complicated issue…it seems a bit disingenuous to list this as one of ‘a thousand cuts’ of society not valuing life. In the end, we can only value things if we know what they are, and Alfie seems already to fall outside of what we’ve decided is ‘human life’.

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  18. I’ve lost a child to circumstances no one could control (congenital heart defects), and my heart and mind recoil in horror and revulsion at the thought of bureaucracy deciding she wasn’t worth fighting for.

    This is what civil libertarians warn against when the push for socialized (“universal”) healthcare results in monstrosities like Obamacare, which was always meant to fail and leave us no option but single-payer healthcare

    So here’s a fun story:

    I, like your child, was born with a congenital heart defect, and would have died within a week without medical treatment. In my case, my heart defect was correctable.

    However, due to said heart defect and various preexisting conditions resulting from it, I was not able to get health insurance as an adult. I don’t mean I couldn’t afford it…they wouldn’t even issue it.

    Until Obamacare.

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    • Here’s to the uninsurable. I’ve got the mildest possible form of seizure disorder in adults. (Nocturnal seizures, maybe every three or four years unmedicated. Responds perfectly to the cheapest, most reliable, side-effect free medication possible. Stuff costs about 8 bucks a month, cash without insurance, and I have never had a seizure when on it. Not in decades).

      Could not get insurance on the “free market” prior to Obamacare. Not even stuff that didn’t cover the seizures. (Which, bluntly, cost about 200 a year to handle. One 15 minute neurologist visit a year, and 12 months of medication. No tests, no nothing. Even when I had them, the worst problem is strained muscles and bruises).

      Couldn’t get it. If I’d spent the last 20 years doing independent contracting, I’d probably me making quite a bit more money now. But that literally wasn’t an option, not if I wanted any kind of actual health insurance.

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  19. Welcome, also a fine and thought provoking article. I hope I can muse more on it later.

    That said I think your point on Downs syndrome babies being aborted is badly misplaced. As far as I’m aware that is the result of pretty much nothing but individual informed choices with little to no state involvement in that decision at all. I struggle to see how those individual choices have any relationship to the other state mandated decisions you’re talking about though it is, certainly, interesting to know how dramatically anti-choice sentiments collapse when the road actually rises up to meet the rubber.

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    • That’s a good point, actually, and if I had only been talking about single payer universal healthcare, I’d absolutely agree with you. I used it as an illustration of the devaluation of human life, and perhaps I should have expanded on that more. I’m sure I will at a later date, since I have all kinds of things to say about everything. ?

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  20. I spent some time in the UK on business, mainly dealing with our foreign assignees but also some with the locals. I don’t recall the subject on one occasion, but it probably was over the July 4th holiday. One of the expats said “an know you see the difference between “subjects”, meaning the Brits, and “citizens”., meaning the Americans. There really was a different attitude towards the gov’t. But, no fear…America is slowing coming around to being subjects again. Hell, people actually WANT that. Give it a few more decades and they’ll long to be slaves as long as they are “safe”.

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  21. (comment censored – I’ve been saying for months that comments that exist only to attack the writers of a post, and/or to complain about a post’s inclusion on the site, are most unwelcome. That still holds, and will continue to hold, and will probably be given less of a patient response than previously. I or another mod may will just delete the comment without explaining. Argue points, find ways to be civil, if you feel the need to compare the site unfavorably to Fox News, do so in a way that doesn’t drag the writer of a particular post as well (eg you can always write the inquiry address). And if you think being willing to host and reflect upon some particular post you don’t like makes us into the equivalent of Fox News, gentle reader – give your head a shake.– maribou, moderator.)

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    • I assume from your censored comment that you are not returning, but if you do, please read what I said in your censored comment before making a comment like that one again.

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  22. I like having the government (the VA) as a medical care fail-safe. I would never want to go to a complete government run system because our government bureaucracy is very, very bad when it comes to reviewing it’s own decisions, especially when they are big ticket decisions.

    I like having the government in more of the role of referee, rather than sole provider. An entity that can serve as an external appeal to contested decisions. And I don’t really trust the courts to act as that, because all too often, they side with the government unless the government is being grossly egregious in their decision-making. Way more often than they side with larger corporations.

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