Let us agree (how) to disagree

By Megan McArdle

Says Ezra of my health care posts:

It relies on unproven and incorrect premises ("Most advocates of single payer, I think, care most about this justice claim. They may also think that they can make the system more efficient, but if one could somehow prove scientifically that a private system would be cheaper and better, they would still favor a public system as long as a substantial population remained uninsured); brackets the argument about efficiency then pretends it doesn't figure into reformer's claims; radically overstates individual culpability for illnesses; elides the fact that living a healthier life just means you die from something expensive later; mistakes an intergenerational compact (wherein each generation pays for the next, rather than making a one-time transfer) for charity; and appears to miss the fact that Medicare already exists, and so single-payer would not mean more resources would be transferred to the old, thus obviating the central point. And that's just a partial list!



It's hard to argue with vague generalities, but here goes,.

I could be wrong about the first claim, but if so, I would like to hear from a large number of single-payer advocates who will say that if the American system could be proven to provide higher quality care per dollar on average than other industrialised system, then they would be content to leave 40 million people uninsured.

The second claim isn't so; I don't pretend that efficiency doesn't factor into reformer's claims. I just left it off because health care is too big a topic to be attacked in one post. I have, as Ezra knows, in the past addressed efficiency claims; I will again in the near future.

But in health care, as with so many arguments, there is an annoying tendency on all sides to shift back and forth between arguments. One starts by arguing about morality (when is society entitled to take money from one group of people to give to another, and how much), and your earnest young policy reformers says "But what really matters is that it's more efficient!" Then you start to argue about efficiency, and suddenly your opponent says "But what about the suffering old people?"

This is not a good way to pick a health care system, or much of anything else. One should establish some first principles, and then use them to generate a health system which will hopefully maximise them. If you simply accept, as received wisdom, that a single payer system is either good or bad, and that people who disagree with you are immoral cretins, then there's not much point in our arguing.

But if you don't accept that then presumably the object of this discussion is (at least theoretically), not to simply find which argument is tactically most superior at the given moment to support your position; it is to establish the first principles and empirical data from which we will reason to a conclusion. And then try to reason to a conclusion.

Which is not to say that we will agree. Ezra and I will almost certainly not agree; we hold different priors about things like autonomy, individual rights, and government efficiency. Both of us have already reasoned to a conclusion from which, barring substantial new evidence, we will probably not budge. But we can at least flesh out our areas of agreement.

So that post was an attempt to establish, at perhaps unfortunate length, the first prior of my argument: that the old and/or sick are not entitled to get money from other people simply by virtue of being old and or sick. They may be entitled to get money for health care for other reasons: because they are needy, or because they were promised that care (or should have been promised that care) in exchange for joining the military. Or other reasons we might argue. But merely having aged, or gotten sick, does not in and of itself give you a moral claim on society; as I said in a prior post, Warren Buffet doesn't deserve to have my dry cleaner buy him health care simply because he is older and sicker.

That does not, as I think I repeatedly said, necessarily mean we shouldn't have single payer. It simply undercuts a particular argument in favor of single payer: that society has a duty to care for the sick, full stop. Society also has a duty to clothe the naked and feed the hungry, but we have successfully outsourced most of that duty to Green Giant and Calvin Klein.

But I am not claiming that this is the only, or even the main, argument deployed by advocates of single payer. I'm just trying to put it behind us, so that once we are talking about something else, I don't have to deal with someone saying "But . . . but . . . they're sick!." I am laying the burden on my opponents to convince me that the people we are helping are not merely sick, but also meet some other condition, such as need, that entitles them to the transfer.

I am well aware that Ezra and others are trying to make a sort of "Sick+" argument in favor of single payer. In order to help those who are needy, they say, we have to have single payer, because of problems with the way that medical markets work. I disagree, for reasons I will lay out presently. But I am certainly not under the impression that I have already refuted those arguments (at least not on this blog. I've just tried to map the boundaries of the dispute. Because I do, fairly frequently, have single payer advocates pounding on the table asking why I don't want to help sick people?

As for the rest of it, it confuses sufficient with necessary conditions (I don't need a lot of sick people to be very responsible for their conditions; I just need a few to be partially responsible, since in aggregate, the unsick are not at all responsible). The bonus random reference to healthy lifestyles is a rejoinder to another, different argument about cost-benefit analysis that I was not making.

It assumes an agreement about intergenerational compacts that I find dubious and do not share--to the extent that there are society-wide intergenerational duties, I think they run one way, from present to future, and involve a) conserving a common stock of resources and b) not bequeathing them debts. That means the government shouldn't run a deficit other than in times of war, and it also shouldn't promise expensive benefits to be paid out of the pockets of people who can't yet vote, or indeed breathe.

And it ends with a claim about Medicare that I've seen before, but which I find extremely odd. People don't magically start getting sick when they turn 65. The near old, those in their late fifties and early sixties, also consume a decent amount of care. Moreover, any single payer system I'd envision would cover nursing home care and prescription drugs and home health care workers, for which many seniors currently pay a substantial sum out of pocket. It's hard to envision how a single-payer system could fail to increase the net social transfer from young to old, though I agree with Ezra that that transfer is already large.

This article available online at:

http://www.theatlantic.com/business/archive/2007/08/let-us-agree-how-to-disagree/1804/