Socialized Healthcare and Paternalism


Conor Duffy

Conor is a neuroimmunology Ph.D student based in Dublin. He's particularly interested in science and health policy, liberalism, and how the two interact. You can find him tweeting @conorduffy_7.

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94 Responses

  1. Avatar LeeEsq says:

    Societies have debated how free should people be to make bad decisions long before the welfare state came into existence. Even during the classic era of the nigh-watchmen state, there was a lot of state paternalism and enforcement of what you can call popular traditional morality like campaigns against masturbation and sex, drinking, or drugs. Governments started liberalizing their attitudes towards enforcing popular morality after the creation of the welfare state, not before it.

    There are welfare state advocates that do take a very paternalistic approach towards how people should live their lives but not all of them. I’m not exactly with them but I think that some level of state paternalism is necessary for a well-functioning society. Aggregate bad individual choices can have adverse effects on families, friends, and society as whole. We can’t eliminate them but we can try to blunt their impact. There is also a lot of evidence that food companies have willfully engaged in practices and withheld information that led to the current obesity crisis like sugar companies trying to down play how bad sugar can be for humans.Report

    • Avatar Conor Duffy says:

      Hey LeeEsq – I’m not arguing against a welfare state or universal healthcare, just specific models that seem to justify more paternalism than alternatives.Report

  2. Avatar Jaybird says:

    A million years ago, we argued over the Big Gulp thing in NYC.

    One point that was made over and over again was a variant of the argument that said “hey, if I’m responsible for your health care then I’m responsible for your health.” (Seriously, just check out the comments and see the fun things that were argued.)

    Anyway, That Pirate Guy had my favorite comment of the thread:

    I have no patience for the argument that publicly subsidized healthcare justifes law trying to shove people into healthier life-styles.

    If it weren’t for the evidence before my eyes in this very thread I would swear that anyone making the argument was a conservative being a giant concern troll.

    I understand the instinct to Paternalism. I mean, we all have responsibilities to each other. It’s that when I see my responsibilities established, I find that my eye starts wandering and I start wondering “hey, what is that guy’s responsibility to me?”

    And that’s the mechanism where we see how Socialized Health Care morphs from “Meeting An Obligation” to “Imposing An Obligation”.

    And, if you look, you see the same instinct under there that says that welfare recipients need to get drug tests. “Look, I don’t mind making sure that you have X, Y, and Z… but dang it, I have to pee in a cup and work all dang day, if you’re getting by with the X, Y, and Z that I provided, you’re damn sure not going to be stoned at the same time!”

    I mean, we all have responsibilities to each other.Report

    • Avatar Conor Duffy says:

      Heh, thanks for the link, hell of a comments section!

      I think it’s an unfortunate reality that this instinct exists, so when we’re designing welfare institutions, we should be careful to try and undermine these arguments before they’re even made. And the problem is once you’re punitive in one sphere (e.g. banning big soda bottles), it becomes more difficult to oppose further punitive measures (e.g. drug tests).

      A good point made there was that if the idea is to save on costs, that should justify subsidies or other ‘carrot’ style approaches – after all, it should still be an overall saving, and the freedom for those who aren’t bothered is retained. I’m pretty opposed to that kind of managerialism in general, but at least offering a carrot instead of a stick makes it the mule’s choice about whether to move and get the reward, rather than the coercion inherent to bans and such.Report

      • Avatar Jaybird says:

        I’m not sure it’s only about saving on costs. (If we wanted to save on costs, we’d let smoking become a thing again. Remember when you could smoke at Denny’s? Mmmm. Good times.)Report

    • Avatar Dark Matter says:

      I start wondering “hey, what is that guy’s responsibility to me?” And that’s the mechanism where we see how Socialized Health Care morphs from “Meeting An Obligation” to “Imposing An Obligation”

      There’s a lot of math backing that emotion. HC is expensive, UHC would be very expensive, some of the big cost drivers are “lifestyle” diseases, i.e. people not taking good care of themselves.Report

  3. Avatar Chip Daniels says:

    These conversations tend to race toward the poles, so it might be better to begin with what middle ground is shared.
    Sure, the freedom to make dangerous and unhealthy decisions is something to preserve. And the idea of pricing in the consequences of those seems pretty fair.

    Paternalism actually has two sides to it. When you are a parent of an adolescent, there are twin impulses that sometimes clash.
    One, to foster a sense of obligation, duty, and discipline. Proper hygiene, study habits, seatbelts, condoms.

    But another is to foster a spirit of adventure and exploration and bravery. Rock climbing, hang gliding, dating, parties. Learning how to drink, learning how to navigate sexual relationships.

    “When you’re living in my house you obey my rules!” is the parental version of nanny-statism.

    But we can also reduce chafing nanny-statism by becoming more generous and forgiving.

    “I don’t want you to drink, but if you do, call me and I will give you a ride and I will ground you in the morning.” is how parents often resolve the conflict.

    Suppose we provided health care freely and generously, to drunks, heroin addicts and obese smokers without judgement or blame?

    Suppose we stifled the instinct to write long essays about welfare queens and strapping young bucks buying unhealthy food on the taxpayer dime?Report

    • Avatar Jaybird says:

      When you are a parent of an adolescent, there are twin impulses that sometimes clash.

      Ooooh! Let’s expand this out! Would you say that the people who have jobs and pay taxes are more like the parents and the people who don’t are more like the adolescents?Report

      • Avatar Chip Daniels says:

        Sure, lets race to the poles.Report

        • Avatar Jaybird says:

          It’s *YOUR* analogy.Report

          • Avatar Chip Daniels says:

            What if I told you Neo, that in a civilized society there are we are all simultaneously parents and adolescents, free citizens navigating the desires for both community and freedom?

            And to further bake your noodle, this process entailed negotiation, where risks and responsibilities were accepted or rejected.

            What if I told you that blame and judgement were a hindrance to this process, not a help?Report

            • Avatar DensityDuck says:

              “you say this is the pole, sir, but I say to you this is in fact the MIDDLE, and movement AWAY from it represents a pole!”Report

            • Avatar CJColucci says:

              You’d be wasting your time. But you probably knew that already.Report

            • Avatar Jaybird says:

              Well, that’s a *MUCH* different argument than “you’re racing to the poles”.

              we are all simultaneously parents and adolescents, free citizens navigating the desires for both community and freedom.

              This makes sense to me. Is this something that is measurable? Like, this guy is 40% parent, 60% adolescent and that woman is 75% parent, 25% adolescent or is this something more spiritual where all of us are fully parents and fully adolescents (as soon as we stop being adolescents, anyway)?

              I mean, when *I* was an adolescent, there were a lot of responsibilities that I didn’t have but there were also a lot of freedoms that I didn’t have either. (And this is literal adolescence, not figurative.) As I grew, I gained more freedoms commensurate with my responsibilities to the point where I finally looked around and saw that I had a job and a life partner and a mortgage and a contract with the city for garbage pickup on Tuesdays.

              And that strikes me as being significantly more “adult” than I was when I was 25 and all I had was a job and an apartment and a pack-a-day habit.

              What if I told you that blame and judgement were a hindrance to this process, not a help?

              What if I told you that accepting blame and judgment is one of the things that distinguishes adults from adolescents?Report

              • Avatar Chip Daniels says:

                What I’m trying to move away from is the transactional model of relationships that marks dysfunctional families.

                Because freedom only exists as an obligation by someone else to defend it. So everyone is simultaneously giving and taking.

                So blame and judgement isn’t wrong, just unhelpful- e.g.:

                “If you smoke, we will refuse to give you health care!”

                “Oh yeah? Well if you refuse to give me health care, I will refuse to give you police coverage!”

                I don’t see how this leads to a productive outcome.Report

              • Avatar Jaybird says:

                It’s *YOUR* analogy.Report

              • Avatar Brandon Berg says:

                I get that you find it helpful, in advancing your ideological agenda, to obscure the fact that the nature of welfare state is that some people mooch, and other people are mooched off of. But it is a fact, as I’ve explained to you multiple times, and it would be super cool if you could stop lying about this. As I said to Saul, maybe you should ask yourself why it is that your ideology is best advanced by this sort of blatant dishonesty.Report

              • Avatar Chip Daniels says:

                I used the family analogy because the “moochers” theory is very much like a bad marriage, where people start making lists of who provides what, in order to create a sense of debt on the other person’s part.

                Peeling the onion of who provides and who takes ends up in madness.

                Who provided the safe environment for land to be farmed? Who provides the court system that recognizes contracts?

                Virtually every person will spend the first and last years of life helpless and dependent upon the generosity of the collective. How can we apportion this debt and repayment?

                Even if you pursue your own line of logic, what is your end goal?
                What would the world look like if everyone played that game?

                Why would anyone even want to live there?Report

              • Avatar Jaybird says:

                Part of the goal of a healthy family is for the parents to turn the children/adolescents into adults who can then take care of themselves (and perhaps even have children of their own who can be raised in such a way that they go on to become adults who can then take care of themselves (and so on)).

                If an adolescent never reaches the point where they can never take care of themselves… then what?

                If I play this conversation out in my head, I see you going immediately to asking about the parents and wondering what is to be done with how they screwed up and created perpetual adolescents.

                What sanctions should be held against these parents?

                Even if you pursue your own line of logic, what is your end goal?

                For me, the “end goal” isn’t an “end goal” as much as the creation of a “sustainable process”.

                The parents create children who can grow up to become adults capable of taking care of themselves. Perhaps even have children of their own… and then their job is to help the children become adults capable of taking care of themselves (and perhaps even have children of their own).

                End goal? There is no end.Report

              • Avatar Chip Daniels says:

                Yes, that’s similar to my original point, that paternalism is as much about fostering independence and risk taking as it is about protecting and caretaking.

                For example, think of how the idea of patents is to foster risk taking. We the collective body use our coercive power to protect patentholders, subtly “nudging” people to create things.

                Part of caretaking, the social welfare system, is to also do this. We make the world safe to take risks. Its a truism that most entrepreneurs have gone bankrupt at least once; that is to say, all of them at one time were net takers, relying upon the mercy of the collective.

                This fear that people will mooch, or become perpetually incapable of taking care of themselves seems greatly exaggerated.

                It especially seems silly in light of all the commentary we hear about how the global economic order has enriched all of us to where medieval kings envy us.

                Are we then so impoverished by moochers that it is a problem?

                I would think that the proof of the success of the global economic order is that it causes us to be generous.Report

              • Avatar Jaybird says:

                Are we then so impoverished by moochers that it is a problem?

                You stopped using the metaphor just a hair early.

                If someone is incapable of taking care of themselves, they’re in a place where we, as parents, need to help them become self-sufficient. We don’t give up on them.

                Indeed, we have a responsibility to them.

                It’s not about them sponging off of us.

                It’s about our responsibility to turn them into a responsible adult.

                You shouldn’t be so willing to abdicate your responsibilities. That’s an adolescent attitude towards them.Report

              • Avatar Chip Daniels says:

                In what way am I abdicating responsibility?Report

              • Avatar Jaybird says:

                By leaving the “moochers” to “mooch”, instead of helping them grow into adults capable of taking care of others.Report

              • Avatar Chip Daniels says:

                If you and I agree we should help people, we probably just disagree over what form that help should take.

                Which is pretty common, even with parenting.

                At what point we let people fail versus intervening is one of the most difficult decisions to make, and there really isn’t a one size fits all solution.

                Bankruptcy laws are a great example.
                How much debt should be forgiven? How much of their possessions should the debtor be allowed to retain? How many times, how often, can this mercy be extended before it just becomes mooching?

                I don’t know that I can give easy answers. But I’m not seeing it as a major problem yet.Report

              • Avatar Jaybird says:

                The help should take different forms and different people probably need different things (as in: something that works with one person might fail spectacularly with another and the thing that would help the other person might not move the needle on the first).

                But if the help doesn’t result in self-sufficiency on the part of the recipient, it should be measured as a failure.

                “But I’m not seeing it as a major problem yet.”

                Because you’re looking at it from the position of “who might be mooching off of me” and then shrugging when you don’t notice the number rather than from a position of your having a responsibility to all of the adolescents under your care to help raise them not be a moocher in the first place.Report

              • Avatar Chip Daniels says:

                Are you really sure you can parse out moochers from people who just need help?

                And why speak in terms of hypotheticals?

                Right now, in every city, is a skid row mission that gives away free food and clothing to anyone who asks.

                Why don’t we see millions of moochers taking advantage of this? Why do you personally quit your job and just loaf around on the free food and shelter they provide?

                Because almost everyone is too rich to see that as a preferable option.

                So who goes to the missions?

                Or addicts, mentally ill, and people who for whatever reason have seen their lives crater into catastrophe?

                And who says the help that is offered isn’t doing just what you say, helping those who can get back to self sufficiency, and those who can’t, palliative care?Report

              • Avatar Jaybird says:

                Why don’t we see millions of moochers taking advantage of this?

                You jumped back to “moochers” again. I thought we were talking about adults vs. adolescents. Would you rather use Brandon’s framing than the one you brought up at the beginning?

                We can switch to that, if you’d like.

                Why do you personally quit your job and just loaf around on the free food and shelter they provide?

                Because I was raised to be an adult who could take care of himself (as opposed to a perpetual adolescent who saw it as someone else’s problem).Report

              • Avatar Chip Daniels says:

                Are you sure you can parse out people who are like you, versus people who are perpetual adolescents?Report

              • Avatar Jaybird says:

                Eh, I’m sure if I were given extreme examples of both, I’d be able to say “this is the person who legitimately needs help” or “this is the person who has been failed by society”.

                In the meantime, we should probably just have a norm of sorts that says “you should be an adult who can take care of others… if that’s not possible, you should be an adult who can take care of yourself. If that’s not possible, then we, as a society, are prepared to offer a helping hand.”

                An established norm like that one should be able to do the heavy lifting within each individual agent.Report

              • Avatar Chip Daniels says:

                Sure, extreme examples are easy, but rare.

                You don’t think we already have a norm that encourages people to take care of themselves?Report

              • Avatar Jaybird says:

                You don’t think we already have a norm that encourages people to take care of themselves?

                I think that the norm that used to exist was stronger than the norm we have now. I suspect that the norm we’re going to have in the future will be weaker still.Report

              • Avatar Dark Matter says:

                Are you sure you can parse out people who are like you, versus people who are perpetual adolescents?

                At an individual level? Probably not.

                At a sub-cultural level in terms of percentages? Probably yes.

                Look for kids who don’t have fathers in their lives, and all the other things we tend to associate with poverty, especially concentrated poverty, and you’re pretty much there.

                Not only does poverty create bad things but bad choices also create poverty.

                Of course this instantly leads to politicians in one sub-culture asking why their tax dollars are being misused and are enabling dysfunctional behavior.Report

              • Avatar Chip Daniels says:

                That’s certainly true, but raises many other questions.

                For example, conservatives have made very good points that the culture of the autonomous individual has driven much of the growth of splintered families, which drives poverty.

                But then, wouldn’t the corrective to this be a stronger emphasis on suppressing the individual will to the collective norms of morality and behavior?

                I’m not (necessarily) opposed to this, but it seems interesting to consider that the alternative to “I am obligated to pay taxes for fatherless children” would be “I am obligated to take care of my family”.

                See, this is why I don’t see it as a coincidence that the Bismarkian social welfare concept arose immediately after the Enlightenment concept of the autonomous individual became widespread.

                The social welfare state allows us to leave our families (children, elderly parents, sick relatives) in the care of the state while we pursue our individual goals.

                Is this better or worse? I am not entirely sure.Report

              • Avatar Jaybird says:

                I mean, we all have responsibilities to each other.Report

              • Avatar Chip Daniels says:

                You keep using that phrase.

                I do not think it means what you think it means.Report

              • Avatar Jaybird says:

                Now we just have to hammer out which of us is confused.Report

              • Avatar Marchmaine says:

                “But then, wouldn’t the corrective to this be a stronger emphasis on suppressing the individual will to the collective norms of morality and behavior?”

                This is something worth thinking on because I think we get at the nub of some important issues that are somewhat difficult to reconcile, but which illustrate why (I think) we’re running in policy circles.

                What Chip identifies seems to me part of a Triangle:
                A: Libertarian Individual Autonomy
                B: Liberal Collective Action
                C: Conservative Communitarian Action

                Its not a perfect representation, and all political strains partake of each part of the triangle to some extent… but, if we allow the simplification it helps us noodle through some items that are circular, or triangular.

                As we maximize individual autonomy, there’s a recognition that the individual loses some communitarian protections, which we seek to remedy via Collective systems. The Collective Systems, however, are rather abstract bureaucratized systems that lack the communitarian elements of Trust and Cohesion such that “gaming” the System (let’s say mooching) is illegal, but is somewhat encouraged by a desire to maximize individual autonomy… which leads either to greater systemization of the rules or calls for greater Communitarian cohesion. Sometimes both. But, Communitarian cohesion is erodes Individual Autonomy while Collectivisation increases it. However, Communitarian policies enjoy widespread support, less “mooching” and general effectiveness at the expense of some exclusionary mechanics that keep the system “High Trust” and somewhat self-policed… but all at an expense to pure autonomy and suffering some brittleness to rapid expansion and/or friction within society with regards what constitutes consensus… so the harder we push for Individual Autonomy, the less Communitarian our Systems… and as Communitarian support for Systems erode, we redouble on Collective systems which attempt to maximize Individual Autonomy, but which then suffer from (potential) widespread defection/gaming/mooching… which leads to more systemetized Rules which we *don’t* experience as Communitarian goods, but as coercion against our Autonomy… which spurs defection… which spurs more systemetized rules, etc.

                My lose more friends and alienate the OT commentariate thought for the day is that we as a Political Entity think that we’re fighting against excessive Communitarian evils where we’re really in an Individual Autonomy / Collevitvist feed-back loop.

                Which is why this particular “Conservative Communitarian” can be completely in favor of some sort of “collective” health-care approach, but remain skeptical that the Liberal approaches will make things better rather than worse.Report

              • Avatar Dark Matter says:

                …conservatives have made very good points that the culture of the autonomous individual has driven much of the growth of splintered families, which drives poverty. But then, wouldn’t the corrective to this be a stronger emphasis on suppressing the individual will to the collective norms of morality and behavior?

                Intuitively this seems like a good idea, but it’s so hard to do it calls into question the success of anything which depends on it.

                The anti-vax movement is clearly proven by science to be stupid, self destructive, and actively endangers others. We suppress the anti-vax movement, but that this is even an issue should say a lot about how much power society has here.

                In terms of fighting “splintered families which drive poverty”, what would be solutions? Give every female a 10 year birth control implant at the age of 12? Maybe only removing it if they get married? Reduce gov benefits if they have kids out of wedlock? The gov has pushed marriage as a solution before.

                Culture is extremely hard to change. The gov’s tools and power are very limited. We end up dealing with human nature and vast numbers of people won’t obey a law which intrudes too much. We’re a democracy and there are serious limits to how much pain the gov can impose on people.

                Ending poverty or improving general income in various groups or whatever is something we’d have already done if we knew how. If UHC needs to wait for getting rid of multiculturalism and different levels of poverty in different sub-groups, then it’s going to wait a long time.

                Maybe it’s better to ask, “What does UHC look like in a (deservedly) low trust society?”Report

    • Avatar DensityDuck says:

      “Suppose we stifled the instinct to write long essays about welfare queens and strapping young bucks buying unhealthy food on the taxpayer dime?”

      Chip, my man, you can get as excited about strapping young bucks as you like, but just do remember that it wasn’t conservatives who banned large cups of soda.Report

      • Avatar Chip Daniels says:

        You are absolutely correct.
        The desire for helping people DOES in fact slide easily into unhealthy control of them and liberals as as susceptible to it as anyone else.

        Which is why I referenced generosity, where we foster a spirit of giving even when it feels like we are being taken advantage of.Report

  4. Avatar Jaybird says:

    San Francisco banned Juuls. Which is good, because nicotine is addictive.

    (Cigarettes are still legal, though.)Report

  5. Avatar Chris says:

    I wonder if you’ve heard of a thing called medical insurance, and understand how it works.

    Anyway, if people who would otherwise have died for lack of healthcare get to vote on whether to tax cigarette smoking, I’m OK with that.Report

    • Avatar Jaybird says:

      Medical Errors are the third leading cause of death in America (after heart disease and cancer).

      Seems to me that we will fix the problem with the Boomers as soon as all of them get on Medicare.Report

      • Avatar Michael Cain says:

        You’ll have to explain the relationship there to me.

        My Medicare is Kaiser’s Medicare Advantage. A number of the possibilities for mistakes are dealt with by their overbearing health records system. Every doc/nurse I see has access to my full record. No specialist ever asks, “What prescription drugs are you taking?” and trusts my memory — they look it up. The computer nags everyone — docs when I’m in the office about things like out-of-date vaccinations, robocalls to me when it’s time for an annual wellness visit, etc. I understand there’s a rule-based system in there somewhere that helps pharmacists avoid questionable drug combinations/dosages.

        I had a wellness visit yesterday. By the time I got home, I had an e-mail telling me to check my messages at The PDF I downloaded had a summary of everything the doc and I had talked about, instructions on how to handle the urology referral for a symptom that needs to be checked, an order to the doc to consult with orthopedics within five days about an unusual lower leg problem, a reminder that I have an appointment with an ophthalmologist next month, and a reminder that I haven’t used my Silver Sneakers gym membership. Oldsters who don’t like computers can get the same thing sent to them — or a responsible caregiver — by paper mail.

        My wife calls it their “let’s not kill you with stupid oversights” system and loves it.Report

        • Avatar Jaybird says:

          I have no idea *WHY* medical errors are #3.

          I just know what the stats are.

          (Maybe this is one of those things like Public Schools. I went to an awesome Public School. Seriously, Westchester schools are feeders to the Ivy Leagues. But not all Public Schools are awesome. Could be the same for Medical Care on this side of the tracks versus that side.)Report

          • Avatar CJColucci says:

            I’m reminded of being told in my Criminal Law class that homicide was the 3d greatest cause of death among adolescent and young adult males. (This was when crime was much higher than it is now, and before AIDS, so I’m not sure if it is still number 3.)
            Sounded awful. Then I thought about it a bit. What should be the number 3 cause of death for males in that age group? Certainly not cancer, heart disease or the multifarious ills of old age; they aren’t old. Being adolescents and young adults, they by definition haven’t died of childhood diseases. Being males, they didn’t die giving birth. Many of my peers died in auto accidents, some in work accidents, some by suicide, some drowned. If you leave accidental deaths and suicides aside, what else but homicide is likely to be a major reason a young male would die?
            Doesn’t mean that the level of homicides wasn’t unacceptably high, but its relative ranking as a cause of death didn’t tell us much.Report

            • Avatar Jaybird says:

              While it’s certainly true that you gotta die of something and something is going to be in 3rd place no matter what, I was kind of hoping that “Health Care” would be below Strokes.Report

            • Avatar Dark Matter says:

              …its relative ranking as a cause of death didn’t tell us much.

              It tells us where to focus our efforts for improvement.

              Young children die in pails of water. Since it’s in the single digits removing it as a source of problems wouldn’t help much.

              If that sounds laughable, terrorism and mass shootings are also a very rare events, to the point where they’re effectively unrelated to the body count we get from guns which is driven by other events.Report

          • Avatar Michael Cain says:

            No, what gets fixed/changed with the Boomers on Medicare?

            When we transitioned from a Kaiser exchange policy to Kaiser Medicare, our deductibles, copays, and drug costs moved in assorted directions. Oh, and the monthly premiums went down. Thank you all for continuing to fund the program by which I paid for my grandparents’ and parents’ medical care in their old age.Report

            • Avatar Jaybird says:

              Well, given that health care errors are the #3 cause of death, my assumption is that the more health care, the more chance for fatal errors.

              It’s really dark humor.Report

  6. Avatar PD Shaw says:

    My wife’s employer is a medical facility that sells us our insurance. When Obamacare passed, it implemented tiered pricing for being overweight, but also required the employee to participate in weight loss services. And being in a weight loss program waives the added fee so long as each following year, weight declines.

    I noticed three odd things about this policy. One is that it is for the employees, not other adults on the policy. I am free. Also, the policy was implemented when Obamacare passed, and since the employer self-insures, it is exempt from almost all of the Obamacre requirements. IOW, I don’t think this was required, but the change in laws appeared to legitimize something employees may have strongly disliked.

    Finally, a co-worker enjoying the benefits of the weight loss program, while unconvinced of the strictures of BMI, did want to be more active and felt constrained by certain large natural endowments. She arranged an appointment to have them reduced, but was told that she would need to show progress in a weight loss program in order to be eligible for coverage for elective surgery. I’m not clear on the specifics, I picked-up the strong sense of helplessness as she climbed the Escher stairwell.Report

    • fillyjonk fillyjonk says:

      Wow. That’s even more intrusive than some I’ve heard of. What happens to a person who participates in weight loss services but fails to lose weight? Fines?

      My campus has a voluntary ‘wellness’ plan which entirely revolves around BMI/weight. So a person could, conceivably, wind up conforming in an unhealthy way (eg., crash dieting or excessive exercise to the point of injury). I exercise and I strive to eat healthfully (but am kinda fat, though my doctor has never told me I need to lose weight – she says all my blood numbers are good, she’s happy I eat my veggies and exercise) but I don’t want to participate in weekly public weigh-ins, which is a feature of this plan.

      There’s also a “knock a trivial amount off your deductible if you fill out a long survey” and I chose not to do so, on the grounds of “I don’t know who’s going to be privy to that information” (it was not spelled out). A colleague with fewer body-issues than I have, and less concern about his privacy, did it, and said it was “very intrusive,” even getting into stuff like sexual habits and the like so….yeah…no. If I have a concern about something “personal” I’ll bring it up with my doctor. Otherwise, no one needs to know.

      Though I suspect there will come a point where we’re REQUIRED to fill the surveys out, and maybe REQUIRED to participate in “official” exercise. (One reason I don’t do the “wellness program” is that the exercise periods they count as official are times when I’m either in class, or my brief lunch break – I get up early in the morning to work out and feel like I shouldn’t give up my lunch break just for the appearance of conforming to what they want)Report

      • Avatar PD Shaw says:

        I’ve probably conflated a few different aspects. If an employee is one pound overweight by BMI, they pay a higher premium for healthcare insurance. An employee can just pay it, but to get a one year reprieve, one needs to get into some sort of program. Longer reprieves require progress, if only by one pound towards normal weight. But let’s say one loses ten pounds each year for four years straight, but then gains a pound the fifth year — that’s treated as no progress, so a higher premium.

        It all seems pretty crazy to me. I’m skeptical that there are significant health impacts from being moderately overweight, and I think a lot of obese people would find this to be too unforgiving and either just pay the extra premium or look for work elsewhere.

        The breast reduction surgery was a whole different thing. She was going to have to explain to a whole different group of people that she’d been trying to lose weight for several years, though she wasn’t merely doing this to lose weight, it’s about discomfort, etc. They simply may not like to pay for this surgery.Report

        • Avatar Chip Daniels says:

          So…you can choose whether to pay with money, or a pound of flesh?

          Man, this season of Black Mirror is really dark.Report

  7. Avatar Saul Degraw says:

    I think this is kind of a very abstract and kind of bullshit definition of freedom. One of my really big axes to grind with the modern right-wing and libertarians is that they deem themselves the sole definers of freedom. This definition of freedom seems to swing towards an ultra-Randian one that puts business and wealth rights uber-allies.

    What about the ideas of freedom from want? freedom from fear and insecurity? Or perhaps providing a solid welfare state with guaranteed health insurance might encourage people to take more business risks and start their own companies? I’ve been laid off randomly before and it is not fun. Because I graduated law school during the height of the recession much of my legal career has been spent on freelance projects. Some were very long and paid well. Some were short with mediocre pay. Only three jobs came with traditional benefits. Obamacare helped me get insurance for much of the time from 2011 to 2017.

    There is also a lot of hyperbole. Lots of people in countries with socialized health care still make bad decisions. There is still plenty of junk and processed food that is cheap and easily available in Europe.Report

    • Avatar DensityDuck says:

      Free from the terror of making the wrong decision by having a government-defined set of Definitely Right Decisions to choose from, and anything else is illegal!Report

      • Avatar Saul Degraw says:

        I think you are completely ignoring everything I wrote. There is plenty of junk and processed and unhealthy food all over the world. I have not seen any country with more robust welfare states try to ban it despite the fever dreams of the right.

        But information does cause people to make different decisions. This is not a surprising fact and the display of calories or a slight tax might (gasp of horror) encourage people to eat slightly healthier sometimes or to forgo the ultra-sugared, ultra-caloried drink for water sometimes. This is not a boot of fascism coming down. The boot of fascism coming down is putting kids in detention centers/concentration camps and then arguing with a straight face that you don’t need to give them blankets, toothpaste and brushes, showers, baths, soap, etc.

        You might really want to rethink your priors here. I doubt you will but it would be nice.Report

        • Avatar Jaybird says:

          I have not seen any country with more robust welfare states try to ban it despite the fever dreams of the right.

          It took me 10 seconds to google this.

          Seriously, it took me longer to do the html tags in this comment.Report

        • Avatar DensityDuck says:

          Or it’ll make the higher-wealth people shop at stores outside the city, causing the stores in the city center to dip below sustainable income and close, leaving the lower-wealth people with no actual food store in their neighborhood, which is what happened in Philadelphia.Report

    • Avatar Oscar Gordon says:

      I don’t object to your freedoms, so long as the method(s) by which your freedoms are established does not interfere with me exercising mine.Report

      • Avatar Chip Daniels says:

        I mentioned upthread that freedoms by their very nature, interfere with others.

        Freedom requires protection, which requires collective action which requires interference to some degree.

        But “to some degree” is doing all the work here which is why these high level abstractions make it difficult to get anywhere. They pose things in terms of crisp absolutes when what we need are messy kludges.

        I’m thinking here of speed limits. There isn’t some magic number which yields optimum freedom and maximum public safety.

        But we as citizens raised it from 55 to 65, after agreeing that the cost of a few more deaths was worth the freedom to drive faster.

        Is the freedom to drink whiskey worth its cost? Would the freedom to use heroin be worth the cost?

        These can’t be answered in the abstract, since they are value judgement requiring negotiation and consensus.Report

        • Avatar Oscar Gordon says:

          But we as citizens raised it from 55 to 65, after agreeing that the cost of a few more deaths was worth the freedom to drive faster.

          Technically, it was raised to 65 because the roads were largely designed to safely handle traffic at that speed. So we didn’t decide more deaths were worth it, we decided that the additional cost of building a safe, higher speed roadway was.

          But otherwise, yes, I get your point. I like to think of helmet and seat belt laws. Does the requirement to own and use a helmet or seat belt impact your freedom to drive or ride? Yes, it does, for some people. But that impact is relatively minor[1] compared to not only the lives saved, but just the reduction in injuries.

          [1]The cost of including a seat belt in a car is now such a minor percentage of the total cost as to be negligible. And you can get a helmet that satisfies the requirement for less than the cost of a tank of gas in your car.Report

          • Avatar George Turner says:

            I once calculated the number of extra months someone would spend driving over their lifetime at the two different speed limits, given the average miles an American drives per year. I compared that to lifespan, mortality numbers, etc, and concluded that at the lower speeds more people were aging to death getting from A to B than were dying in crashes.

            This was inspired by my father’s observation that if you work out for an hour a day for your health, you’ve wasted four or five years of your waking life working out.Report

    • Avatar Brandon Berg says:

      I get that you really hate when people insist on acknowledging the gratis/libre distinction, but there really is a crucial difference between free speech and free shit. If obscuring the difference is really so important to advancing your agenda, maybe you need to be looking inward for the problem, instead of blaming other people for pointing it out.Report

    • Avatar Dark Matter says:

      What about the ideas of freedom from want? freedom from fear and insecurity?

      “Want”s, are by their nature unlimited. Ditto “fear” in this context.

      Thus the criticism that what is needed is “more”. Thus HRC can be a part of an administration which rolls out a solid expansion of this kind of thing and still run for election on “more” free stuff that needs to be handed out.

      Or perhaps providing a solid welfare state with guaranteed health insurance might encourage people to take more business risks and start their own companies?

      I’m all in favor of starting more companies. I’m not in favor of seriously overpaying for stuff, so put some numbers on the table and we’ll talk. My expectation is that our HC needs to be made a lot cheaper before we can afford UHC.Report

  8. Avatar JoeSal says:

    Excellent work.

    This doesn’t address the problem of socialized health care becoming inefficient. There is no free market competition devoid of regulation and guild systems creating barriers to entry, and the picking winners and losers problem.

    For folks that would opt out of the nanny state, there would need to be a efficient healthcare system that opted out of the socialism of social health care.

    The problem is the folks with the social preferences can’t make the socialized systems work on their own and have to force the whole of society into their ever increasing doomed model.

    They have to entangle everyone to make it work as long as possible until its eventual cascade failure at the end.

    The problem with medical insurance is it moves chance processes into social constructs, and I am seeing little to no evidence that is a good thing in long time horizons. It also allows the social folks to point at another social construct and say “look at that, those greedy capitalists they are terrible”, when they are actually pointing at a chunk of socialism built into capitalism.

    The whole thing is dishonest from top to bottom. The worst of it is entangling each other “for the good of society/collective”.

    At what point in time do the social constructors bear the responsibility of recognizing what they are doing is harmful. Until I see a considerable amount of that, I will recognize no authority in social constructs or the people pushing them on the rest of us.Report

  9. Avatar DensityDuck says:

    The issue, to me, is less the social requirement to Not Do Unhealthy Things, as it is the fact that this will disproportionately hit the people who…haven’t got the money for anything else. Report

  10. Avatar George Turner says:

    Scandinavian countries, with long experience of a national health care system, have been moving toward private employer-based health care.Report

    • Avatar Saul Degraw says:


      • Avatar George Turner says:

        Daily Signal story from June 13.

        The nut of it is this:

        Private plans in Sweden and Norway are mainly designed to supplement the government-run plan.

        In addition to covering out-of-pocket costs, these plans also guarantee prompt access to specialists or elective procedures, which the state plans often fail to provide.

        Denmark also allows “complementary” insurance plans, which cover services that are partially or not at all covered by the national system, including dental and vision services.

        This growing European interest in private health insurance typically stems from dissatisfaction with the state-run systems, which often provide poor or incomplete coverage and long wait times.

        By contrast, private plans offer wider coverage, shorter wait times, access to private facilities, and more flexibility in patient choice.

        It also touches on one of the fundamental problems with socialized or nationalized plans, which is that by their nature, all patients should be treated equally. One citizen isn’t more important than any other, in the legal or moral sense, so any prioritization that does exist will be the same as battlefield triage, based on whose would is the most serious.

        But reality is somewhat different. Most people can wait six months or a year to get their knee surgery. A star forward can’t, nor can his team. Some workers are really important and need to get in, get it done, and get back to their jobs. They or their company will pay a lot of money to make that happen.

        As an aside, Sweden also praises private for-profit primary schools.Report

        • Avatar Saul Degraw says:

          The Daily Signal does not seem like the most bias free source of information regarding the specifics of the detailsReport

          • Avatar George Turner says:

            Well, here’s the same thing from the UK Guardian

            Despite its reputation as a leftwing utopia, Sweden is now a laboratory for rightwing radicalism. Over the past 15 years a coalition of liberals and conservatives has brought in for-profit free schools in education, has sliced welfare to pay off the deficit and has privatised large parts of the health service.

            Their success is envied by the centre right in Britain. Despite predictions of doom, Sweden’s economy continues to grow and its pro-business coalition has remained in power since 2006. The last election was the first time since the war that a centre-right government had been re-elected after serving a full term.

            As the state has been shrunk, the private sector has moved in. Göran Dahlgren, a former head civil servant at the Swedish department of health and a visiting professor at the University of Liverpool, says that “almost all welfare services are now owned by private equity firms”.


    • But since 90% of them work for the government …Report

      • Avatar George Turner says:

        Scandinavia’s public sector is 25 to 35%, larger than the UK or Canada (both around 22%). It’s highest in Norway (35%, the same as Saudi Arabia) but Norway is basically an oil company, so all the petroleum workers count as government employees. Kuwait and many other petro states have a really high percentages of people in the public sector.Report

  11. Avatar James K says:

    Good article, Connor. I particularly appreciated your comparison of different government health systems, rather than stiing at the mor eabstract “market vs government” level.Report

  12. Avatar North says:

    Good meditation on the dangers of liberal paternalism. Liberals can (and should) disagree strongly with libertarianism as a principle for operating society in general without discarding it as a valuable tool and null hypothesis to measure existing and proposed state actions and programs against.Report

  13. Avatar Brandon Berg says:

    It’s possible that the Netherlands has fewer such regulations simply because it doesn’t have as bad an obesity problem as the UK. Or maybe continental Europeans are just more into subsidizing other people’s poor choices. Inferences about general rules drawn from a handful of data points are always going to be questionable.Report

  14. Avatar Brandon Berg says:

    Favouring a Dutch-style system, where unhealthy choices could be at least somewhat priced into costs

    I don’t think it can be. According to the Wikipedia article on Dutch health insurance,

    Private insurance companies must offer a core universal insurance package for the universal primary curative care, which includes the cost of all prescription medicines. They must do this at a fixed price for all. The same premium is paid whether young or old, healthy or sick. It is illegal in The Netherlands for insurers to refuse an application for health insurance or to impose special conditions (e.g. exclusions, deductibles, co-payments, or refuse to fund doctor-ordered treatments).

    It seems that the insurers are required by law to distribute the costs of poor lifestyle choices equally among all customers, so the situation really doesn’t seem so different as from the UK.Report