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What’s Wrong with the World is dedicated to the defense of what remains of Christendom, the civilization made by the men of the Cross of Christ. Athwart two hostile Powers we stand: the Jihad and Liberalism...read more

Health Care and Social Obligations

Somewhat astonishingly (though why I continue to find this astonishing, at my age, remains a mystery), recent discussions of health care as a type of social provision have precipitated impassioned declarations of (what certainly sounds like) libertarian ethical norms: the (allegedly - this is the locus of a begged question) mere fact that someone is suffering from a malady, the treatment for which he cannot afford out of his personal resources, does not imply, create, or impose, let alone entail, an obligation on the part of any other individual to remedy that want. So strong is this libertarian principle that it is not merely 'socialized medicine' that traduces it, but the very vaunted private health care system itself, which, through the mechanisms of mandated insurance coverages, risk-pooling, and the proscription of genetic screening, ensures the extension of coverage to many who would be excluded were risks to be individualized. The sick do not have a right to our money, in order to procure treatment, not even the comparative pittance factored into an insurance premium so that such higher risks might be adequately underwritten. Presumably, a starving man would not have a right to our bread, either.

Moreover, in accordance with such principles, those risks should be socialized on a purely voluntary basis, in and through families, churches, and other voluntary institutions established for charitable purposes; there obtain no enforceable claims upon such benefactions, which should alight upon the sick and infirm only insofar as those possessed of health and wealth will it, and only to that degree made possible by the gratuitous movements of their sovereign wills.

Much could be said of this, especially that a species of economistic dogmatism now impels some ranged along the right spectrum of our political culture to war against an inevitably flawed, but fundamentally decent, system, and this in the name of an ideological figment which cannot be translated into reality, and that this intransigence will eventually beget something far worse. The endeavour to fully marketize the domain of health provision, leaving the individual naked, with all of his weaknesses and frailties, before the utterly impersonal and unforgiving mechanisms of the market, petitioning those who clutch their wealth to their breasts like the misers of many a parable for relief, as a pious man might petition the Almighty, will shipwreck on the very structural foundations of modern society. Indeed, the argument has already been sketched:


...since the origin of any thing is, at a minimum, a clue to its nature or essence, we ought to attend to the fact that widespread health provision was originally a ministry of the Church, and founded as a charitable endeavour. Nevertheless, the Church or, more broadly, charitable institutions, can only assume such a tremendous burden - particularly in a more complex modern society - if they can command vastly more social authority than they do presently, exercise more overt social power on the basis of that authority, and command a greater percentage of adherents' resources than those adherents presently provide under our purely voluntaristic models of giving. One cannot recreate a social form without first recreating its conditions of existence.

The problem is amenable of simple restatement, yet the solution is difficult: yes, there was a time when the provision of health services was largely under the direction of the Church, when this was mainly a charitable work, and occurred under the auspices of few, if any, civil laws; and in those times, the Church wielded such authority and power and wealth as modernity has stripped from Her, and, not to mention, standards of care, and the technologies by which those standards were realized, were orders of magnitude more primitive. Libertarians, I can only assume, presuppose that the existence of any social institution is as arbitrary as the movements of will in the breast of the superman; that we have the health care and insurance systems we do is thus arbitrary, not in the loose sense of being artifactual, but in the strict sense of reflecting, and conforming to, no facts in the real world. We only have them because certain interest groups have foisted them upon us, and not because they answer to any aspect of reality - and those people are very bad for doing the foisting.

In reality, total expenditures on health care exceed the wealth commanded by all churches combined; moreover, a perusal of the budgetary statements of the average church - say, a parish like my own - will confirm that there exists no fiscal fat that could be trimmed to pay for 'routine' cancer treatment, let alone every medical necessity that would portend the bankruptcy of a family. The counsel that 'we cannot know unless it has been tried' is not merely an exercise in ideological anachronism, but a declaration that folly is not folly until it has been performed.

Moving onward, of course it cannot be the case that medical need generates an individual claim right, enforceable against any individual who might be supposed to possess the requisite resources. This, not because there obtains a 'right' not to support one's ailing fellows, or to the disposal of every last farthing of one's wealth, but because it would be absurd, contradictory, to have society enforce claims against individual members, when such claims would be both unpredictable and catastrophic. Such a claim-right would enlist society in the destruction of its constituent members, pitting some segment of society against another; and what society can endure if a faction within it claims the right of undermining another? The skein of ordinary and healthy social relations would be rent, and irreparably. But why tarry on this rhetorical trope any longer? No one seriously supposes that such an arrangement would ever be instituted, and it is merely reflective of the histrionics of the sovereign individual when his plenipotentiary powers are challenged.

Perhaps, then, there obtain no claims upon society for health provision, just as the libertarian - the dogmatic sort, I should say - asseverates. In that case, it would be perfectly consistent with principle to permit people to perish, willy-nilly: let all men be smitten with disease and infirmity, only touch not the Holy Ark of the individual's sovereign will, and his property rights. This, too, however, would be absurd, and for reasons consonant with those already articulated. If it would be a grievous impairment of the stability and goods of society for any individual to be liable, at any time, for the full expense of some other's infirmities, so also would it be a grievous impairment of society and its goods if the lives and fortunes of its constituent members, individuals and (more importantly) families alike, were to be exposed to the personally and financially ruinous risks of catastrophic, chronic, and unpredictable illness and/or debilitation. In the former scenario, what security in his dealings, plans, and prospects could an individual possess, if at any time, some infirm person could wield the cudgel of the state to secure the means of his care? In the present scenario, then, what surety could any individual, any family, any undertaking, possess, liable as they would be, naked before a pitiless Market, for the entire cost of an infirmity? There could be none, and individuals, families, and their undertakings - businesses and other callings beneficial to society - would stand beneath a proverbial sword of Damocles, and fall to bankruptcy and ruination with regularity. This would foster nothing but instability, inconstancy, a pervasive fear of impassive fate, and the notion that it could be justified by some individual 'right' is merely another claim that society is obligated to enforce the means of its destabilization or dissolution. Let us speak plainly: there exist no rights to the destruction of the social conditions of rights, no rights to destabilize the very foundations of the enforcement of rights-claims.

We must speak, therefore, of a sort of social good, which can be secured only by a collective undertaking, in this instance, private entities which aggregate and pool, thus mitigating, risk. The assertion of a 'right' to a purely individualized system of health provision, such that no wealth need ever be spent involuntarily on the mitigation of the risks and the care of the infirmities of the less fortunate, is another form of the incoherent claim that we ought to collectively enforce a claim-right against collective institutions and agency: society should enforce the claim that there exists no such thing as society. This is a truly peculiar form of intellectual autism.

For those, however, who might find all of these ratiocinations inapposite, there remains a purely pragmatic consideration: the marketization of health provision will exacerbate inequality quite radically, which will be perhaps more destabilizing than our burgeoning economic inequalities, considered in themselves; and confronted by such dismal prospects, people will agitate, not for the old, flawed system of private insurance, but for socialized medicine. And they will receive it. And the sophisters and calculators of the right, ever blinded by some spectral, Cartesian vision of economic rationality, will have enabled it, by making the unreal the enemy of the imperfect, real, and good. It won't be the first time, not by a long shot, and it probably won't be the last time, either.

Comments (53)

I've now read the comments on the other thread and understood doubtingt not to be saying that there shouldn't be risk pooling in the form of private insurance policies but rather objecting to laws against discrimination on the basis of genetic screening--in other words, wanting such risk-pooling groups to operate in a less regulated fashion than insurance mandates for particular coverage would create. That doesn't seem so radically libertarian to me; in fact, it makes a certain amount of sense. The whole idea that people with a particular property (in this case, some genetic marker) should be allowed to be charged more but not too much more is one I find puzzling and more than a bit arbitrary from an ethical perspective. Some obligations are obvious to the natural light, but the just price for insurance to a person with such-and-such a genetic makeup just isn't. At least, not to me. Moreover, you must surely know that anti-discrimination laws are not going to permit using genetic screening to set prices at all or make any difference on that basis (that would be by definition a form of discrimination), so perhaps even from your perspective across-the-board anti-discrimination laws of this sort should seem too draconian.

I've already said that I think a widespread use of genetic testing to set insurance rates is foolish and inaccurate and would probably lose money. But if we set that question aside, it seems to me that we should remember the days when there was this notion called a pre-existing condition, which no longer seems to exist in health insurance. At least, I never hear about it anymore. Has it been legislated out? I don't know. I certainly didn't _like_ the use of that notion by insurance companies. It once looked like it was going to cost me money I could very ill afford, though a kindly secretary found a way to get the money back for me (I never found out how). But it never so much as occurred to me to say that it was _morally wrong_ for insurance companies to refuse to cover pre-existing conditions. Yet such clauses could indeed have disastrous consequences for people who changed jobs. So, too, can the very tying of insurance to jobs, since people lose their jobs. Yet looked at from another perspective, it's good that employers offer this benefit, as it covers lots of people who wouldn't otherwise be covered. Do we want to say that everything that could have disastrous consequences for people must have a program to address it, if not by direct government coverage (which I understand you aren't advocating), then by a government mandate on the private sector? This isn't obvious either.

Finally, I know, Maximos, how much you dislike it when Bill Gates says that if you don't allow employers to outsource in one way they will outsource in another. (I forget exactly how he put it.) You regard this as a sort of nasty capitalist threat--"My way or the highway." But to me it sounds rather a similar sort of thing to say, "Make unfunded mandates to private sector insurance or else people will clamor for nationalized health care." Well, if they do, they'll be very foolish, and if they get what they clamor for, a lot of very serious harm will be done. And we should fight nationalized health care good and hard. We aren't obligated to endorse this or that specific mandate to insurance companies in order to, as it were, earn the right to point out the crushing and man-eating folly of nationalized health care.

The whole idea that people with a particular property (in this case, some genetic marker) should be allowed to be charged more but not too much more is one I find puzzling and more than a bit arbitrary from an ethical perspective.

Why? Of course, the animating idea is that prospective insurance policyholders will still supply information regarding family histories of illness, but that this information will not be minutely detailed in such as way as to permit the weeding out of the unfit. The intention is to foreclose upon the increasing pursuit of certainty in actuarial analysis. How can it be arbitrary, in the sense of unreasonable or rationally unjustifiable, to prevent entire categories of people from being excluded from health provision? To the contrary, the arbitrary measure would be to permit their exclusion - for all of the reasons hitherto discussed, and because it would amount to the privileging of some utilitarian measurement of economic efficiency, along with the strange notion that we should maximize the marketization of morally-indifferent, unchosen differentiations. In other words, either such differences will be moderated by means of policy, or we will be practicing de facto eugenics, through the mechanisms of economics, the modulations of the market. What seems arbitrary to me is the privileging of economic metrics over social, moral, and physical goods.

I must also register a complaint against the phrase, "more but not too much more", inasmuch as it does not really touch the crux of the issue; the phrase makes it sound as though what is being attempted is an exercise in central planning, when, in reality, what the debate concerns are the parameters of the marketplace, and the interaction of those parameters with necessary nonmarket considerations; furthermore, the question is not so much a matter of degrees, with bureaucrats fiddling at the margins, but a case of orders of magnitude: either a little more here, or prohibitive, invidious, and exclusionary measures there.

Some obligations are obvious to the natural light, but the just price for insurance to a person with such-and-such a genetic makeup just isn't.

No, the just price for insurance is not obvious to the natural light; then again, no one is attempting to establish that just price. What is being made is a declaration that, whatever the just price might be, it is not that price at which vast numbers of the genetically unblessed are excluded from coverage, priced out of the market. It is an exercise in apophaticism, if you will: we might not be able to say what the just price is, but we can say what it ain't.

But to me it sounds rather a similar sort of thing to say...

The similarity is superficial, in my estimation. Bill Gates is essentially issuing an ultimatum of the type, "Permit me to treat my neighbour unjustly in manner A, or I will treat him unjustly in manner B." In the case of insurance mandates - to which I consider the term "unfunded mandate" inappropriate; they are funded, by all of those who purchase health insurance; that is the point - the argument is that one injustice should be forbidden, lest people seek refuge in another one. Gates is declaring his intention to do injustice, come what may; I am arguing that if one injustice is perpetrated, others will follow.

"We aren't obligated to endorse this or that specific mandate to insurance companies in order to, as it were, earn the right to point out the crushing and man-eating folly of nationalized health care."

Of course, if we consider the experience of every other industrialized nation, all of whose health care systems provide outcomes as good as or better then ours at far less cost per capita, we might come to a less ideologically driven conclusion about the various national health care options.

I think Maximos is correct to put this as a Libertarian dilemma. I think the government can have a good roll in aiding markets. Let's take something relatively innocuous but quite common elsewhere: Many cities regulate that retail operation cease at 7:00 in the evening on week nights. Now some would claim this is a gross infringement on the free market. Others would claim this enhances the market, because without this restriction there would be fewer businesses competing in the market since extra staff would be required to man longer operating hours. Markets themselves don't reduce prices, competition does. Probably the better question to ask along the way is does the proposed regulation (or absense thereof) increase or decrease competition that we desire. A lot of competition on the insurance side goes to pre-screening. Pre-screening saves relatively few lives. (There are a few people who learn of potentially fatal conditions in life insurance screenings for example who go on to get treatment.) It also places more people on the public dole, since society won't tolerate health coverage being widely denied.

Very briefly and on the run, I really do think that when it comes to the particular thing that sparked this discussion--genetic screening and insurance premiums--there is no getting around the fact that what you're calling for, Maximos, is the imposition of a particular price that you regard as a just price. You brought up the phrase "central planning," not I. But now that you mention it, it does have rather that sound. Now, as I keep pointing out, anti-discrimination laws won't let people be charged more on that basis _at all_, but I understand that your proposal is that they _should_ be allowed to be charged more, but not so much as to be priced out of the market. I really cannot see how this is anything other than governmental price regulation of a fairly specific sort, premised on the idea that some prices for health insurance for particular people are "too high" and must not be permitted, though some rise for them may be permitted. In that area of policy, that is the crux of the issue, because that is what you are proposing concretely. The reason I say that it seems ethically arbitrary is precisely for the reason that I gave: It does not seem to me that there is a clear, nonarbitrary, moral answer to questions such as, "How much is too much to charge people for health insurance premiums on the basis of their having a particular genetic marker that insurance companies consider (perhaps irrationally) to be an indicator of risk for claim-making? How much more is it okay for insurance companies to charge such people?" That really is asserting that there is at least a just price range that you can discern as a clear moral matter, and I can't discern such a range, and especially not as a matter of *justice*.

There is no necessity of discerning a specifiable range with any degree of precision; this is not the object of the policy, whereas the prohibition of certain screening procedures, which would have an exclusionary effect, is. When I was examined prior to purchasing a life insurance policy, or before enrolling in a health coverage plan, I submitted to a routine physical examination, and supplied information pertaining to family histories of selected maladies; in consequence of the latter information, my insurance premiums were marginally higher than they would have been otherwise. However, those premiums were not established by law; there was no attempt on the part of some legislature or regulatory agency to say, "this far and no further." Rather, mandatory coverage regulations necessitated a probabilistic calculation of risk, which was at once reflected in my premium and factored into the premiums assessed for all policyholders. This is not central planning; the notion that it is, or might be, is truly an instance of defining central planning down - yet another exemplification of that tendency to presuppose that anything other than the unhindered, "natural" operation of The Market is essentially communism, when, in reality, all that has transpired is that that same Market has established my rate, within a socially-defined set of parameters. In other words, the establishment of parameters or limits for the operations of the Market is not equivalent to setting a price; rather, the parameters are reflected in the price, in this instance, positively for me, and those like me, who might otherwise confront prohibitive up-front costs. It occurs to me, moreover, that an aspect of the problem is that conservatives tend to assume that regulation's effects are more or less univocal - that they always have negative effects, whether shortages, price increases, or whatever. In this case, the effects of such regulations as I am defending are largely positive; I suspect that this is why, in health-care debates generally, the specter of central planning is invoked so readily - there really is no sound reason, where access to care is concerned, to abolish these regulations, but if people can be terrified of socialized medicine, they might acquiesce, in the belief that they will thereby avoid that dread monster. And I have no compunction about calling a spade a spade, or in this instance, a scam.

"Rather, mandatory coverage regulations necessitated a probabilistic calculation of risk, which was at once reflected in my premium..."

I don't understand this. We just bought life insurance a couple of years ago. They asked to see all sorts of records and have answers to all sorts of questions, as you say. What do you mean regarding "mandatory coverage regulations"? Are you saying that they weren't allowed to ask you some questions but were allowed to ask you others? Which ones, if so? I just don't get that. If anything, it would seem that there is no particular reason to rule out genetic screening in health insurance by law but to permit questions about family history in pricing life insurance. I was just thinking of using this very example. After all, widowhood can be a drastic experience and upheaval financially, and pricing people out of the life insurance market if they have a particular family history seems like the sort of thing that could happen, given what most people are willing and able to pay for life insurance. That is, if you had a really awful family history.

"[T]here really is no sound reason, where access to care is concerned, to abolish these regulations..."

The genetic discrimination regulation was _just passed_. And there really wasn't much debate about it ahead of time that I know of. You write as though questioning it the week after it comes up in the news amounts to trying to "abolish" some long-established status quo. Or are you thinking of some other regulations?

They asked to see all sorts of records and have answers to all sorts of questions, as you say. What do you mean regarding "mandatory coverage regulations"?

Exactly. Applying for health insurance can involve a similar process. And because 1)that family history is not nearly as precise as genetic testing will be at some point in the future, and 2)insurance regulations tend to mandate that policies cover a plethora of ailments, to which some individuals will be more liable than others - ie., everyone, more or less, purchases coverage for cancer treatment, although certain family histories will carry a higher probability of disease than others - with the consequence that, while my premiums may be somewhat higher, they are not astronomically so, since my risk can be factored into the rates of all premium-payers.

If anything, it would seem that there is no particular reason to rule out genetic screening in health insurance by law but to permit questions about family history in pricing life insurance.

Certainly there is, at least on any rational prospect of the future of the science. Genetic testing will become increasingly precise, and while this will never enable certitude - excepting many genetically-determined ailments, of which we already know - it will enable a nearer approach thereto; the probabilistic guesses of the men in white lab coats will become more probably correct, and that on an individual basis. Family history is not nearly so fine-grained a source of such calculations, though it can be broadly indicative.

Or are you thinking of some other regulations?

Genetic screening is merely a more concentrated instance of the issues raised by mandates, for example, that insurance policies cover cancer or heart disease; the object of both policies is to ensure that risks are dispersed, so as to increase coverage across a wider swathe of the population. Mandates ensure that the costs of cancer coverage are broadly socialized, so that those at higher risk are not priced out of the market; the prohibition on genetic screening aims to ensure that those that can be identified as higher risks by means of such testing are similarly treated, their risks socialized as well. I'm considering these facets together, since the demand voiced by some - that insurance products be tailored specifically for the individual alone - will create the problem that actually-existing insurance programs are designed to prevent.

I've tried to do a bit of quick googling on mandatory cancer coverage. My impression from that quick look is that any such mandates (and I can't tell if they are spread all over the country) are usually made at the state level and thus may vary from state to state. Does that sound correct?

Now, I won't hide the fact that I'm not terribly thrilled with such mandates. I try to avoid speaking of such things in terms of rights. I'm not inclined to say that employers have a right not to be charged for insurance that has all sorts of mandated coverage, nor that insurance companies have a right not to offer such coverage across the board. I'm quite sure employees don't have a right to have such coverage. So let's leave rights out of it. I just am strongly inclined to say that such mandates are a bad idea. We already know about catastrophic-loss-only insurance. That's a variant already. It seems to me that the health insurance industry could use _more_ variants in types of coverage rather than more standardization, and that this might (I'm not certain) actually bring costs down. So a "no cancer" policy or a "cancer coverage costs you more" policy would just be another type of health insurance.

But even though I'm sure we'll disagree about that, can we at least agree that it would be better, not to mention more plausibly constitutional, if any such standardization-of-coverage mandates came at the state rather than the federal level?

It seems to me that those of us who are healthy should count our blessings and joyfully help to defray the horrendous expenses involved with healing those not so fortunate. If you can suggest a way more efficient than government to collect the necessary revenues, identify and evaluate the need, and write the checks, than government, I'm all ears.

I'm in complete agreement regarding the state level being the appropriate vehicle of such mandates, and I'm all but certain that such decisions are made at the state level. However, if the insurance industry were to experience a certain degree of consolidation, then federal mandates would become more or less inevitable. Federal legislation addressing genetic screening, though, was the only means by which that question was likely to be resolved.

It seems to me that the health insurance industry could use _more_ variants in types of coverage rather than more standardization, and that this might (I'm not certain) actually bring costs down.

That would depend upon the principles driving the variation. If there we no-cancer-coverage policies, and cancer-coverage policies, those purchasing the latter would tend to be those at higher risk for developing the disease, and this reality would be factored into the premiums; you would essentially have a self-financing higher risk subgroup, which is a recipe for precisely the problems that I've been decrying.

Suppose there were a test that could tell you, with utter accuracy, whether you were ever going to get a particular kind of cancer that is costly to treat. In such a case insurance coverage for that cancer would be close to impossible. No one whose test came back positive would be willing to spend a dime for cancer coverage, whereas insurance companies would only be willing to offer coverage for that cancer to a person who tested positive at a price so high as to be basically cost prohibitive. Overall, this knowledge would be a net benefit to society, as the vast majority of folks who test negative won't have to pay for coverage of a disease. There will, however, be a small minority of folks (those who test positive) who will be worse off, since, unless some third party steps in to help, they will be forced either to pay for the treatments out of pocket or, if they cannot afford to do so, go without.

It seems to me that there are (at least) two different ways of dealing with this problem. One would be to ban the test. The other would be for the government to allow the test, but say that it will pay for treatments for the disease (beyond a certain amount, or percentage of income). Of the two options, the latter strikes me as being preferable at least in theory, since you wouldn't have the same issues of overhead, the treatments could be funded through progressive taxation rather than the more blunt instrument of higher premiums, and there might be costs and hardships associated with the disease that could be eliminated through preventative measures and/or early treatment. I would concede, though, that there may be issues of political economy that make the former option the better choice.

It seems to me that there are (at least) two different ways of dealing with this problem.

As I have already commented upon the second of the two possibilities, or some reasonable approximation thereof, in one of the earlier threads, and have no desire to recapitulate for the 789,352th time my reasons for believing that it would not be more efficient, I'll content myself with observing that a)it is passing strange that an enthusiasm for market efficiencies has come full circle to an appreciation of the benefits of government intervention, in this instance, the (political) socialization of high-risk patients, so that some sphere of increasing market purity can exist; b)that tax policy - even progressive taxation (though the issue here is genetic fitness, not wealth, and the two are not coextensive by any means (though the danger of much innovation nowadays is that the two categories will increasingly overlap, and that quite invidiously) - normally regarded as exerting all manner of distorting pressures upon the private sector, and upon individual and family decisions, is now regarded as preferable to... just setting parameters for the market, when markets... always have parameters, moral and otherwise; and c)that unless the genetically unfit are going to be herded into a discrete state-managed health system, they will be served partially by the private sector, and partially by a state system, which just screams, "Inefficiency and Cost Overruns! Followed by Rationing! And higher taxes."

It's just not all that obvious that the second option is the way to go; that free-marketers are somewhat inclined in that direction suggests something has gone awry.

that there may be issues of political economy that make the former option the better choice.

Those issues can be grouped under the rubric, "Widening inequalities in any sphere ultimately, some directly, and some indirectly, through meandering paths, subvert the representative quality of republican politics." Specifically, the prospect of an increasing overlap of economic, cognitive, political, and genetic elites ought to kindle a metaphysical horror in the breast.

Overall, this knowledge would be a net benefit to society, as the vast majority of folks who test negative won't have to pay for coverage of a disease.

I'm not sure we can really say this. At the macro level, it is only a benefit if we as a society are going to deny care. Otherwise we are just choosing other methods of allocating cost. Are we likely to have a responsive health care system when those who aren't sick don't have a significant fiduciary interest until they sick? What kind of price signaling can we expect when upwards of the first $5,000 (between deductibles, co-insurance, and copays) in treatment are uncollectable or very expensive to collect? One could say we would get what we have today, inner city hospitals closing and suburban hospitals with excess capacity.

It is kind of interesting to compare taxation efficiency for a moment, because there is plenty of applicability to the health care world. There is the fee for use model. For example you pay $50 at the DMV for a license. You pay $75 for a plate, etc. That process is relatively expensive for each dollar collected. You have the poll tax, which is one of the easiest to calculate and fairly easy to collect. You have the income tax what is very expensive to calculate at an enforcement level and more difficult to collect. Different taxes are assessed in different ways to encourage behavior. What dominates the health care debate is the implicit and often explicit belief that over utilization is the primary driver of excessive costs. This is why many conservatives are obsessed with fee for service. On the empirical side comparing utilization between countries, there just isn't all that much evidence that this is the case. Varying estimates place gains that could be made under single payer at over 30% due simply to allocative efficiency. Is it really a societal benefit in the health care arena to try and insure the patient pays every last penny of what they receive in care or would society be better served attempting to bring down the cost of care through supply side regulation that encourages reducing the cost of treatment?

"it is passing strange that an enthusiasm for market efficiencies has come full circle to an appreciation of the benefits of government intervention"

Why should you find this strange? The "pure" market solution in this case would be to say that insurance companies could use the test and if this meant some people couldn't afford treatment, then tough. If we both agree that this is unacceptable and some sort of government intervention is called for, then surely the question should turn to what kind of intervention would be best, should it not? If the market does a better job of providing care in, say, 95% of cases, and the government does a better job in 5%, then I fail to see why it should be shocking to think that the 5% of cases should be handled by the government and the rest left to the market.

Also, note that I said only that government payment would be preferable to regulation in an ideal situation. I was quite clear that, in the real world, there could be issues of political economy that would make it a worse choice.

"What dominates the health care debate is the implicit and often explicit belief that over utilization is the primary driver of excessive costs."

I think the issue is not so much that we use too much health care (though there could be a kernel of truth to this) as that we spend too much on health care, and one of the reasons we do this is that we aren't paying for it ourselves. When a third party is paying for something, you may use more of it than you would if you had to pay, true, but you also become price insensitive. It's not like the man with "dinner insurance" is going to eat three dinners. But he might order more expensive dinners, even if the increased quality of food wasn't worth the cost. When you have a system where the vast majority of consumers lack this price sensitivity, providers lose the incentive to compete by offering lower prices, and thus you lose a key mechanism that keeps prices low in other industries.

If we're going to go the inter-country comparison route, then I'll see your Canada and raise you Singapore. The fact is that the U.S. government already spends more per capita on Medicare and Medicaid than Canada spends on its entire system, which suggests, to me at least, that having the government pay for everything isn't what's keeping the cost of health care in Canada down.

The trouble is that the percentages of the population priced out of the private sector health care system would be much greater than a mere five percent, if, in the absence of mandates and the ban on genetic testing, insurers could screen out, or assign a prohibitive rate, everyone with a genetic malady, and everyone with a looser potentiality - as estimated based on family history, etc. - for developing serious illnesses.

If the market does a better job of providing care in, say, 95% of cases, and the government does a better job in 5%

I perceive this as somewhat misleading: the government would not do a better job at caring for the hypothetical five percent; the real issue is that the private sector might not turn a profit on that five percent, or might endure "unacceptable" losses. Besides, there is no guarantee that the government program for the five percent would be adequately funded. It seems to me that this formulation conflates quality and cost of care - it costs "too much" for the private sector, and therefore government would do a "better job". If the issue is the quality of care, then the private sector will do a better job. If the issue is cost, then you take your odds.

Maximos,

I choose 5% as an example, not a prediction. Maybe the number would be higher; maybe lower. Who knows. I will say this, the larger the percentage of the population that has one of these genetic markers, the less having one of these markers would raise your premiums. We already know how often certain illnesses occur and how much they cost to treat, and having the genetic test isn't going to change that (if anything it could make the whole system cheaper through early treatment). Having the test may change how much of the cost of illness is borne by each individual, but it doesn't increase the overall cost.

Here is another aspect of the puzzle that has been unmentioned. It is interesting to SAY companies cannot use genetic testing, but enforcing it (and even defining it) may be a larger challenge than you have imagined. The heart of genetic testing is fairly easy to identify, but the edges of the arena are not necessarily so easy to locate. As far as enforcement: it is usually a losing battle to try to keep honest-to-goodness real knowledge out of the hands of those who want it and can find a use for it (as the Communists found out though it did take a while). You are literally pushing against a basic economic instinct, metaphorically trying to shove water upstream. You may succeed for a while, but in the long run it is the kind of effort which simply can't continue - ways around the restriction will be found.

But what really has me puzzled about this whole debate is why: by far the majority of Americans who have health insurance have it through work. Group health plans do not do genetic testing. The essence of "group" here is that they are all treated together for pricing. Has something changed? What did I miss?

What I still don't understand is how you can ban discrimination on the basis of genetic testing, perhaps even ban genetic testing by insurance companies (?), yet have people with a particular genetic marker be charged a bit more for their premiums. I mean, the company wouldn't even know who they were. So I just don't get that at all.

I'm as lost as I have ever been when it comes to concrete health care policy, though I certainly have sympathies with Maximos' critique.

But a factual point:

The 'preexisting condition' exclusion is alive and well. I was just discussing a particular case of it with someone the other day - he had been badly burned by the fact that his previous employer had (fraudulently) failed to pay premiums, and that his wife's medical issues were preexisting conditions - and therefore not covered - as far as his new employer's insurance is concerned. This has become more limited under HIPAA, though if you need treatment right now rather than after the HIPAA time limits that is small comfort.

It is interesting that this whole thread is eloquently, even passionately, discussing how best to hang on to the maximum amount of money, when it would seem that the issue should be how to heal the maximum number of people.
Is it even possible to come at the issue from the side of the afflicted, rather than from the side of the incorporated?

The sick do not have a right to our money, in order to procure treatment, not even the comparative pittance factored into an insurance premium so that such higher risks might be adequately underwritten. Presumably, a starving man would not have a right to our bread, either.

Do the unclothed have a natural right to the public treasury to get clothed? How about those who don't have homes?

A starving man might ask for mercy and receive it for stealing bread, but it is objectively still theft and the forgiveness we give him is simply grace. The man has no natural right to my bread, but his circumstances as a fallen creation of God might warrant mercy and grace.

You may call the current system decent, but it is hardly just. It is especially unjust that hospitals must provide emergency care to the indigent without any promise whatsoever of compensation. That, Maximos, is slavery in the most literal meaning of the word. Slavery is nothing more than the condition of being coerced to work for someone else's benefit without compensation or where they confiscate part of your compensation without just cause.

Slavery is nothing more than the condition of being coerced to work for someone else's benefit without compensation or where they confiscate part of your compensation without just cause.

This sentence seems to be constructed to be true by definition (with the possible exception of the 'nothing more'). Given that it is true by definition, I'm not sure it is helpful. So let me tease out two points (without necessarily answering the questions they raise) in a way which is not tautological:

1) Slavery is not "being coerced to work". Slavery (at least when we use the term to refer to something which is always morally wrong) is to treat a person as chattel, as nothing but property. Slavery is a species of lie inasmuch as it treats a person as not-a-person.

Furthermore, it simply isn't true that it is always wrong to coerce someone to work (even when 'coerce' means that, for example, jail time is a consequence of disobedience). As a fairly trivial example, it is illegal to sell onesself into slavery and yet a soldier can be punished by jail time for going AWOL -- that is, for refusing to report for duty and obey lawful orders.

In general, I think the concepts of 'slavery' and 'property' - not to mention 'coerce' - that we modern people tend to work with unreflectively are in fact rather problemmatic.

2) "Without just cause" begs the question, since precisely what is at issue is the extent to which (for example) a literally starving (that is, literally dying of starvation) man has legitimate claim to a wealthy man's bread.

Never mind the wealthy man and his bread; we can see that he has had his reward. I don't know if a starving man has a right to eat and live, or not; I do believe, however, that even a poor man has an obligation to share that bread with the starving man.

2) "Without just cause" begs the question, since precisely what is at issue is the extent to which (for example) a literally starving (that is, literally dying of starvation) man has legitimate claim to a wealthy man's bread.

Where does this legitimate claim come from, Zippy? "Natural law?" Funny thing is, no one can actually agree as to what natural law dictates. It's a legal code without any publication that we might know what it dictates. Now, if you want to argue the Bible here, the poor man does not have a property right in the rich man's food. Rather, by grace his theft is tolerated as a necessary condition of the fallen world. Doesn't free him from the aspect of it being a sin; Jesus would never have stolen bread to feed himself, if you will.

Suppose a community is full of starving. Does the government have the right to go onto a farmer's land and seize his entire crop without just compensation to distribute to the people?

Where does this legitimate claim come from, Zippy?

I did not even so much as say that there was one. I simply pointed out that you were begging the question.

Funny thing is, no one can actually agree as to what natural law dictates.

Yes, well, the fact that people disagree about something means there is no truth, I suppose. Or to put it as a famous man once did, "what is truth?"

Jesus would never have stolen bread to feed himself, if you will.

Can we be sure of that? Jesus, after all, did cite the incident of David taking the show bread from altar of the temple to feed himself and his hungry men. Was that not a theft? Yet Jesus used that example to justify his disciples rubbing the husks off grain on the Sabbath.

Does the government have the right to go onto a farmer's land and seize his entire crop without just compensation to distribute to the people?

The point there is that the government should not need to do that. The farmer (presumably along with other farmers) should voluntarily give of his crop. If he is a Christian farmer, that is. If not, I guess that he releases his dogs, loads his gun, and goes out to protect his fields from the need of his neighbor.

If not, I guess that he releases his dogs, loads his gun, and goes out to protect his fields from the need of his neighbor.

Great line.

Maximos--
Thank you. I've very much been enjoying your recent series of posts and the discussions they've given rise to.

Yes, well, the fact that people disagree about something means there is no truth, I suppose. Or to put it as a famous man once did, "what is truth?"

I never asserted that there is no truth. My skepticism about natural law comes from the fact that there are many schools of thought as to what it is, and none of them can prove conclusively what natural law is and demands of us. Being a Protestant, I regard God's revelation as the only "natural law." Since God only demands repentance from non-believers, that and abstaining from violence against people and property are pretty much the only things I would expect from them as well.

It cannot be stressed enough that the very reason we live in such a debauched age is in part due to the creation of new economic rights like the right to access to healthcare and food. The moment you accept the premise that a sick person, in any circumstance, has a right to healthcare, you lay the foundation for society to begin controlling, and eventually confiscating the labor and fruits of the medical profession.

Does this logically follow? Not exactly, but observation shows that it does. Since logic is dependent on the data that it operates on, it would be better for conservatives to unilaterally reject the notion that anyone has a right to healthcare on the grounds that it will typically lead to a very anti-conservative situation for the medical profession over time.

So far as I'm concerned, our commenter "Blackadder" made the crucial point on this thread, several days ago:

"...the U.S. government already spends more per capita [i.e., per the entire population of the U.S. - not just the minority who are covered by Medicare, Medicaid, etc] on Medicare and Medicaid than Canada spends [again, per capita] on its entire system..."

And Maximos is all worried about the malign influence of libertarians on American healthcare policy?

I mean, what's up with that?

My skepticism about natural law comes from the fact that there are many schools of thought as to what it is, and none of them can prove conclusively what natural law is and demands of us.

That is as true (or untrue) of the laws of physics. Should I then doubt that there is any truth to the law of gravity?

Should I then doubt that there is any truth to the law of gravity?

With regard to this interesting question, may I ask if there is an absolute equivalence between the laws of gravity, which can be expressed mathematically, and elements of Natural Law, which can be expressed only by a logic, the premises of which could be said to have been posited arbitrarily?

My point was simply that in the obvious cases - say torturing a child to death or dropping a rock from five feet up - we all see and agree what the natural/physical law entails, in the rough. The more difficult and subtle the case, the more disagreement. Yet we don't call into question the very existence and pertinence of objective truth w.r.t. gravity simply because of this 'disagreement gradient'; neither ought we call into question the very existence and pertinence of objective truth w.r.t. morality because of a corresponding 'disagreement gradient'.

Reality doesn't care about our disagreements, and doesn't lose any of its objective actuality when we stamp our little postmodern feet in impotent epistemic outrage. For that reason I have absolutely no sympathy whatsoever for the sort of argument that appeals to disagreement. Yes, people disagree about all kinds of things. So what? That has absolutely no bearing on the real things about which they disagree, and moral obligations are real things.

Mind you, to be fair I should say that I have a great deal of sympathy with this statement:

It cannot be stressed enough that the very reason we live in such a debauched age is in part due to the creation of new economic rights like the right to access to healthcare and food.
I think the problem runs deeper though. As I have written before on this blog, I think that while it is possible to express moral obligations in terms of "rights" it is generally inadvisable to do so because of the built-in corruptibility of the discourse.

I disagree fundamentally with the presupposition of most libertarian criticisms of American health care policy, namely, that the problem is that we just consume to much of it, because we are ostensibly insulated from the costs. Spiraling health care expenditures are not the result of too many routine visits to the GP for the sniffles, when everyone knows in advance that there really is nothing to be done beyond riding out the cold, and they are not the result of overconsumption of health services that fall somewhere between an ordinary broken bone and transplant surgery. People generally request such procedures and services when they need them or are informed by a physician that they stand in need of them. The introduction of price sensitivities presupposes that much of this is elective, such that great savings will materialize if people are liable for all health expenditures up to, say, $5000, and many opt to do without. Alternatively, the idea is that people will shop around for lower prices. This strikes me as dubious, inasmuch as, if one needs, for example, surgery for carpal tunnel syndrome, one a)cannot really spend an inordinate amount of time price-shopping (one cannot use a hand, and needs to have that rectified asap), and b)is not going to find a surgeon who will perform the procedure for $300, as opposed to several thousand dollars. The savings just aren't there.

Modern medicine is costly because of technological advancements, and the availability of life-sustaining and prolonging treatments, therapies, and procedures for those who would have died sooner in earlier ages, or suffered lengthier periods of debilitation - that is, if one wishes to look at the macro, slices-of-the-pie level. There are also problems stemming from the vast population of illegal labourers, who overburden the system and compel cost-shifting. And I'll not gainsay that there are inefficiencies in the federal programs. But the idea that those of us who have insurance are simply receiving too much care, and need to cut back, and that our refusal to do so is causing costs to rise logarithmically, doesn't make much sense. And, on the macro-level, the introduction of market-based price sensitivities will lead to rationing just as surely as any scheme of socialized medicine.

Hence, my objections to the libertarians are the mirror of the customary objections to the socialists; health care policy will be least injurious if it is a mean between the extremes.

As regards the bit about the creation of new rights, well, I am at once sympathetic and hostile: sympathetic because the entire discourse of rights has been corrupting, leading people to confound their wants and what is objectively owed them in a social milieu, hostile because those arguing against the socialization of risks in the private-sector insurance system are implicitly, and often explicitly, appealing to that very discourse in order to articulate a "right" not to do something - in this case, assume some small measure of responsibility for the sick and weak among us. Well, that, and the attempt to baptize laissez-faire on the slippery slope; it's not even remotely justifiable to permit the infirm to go untreated on account of the (justifiable) fear of socialism. Between the two poles, there is a vast expanse within which prudential judgment can, and ought to be, exercised; the slippery slope argument is often merely a rationalization of a refusal to reason prudentially and circumstantially. If there is no right to health care, neither is there a right not to provide health care. There obtains, however, a general duty to establish and maintain some mechanisms of social solidarity, where the resources of individuals and families, left to themselves, would be inadequate to objective requirements.

...new economic rights like the right to access to healthcare and food.

It occurs to me that the two main activities going along with the preaching of Jesus were provision of food to the hungry and of healing to the afflicted. Both of these material entities were analogized metaphorically by Jesus in his preaching to the provision of spiritual "nourishment" and the forgiveness of spiritual impairments. It makes little sense to me to quibble over whether people have a "right" to these things. In point of fact, people need these things. I wouldn't speak of them in terms of "rights," or lack thereof, but in terms of "need" and "obligation." If "right" comes into it at all, I would ask whether those who have these things in abundance have the "right" to withhold them from those who lack the means of acquiring them to meet their very real necessity as the means of survival. Property rights, which were originally nothing more noble than sufficient "fire power" to protect confiscated material wealth from theft by force, and which later evolved into a mutual agreement to collectively protect those rights, never, for the Christian, exempted one from the obligation to charity. So, how do we speak in this connection about "new economic rights?"

Property rights, which were originally nothing more noble than sufficient "fire power" to protect confiscated material wealth from theft by force, ...

I thought it was a reasonable post up to this point, but here I have to disagree strongly. There are many ways to go about disagreeing strongly, but one way in a group of Christians is to point out a few words spoken quite directly by the Almighty: "Thou shalt not steal".

And the pattern of which I spoke was established well before the time of Moses.

"confiscated material wealth..."

Confiscated!

Okay, that's it. I let the neo-Marxist junk go so far and just so far without voicing objection. So all property is theft, eh? And for crying out loud, think how self-refuting this is. If there were no such thing as legitimate property rights in the first place, then "confiscation" wouldn't mean anything as a pejorative term either, now would it?

And I would add to Zippy's comment, "Thou shalt not covet...anything that is thy neighbor's."

Just think: You're God, and you're only gonna give 10 commandments. Why include that one? (HT to PJ O'Rourke) The poison of envy and of an assumption of a right to another man's goods is the root of much evil.

You will note that I follow up the "confiscate" (think cattle raids; think land grabs by nomadic hoards) with: "and which later evolved into a mutual agreement to collectively protect those rights." It is at this point in the development of civilization that we have the likes of Hammurabi and Moses--the great law-givers. Before God revealed the Law, the rule was force. I don't see that I've said anything controversial (or Marxist) here.

Before God revealed the Law, the rule was force. I don't see that I've said anything controversial (or Marxist) here.
It may not be Marxist, but it is definitely Hobbesean.

I would say that it is neither "Marxist" nor "Hobbesian" but simply descriptive of the natural history of mankind. It is a relatively recent development that any man, other than the local/regional/national strong man/chietan/king could be properly said to securely own anything, lacking the power to defend it by the strength of his own arm, plus, perhaps the strength of his own, family/clan/tribe.
If this is Marxist or Hobbesian (I'm no expert on either), then it is only because Marx and Hobbes accurately take note of the early history of mankind.
I mentioned it only to say that, in my opinion, the notion of "rights" is less valuable, in thinking about the needs one's neighbor, than is the notion of "obligation." Rights are mostly invoked contra one's neighbor, rather than in his aid. Rights are still dependent on force to defend--or "enforce"--them for this very reason. Obligations, however--the unstrained qualities of mercy--are not coerced, but fall, as the poet said, like the gentle rain. (Or not, as is most usual, of unfortunately.)

I would say that it is neither "Marxist" nor "Hobbesian" but simply descriptive of the natural history of mankind.
That is what Marxists and Hobbesians think of their theory, of course. But it is far from uncontroversial, and some suspect it of being a mythological trope invoked to justify certain aspects of modernity (and in particular the denial of the natural law).

Rob 2, I think your point, though, is that nothing can be said really to be _properly_ owned or owned in a natural fashion. Now, even in a hunter-gatherer culture, a particular person might get something entirely legitimately and by his own efforts--by gathering food or making a tool or something--without confiscating it from anyone else, and it would then belong to him in a natural fashion so that it would be _wrong_ simply to come up and take it from him. The fact that he could prevent this wrong only if he was strong enough makes no difference to the rights and wrongs of the matter and does not make it the case that his ownership simply _means_ his rule by force over others. Again, this way of looking at it treats ownership as entirely artifactual and puts the favorable presumption on anyone who wants to take something from someone else--it's either neutral, because force is the only law, or else it's positively legitimate, because the taker has a need and the person with the stuff is acting reluctant about satisfying it. I cannot tell you how misguided I think that approach to be.

As a non-resident neo-Marxist - or at least as I've been apparently labeled - I would say the argument is tending toward anarchism. Anarchists tend to reject the right of the State to act in its own interersts. If we want to do history lessons, health care has always had some sort of public interest even if the action was simply to quarentine. Looking to the Good Book, we can look at lepers and the requirement that they be inspected by a priest before they could be allowed within the city gates. Moving forward, public sanitation in some places was opposed by people but imposed by the State for the people's well being. Modern practices like compulsory immunizations enjoy wide support, and we have no difficult seeing a compelling interest in requiring them, even deeming those who don't obtain them unable to be publicly educated. In a number of parts of health care it is difficult to argue that benefits are purely private. Hospitals by their nature and design are public benefices. As we move further out, outpatient surgeries have more the appearance of a private good. If we take a step back though and place ourselves in an agrarian culture, even that would be considered a public good. A society would desire as many healthy hands to pick the harvest so that none of the harvest would goto waste. Additionally there would be an interest in not having to feed someone who could not pick food, so the community would want to take measures to prevent the able bodied from being rendered unable.

By some of those arguments, Forrest, food production should also be nationalized, and parents should have to fill out forms showing what they are feeding their children on a daily basis, because it is "in the public interest" that everyone be properly fed. And the same with the production of clothing. After all, naked workers might get sick, and then they couldn't work for the commune, er, I mean, the community. I wonder if it might occur to people at some point that just because it is "in the public interest" for a large number of people to have some good, it does not follow that the proper way for that good to be distributed is in a highly state-controlled manner, much less _by_ the state.

By some of those arguments, Forrest, food production should also be nationalized...

Your prudential calculus obviously differs from mine. You obviously prefer to deal in caricature. Perhaps you will one day recognize that indifference to an obligation is just as evil as incompetence in fullfilling the obligation.

a particular person might get something entirely legitimately and by his own efforts--by gathering food or making a tool or something--without confiscating it from anyone else, and it would then belong to him in a natural fashion so that it would be _wrong_ simply to come up and take it from him.

The point that I was trying to make was not a point about the nature of property, but rather about the nature of "rights." In your hypothetical hunter-gatherer society, it might well be a major transgression to steal an item from another in your family/clan/tribe. It might, however, be a matter of great pride and social acclaim to steal a similar object from the neighboring member of another tribe. Thus the property right was not the kind of universal right that we understand today. Stealing might even have been seen as a duty. Thus rights were originally a matter of cultural and trans-cultural consensus and were contingent upon a relational context.
Where we have divine revelation authorizing or commanding a specific behavior, this (needless to say) trumps any previously valid cultural norm.
I don't know, however, that we can identify as universally human any "natural law" that is not founded in the supernatural.

"In your hypothetical hunter-gatherer society, it might well be a major transgression to steal an item from another in your family/clan/tribe. It might, however, be a matter of great pride and social acclaim to steal a similar object from the neighboring member of another tribe. Thus the property right was not the kind of universal right that we understand today."

So you see that as entirely culture-relative. I don't agree, certainly.

So you see that as entirely culture-relative. I don't agree, certainly.

Since the example of the Ten Commandments was raised earlier, we might consider the fact that, for instance, the proscription against murder seems to have been a proscription only against murdering other Hebrews. Persons worshipping other gods were, ipso facto, fair game. Thus, the injunction was not against man-killing per se, but only against killing God's chosen: culturally relative. E.g., the assassination of Holofernes by Judith is a cold-blooded murder as perceived by the other cultural group, regardless of its political benefits for Judith's particular people.

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