Thursday, March 25, 2010

Libertarians and health care

I've been having an email discussion with a libertarian friend of mine about the recent passage of the health care reform bill. While the exchange is already too long to post in its entirety, I did want to put up some excerpts. It started when I received an email blast saying that the bill is an inappropriate use of funds to interfere with the functions of private enterprise.

The first thing I mentioned is that I have a personal interest in the bill's provision that patients cannot be denied coverage for pre-existing conditions, as I have already gone through the experience of being denied coverage due to a mild case of high blood pressure that requires me to take some low dosage pills. Luckily, I got a new job later that covered me, and I can now extend the same plan under COBRA if I switch jobs. But it was a tense few months for me.

Later, I wrote:

Me:
Libertarianism has always struck me as a severe case of having only a hammer in your toolbox and perpetually seeking nails. Is the economy doing well? Then it's time to lock in those gains by eliminating regulations. Is the economy doing poorly? There are too many regulations. Is the economy still doing poorly after regulations have been gutted or deliberately unenforced in a particular area? The measures didn't go far enough; the solution is to roll back more of them. When I say that I am results based, what I mean is that you should be willing to actually compare economic conditions during different times or across different countries that have more or less regulation in these areas.

Libertarian "experiments" don't appear to confirm their hypotheses, because countries with varying degrees of regulation don't appear to reflect the claim that an unencumbered economy is a healthy economy. Let me demonstrate with a little on-the-spot research. The United States ranks 38th in a list of countries by life expectancy. Quick spot check. Among the top three countries:


All three of these countries I just looked up have stronger government involvement in health care than the bill that just passed. By contrast, let's take a look at the bottom three.


This is the kind of elementary research that I mean when I say that I would prefer evaluation to be driven by outcomes and evidence. Now, granted, health care isn't the only factor in life expectancy. However, there is a clear correlation that seems to belie the assumption that "more public involvement => worse results." Obviously I haven't done an exhaustive survey of all 195 countries on the list. But I'm willing to bet that a completed graph would retain the overall pattern that countries which spend more public dollars on health tend towards higher life expectancies, and vice versa.



Lib:
Of course people are healthier when there is more access to healthcare. The question is, who is better at providing the health care. Governments make the claim to cover everybody. But that's all it is, is a claim. We hear a lot about private insurance companies rejecting individual people's claims. But that's nothing to the number of people rejected by government plans. Just look at Massachusetts.

Me:
I think I've covered this question pretty well by my back-of-the-envelope survey of other countries. But all right -- I took you up on your request and looked. First thing I found was that Massachusetts has the lowest rate of uninsured residents in the country, at 5.5%. It was 8.7% in 2006, before the bill was enacted, so it has dropped significantly. The highest uninsured rate? That would be Texas, illustrious home of no state tax, clocking in at 26.9%.

I also looked for something to corroborate your implication that more claims are denied in Massachusetts than in most other states, but have so far come up empty handed. If you have evidence that Mass's system has enough negatives to offset the very excellent coverage rate, I'm sure you'll let me know. In the meantime, I'll continue my previous theme and take a look at life expectancy by state.

Huh... what do you know? Liberal Massachusetts with their public health program is fifth highest on the list. Texas, with the highest number of uninsured, comes in at 34.

Now, you might fairly regard this as a little bit of sleight of hand, since Mass only enacted their health plan a few years ago, and the results on life expectancy could hardly be expected to be measured thoroughly by now. However, Mass has always been demonized by economic conservatives as being an example of rampant "socialist" liberalism at its worst. So I'm content to have past results of this horror be reflected by the life expectancy now.

In a followup letter, this exchange occurred:

Lib:
The best analysis I've seen of [a nation's economic strength] is the Economic Freedom Index. The way I found out about this web site was a few years back when it made headlines (at least in Europe) that the US was no longer in the top 10...

http://www.heritage.org/index/Ranking.aspx

Me:
That's interesting, but it is begging the question. The Heritage Foundation is a well known conservative economics think tank. Any standard they use for measuring "Economic Freedom" is bound to involve qualities which are in line with the goals of the Heritage Foundation. Such a concept is inherently subjective, and assumes that the things that you want out of a government (i.e., lack of public funding for health care) are for the best. You can probably see why I'm hesitant to accept this as a neutral measure of how good those countries are.

Lib:
[I don't] value life expectancy if it interferes with quality of life. I had the privilege of sitting in on a health panel at Renaissance Weekend last year. There were many doctors and hospital administrators from Massachusetts. They were talking about a patient they refer to as the "Six Million Dollar Man" because there is no limit to what they are obligated to pay to keep this particular patient alive. To continue end of life treatment to this extreme will break the budget if everyone recieved such care.

Me:
You are, again, begging the question. I chose life expectancy because it is a relatively easy to obtain quantification of the overall health of the nation, one which is objective enough that it can't be easily fudged. If all else is equal, I assume you and I would agree that we'd rather live a longer life than a shorter one. (Or as Dave Barry once eloquently put it: "Son, it is better to be rich and healthy than poor and sick.")

But you've introduced a red herring, in saying "if it interferes with quality of life." Without providing any supporting data to show that quality of life suffers a lot from living in Japan, Hong Kong, or Iceland, this has nothing to do with what I said. If you'd like to pick another neutral measurement of quality of life, make a suggestion. But I'm not taking "The Heritage Foundation likes them" as an answer.

Here's an example of another standard you might pick for "quality of life." There is an organization that takes a snapshot of self-reported happiness by country.
http://www.nationmaster.com/graph/lif_hap_net-lifestyle-happiness-net

DEFINITION: This statistic is compiled from responses to the survey question: "Taking all things together, would you say you are: very happy, quite happy, not very happy, or not at all happy?". The "Happiness (net)" statistic was obtained via the following formula: the percentage of people who rated themselves as either "quite happy" or "very happy" minus the percentage of people who rated themselves as either "not very happy" or "not at all happy".


In a similar vein to my previous message, I note that the top three countries -- Iceland, Sweden, and Denmark, all have universal health care.

19 comments:

  1. Thanks for posting this. It really lays out the debate quite well between two critically thinking people - unlike what you often find on TV.

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  2. I dare say that I find arguing with libertarians to be more frustrating than arguing with theists. Probably because they pretend their position is a skeptical one.

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  3. Anonymous1:35 PM

    You compare 3 countries with healthy economies that are not at war with 3 countries in subsaharan africa that have no stability whatsoever.

    Libertarianism is a pet issue that you get very passionate about and tend to argue poorly. You develop a straw man position of defining libertarianism in its most extreme case and then argue against that. It works the same as if someone else defined you as a Marxist. Of course it is easy to "win" an argument when you define what you are arguing.

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  4. Say, Anonymous, would you mind logging in and identifying yourself if you're a regular?

    Actually your point did come up in the conversation, but I neglected to post that portion of the exchange thus far. I wasn't singling out the African countries; I was just picking whatever countries happened to fall on the top and bottom of the list. Suggest another metric and we can discuss that one too.

    Here was that portion of the email exchange.

    Lib:
    You probably know I'm going to point out that those African countries lacking in government health care are lacking in wealth for private health care as well. There's not much for the government to redistribute. It's often said that money isn't everything, by that meaning wealth isn't everything. But it's a lot. It's a whole lot.

    Me:
    These two facts are not unconnected. Generally as a country increases in overall wealth, it is correlated with a rise of public spending on common needs, such as infrastructure, social safety nets, and public health concerns. Your argument seems to be that wealthy countries would inevitably become even wealthier if they could somehow decouple these two trends, and create the wealth without bothering with all that public spending. I'm saying that there is scant evidence from history that would bear this out.

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  5. In my view, libertarians are impervious to evidence. Even Michael Shermer made a fool of himself when he said that any homeless guy can work himself out of poverty if he wanted. (Yes, he said that on a POI episode).

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  6. "In my view, libertarians are impervious to evidence. Even Michael Shermer made a fool of himself when he said that any homeless guy can work himself out of poverty if he wanted. (Yes, he said that on a POI episode)"

    Well that is indeed true..if said homeless man has no limit on how many cocks he's willing to suck


    @ Anonymous and co.

    Why don't we look at the Happiness index and other statistics like that. Generally Japan is surprisingly high (especially for its high suicide rate, maybe it's because unhappy people there are more likely to exit and thus not skew the result?) as are the Scandinavian European countries. Countries with health care, are higher than those without. I remember reading these in my People Resources and Populations class. America comes out disturbingly low when you adjust for the net wealth and gross product of the countries. If all countries were as wealthy as each other, America would be dismal in health care, our system is greatly inefficient in terms of dollars per pound. Our education isn't that hot either, no surprise.

    Note, in the class we just looked at the top, ie all first world nations. America still is not meeting its potential when you remove the developing, impoverished, and anarchist states.

    In a positive note on the statistics (at least as far as I'm up on them) Abortions are actually down in our nation, and while unwed pregnancies are up, unwanted pregnancies are down (ie more women are secure in being single parents and choosing to give birth unmarried) The highest demographic for abortions turned out to be married women.

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  7. Here in New Zealand we have a free public healthcare system, it's not the best system in the world, but it is there for the people that can't afford private healthcare, which is undoubtedly a higher quality service. Even though I have private health insurance myself, I wouldn't want the government to get rid of the public system ever. We need the public hospitals.

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  8. I've never had much time for Libertarians - they always come across to me as the religious fundamentalists of politics who are so totally convinced that their approach is the only one that can work, and by extension any others are near-totalitarian by nature. The arrogance you find in Libertarian writings is shown through the inference: "You must be a complete moron not to recognise that libertarianism is *obviously* the best system!".

    One common theme I've noticed is those who are against government based healthcare point to countries that have it and say "It's far from perfect". That always seems to give the impression that outcomes in the USA are near perfect or represent the best that are achievable. Clue: they aren't.

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  9. I fully admit that this is a straw-man, but nevertheless it is a tendency I find among libertarians.

    Libertarianism is an "ism", which always raises a red flag for me. Usually isms are things that take a narrow, overly-simple idea and raise it on a pedestal. In their case, it seems to be "government bad, free market good".

    I understand the idea, I just don't understand what good it does to latch onto such a narrow principle and try to apply it to everything. It may apply some of the time, but it falls wayyyyy short of "working" for most issues.

    Plus, it's always seemed just a step away from objectivism, which is no good.

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  10. Libertarianism is an "ism", which always raises a red flag for me. Usually isms are things that take a narrow, overly-simple idea and raise it on a pedestal.

    Oh, you mean like atheism. ;)

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  11. Kazim:

    The key word there was USUALLY!

    Damnit, I knew you'd catch me in something.

    Do you get my point though??

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  12. Yeah, but I try not to attach too much importance to the words people use to describe things. After all, it's easy for people to demonize an idea by giving it a fake name, like "Scientism" or "Video gamism."

    Libertarians, of course, have a host of their own ideological problems. I agree about the "government bad, free market good" angle, but this correspondent has called me on it a few times by saying that he does, indeed recognize that private corporations do irresponsible things all the time.

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  13. Kazim...Do not want to get too sidetracked, and I have not read the post, but I want to briefly respond to something you said if your last comment:

    "After all, it's easy for people to demonize an idea by giving it a fake name, like "Scientism" or "Video gamism.""

    Scientism is a real thing, and it is a thing that...perhaps not "demonized" persue, but I think it is a real problem. And I think it is a problem that many in the skeptic movement have. Scientism is the idea of using science to answer questions outside of what a person views as being outside its scope. For example, I do not think science can answer moral questions for us. It is not designed to do that, though it certainly can inform those moral questions. But people that would try and look only to science to answer those questions...I think that is a problem, and that would be scientism. (I think Shermer falls for this when he says that you can get an ought from an is, for example). I think part of the knee jerk reaction to scientism is that it can be something that is someone subjective, and often we here religious people call atheists that when we try and apply science to god (which, if the god has an effect on the natural world, science is the right tool to gather information...including regarding the existence...of that god). But science cannot tell us if life is good, if capitalism is good, or right, or "natural." It cannot tell us if it is okay, or not okay, to rape or kill, to give or forgive. Science gives us the best information about our natural world; about reality. Anyone that tries to use science beyond that realm, however, if engaging in scientism.

    At least, that is my thought on the topic.

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  14. I would add this about Mass health program. There is no public option, no government care in it at all. It is pretty much exactly like the health care that passed congress. There is a mandate for everyone to have coverage, and a private insurance exchange. Mass gov't offers subsides to individuals in order to purchase private insurance in an insurance exchange.

    So, there is no gov't health insurance. Merely, a market place that people are required to enter, with some government regulation of the market place to prevent the most egregious of violations.

    I thought I would just point that out.

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  15. Video Gamism is officially my new religion.

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  16. Not just the excellent health care system here...but in all regards, Japan is a great place to live.

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  17. "but this correspondent has called me on it a few times by saying that he does, indeed recognize that private corporations do irresponsible things all the time."

    He just believes it's their right to do so? How's the acknowledgement any better than saying "shit happens" or "HaHA!"

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  18. To "Varsha Pawar":

    Your comment was rejected, because I do not accept advertising in the form of phony astroturf messages. You ought to be ashamed of what you do for a living.

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  19. @Russell

    I'm not a libertarian, but I must agree with Anonymous (and the libertarian you're arguing with via email) to an extent on the issue of you using said war-torn states. Controlling for variables is a key component in any reputable study, and I think your point would've perhaps been better served if you'd instead used the "bottom 3" for life expectancy among first (or perhaps first and second)-world countries.

    @Sparrowhawk

    I agree with what I think you were trying to say about isms. I find it helpful to phrase it thusly (and feel free to call me out if this isn't what you were driving at): I don't do ideologies, only ideas.

    For example, I agree with many tenets of what I would call feminism; I'd certainly agree with the dictionary definition of it. But "feminism" is an ideology, which means it's open to interpretation.

    A feminist can assert any crazy belief they might have (for example, that ALL pornography is a personal and violent assault on women), and say that it's part of feminism, and that if you don't agree with them, then you're not a feminist. But since there's no central authority on the ideology where one can appeal, it just becomes a series of "no true scotsman" fallacies.

    One can take the central principle of feminism, "women and men should be equal," and go just about anywhere with it; there is no guarantee that this belief will lead you to rational conclusions. In short, calling myself a feminist would open me up to defending positions I do not hold.

    Atheism, by contrast, isn't really an ideology at all, despite its being labeled as an "ism." It's an idea, just one idea: its holder does not believe in a god.

    Another way of putting it might be that I do beliefs, but not belief systems. But you get the picture.

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