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Universal Health Care:

Some comments to Ilya's post on Brink Lindsey reminded me that I get puzzled when I see libertarian and conservative think tanks (and individuals) go ballistic whenever anyone suggests having the government require "universal health care." See, e.g., the controversies in Massachusetts and California. It seems to me we already have universal health care; by federal statute, anyone has the right to show up at any hospital emergency room in the country, and get whatever care they need regardless of their ability to pay. Now, admittedly, this is an especially dumb kind of universal health care, because it neglects primary care, focuses on especially expensive emergency care, and turns emergency rooms into family physician's office (except, to avoid draconian liability under federal law, emergency rooms will be much more eager to order every possible test under the sun, lest they be accused of neglected their federal law obligations). The costs of such care, along with whatever other costs to the health care system the uninsured are able to pass on (bills not paid, contagious diseases spread, whatever), are paid by the rest of us, as surely as if they came out of the tax system. Moreover, healthy individuals who rely on the safety net for their care instead of paying for their own insurance (as well as employers who don't provide insurance) are free-riding on the rest of us. I'm against socialized medicine, and I'm against a single-payer system, (and I'm against Medicare for that matter, which not only subsidizes many well-off rich, but could hardly be better designed to waste money if it were done intentionally), but I simply can't get up in arms about "universal health care." We have a version of it already, but it's just a stupid and counterproductive version, and I'm willing to listen to alternatives that are less costly and more efficient, even if it means that the government is more directly involved, as with employer mandates.

FantasiaWHT:
How about the proposal, passed in Wisconsin by its Democratic Senate (and being blocked by the Republican Assembly) to levy the largest state payroll tax increase in the history of the United States ($15 billion, doubling the current payroll tax and weighing in at a massive 6% of the State's GDP) to provide Universal Health Care?

That gets me up in arms, especially considering a study just named Wisconsin as having the country's best health care system. And that if you have two wage-earners in the household, you're going to be paying double. And that the State will be taking roughly the same amount in payroll taxes that the federal government does.

All to, like you say, David, create a system that, for all intents and purposes, already exists.
7.11.2007 5:12pm
ATRGeek:
I agree with David: we already have a terribly inefficient universal health care system. The basic reason is that like it or not, as a society we are not willing to let seriously ill or injured people go untreated because they cannot pay for medical services, and that is essentially as fundamental a political fact as you will ever find. So, as I noted in the other discussion, I think the most productive role libertarians can play in these debates is to help guide us toward the best possible universal health care system.
7.11.2007 5:18pm
Steve:
Was this post inspired by Bush's bizarre comment yesterday about emergency rooms?
7.11.2007 5:19pm
DavidBernstein (mail):
I don't know what Bush comment you are talking about. Note that this post is not meant to endorse any particular version of uhc that has been proposed or enacted.
7.11.2007 5:24pm
rjh:
The MA system is not "universal health care" as usually defined. What MA has done is institute mandatory minimum healthcare insurance, more like the mandatory minimum auto insurance. Then there are subsidies for those with low incomes and penalties for non-participation. This works in conjunction with the de-facto universal health care option of EMTALA. It is specifically targeting the free-rider aspect of the system.

We'll see whether the conflicts between the "insurance should cover everything" and the "free rider elimination" can be resolved successfully in MA. They outcome so far looks hopeful, in that they have not (yet) layered massive requirements onto the minimum insurance converage. The extras are not too bad yet.

MA has some advantages compared with other states because it has a low unemployment rate and a low un-insured rate. The free rider effect is also significant. Over 16% of un-insured were persons with incomes over $100,000. There are many young healthy uninsured who are part-time, freelance, or small company employees. They previously faced serious administrative headaches in obtaining insurance, and had little motivation to bother. The law makes it relatively easy for them to find basic insurance, and the penalties motivate them and the small employers to get the insurance.

A few years should tell whether this has a really noticable effect or not.
7.11.2007 5:25pm
Henry Bramlet (mail):
David- Universal Health Care isn't in and of itself a horrible thing. But the problem we have is that the current health insurance regime obfuscates costs from the consumer. In effect, Universal Health Care is welfare with the payments being handled by a private party, rather than the US Government. It is every bit as objectionable to libertarian ideals as socialized or single-payer healthcare because individual consumers of health care have no cost sensitivity with their consumption.

This Study by the NCPA is a pretty good analysis of how out-of-pocket health care expenses have brought down the costs of health-clinic costs as well as elective surgery such as cosmetic surgery and lasik.

To me this says that we need to be figuring out how to change our current insurance system to return cost sensitivity to the individual consumer. When I go to the doctors office or go in for surgery, I should be considering cost in my choices of how the surgery should go or how my post-op treatment will be carried out.

This may sound pretty cruel, I agree. But the alternative is that some bureaucrat is deciding how cost will factor into my treatment, which I think is worse. Over time, ever one will be better off because their price sensitivity encourages the market to develop cost-conscious treatment options- just as it has done for other markets.
7.11.2007 5:27pm
David Matthews (mail):
I see a fundamental, and very troubling, difference, between Massachusetts' health insurance law, and any other law on the books that I can think of.

Under the law, I'm required by law to purchase something. And there's no way around it. This is not like car insurance. If I don't want car insurance, I simply don't own a car. This is not like homeowner's insurance. If I don't own a home, I don't need insurance. But for mandatory health insurance, what are my options? Basically, leave the state, or die. Heck, I can even avoid paying taxes, if I keep my income low enough. But here is a government requirement forced on me, simply by virtue of my having been born.

OK, I take it back. This is somewhat similar to the requirement to register for the draft with the selective service, a law which I also find troubling. But at least that law does not require me to make a purchase from a private party, as a price for my being allowed to live in the state.

I don't know that there's even a conscientious objector exception to these laws, whereby I could avoid purchasing insurance, if I swear to never use a hospital or see a doctor.

(Incidentally, this is purely a theoretical objection on my part, since A) I don't live in Massachusetts, and B) as a state employee in Minnesota, I have amazing health care coverage, obtained through collective bargaining by my union, and paid for through the coercive efforts of the state, at the expense of the hard-working honest taxpayers of Minnesota.)
7.11.2007 5:27pm
bittern (mail):
Henry Bramlet, David Matthews,
Pls reread ATRGeek's paragraph and adjust accordingly.
7.11.2007 5:33pm
rarango (mail):
But...But...Professor Berstein: what about the 45 million (or so) Americans without health insurance? :)

very nice critique, BTW.

On a more substantive note re health insurance: I would propose a system based on prevention wherein prenatal care is subsidized to increase good birth outcomes, and immunizations are subsidized along with annual physicals until the age of 18. After that, annual physicals and recommended screenings are subsidized and those subsidized exams are linked to risk factors. Prevention is far cheaper than intervention.
7.11.2007 5:36pm
Steve:
I don't know what Bush comment you are talking about.

Bush reportedly said:

"The immediate goal is to make sure there are more people on private insurance plans. I mean, people have access to health care in America," he said. "After all, you just go to an emergency room."


Just a funny coincidence, really, since I've never heard anyone make this interesting point before. Maybe you and the President have some sort of Vulcan mind-meld.
7.11.2007 5:36pm
Kelvin McCabe:
Agrees with David B's main point regarding our already existent universal coverage. As an aside, my older brother is an ER nurse in the greater St. Louis region. He and the doctors and other nurse practitioners get so pissed when poor uninsured people use up essential services in the ER, like ambulances, because they have a fricking cold.

Apparantly, the poor are in the know regarding mandatory emergency service. So they call 911, make up a story about their alleged emergency, the ambulance shows up, gives them a free ride to the ER, where they run all kinds of unecessary and expensive tests (which dont get paid by the patient), just to ultimately give them some cold medication and send them home. Heaven forbid someone actually need that amublulance! Or that room! Or that machine!

It isnt all about money; its about channeling non-serious patients to a proper place and leaving the emergency room to handle actual and real emergencies, which apparantly doesnt happen as often as one would think. The health care situation is beyond pathetic. Its criminal.
7.11.2007 5:43pm
David Matthews (mail):
bittern, there's nothing in what ATRGeek said that affects my argument at all. I voiced no opinion about universal health care, but found it terribly troubling that I could be forced by law to make a purchase from a private corporation, with no exception and no way out.

If what you mean by "adjust accordingly" is that I should follow "the best role for libertarians...." then perhaps I already did. A government should not force me to make a purchase from a private corporation as a precondition of my inalienable right to life. So, clearly, that approach isn't what I'd call the best one.
7.11.2007 5:44pm
Whadonna More:
Universal health care quickly causes the quality of care to go down, if the single payer can prevent good providers from charging more for services. There's a reason the English don't run into doctors with American accents.
7.11.2007 5:53pm
springjourney (mail):
You have got to remember guys, that HealCare in U.S. is a worst monopoly in the world. Private organization created by doctors and pharmacists and supported by the governement have a power to regulate health care prices.
Accordingly, in order to fix Heal Care system those organization should be destroyed or some kind of alternative has to be created. That will create competition and as a result price of Health Care going to go down.
7.11.2007 6:00pm
loki13 (mail):
The problem I have with arguments like Henry Bramlet's (supra) is that cost sensitivity is not the same force in health care decisions as it is for other more traditional economic decisions.

Most (non-hypochondriac) people do not choose to 'over-consume' health care. They 'consume' health care when they need it, and do not when, well, they don't.

As for making informed decisions, the vast majority of people follow the recommendations of their doctors. If a doctor recommends an operation to save your life, you follow that advice. I am not sure what the benefit of having every patient look over the cost/benefit of each type of anaesthia (sp?) would be.

For cosmetic operations, of course, this is not true. But I believe that preventive and curative health care does not fall under traditional 'rational consumer' patterns of classical economics.
7.11.2007 6:02pm
loki13 (mail):
The problem I have with arguments like Henry Bramlet's (supra) is that cost sensitivity is not the same force in health care decisions as it is for other more traditional economic decisions.

Most (non-hypochondriac) people do not choose to 'over-consume' health care. They 'consume' health care when they need it, and do not when, well, they don't.

As for making informed decisions, the vast majority of people follow the recommendations of their doctors. If a doctor recommends an operation to save your life, you follow that advice. I am not sure what the benefit of having every patient look over the cost/benefit of each type of anaesthia (sp?) would be.

For cosmetic operations, of course, this is not true. But I believe that preventive and curative health care does not fall under traditional 'rational consumer' patterns of classical economics.
7.11.2007 6:02pm
Steve:
A government should not force me to make a purchase from a private corporation as a precondition of my inalienable right to life.

God, I hope you don't have to live under the jackbooted fascism of no-fault auto insurance. I'm not sure you could bear the oppression.
7.11.2007 6:13pm
David Matthews (mail):
Hmm, Steve, I don't recall the government forcing me to own an automobile.
7.11.2007 6:15pm
Ramza:
@ David Matthews

You don't seem to understand that you are forced without your consent (only way to escape it is move or death and even then you are trapped) to pay for something you don't want via taxes. We have universal care, but it is in an unproductive heavy cost low benefit fashion.

What the Mass. law changed was instead of taxes providing this service it was private insurance. The only difference is who the person you paid the forced money too. Would you still have the same complaint if Mass. raised taxes followed by giving a universal health insurance tax credit of $1,500 that you must spend on some form of health insurance? Same thing is happening it just has one more procedural step.
7.11.2007 6:17pm
Steve2:
"Universal health care quickly causes the quality of care to go down, if the single payer can prevent good providers from charging more for services. There's a reason the English don't run into doctors with American accents."

What I always wonder is how not getting care at all factors into the "quality of care will go down" argument. Take preventative care. Yes, we all know emergency rooms can't turn people away (I remember carrying a friend with a lacerated foot into an emergency room and reading the sign about "Legally, we can't tell you to go away even if you can't pay."). But with the argument that quality of care will go down on routine or preventative medicine, do people who are currently getting no care due to financial reasons get counted against the quality of currently available care. Ditto waiting lists. When people talk about the wait time for elective treatments in nationalized health care systems, it's generally in terms of "It's longer than the wait for the same thing in the U.S." What I always wonder, and have never seen specified, is whether the calculated wait in the U.S. includes the effectively-infinite wait for howevermany people willll never be able to get it.

I also wonder what sort of healthcare gets counted in those things, and what sorts of tradeoffs get made regarding the type of healthcare available. I know, for instance, that I'd be willing to support a system that flat-out banned fertility treatments if that would free up resources for better universal pre-natal care or childhood immunizations. Likewise, if banning cosmetic surgery would guarantee an increase in the number of medical practioners available for heart disease and cancer screenings, I'd probably be supportive of it.
7.11.2007 6:19pm
Hattio (mail):
Steve says, referring to Professor Bernstein;

Maybe you and the President have some sort of Vulcan mind-meld.

I disagree with most of what Prof B writes, but that is freaking insulting.
7.11.2007 6:22pm
Shake-N-Bake:
David Matthews, if you lived in Michigan, they combined with the automakers effectively have done so by dismantling virtually all public transportation (beyond a few buses and the laughable People Mover in Detroit). And they have no-fault insurance there.
7.11.2007 6:24pm
David Matthews (mail):
Ramza, of course, we all pay for stuff through taxes, whether the war in Iraq or abortions or superfund cleanups or defaulted health care bills, and whether we agree with them or not. I'm not sure how anyone could fail to understand that. Gee whiz, that's what taxes do, force you to pay for stuff.

"The only difference is who the person you paid the forced money too [sic]."

Isn't that what I just said? And would I still have the same complaint, if there were a tax increase followed by a tax credit, followed by a mandated expense? Yes, the problem is with the "must spend" that you yourself highlighted.

I have a big problem with being held criminally liable for failing to give my money to a third party, when my only implied consent was that of exiistence.
7.11.2007 6:35pm
byomtov (mail):
I don't know that there's even a conscientious objector exception to these laws, whereby I could avoid purchasing insurance, if I swear to never use a hospital or see a doctor.

David,

The trouble is that such an exception is worthless. The fact is you are going to use medical services under soem circumstances. When you are injured in a car wreck, or have heart attack, are you really going to insist that you just be left to lie there? I doubt it.

But even if you are that 1 in a billion who will die rather than ask for treatment, how will the medical personnel know? You're unconscious. You need emergency treatment. Are ER staff, or paramedics, supposed to start figuring out if you're a conscientious objector or not? How? Suppose you wake up long enough to tell them. Well, let's see. You're badly hurt, not wholly conscious, in some pain, likely you've been medicated some way. They are supposed to take your claims seriously?
7.11.2007 6:41pm
David Matthews (mail):
byomotov,

It's not worthless. For example, Jehovah's Witnesses refuse blood transfusions, even if such a refusal means certain death, and the medical profession is forced by law to honor that, and yes, they do take the claims seriously. The lawyers and law professors around here could point us to the cases that have involved whether or not to give transfusions to the minor children against the parents' wishes, but in the case of an adult, there's no question that a refusal of particular medical treatments, or of medical treatment in general, must be honored.

But my point is not that such an exception is very workable, but that a law that logically requires its consideration is problematic.

There is a fundamental and serious difference between a law that says, "the government will provide health care for all," and one that says, "as a precondition for merely being alive, you are required to purchase, from one of our approved vendors, a health insurance policy."
7.11.2007 7:02pm
Steve:
I have a big problem with being held criminally liable for failing to give my money to a third party, when my only implied consent was that of exiistence.

Your implied consent is exactly the same implied consent you give to paying taxes; if you don't like the system of mandated insurance, you can elect representatives who will oppose it.
7.11.2007 7:14pm
Andrew MacDonald (mail):
@ David Matthews

I guess the point people are trying to make is that you are effectively already forced to "buy" health care via paying taxes that subsidize emergency care for you that will be there whether you want it or not.

In some sense, this is "outsourcing" the health care from government subsidies to private individual choices.
7.11.2007 7:16pm
byomtov (mail):
David,

Of course the conscious informed refusal of medical treatment by an adult should be honored. My point is that in many cases such refusals can not be made, and in many others they will not be made. People change their mind, or are in no position to communicate at all.

Still, you clearly do see the problem. Are you saying you would not object if the government adopted a universal plan funded by taxes?
7.11.2007 7:17pm
Thorley Winston (mail) (www):
Under the law, I'm required by law to purchase something. And there's no way around it. This is not like car insurance. If I don't want car insurance, I simply don't own a car. This is not like homeowner's insurance. If I don't own a home, I don't need insurance. But for mandatory health insurance, what are my options?


Well in Massachusetts you have the option of setting aside an amount (a $10,000 bond IIRC) estimated to cover your out-of-pocked medical expenses should fall seriously ill. So basically you're allowed to "out of" of getting health insurance so long you've set aside an amount sufficient for you to "self-insure."
7.11.2007 7:18pm
Henry Bramlet (mail):
Loki-

You are incorrect. In fact people "over-consume" (by which I guess you mean "consume more than they would normally be willing to pay for") health care all the time- just as they over-consume all sorts of services that are free.

There are alternative treatments to nearly every illness out there- some being less effective than others. Some are less comfortable than others. If you follow the link that I provided, it will show you that Out-of-Pocket clinics can provide the same level of care as Doctors Offices at half the price. Why? I say it is largely because the people going to the OOP Clinics are cost-sensitive.

Likewise, people who are responsible for the cost of their Post-Op care are more judicious with the use of pain killers and in their choices around follow-up appointments. This is born out in studies of people who have undergone elective surgery (where the recovery is similar to non-elective surgery, but unpaid by a 3rd party).

Note that I am NOT saying that there shouldn't be safety nets for the poor. My point is that we shouldn't be approaching schemes that remove the burden of cost-sensitivity from EVERYONE. That is what causes our Health Care Costs to spiral out of control right now.
7.11.2007 7:20pm
ATRGeek:
Actually, you can refuse some medical treatments, but not others. See Jacobson v. Commonwealth of Massachusetts, 197 U.S. 11 (1905) (holding that the state could order compulsory smallpox vaccinations).

In any event, I am not quite sure I see the "fundamental and serious difference" between a law which says the individual must purchase health care insurance from the state (which is what happens when you pay taxes and are entitled to receive state-provided health care) and a law which says the individual must purchase health care insurance from an approved vendor but not the state itself. Is it the profit component? I'm really not sure.
7.11.2007 7:27pm
David Matthews (mail):
Steve,

Steve, no it's not "exactly the same." There are two fundamental differneces:

1) Taxes are based on income or sales, not on existence. I can adjust how much, or even whether, I pay taxes, based on how much I earn, or what I purchase, or, thanks to tax credits and deductions, how I choose to spend my income. Reportedly, there are multimillionaires who pay not a cent in taxes, completely legally, based on choices they make. None of these alternatives exist in the health care example (although, apparently, if I'm indigent, I can get some help from the government.) It is, quite simply, an existence tax, which is more reprehensible than a poll tax, by far, since I can't even avoid it by refusing to vote.

2. It's not paid to the government, but to one of a select group of government-approved private companies. I'm guessing by the tenor or your comments, that you'd be very comfortable with a Mitt Romney administration deciding for you which private companies you are compelled to give your money to?
7.11.2007 7:28pm
Porkchop:
Wow, 30 posts in already and no one has mentioned Michael Moore and Sicko!

I saw the movie three days after my insurance company denied coverage for a major surgical procedure. It kind of struck home.

David is exactly right - we have an incredibly inefficient, irrational healthcare delivery system.
7.11.2007 7:34pm
David Matthews (mail):
ATRGeek,

"I am not quite sure I see the "fundamental and serious difference" between a law which says the individual must purchase health care insurance from the state (which is what happens when you pay taxes and are entitled to receive state-provided health care) and a law which says the individual must purchase health care insurance from an approved vendor but not the state itself. Is it the profit component?"

So you also don't see the difference between the Army delivering its own fuel in Iraq, and outsourcing it to Haliburton?

You don't see the difference between the Army Corps of Engineers rebuilding the Gulf after Katrina, and the government handing the money in sweetheart contracts to Bush's "Pioneers"?

There's nothing wrong with profit, honestly earned, but when I'm forced by the government to give you a profit, well, that's not capitalism, that's not libertarianism, that's not even communism, it's just an open invitation for cronyism.

I do see a difference between the government taking my money and keeping it (or using it), and the government forcing me to give my money to another private party. In philosophical terms, I find it just plain wrong, and in practical terms, it opens the door to huge amounts of corruption (as we've witnessed in the present and immediate past administrations.)
7.11.2007 7:42pm
ATRGeek:
By the way, I agree we should try to foster cost-sensitivity where possible. One of the real tricks, though, is making sure people do not skip things like preventive care, maintenance medicine, and child care when cutting costs.
7.11.2007 7:50pm
ATRGeek:
David,

Of course I don't like cronyism, but I don't believe that in either of your two examples were people being forced to pay funds directly to third parties. And if the problem in question exists whenever the government goes to outside vendors for goods or services, that is a very big problem indeed.
7.11.2007 7:56pm
jimbino (mail):
We do not now have universal healthcare. Under universal healthcare, all medical practitioners would end up working as government employees. Who wants medicine to end up as bad as our mail service, our public education or our garbage collection? Not me.

Furthermore, universal healthcare would subsidize the poor breeders seeking prenatal and perinatal care, as well as the superstitious alternative medicine types, which our present system does not do. Imagine how much controversy, and how many lawsuits, will ensue to guarantee the Chinese medicine types, the Christian Scientist types, those seeking abortions, etc, their fair share!
7.11.2007 8:06pm
TechieLaw (mail) (www):
Perhaps if you want to avoid a single payer system, you should propose ways to improve the current mess of a system we have.

I'm a reasonably healthy person. But I can tell you horror stories about trying to deal with my insurance to enforce my rights. The current system is a complete maze that's rigged against the patient. In one case, I called in advance to confirm that a particular hospital took my insurance for a particular procedure. After I got home, I got the nasty surprise that the *doctor* I saw took my insurance, but that various other tests, technicians, and supervising doctors who billed were *not* covered. When a person is sitting in excruciating pain, I'm sorry to say that they're not quite able to prepare and take a deposition of the intake nurse to confirm that every possible combination of medical procedures is covered. "Do you take my medical insurance?" should be sufficient.

It took over a year of phone calls, letter writing, and overall misery to get somebody to step up the plate and resolve the issue of the thousands of dollars involved. That's right, over a year. And if it hadn't gotten resolved (by finally reaching the one employee at the hospital who seemed to understand what had happened and was willing to negotiate a settlement price), I would have been in the situation of choosing between (1) paying money I didn't think I owed, (2) not paying the money and having them destroy my credit history, or (3) filing a lawsuit. None of these are good options.

I'm a reasonably healthy guy. Imagine somebody whose body is wracked with cancer trying to manage their life while fighting this type of nonsense. The insurance company's policy generally seemed to be "if we give him the run around multiple times, eventually he'll just give up and pay it himself." If there's a way for the free market to fix this problem -- keep in mind that most people have very few affordable choices w/r/t health insurance -- I'm all ears.
7.11.2007 8:22pm
Steve:
Taxes are based on income or sales, not on existence.

Or on the amount you own at your death, or what have you. The system of taxation that we have today exists by virtue of your implied consent, as a citizen and voter. You seem to be saying that you're fine with the government imposing financial obligations on you, as long as there's some theoretical choice you can make - like choosing to not work, have no income, and make no purchases - whereby you could avoid those obligations. It's a really odd distinction you're drawing.

I'm guessing by the tenor or your comments, that you'd be very comfortable with a Mitt Romney administration deciding for you which private companies you are compelled to give your money to?

I'm not sure at all what you're saying here. If the government mandated that I had to buy insurance from a licensed insurer, no, I don't have a problem with that, any more than I have a problem with the government requiring me to pay taxes so that the government can provide me with insurance. Of course I would have a problem if Romney mandated I buy insurance from his brother's insurance company or something silly like that.
7.11.2007 8:24pm
alkali (mail) (www):
It seems to me we already have universal health care; by federal statute, anyone has the right to show up at any hospital emergency room in the country, and get whatever care they need regardless of their ability to pay.

This isn't quite true: my understanding is that you get care for emergency conditions. Showing up with a lump that wasn't there a month ago won't get you emergency care.
7.11.2007 8:27pm
David Matthews (mail):
"if the problem in question exists whenever the government goes to outside vendors for goods or services, that is a very big problem indeed."


It is a very big problem, indeed. And the more often and farther afield we go, the bigger it gets.

Hmm, rather ironically, while writing my reply, I just got a phone call from a collection agency, trying to collect some mysterious $1000 that my ex-wife incurred in health care costs at some time in the past two years, which I have supposedly been informed of, but am totally unaware of (and thankfully not in any way possibly responsible for), complete with threats to contact my employer, threats to (I kid you not) put a lien on my house, and repeated requests for me to "behave professionally," capped with a sudden hang-up from the caller when I (rather politely) asked her to carefully spell her name, so that I would be able to use it in future correspondence. So, much like Paul (nee Saul) somewheres outside of Damascus, I've suddenly become a big proponent of universal, single-payer health care (and at the moment I don't care if it's provided by the VA, Enron, Haliburton, Loral or Global Crossing).

Please disregard all previous comments that might contradict this one.
7.11.2007 8:28pm
David Matthews (mail):
Steve,

What's your opinion of a poll tax? Is it ok to force someone to pay money to vote? Or is it merely ok to force someone to pay money to breathe? I don't think that the distinction is odd at all, or at least, the Supreme Court has not held it to be odd, that behaviors can be taxed, but existence, and other fundamental rights, cannot.
7.11.2007 8:32pm
Thorley Winston (mail) (www):
It seems to me we already have universal health care; by federal statute, anyone has the right to show up at any hospital emergency room in the country, and get whatever care they need regardless of their ability to pay.


The type of care that they're obligated to provide you under EMTALA is pretty limited to "emergency medical conditions" and they can deny you care if they don't diagnose your ailment as being an "emergency medical condition." Also once you're stabilized and discharged their obligations under EMTALA pretty much end. Of course if they improperly diagnose or stabilize you might have a claim for medical malpractice but that's true regardless of EMTALA.

As far as the actual cost of uncompensated care for the uninsured, it's pretty small (about 3% of all health care spending) and that cost drops to about 1% when you factor in the additional taxes paid by individuals without health insurance and their employers. The problem is that most of the additional taxes go to the federal and (sometimes) State governments while much of the tax cost for uncompensated care is picked up by counties and States. So it's really more a question of matching the additional tax monies paid by the uninsured to the facilities providing the care to the uninsured than it is imposing a great additional burden on other taxpayers.

Given that this is such a small (and mostly self-correcting) problem, I'm not sure "universal coverage" needs to be a goal of the government. If you want to increase the number of people who have private health insurance, free-market reforms like Association Health Plans which lets small groups of people like the employees in a small business form risk pools to buy health insurance at rates comparable to larger employers would probably take care of most of the problem (in Minnesota that's a large chunk of the working uninsured). Or you could go for a proposal like Representative John Shadegg's CHOICE plan that would let consumers buy an insurance policy anywhere in the country without regard to the various unfunded mandates imposed by the States which increases the cost of health insurance premiums about 30%. Or you could even go with a modified version of Massachusetts' Commonwealth Care but instead of mandating that people buy health insurance (or that employer's provide it) or self-insure, set up a central exchange where people or AHP's can shop around for various plans with various features and pay for it themselves.

I have to say though, I'm a little puzzled. For a guy who fancies himself a "libertarian" you seem awfully quick to accept that if the system has problems the solution is "more government." I can understand how a libertarian would be conflicted or have an honest disagreement over what role the government would have in an issue like immigration, abortion, defining civil marriage, defining the limits of parental authority, or the death penalty. But health care is one of those issues that really should be pretty cut and dried for libertarians over whether there should be more or less government financing and control.
7.11.2007 8:33pm
DavidBernstein (mail):
TW, I'm not, and don't intend to be, a health care expert, so I'm not familiar with the details of many of the plans you suggest, but my point was not that we couldn't improve things via market mechanisms, because surely we could, but that the focus should be on improving things, not whether a plan is deemed to provide uhc, given that we all pay the uninsured's medical bills one way or another anyway.
7.11.2007 8:42pm
Thorley Winston (mail) (www):
I'm guessing by the tenor or your comments, that you'd be very comfortable with a Mitt Romney administration deciding for you which private companies you are compelled to give your money to?


I'm not sure at all what you're saying here. If the government mandated that I had to buy insurance from a licensed insurer, no, I don't have a problem with that, any more than I have a problem with the government requiring me to pay taxes so that the government can provide me with insurance. Of course I would have a problem if Romney mandated I buy insurance from his brother's insurance company or something silly like that.


What if you had a requirement that you (not "you" specifically but "you" in the generic sense) or your employer (if it's already providing your health insurance) purchase health insurance or self-insure (as is the case in Massachusetts) but you were able to chose a policy from any insurance company that was licensed in any State and not just from among the ones licensed in your own?
7.11.2007 8:42pm
David Matthews (mail):
"as long as there's some theoretical choice you can make"

Wooah, I read too fast and missed this. It's not theoretical at all. President Clinton used to call them "targeted tax breaks." The whole tax incentive theory is based on the reality of these choices. If I buy a Prius, I get $1600; if I give money to Pat Robertson, I get credit, not only in Heaven, but also on Earth, praise Jesus! My lovely community college students would get a fantastic tax break, if only they earned enough to itemize. Yes, the system of punishments is entirely based on behavior. When I buy raw vegetables, no tax! When I buy a veggie burger, tax!

A tax on life is fundamentally different. It taxes me for what my Creator endowed me with. And I am fundamentally bothered by a government that says:

"You are David Matthews. Because you exist, you are required to pay X dollars to this or that private company. Your alternative is to pay a fine of nX dollars to us, then pay X dollars to this or that private company."
7.11.2007 8:44pm
TechieLaw (mail) (www):
David Matthews: I was once contacted by a collection agency working for a hospital for a medical procedure I had undergone one year before. Without going into the gory details, I had been under the knife for the benefit of a 3rd party who was supposed to be responsible for paying all the bills. The hospital had screwed up the billing address, and after a year, I got a nasty phone call demanding that I immediately pay some enormous amount ($25,000?).

Thankfully, in this case, the collection agency had a lawyer on staff who had some familiarity with these types of 3rd-party payer situations, and quickly realized that the type of procedure indicated that I was a volunteer, not a patient. Everything was resolved quickly.

But, I can't imagine what type of hell this would have been like had this agency's employees had the same level of competence (think: monkey-with-script-tied-to-phone-and-computer) of my current insurance company. My credit would have been ruined well before the issue was resolved.

(For whatever it's worth -- the procedure was common enough, and the 3rd party payer common enough, that anybody with an ounce of common sense in the hospital's billing department should have figured out the problem. But they didn't.)
7.11.2007 8:47pm
Thorley Winston (mail) (www):
TW, I'm not, and don't intend to be, a health care expert, so I'm not familiar with the details of many of the plans you suggest, but my point was not that we couldn't improve things via market mechanisms, because surely we could, but that the focus should be on improving things, not whether a plan is deemed to provide uhc, given that we all pay the uninsured's medical bills one way or another anyway.


I could understand thinking that if someone who was talking about or proposing UHC had a proposal that wouldn't result in increased costs (either through taxes or unfunded mandates) but pretty much all of them like the ridiculous "Medicare for All" meme that was so hot earlier this year among the Nanny Statist crowd are going to result in a much larger cost than the comparable pittance paid now for uncompensated care for the uninsured (including the over-hyped ER visits). So I'm not sure it's a bad idea for libertarians and conservatives to as a rule of thumb oppose any plan that calls for "universal coverage" unless or until its proponents can prove it would cost taxpayers and the insured less (and no, proposing to shift costs from the government to the private sector or vice versa in a manner that results in supposedly "lower net costs" ought to raise the same red flag).
7.11.2007 8:54pm
Dick King:
Some religions require their members to refuse all medical care, and some such members actually do it. Does Massachusetts allow those individuals to opt out?

-dk
7.11.2007 8:57pm
PersonFromPorlock:
Interesting that nobody's mentioned fire departments, which were originally run by private insurance companies for the sole benefit of their customers. Their replacement by civil fire departments would seem to provide a pretty good pattern for government supplanting private medicine.
7.11.2007 8:58pm
John A. Fleming (mail):
Clearly, health care is a distored, dysfunctional market, and requires much more thinking before proposing changes, than can be expressed in a Volokh conspiracy comment.

And ignoring for the moment, that the loaded term Universal Health Care = single payer [government] system = the same crappy health care for everyone as rationed by elected politicians and government health care bureaucracies.

I'll just comment that using Professor Bernstein's claim that our current universal health care is inefficient, I would expect that any government-mandated change that would attempt to get poor people out of reactive emergency room mode and into clinic visits for health maintenance, should immediately result in lowered health insurance costs for everyone. So if the government is going to mandate that you buy insurance, it should also mandate the lowering of health insurance prices for everyone. And if total health costs rise, or health care quality declines then everyone knows the government program was a fraud.

And I'll just mention that Walmart and others are in the process of opening up low-cost health clinics in their stores. Unfulfilled need equals market opportunity. Once the government mandates a single way to solve a problem, a way that usually involves transfer of everyone's money to the government, it chokes the life out of the creative destruction of the marketplace, a diversity of solutions, products and services pursuing unfulfilled needs.

So don't be in such a hurry to give the government power over health care. Instead of expert deep-thinking for an effective government-mandated plan, why not free the market to find it through a thousand experiments. And let us vote with our pocketbooks.

(As I mentioned above, specific proposals for transition from a government-distorted health care system to a robust marketplace-driven system, is a too-long topic for this forum.)
7.11.2007 8:59pm
David Matthews (mail):
TechieLaw:

Thanks for the story, and, yeah, there's no doubt our system is broke. If Michael Moore had been someone besides Michael Moore, and had not gone to Cuba, and had not gone out of his way to insult the current adminsitration (ok, I repeat myself, "if he had been someone besides Michael Moore,") his statement that his film wasn't "left or right" would have been accurate. I think, between Health Care and Immigration, these are the two things a presidential candidate has to find a way to address, and she or he will walk away with the election.

In my personal situation, I can't imagine what my credit rating looks like; my solution to the health insurance mess, as well as a myriad of other post-divorce messes, was to become "debt-free." Thankfully, around here, you can buy a fixable house for less than $30,000, so I did that. Fixed it, paid it off, and now will weather whatever storms come next. And as long as I don't need to borrow money, who cares if I'm a 450 or a 750? Oh, and I also made friends with a good small-town lawyer, whom I will memorialize in song, for whatever that's worth, since the pittance I've paid him won't touch what he's done for me.
7.11.2007 9:07pm
TechieLaw (mail) (www):
Jon A. Fleming: *How* do you free the market? And how do we vote with our pocketbooks?

I've had employer-sponsored healthcare plans before. When I have searched for private plans, they have invariably been 30-40% higher in cost for less service. In other words, I'm at the mercy of my employer, who is probably trying to control costs in their own way regardless of what I want.

I'm perfectly willing to consider free market experiments, I would just like somebody to tell me what they look like and how they will resolve the situation of patients, health professionals, and insurance companies all trying to pass the buck: when this happens, it's the sick patient with no energy to fight who always loses.

Perhaps there's some other system out there that might work? A friend who lived in England -- and who is a staunch libertarian -- told me that she used *both* government insurance *and* private insurance. Government insurance was for emergencies and regularly scheduled visits. Private insurance was for less critical issues. She seemed happy with that balance.
7.11.2007 9:07pm
David Matthews (mail):
Clearly, health care is a distored, dysfunctional market, and requires much more thinking before proposing changes, than can be expressed in a Volokh conspiracy comment.

A small correction: I'm guessing that many visitors here have done the thinking, but might have a hard time expressing the correct changes in a VC comment. Otherwise, what you said. Personally, I've thought out a very detailed, and probably completely unworkable, solution. I shared it with my brother, the doctor, and was a bit disappointed by his response ("what's this crap and why are you wasting my time? -- to paraphrase), but I'm sure I'll secure my own blog site, and post my manifesto sometime soon.

Anyway, yes, I agree with you that any solution, or even any attempt at a solution, goes well beyond what we can find at VC, even from the sharp folks like Bernstein, Volokh, Kerr, Adler, etc.
7.11.2007 9:22pm
A.S.:
I'm willing to listen to alternatives that are less costly and more efficient

Somebody wake me when a plan is proposed that is "less costly". I don't think I've ever seen one.
7.11.2007 9:39pm
Smokey:
Ben Franklin, commenting on the proposed Constitution: ''This is likely to be administered for a course of years and then end in despotism when the people shall become so corrupted as to need despotic government, being incapable of any other.''

Well, Ben, we've arrived at despotism when health care becomes a mandatory requirement. Only a despotic government would impose health care on everyone, willing or not. And truth be told, government health care is being pushed by politicians for their vote-pandering and for their personal power aggrandizement.

Few government actions are more despotic than a forcibly taking over between 14% - 17% of the entire U.S. economy, when no one is denied health care in this country.
7.11.2007 9:45pm
A.S.:
Oh, and BTW, I should have mentioned, saying that we should just follow France because France only pays X% of their GDP on health care while we pay Y% of our GDP on health care - that's not a plan that is "less costly". France is not the US, and there's no reason to think that implementing the French system of health care here would cost the same as it does in France.
7.11.2007 9:45pm
A.S.:
<i>Only a despotic government would impose health care on everyone, willing or not.</i>

Oh, I don't know that "despotic" is the right word. I'd use "authoritarian". Obviously government control of the entire health care system is far more authoritarian than anything Bush has ever even dreamed of doing. But, then, most of the people pushing government-controlled health care are authoritarians.
7.11.2007 9:48pm
Steve:
A tax on life is fundamentally different. It taxes me for what my Creator endowed me with.

What I'm saying is, when you have a problem with paying tax just based on the fact that you're an American citizen, but you have no problem with paying property, income and sales tax because theoretically, you could go your whole life without owning property, earning income, or buying anything if you chose to, then you're rationalizing the distinction in a very weird way.
7.12.2007 12:19am
David Matthews (mail):
OK, Steve, I'll try one last time, although you have ignored my question repeatedly. Why is a poll tax illegal? Is it "rationalizing the distinction in a very weird way" to say that you can't tax someone to vote? Now, why is it "rationalizing the distinction in a very weird way" to say that you can't tax someone for simply existing? I don't believe these distinctions are "very weird" when they are also held by the Supreme Court. Certain behaviors can be taxed (earning income, smoking cigarettes, driving a car); others (voting) can not. I put "breathing" in the can not category. You, apparently, do not.
7.12.2007 6:37am
A.C.:
I've only just managed to get my brain to accept a mandate (individual or employer, depending on details) for carrying high-deductible INSURANCE plans to cover major medical events. I would not expect these plans to cover much of anything that happens to a health person in an average year, but I would expect them to kick in to prevent financial disaster in the event of a major illness or accident. This means that doing the plan's paperwork would be a rare event for most people, and that the plans should be relatively cheap compared to most insurance on the market today.

My reasoning is that most people don't exactly like being hit with a $2,000 bill they weren't planning for, but most can take the hit (perhaps by working out a payment plan) without disaster. A $100,000 bill is different, and that's when you get the problems with nonpayment and free riders.

As for preventative care, it may make sense to subsidize that for the poor (not for everyone). But we ALSO need to look into ways to bring the cost of routine care down for everyone, as in the Walmart example mentioned above. CVS is also starting these clinics in some areas. Putting clinics near homes, workplaces, and shopping areas should help too, as well as having hours when working people can actually go. Finally, I think there should be a very high priority on finding new medical tests that are less invasive and humiliating for the patient. Things that can be done at home and mailed in are ideal. I have seldom skipped a medical exam for financial reasons, but I've often rationalized not going because the experience is just too unpleasant. Not everything is financial.

People who scam the system by using the emergency room for trivial complaints? I say shame 'em. If they think they are being clever, they'll keep doing it. If they get treated like child molesters by their friends and families, they might think twice. Having a cheap drop-in clinic right down the street should take care of the people who only use the emergency room for lack of a better option, but anyone who actually brags about cheating should be taken down several notches as a matter of principle.
7.12.2007 6:44am
ATRGeek:
As is apparent from some of the comments, a lot of the confusion in these debates is caused by equating universal health care with either socialized medicine (state-run hospitals with state-employed health care professionals, ala the VA) or single payer plans (ala Medicare). I suppose at one time it may well have served libertarian interests to foster this confusion, insofar as it helped stall major health care programs regardless of their nature. But I think libertarian-minded people (a category in which I include myself) need to recognize that the political field has shifted, and I think it is quite likely today that people who refuse to make distinctions between various universal health care programs are just going to be removing themselves from the debate.

By the way, I think libertarians should actually take a close look at the French system. It is not exactly the libertarian ideal, but the French consciously tried to maintain various private and free-market elements. So if nothing else, I would think libertarians could point out that the French system has gotten better results than some of its more statist rivals in other countries, and argue that was because of these private/free-market elements.
7.12.2007 8:55am
Thorley Winston (mail) (www):
But didn't the study indicate that abstinence-based education was no more (or less) effect than the standard education? So, wouldn't the choice be between alienating a substantial segment of the public and not alienating them?


That's pretty much it in a nutshell (although apparently the kids who went through at least one of the abstinence-based sex programs were more knowledgeable about STD's than kids who didn't have any formal sex education or went through a non-abstinence based program). If there's an ideology that's being skewered by the science, it isn't the one that's trying to promote traditional values (e.g. abstinence until marriage) so much as it is the one that thinks throwing more money at programs for kids is almost invariably the answer no matter the question.
7.12.2007 1:34pm