The Right’s Health Care Principles

For anyone who doubted my earlier post — in which I noted that one of the Right’s main complaints with Obamacare is its insistence on covering poor people — I’d like to present you with a bit of proof. Here’s an especially arresting quote from the widely read and respected libertarian economist Tyler Cowen. He’s outlining what he believes the Right should support rather than the Obamacare mandate:

2. A rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor. Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence. We need to accept the principle that sometimes poor people will die just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods — most importantly status — which lengthen their lives and which the poor enjoy to a much lesser degree. We shouldn’t screw up our health care institutions by being determined to fight inegalitarian principles for one very select set of factors which determine health care outcomes.

(h/t Yglesias)

85 thoughts on “The Right’s Health Care Principles

  1. There ya go. We can go back and forth over the relative efficacy of free-market vs. governmental intervention, this plan vs. that plan, top-down vs. bottom-up, etc. ad nauseum, but at the end of the day this debate really isn’t about economics. This is fundamentally a clash over morals.

    Should the fact that you live or die be dependent upon your individual financial fortunes, often for reasons totally beyond your control? If you say yes, then at some level you are placing property over people. I hate to put it that starkly, but anything else is just a bunch of philosophical yadda-yadda, blah-blah. Either you believe your right to hold onto a bit more property trumps another person’s right to live or you don’t.

    • Either you believe your right to hold onto a bit more property trumps another person’s right to live or you don’t.

      Not exactly, you’re forgetting one thing:

      Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.

      Trying to equalise health care consumption in the face of the above constraint means that you don’t mind reducing poor people’s absolute quality of life so long as the rich people’s health care outcomes are reduced even more. That’s like pouring acid on your whole face because you think your nose doesn’t really fit your face.

      On the whole, I am of a mind to agree with the main article. The right doesn’t really care about egalitarianism. Since there really isn’t much going philosophically for egalitarianism (about money resources or for that matter health outcomes), I’m of the mind that the right should own their lack of egalitarianism. It isn’t anything to be ashamed of.

      The question that the left should be asking themselves is how they can live with themselves if they think that Rawls’s difference principle is too inegalitarian for them. Why is equality so important that it is worth sacrifising the wellbeing of even the worst off in society over?

      • The idea that universal health care reduces the quality of life for the poor — the folks in Obamacare who are given subsidies to pay for health care, often in total — is absurd on its face. It’s high-brow Young Earthism.
        • Then that is the argument you should be having.

          Myself, I am of the mind that Cowen overstates his case just a bit. (Sometimes I tend to forget that the situation of the poor in America is much shittier than in Singapore)

          Let us suppose that as it stands, quality of the healthcare for the poor is terrible. Moreover let us suppose that it is so completely terrible that universal insurance coverage will actually improve their situation, then sure, almost any kind of universal coverage will help the poor. i.e. some thouroughly socialist and inefficient program could still be better than the status quo. But whether the poor in america are in such straits vis a vis healthcare is not so obvious a point that it is the equivalent of young earth-ism. The difference (even if you’re right about the effects of a universal program) is more like the difference between punctuated equillibrium and constant evolutionary change.

          Hell, my ideal system has a HSA mandate and universal catastrophic coverage as well as a means tested supplement for the poor. Mybe that counts as universal coverage in your book, and if it does, that is another way in which Cowen is wrong. But note that this is pretty close to Cowen’s ideal system as well. So when he says trying to equalise health consumption, given the context, he is not rejecting universal healthcare. You could have a universal health program, that provides the basics with a private sector that provides a lot more for a larger premium. Healthcare consumption could still be profoundly unequal. Cowen is talking about actually trying to equalise consumption and I am inclined to agree that it is a misguided goal.

          • It’s a lot easier to treat diabetes before it hits the emergency room. it’s a HELL OF A LOT CHEAPER.

            One can easily find ways to equalize care, without increasing costs. Iphone alarmclocks would certainly help with the TWO THIRDS of people who don’t take their medicine properly.

            Know how many ER visits that would save? Neither do I, but I do know what we’re researching…

          • e-notices for medication and aftercare scheduling are a good idea, though we’ll see how effective they are in practice. in areas with heavy smartphone usage they’ll probably be far more effective.
          • It would be a hell of a lot easier to treat diabetes if a whole generation of fat fucks wasn’t creating another. At this rate, based on the numbers I’m seeing, 1 in 3 Americans will have Fat Fuck Disease, aka Type II diabetes. All entirely preventable and curable.
          • WHy don’t we just get rid of the courts? If your wealthy and can afford a gun, you can kill anyone who is poor and can’t afford protection. The rich could settle legal matters by paying off the police or politicians, who ever has the most money gets their way. That makes as much sense as Cowan health insurance plan…and think of all the money we will save! After all there is no other purpose of living on this planet if you can’t accumulate as much money as possible.
      • The American “Left” is mercifully unburdened by what John Rawls thought about anything, to their credit, they’re far too pragmatic at this point to bother. The reason the Right doesn’t “own their lack of egalitarianism” is because making it concrete would be politically toxic and discordant with the values of hundreds of millions of Americans, let alone most American right-wingers, particularly on this issue as borne out by polling (as long as Barack Obama’s name is not mentioned in the poll).

        If we are to accept that poor people are going to die because they are poor, that’s a valid position with a strong foundation, but I pity the man that would actually have to sell this to poor people. “Yes, under our system 90% of the students in medical school go into plastic surgery; yes, a rich alcoholic can drink through 7 livers and leave you with none; yes, your cancer doc is busy today working on Paris Hilton’s chihuahua; and yes, all of our infectious disease docs are busy in Africa working for the Gates Foundation, handing out ineffective mosquito netting in Equatorial Guinea. But we assure you, this is the very best system because John Rawls wrote it in ‘Political Liberalism’.”

        I think the argument of “egalitarianism” is something of a red herring. The poor in the US don’t hate rich people because they’re rich, they hate them because rich people in the US are the most magnificently improvident and wasteful people on Earth. Not many people are willing to put their life on the line to defend the system that made them, and that’s a problem with implications in a lot of spheres, not just health care.

  2. Part of the problem includes such things as Arimidex.

    Arimidex was not available for anybody at all 20 years ago. No one, not even Bill Gates himself could buy it. Now? It’s one of the most expensive drugs on the market.

    Here’s the question: if Bill Gates could afford to buy this drug for Melinda but people like us couldn’t afford to buy it without selling the house the car cashing out the 401k and poor people couldn’t even think about doing that…

    Is this a case of people dying because they’re poor?

    I ask because when I think of people dying because they’re poor, I think of the elderly dying in apartments in the winter because they can’t afford heat or dying in the summer because they can’t afford air conditioning or even people dying of malnutrition because they can’t afford proper food. Not because people are dying of diseases that, until some point in living memory, we didn’t even have much of a treatment for outside of amputation (and that didn’t even work most of the time).

    • Personally, I don’t think anyone should die from being poor, full-stop. But I accept that’s a radical position in the American context. What I’d advocate is a baseline level of coverage — and I grant that what this baseline is will be decided through debate. That said, the emergency room system in the US stands as something of indirect proof that most Americans agree, or at least accept, my more absolutist interpretation of what’s right vis-a-vis health care.

      An example I’d cite of a real world person who died from not having money, and who quite affordably and reasonably could be alive today, can be found in this piece:

      Nikki White contracted systemic lupus erythematosus about the time she graduated from college. She soon was too sick to go to work, with stomach pains, skin lesions and extreme fatigue. Lupus, a chronic inflammatory disease, is treatable, but treatment requires frequent monitoring for side effects. White became so ill that she had to quit her job, and like most Americans, her job provided her health insurance. She then applied to every individual insurance plan she could find, but of course no for-profit insurance company will cover someone who has chronic lupus. She spent the rest of her short life fighting the Medicaid bureaucracy to try to obtain coverage – coverage that of course would not exist in Barnett’s ideal world, where there would be no Medicaid. Meanwhile her health steadily deteriorated. She suffered a seizure and died at the age of 32. “Nikki didn’t die of lupus. Nikki died from complications of the failing American health care system,” said her doctor T.R. Reid, who writes about her story in “The Healing of America.” If she had lived in any rich country other than the United States, she would be alive today.

      • What I’d advocate is a baseline level of coverage — and I grant that what this baseline is will be decided through debate.

        It seems to me that there will always be an example of someone poor dying when someone rich would not have. If not this disease that we didn’t even have words for until 40 years ago (and, quite honestly, still don’t understand), that one. The baseline will never be high enough until rich people die like poor people do… and no one will be able to point at someone else and say “well, *S/HE* survived!”

        It’s the bad mother from “Solomon’s Wisdom” on a societal scale.

        • I think this is a straw-man, but aside from that it’s relying on a hypothetical whose incidences stand to be extremely low as justification for not helping scores and scores of thousands of people. I won’t even get into the weird, paranoiac fantasies of universal coverage advocates wanting to see the wealthy die.
          • You mean the world in which every single human being from the beginning of recorded history (with asterisks next to Enoch and Elijah) have died and, by all accounts, will die and, as such, we’re discussing issues of not whether but degrees of how long?
          • If we agree that it is not possible for everyone to get the care they deserve, then we will be stuck discussing which groups we want to be screwing over or whether we want to make sure that every single group gets screwed over equally.

            (And, as has been pointed out many times, no one is arguing that every group should get screwed over equally.)

        • Jay,
          sorry. when we’re talking about people dying (or losing their house) because their health care coverage didn’t cover an ER visit for massive internal hemmorhaging (when they had ALL RIGHTS to expect it would) (instead claiming it was a voluntary procedure called an abortion), we aren’t talking about UNKNOWN NEW THINGS.

          Government, right now, pays for BLEEDING EDGE data on genomics. Gates can’t get anything better than what we got for some of our oncology patients (currently piloting).

          Is that so bad? Are you against that?

  3. Isn’t Tyler saying what features a policy that included a mandate should’ve contained in his view?

    That he could make that remark about the poor while in the market as it exists there’s distortion that makes health care artificially expensive (medical patents that make dealing with chronic conditions that depending on treatment could either be kept at bay or turn into catastrophe more likely to head towards the latter due to cost, for one example) is just nuts. Way to go vulgar there, buddy…

  4. Food stamps are funded by holding a gun to the head of the class that creates economic opportunity for the poor. Not only is this an immoral form of coercion, it hurts their prospects of escaping poverty. We need to accept the principle that sometimes poor people will starve to death just because they are poor. Some of you don’t like the sound of that, but we already let the wealthy enjoy all sorts of other goods, like private islands, that the poor cannot even aspire to. We shouldn’t screw up our economy by being determined to fight inegalitarian principles for one very select set of factors which determine whether people eat .
    • There’s an awful lot wrong with what you wrote, but let’s begin with this gem:

      “Food stamps are funded by holding a gun to the head of the class that creates economic opportunity for the poor.”

      This is kind of like when Sean Hannity sneered he never got a job from a poor person. Who do you think buys the stuff that businesses sell? Lots of people, all kinds of people, many of whom are poor. When some vaunted “job creator” gets his miraculous new business up and running, who buys what he makes or sells? (Now, if it’s some business that makes 90 foot yachts or diamond encrusted fountain pens, then, yes, you’re right, poor people are unlikely to help this business; but most businesses don’t specialize in things like that.)

      You might point to, say, the walmart family as glorious “job creators”, the kind of people who keep our economy humming and graciously bestow jobs to the less deserving. But where would this family be without poor people to buy the crappy, cheap shit they sell? I’ll tell you: Out of business, or at least struggling. And how about dear old Sean, the fellow who never got a job from a poor person? Well, what t he hell, do only rich people listen to him? A lot of people without much money listen to him, and buy the shit he hawks on his execrable show. No poor people, a whole lot fewer buyers of Hannity-hawked shit, a lot fewer advertisers on his show, and, lo and behold, sooner or later, poor old Sean might be in a little trouble finding anybody to pay him to excrete into the airwaves.

      Everybody makes the economy run. Rich people can help, no doubt about that. But, shit, waving away everybody else like they’re all lazy moochers, just hanging on to the legs of the Mighty Rich, dragging along behind them and slowing them down in their heroic quest to lift the economy to the heavens is just bullshit.

  5. It’s more than a little unfair to suggest that Cowen is putting this forth as a principle rather than as a simple reality that is in fact always going to be the case. You also cannot take the bolded sentence out of context without acknowledging the preceding sentence. Cowen’s point is in fact wholly consistent with the notion of a baseline level of care. His point is that in any conceivable system, the wealthy are always going to have better health outcomes in aggregate and that any conceivable system that doesn’t accept this reality is going to have the effect of making the poor worse off. And he’s not even saying it will make the poor worse off because of any “cycle of dependency” concept, but because a system that fails to recognize this reality will wind up diverting a lot of money from the poor that the poor could have used for other purposes that would improve their lives (and indeed their health outcomes) more.
    • Keep in mind, this is all in the context of discussing what type of “mandate” the “right” should have supported, and specifically what type of individual mandate. That presupposes a mandate of some sort, which in turn inherently seeks to require a baseline level of coverage for all.
    • Of course it’s unfair. But he’s attributing a position to “the left” (presumably, given this is a suggestion for “the right”) that the left doesn’t hold. Name a single American liberal who thinks the rich should be prohibited from buying more expensive care than the poor are given as their baseline.

      The entire argument is sophomore-level politics, which is why the appropriate response is too.

      • I don’t see him attributing any positions to the left here, even by implication, with the possible exception that he’s saying the mandate in ACA is premised at least in part on the principle that no one should die because they are poor. This is hardly a straw man – it’s frankly a value that conceptually most people agree with and is certainly one of the underlying arguments behind ACA. His point is that this value is unachievable, however morally justified, and the pursuit of it is self-defeating. That argument may or may not be correct, but it is hardly an unfair argument.
        • Now you’re the one ignoring the rest of the quote. The entire thing is supposed to be “[a] rejection of health care egalitarianism, namely a recognition that the wealthy will purchase more and better health care than the poor.” No one holds the position he is rejecting. He is arguing against a straw man, and a really stupid one to boot.
          • Dude. The one he *says* he’s rejecting: “health care egalitarianism”, which he even provides a definition for (by opposition): “that the wealthy will [not] purchase more and better health care than the poor”. No one supports a scenario in which the wealthy will not have access to more and better health care than the poor (maybe some very, very extreme socialists, but do me a favor and find me some before we start talking about what they believe). It’s a straw man.
          • If one says that no one should die because they are poor, and that this should be a primary goal of a policy, what is one saying, as a practical matter?

            I submit that when one makes this statement, they are unknowingly saying that the wealthy should not have access to more and better health care than the poor.

            I further submit that Cowen’s point is that the only way to effectively counter the belief that health care policy should be premised on the notion that no one should die because they are poor is to point out that such a goal is unachievable and to make explicit the recognition that “the wealthy will purchase more and better health care than the poor.”

            His point is, at least in part, that the principle that no one should die because they are poor is inconsistent with the practical reality that “the wealthy will purchase more and better health care than the poor” and that pointing out this inconsistency is something that the “right” has to be willing to do if it is to formulate wise policy.

          • FWIW, I read Tyler’s post back on the 20th and read it exactly the way Mark does.
            I agree it’s not eloquent, but that doesn’t make it wrong.
            It’s doubly odd to hear a complaint about that point from MattY, who has posted no less than three times that I can recall, that we would all be better off if people were able to take the money instead of the health care. Many of people (according to MattY) ould prefer some increased risk (or even certain!) early death if they got to choose even some portion of the money it would cost to keep them alive in many very expensive scenarios.

            Outside of framing, it’s exactly the same point as Tyler is making.
            I would have a lot more sympathy for Elias’ take on this if Tyler hadn’t had the the second sentence:
            “Trying to equalize health care consumption hurts the poor, since most feasible policies to do this take away cash from the poor, either directly or through the operation of tax incidence.”

        • I just added a comment below that speaks to this, but I think you’re giving him too much credit. If we were talking about absolute egalitarianism, you’d be on the right track. But I think his framing the discussion around poor people is crucial.
    • I’ve reproduced the entire quote, so I guess people can make up their own minds about whether sufficient context was provided. I struggle to think of what more I could do other than make the most palatable version of his argument for him.
  6. It may be an unfortunate phrasing, but it’s not just a truth, it’s a truism. Under what conceivable regime will it not be true that greater wealth and power will equate on average with wider, more convenient, and better choices in health care and maintenance, not to mention greater insulation from chronic dangers to health? Even the rich or merely well to do person who chooses a life of greater risk-taking is exploiting an ability to buy “more life” if not necessarily more extended life. The nature of medical technology is likely to exacerbate access differences, and, under the market system, to monetize them ever more explicitly.
    • It is true that more money = better choices. What he says though sounds less like mere admission of that and more like it’s somehow deserved that people die because they can’t afford treatment, as if it’s their fault. As I pointed out, the extent to which many can’t afford it is actually not their doing.
  7. I think this thread has started talking about whether Cowen’s arguing some people will have better health services than others — but if you read his actual words, that’s not what he argued here. He explicitly said poor people will die. Not “less wealthy people” but “poor people.” That, to me, does not logically lead to a conversation about whether or not someone earning $100,000 should have the same services as someone earning $5 million.
    • There is, however, a huge difference between “will” and “should.”

      Look, no one lives forever, but access to better medical services is always going to ensure those with such access will, on average, live longer lives, and those without access will live shorter lives; in other words, those without access to better medical services will die for no other reason than that they are comparatively poor. That may or may not be true (and it certainly seems logically valid), but it’s an empirical claim, not a normative claim.

        • The use of the word “comparatively” is, however, inherent in any use of the word “poor,” especially if we’re talking about the poor in the West in 2012, and certainly if the person using that word is on the political right and is addressing others on the political right. What constitutes being “poor” pretty obviously changes dramatically over time and place, and if we attempt to place a constant, non-comparative definition on the term, we wind up with absurd results, such as concluding that either or both of Louis XVI and a somewhat high ranking kleptocrat in Zimbabwe are “poor.”

          But even if he’s using some constant definition of “poor” meaning something akin to “those on public assistance,” his point doesn’t become any less empirical, nor any less logical. Every dollar that one can spend is a dollar that can be spent on something that will prolong or improve one’s life on average. For example, one who can afford to live in a middle class, or even a lower middle class neighborhood is a lot less likely to be a victim of random crime; can we say that one who dies because of a random crime in a poor neighborhood has died for any reason other than that they were poor? And so on and so forth.

          • The use of the word “comparatively” is, however, inherent in any use of the word “poor,” especially if we’re talking about the poor in the West in 2012, and certainly if the person using that word is on the political right and is addressing others on the political right. What constitutes being “poor” pretty obviously changes dramatically over time and place, and if we attempt to place a constant, non-comparative definition on the term, we wind up with absurd results, such as concluding that either or both of Louis XVI and a somewhat high ranking kleptocrat in Zimbabwe are “poor.”

            I, respectfully, don’t buy this at all. I think you’re contorting yourself into a pretzel-like form in order to defend what you concede by your very contortion is borderline indefensible. When we talk about poor people in American politics we most certainly are not talking about dead royalty or people in failed African states.

            And at any rate, I don’t think it’s right for us to keep steering this into an anodyne and dull conversation about whether he’s making an empirical point. I think he’s advocating a normative shift, or the more fulsome embrace of that already extant value system. And if he isn’t, and he’s just going against maximalist egalitarianism, then I’ll defer to Ryan, who has already done a pretty good job outlining why that’s a waste of everyone’s time.

          • When we talk about poor people in American politics we most certainly are not talking about dead royalty or people in failed African states.

            But that’s exactly my point – the definition of “poor” in the West is incoherent unless it includes a comparative element. In other words, when we talk about the “poor” in the West, we are inherently talking about people who are poor as compared to the wealthy in the West.

            And at any rate, I don’t think it’s right for us to keep steering this into an anodyne and dull conversation about whether he’s making an empirical point.

            But the entire premise of your post is to show how Cowen’s post proves that the Right’s interest in healthcare is in part premised on, in effect, FYIGM. If he’s simply making an empirical point and, as he clearly states, arguing that other uses of resources would more clearly help the poor, then your hypothesis is wrong.

            I think he’s advocating a normative shift, or the more fulsome embrace of that already extant value system. And if he isn’t, and he’s just going against maximalist egalitarianism, then I’ll defer to Ryan, who has already done a pretty good job outlining why that’s a waste of everyone’s time.

            There are plenty of other possibilities, though, not least of which is that he’s saying an effective health insurance mandate needs to expressly acknowledge the reality that the wealthy will always have access to better care, and thus the goal of ensuring no one dies because they are poor is self-defeating.

          • Why are we comparing them to the rich rather than the average or middle class? When we talk about people too poor to afford health care, we’re comparing them, implicitly, with those who can afford health care. Not the rich. You’re not going to persuade me otherwise on this point, Mark.

            Moving on, obviously the reason I don’t want to talk about whether or not he’s making an empirical point is because I don’t think he is. And, yes, my post reflects that.

          • Why are we comparing them to the rich rather than the average or middle class? When we talk about people too poor to afford health care, we’re comparing them, implicitly, with those who can afford health care. Not the rich. You’re not going to persuade me otherwise on this point, Mark.

            Assuming you mean “baseline level of health care,” then:

            1. I’m happy to concede that this is what you and many/most liberals mean when you reference the poor in relation to health care. The point is that it is not what conservatives and libertarians generally mean in that context, particularly when addressing other conservatives and libertarians.

            2. Even if the sole possible definition of “poor” in this context is what you suggest, it remains the case that the poor will still die for no other reason than that they lack less resources than not only the wealthy, but also the middle class and lower middle class, who will always, by definition be able to afford more and better health care than the baseline.

            3. To the extent that you’re saying that Cowen is suggesting there should be no baseline of coverage available to all, that assertion is flatly incorrect and inaccurate, since (a) this is all in the context of discussing what type of individual mandate the Right should have supported; and (b) in the very next paragraph (which you have not quoted above), Cowen writes that a conservative health care policy would need to include “A modest bundle of guaranteed coverage and services. ” IOW: there should be a guaranteed baseline of coverage. He’s made this point elsewhere as well.

            Moving on, obviously the reason I don’t want to talk about whether or not he’s making an empirical point is because I don’t think he is. And, yes, my post reflects that.

            I’ve never suggested otherwise. I of course dissent and have every right to express that dissent.

    • I think the variation is direct, and is intended to be in a market system. If you have five dollars, and I have six, I have $1 more life than you do. Now, you very likely have other fine qualities that I may lack, but those all can be converted into money if necessary.

      Poor people will die, yes. Capitalism does not function without an implied threat of miserable death. Because we live in a global system, we are generally insulated from the more direct threats of more extreme, more lethally miserable conditions. That’s what “jobs Americans won’t do” means: “Americans” are, on average, used to being insulated from the kind of motivating terror that would drive an otherwise sane person to work as a wage slave picking lettuce or at one of those suicide iPad factories in China. That’s what’s going on in Europe, too: Re-introduction of terror into the “lazy” economies of the periphery. It’s what you get when you’re denied the “hammock” that Paul Ryan is so afraid of, since according to the capitalist imagination, people with hammocks don’t work really hard. Democrats design hammocks, Republicans (and most Democrats, in a pinch) collect guns and whips. The perceived necessity of the latter is so fundamental to capitalist relations of production that it’s virtual ideological second nature. What’s also generally missed in this discussion, in our day and First World locations, is that “really hard work” is already a very objective and very real sacrifice of life or, in Marxist terms, alienation of labor for someone else’s profit: A “dying” by inches and hours, the laborer’s spent life being always being exchanged for something less than it’s really worth – that difference being the “surplus value” (-> profit).

      • A “dying” by inches and hours, the laborer’s spent life being always being exchanged for something less than it’s really worth – that difference being the “surplus value” (-> profit).

        This only obtains if you assume the labour theory of value.

        • That last part was a very abbreviated run-through of the LTV, yes, but it’s not just a question of whether you “assume” the LTV, but how you explain market capitalism as a system without whatever you reject in the LTV. You might argue that the system functions or can function on some other basis, but that doesn’t make picking lettuce any easier or more intrinsically rewarding; doesn’t make the agricultural wage slave any richer; doesn’t make the agribusiness owner any poorer; and doesn’t make Paul Ryan any less concerned about potentially productive people satisfied with their hammocks. Polanyi was able to explain the history of market economies – or the globalizing system of market economies – up through WW2 without explicit reference to the LTV, but the terror of the initially reluctant laborer, as well as the destructive market rationalization of land/nature and all social relations, remained essential, not just in theory, but as public ideology, if usually with an emphasis on the positive: law, modernization, productivity, growth, etc.
          • I’m not exactly sure what you mean by explain market capitalism as a system or what you mean by the basis on which it functions.

            Are you asking for what acually justifies capitalism?

            or what folk ideologies would I have to use in order to justify it to people? (if there is actually a difference between the two)

            Or are you asking what make a market capitalist system tick?

            I’m not trying to be deliberately obtuse here. It’s a genuine question.

            At least on the justification side, it would be justified because it does a fairly good job (if not better than any alternative) of contributing to the life-time well-being of the worst off.

            There is a sense in which, especially for the poor, participating in market capitalism is driven by an existential terror of starvation (work for a wage or starve) To the extent that society has support systems (either clan and family based or a social safety net) this existential terror is ameliorated if not eliminated.

            Will a universal basic income completely undermine capitalism? Only if it is so large as to kill any incentive to work. But the existence of incentives to work is not a reflection of the existence of existential terror, at least not if we are too lose about what we mean by existential terror.

          • tick. What makes it tick.

            The establishment of the so-called free market, ideally the self-regulating free market, as a comprehensive system rather than as an alternative or sub-system – made possible under industrial capitalism – has as its objective, its primary effect, and indeed its principle the extensive annihilation of those support systems you mention. This is what Polanyi calls the “stark utopia” of the free market. It’s utopian because it’s not survivable. Labor, nature, and society cannot be completely monetized, but the market encounters them only as monetized. In that sense it pre-annihilates them conceptually, and then proceeds to actually annihilate them, annihilate them materially, until the process is aborted and diverted, because people and in a different way nature and society rebel, and even for the market’s purpose become valueless – but the war never ends.

            A baseline of subsistence, even relatively generous by historical standards – housing, health care, income, education, etc. – wouldn’t destroy all incentive to work. But it would tend to destroy incentive to do highly inconvenient, dangerous, unhealthy, debilitating, miserable, alienating labor. Those describe the conditions of labor wherever “new markets” are created or discovered, and the felt conditions of labor whenever a new round of “creative destruction” seems to be called for – as today by the GOP in the US.

            The early experience of Britain, where this all got started, is extremely instructive. Abbreviating and reciting a bit from memory (also under the gun and whip myself, since I have some debilitating unpleasant labor of my own to get to) under the pre-existing system, the poor were generally taken care of by the village system. Initially, they were guaranteed subsistence, and given payments “in aid of wages” where companies could not operate profitably and also provide a living wage. Over the course of a generation, the system was found to be unworkable – it led to pauperization. There were alternatives suggested and tried, but powerful forces within Britain, with popular support and acquiescence – as almost elsewhere else up to the present day – opted for “productivity,” and eventually a still nominally Christian establishment was generally preaching a cruel to be kind social gospel resembling the fusionism of today’s GOP, in place of all of the traditional commandments to care.

            It’s described in fascinating detail in Polanyi’s book – and has little to do with the aspects of his anthropology and economic history that are in some (often exaggerated) respects dated.

            If we understand the economy as a global system – thus China, thus immigrant labor, thus a whole helluva lot else – we can understand why some regions and nations can enjoy much higher baselines – social services, also environmental protection, human rights, etc. – but the system as a global whole still functions more or less along the same lines, while searching for profit, productive, growth but perhaps discovering its true absolute limits: Those appear as the falling rate of profit – aka “the global financial crisis” – as well as ecological destruction (“climate change,” etc.), and rebellion (“terrorism” and other challenges to neo-imperialism).

            But whether or not we work around those limits for another generation or indefinitely, the main question here isn’t whether the Final Crisis Is Upon Us, but what underlying assumptions motivate Republicans and, actually, many or most Democrats.

          • Those describe the conditions of labor wherever “new markets” are created or discovered, and the felt conditions of labor whenever a new round of “creative destruction” seems to be called for – as today by the GOP in the US.

            At least as far as new markets are concerned (or newly opened ones) the basic fact is that the abject poverty was pre-existing and is caused, not by market capitalism, but by the lack of capitalism in the previously closed economy. While there is a temporary phase where people in such newly opened markets do dangerous work that those of us in developed nations are unwilling to do, this is a temporary condition. Their prosperity will increase fairly quickly and within a generation or 2, the kind of work they will be doing will be safer and (perhaps) less offensive to our sensibilities.

            Moreover, in order for people to voluntarily take up all these undesireable jobs, they must have been so poor previously, that there government was incapable of providing a basic social safety net. Similarly, their family and clan based support system must not have been supporting them sufficiently (because they already had too few resources among themselves).

            Now capitalism has undermined community in some ways. The biggest way is by bringing prosperity to all. It used to be that community ties were strengthened by ties of dependence. If my house burned down, I really depended on the neighbours and the village to do a barn raising. With the advent of insurance, I could now move on without having to depend on my neighbours. this allowed people to flout stifling social rules as alienating one’s neighbours did not have as dire a set of consequences as before.

            The creative destruction of capitalism does hurt the poor (at least in the short term) when they have no support system, but that is why it is not unreasonable for the state to provide a social safety net to cushion the blow.

            Part of the problem with understadning capitalism as a global system is that not all places are equally capitalistic. Those that made market reforms earlier tend to have a higher base line of social services and environmental protection. Other nations will catch up.

            When the entire world has caught up, what will happen to dangerous and unpleasant work? If it is not essential, people won’t do it. If it is essential, people will be paid more or the work will become more pleasant (less dangerous) and people will be more willing to do it. It is a mistake, I think to look st the workd transitioning from previously defective or at least severely inadequate systems and attribute the problems suffered to capitalism

          • Where, Murali, did you learn all of those fables about the introduction (or imposition) around the world of capitalism, market relations, and Westernized politics, law, and culture? You give the impression that you really haven’t the slightest idea how much of the rest of the world views that process, and has viewed it for a very long time, and that you’ve also missed several generations of lively discussion and research done in the West.
          • The question is not how the rest of the world views capitalism, but whether the rest of the world has the right view about capitalism.

            I’m under no illusion that much of western law culture was introduced in some peaceful way. Colonialism was a brutal and fairly horrendous experience. But colonialism is not market capitalism. And globalisation is not neocolonialism (Although american adventures in the middle east may very well be)

            The fact is that a lot of the newly industrialised economies in southeast asia have done very well thanks to global trade and economic liberalisation. Within the southeast Asian region countries which liberalised faster (like Singapore where I live) did better.

          • I’ll admit that my understanding of the history of capitalism is spotty at best. My understanding of the relation between public policy and welfare is somewhat better. I have done some work on the colonisation of southeast asia. I have been reading Fukuyama and Stephen Marglin. Plus, I’m experiencing first had the benefits of economic liberalisation. I’ve seen a free market in healthcare work in India. India is essentially a third world basket case. There is extensive corruption and basically no safety net. Yet, the market in healthcare works. There are competing brands of hospitals. Costs are low, and even though the level of service may be bad when compared to places like Singapore, the quality is not so bad that my Grand Uncle, a US citizen is willing to purchase medical services. Given the way the rest of India is, that the hospitals can provide a level of care that exceeds expectations is a testament to how well markets work.
      • Where, Murali, did you learn all of those fables about the introduction (or imposition) around the world of capitalism, market relations, and Westernized politics, law, and culture?

        Trying to talk down to Murali is unlikely to be a good strategy for someone of your intellectual stature. Try the other direction.

  8. Hmmmm.

    I think the right is actively demonizing the poor on th HC issue, but even so I’m not following Cowen’s recognizing that being poor sucks balls is an argument that the poor should be made to suck balls. The quote you highlighted is something I believe, and is a prime reason why I’m a big universal HC supporter.

  9. All this talk of Rich and Poor is just a little off-point. There are Insurable and Uninsurable People. You can be both rich and uninsurable. Just get old without long term health coverage, you’ll find out.

    Preemie children are a leading cause of bankruptcy. It’s not uncommon for a premature child to run up a million dollars or more in medical care expenses and rare for those expenses to go less than a quarter million for a NICU admission. Those children live in their own little spaceship for a few months. Veryvery expensive. And how can the system bring down the costs? It’s not easy, round the clock monitoring runs up the bill something frightful.

    Premature infants are only one part of the problem. People survive incidents they’d never have survived even a decade ago. Burn units these days are just amazing. Though it might seem callous, I’m amazed how low the fatality rates for our wars in Afghanistan and Iraq have been. These troops are surviving absolutely horrific incidents. The logistics of emergency health care are extraordinary.

    Instead of looking at Rich and Poor, we should be concentrating on another vector entirely: clearing the ER of every case that doesn’t belong there. That’s what’s screwing up the health care system. Get those people into urgent care facilities, where RNs can deal with the millions of little boo-boos and do the triage required to elevate more significant cases to hospitals. That’s where we can do the most good for the least money. Dollar for dollar, if you really want to impact those supposedly poor people, you put in a clinic. This has been known for a century now and we won’t act on it as a society.

    • Of course, the PPACA does exactly this – the Medicaid expansion (which seems unlikely to be overturned) is likely to double FQHC usage over the next few years. And the penalties for readmissions have hospital administrators looking to buy up every FQHC in sight.

      Neither of those changes are nearly as likely to be overturned tomorrow as the individual mandate, but together they are an important aspect of healthcare reform, and one most folks (not necessarily you) are all too ignorant of.

      • i tend to agree (from inside the belly of a beast, as it were) that the trend to consolidate and conglomerate is only going to intensify regardless of what the scotus does.

        done right, urgicare centers are a good solution to a lot of healthcare needs, and take pressure off of er’s, particularly in urban areas.

        • Yeah, you’re both right. I want to see some meaningful stats emerging from the FQHC network, giving us a meaningful picture of where we can make meaningful, cost-effective improvements, specifically eliminating GOMERs.
  10. The quote mishmashes two unrelated points, but you’re right to highlight the “principle.” As some of the comments have noted, you can have an argument about “equalization,” although even that term is misleading. Even in industrialized countries that have gone off the pure free market model and either do single payer or a tightly regulated public utility model, it’s not the case that there are no differences in health care due to viciously senseless egalitarianism, it’s that (as Elias notes) everybody gets a baseline minimum of very effective health care. You can argue about where that minimum ought to be, sure, in terms of how that affects costs and the quality of care. But those countries have managed the minimum in such a way (and at way less cost than we have) so that they get universal coverage and don’t have to accept the “principle” that The Poor Must Die! The quote is revealing because at bottom it’s not really about an empirical inquiry of any kind (because he’s not interested in these well-known facts) but seems way more interested in insisting on subordination of those lower on the totem pole than he is and rubbing their noses in it, even to the point of their deaths. What’s the difference morally between this well-respected pundit dude and those riffraff at the GOP presidential debates who screamed “Let them die!” to the question about lack of universal health care? Maybe the poundit guy went to better schools and has better party manners, but the moral difference isn’t that great.
    • I’ve heard it argued that there are, speaking broadly, two ways that people have gotten rationing to work: 1) by price and 2) by queue.

      It seems to me that #2 “feels” a lot more fair and equal but I also suspect that #1 is responsible for the lion’s share of medical advancements (that quickly become divvied out by queue by other countries in something that strikes me as akin to a free-rider problem).

      • Could it not be argued then, Jay, that the US joining the queue system would eliminate the free rider problem and force everyone to confront the question of paying for medical advancements (or put the objection to bed if it turns out to be a canard)?
        Also since the law in the US already mandates that people are not allowed to be refused treatment isn’t the US already in a queue system albeit a very inefficient and destructive one (where arguably a portion of that inefficiency is creamed off and used to fund medical research and huge salaries in medical fields)?
  11. A brief fisking:

    1. This is why Libertarians will never be trusted with more power than an AA battery: they just won’t do their homework. Switzerland’s health care system strictly regulates the amount of profit.

    2. Again completely wrong. If the wealthy can buy more health care, they cannot buy more life. People don’t die early deaths because they’re poor or rich. They die, often because they made poor choices in life, ate too much, wouldn’t exercise, smoked, drank to excess, couldn’t manage stress, breathed city air, got into avoidable accidents. The rich can make those dumb choices, too. Nobody shuts off the IV because the patient can’t afford it, they shut it down because the patient was Declared.

    3. Modest. There’s only one sound approach to health care and that’s based on statistics. What actually induces early death in this country and how can those deaths be treated or prevented? We don’t have the numbers because there’s no unified data set. The health insurance firms jealously guard those numbers. There’s your Modest Bundle.

    4. Price opacity is a problem created by health insurers. Want to see real price transparency? Go to a plastic surgeon for a breast augmentation. It’s not covered by insurance. He’ll give you a brochure with his prices printed in 20 point Helvetica.

    5. Price controls are ignis fatuus. It’s more akin to auto repair: a low radiator could be symptomatic of a blown gasket or a rotten hose. A case of heartburn could be an overdose of Thai food or a gastric ulcer or a heart condition.

    6. Medical research is important, but that’s mostly done in the context of university hospitals. Most American doctors doing their residency are supported by Medicare. The most effective use of public dollars in health care is vaccination.

    7. No suffering is individual in nature. A father can’t get treated for a heart condition and loses his job: who suffers? His wife and children and employer and everyone else around him in the society. We are all individuals: as suffers one, so suffer we all.

    As for these perpetual beneficiaries and fiscal strangulation, that’s pretty much bullshit. America pays more and gets less from health care in its current incarnations. Physicians aren’t even getting paid on time. The perpetual beneficiaries are Big Healthco and Big Pharma and they’re quite profitable these days.

    Let’s just quit lying to ourselves about this issue. The government won’t be strangled. We’re being strangled as individuals. Leave this to the informed parties and we’ll get first rate, cost-effective solutions. Trouble is, as I keep saying around here, we don’t have the information required to make those decisions.

    • Switzerland is able to pull off quite a great many things due to homogeneity of culture that won’t get off of the ground in a more heterogeneous culture. Even now we’re seeing argument bubble up in Switzerland about cultural issues with regards to authentic Swiss culture vs. other cultures.

      Being more like the Swiss would require us to be more like the Swiss.

      If the wealthy can buy more health care, they cannot buy more life.

      Life expectancy has gone up 15 years since my grandmother was born. *AVERAGE* life expectancy. This is due to a great many things that people wave away when we discuss them in the Heritage threads.

      There’s more than one way to do anything.

      There are a great many medical advancements being done by, of all things, Big PhRMA. We now give pills for things that we used to have to have surgery for, for example (and that’s a good thing). I agree about vaccination, though.

      If big insurance is part of the biggest problem due to, among other things, price opacity (and overhead), then it’d be better to go to something like single payer than have them write a new health care law based on a Heritage plan from 20 years ago (even if the Germans or Swiss *DO* something similar).

      • There’s more than one way to do anything, that’s true. But facts don’t take sides. We don’t have enough facts in evidence to make informed decisions on health care and the Right has made sure we don’t.

        The Libertarians, specifically Cowen, are not exactly helping things along here, babbling about what the rich get and don’t get and how we should think about that problem. Big Pharma is a racket. Didn’t we just have a go-round not long ago about treating Chagas and trypanosomiasis and how drugs don’t reach the poor when we privatise their manufacture? At some point, society is responsible for the General Welfare. And when we hear those words, who jumps up on his hind legs and starts barking and snarling? I leave the answer to that question for the informed readers among us: we both know the answer.

        Health insurance has become a market-distorting force in this country. Forget all other considerations, the fact that it takes more of a physician’s time to get paid than it did to treat the patient, something’s wrong here. The Free Market has not solved this problem, nor will it.

  12. As someone who’s read a lot of Cowen and who generally enjoys his work*, I have to say this was at best, very poorly chosen phrasing on his part. And I do think the charge that it reflects a fundamental failing of conservativism/libertarianism is fair.

    That said – it’s too bad people are glancing so quickly over item #1, because that sounds to me like a ringing endorsement of actual universal healthcare. One system for everyone, with no one excluded. I’m rather shocked his more conservative readers aren’t screaming bloody murder over it, honestly.

    * Though principally his restaurant reviews

  13. This article ignores the massive and ongoing public subsidization of medical research that has taken place in the U.S. Poor people pay taxes too, often a much larger portion of their income, and it seems only reasonable to suggest that they also have access to the fruits of their labor.
  14. I wonder what percentage of blogosphere posts voilate basic natural/behavioral laws, 99.9% perhaps? Let’s see a study, lol.

    Here is a basic law being violated all the time, and implicit herein: resources — and thus goods/services — are finite, whereas human needs/wants approach the infinite, and thus not all human needs/wants could possibly be met at any time.

    Bloomberg fixed ya on this one: http://www.bloomberg.com/news/2012-07-06/some-health-care-for-all-but-not-too-much.html

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