Back to health care blogging

By Megan McArdle

This first sentence is just here for all the bloggers who want to read the first sentence of the post and then go write an angry rebuttal of my claim that poor Americans should have to torture puppies in order to be eligible for Bandaids.

The rest of the post will be for people who want to, well, read the rest of my post.

Anyway, so when we last left off, we had established that I do not believe that people who can afford to pay for their own health care have a right to have other people pay for their health care. We may decide, for various political, economic, or practical reasons, to pay for that health care anyway; but they do not have a right to have that health care paid for by others. To illustrate the point: trash removal is a cornerstone of civilization, and no one should have to wallow in their own refuse. However, given the negative externalities of failing to police one's own garbage while living in close quarters with others, it seems to be more practical, not to mention sanitary, to have the government haul everyone's garbage away. But that doesn't mean that I have a right to have taxpayers pay someone to haul my garbage, when I am perfectly capable of paying for the thing out of my own pocket. There is no generalized "right to garbage removal".

However, there may be other rights which convey the right to garbage removal, or health care. (Indeed, in the case of garbage, I might have a right to have my neighbour's trash hauled away, even if I don't have a right to free removal of my own. This being approximately the root of most libertarian-approved public health measures.)

The right that I see as most likely to convey a right to health care is what I will term, inexactly, "the right to a minimum decent standard of living".

Is there such a thing? The hardcore libertarian/anarchocapitalist answer is "nope". If you didn't cause a problem, says that logic, you aren't responsible for it, even if you have it in your power to avert it. Note that we all believe this in some measure--if you didn't, you would have sold everything you own until you were living at the level of the poorest African, and sent any money that you made above that level to poorer people abroad. Indeed, you'd be urging poor people in America to do the same. But most of us aren't that ruthlessly consistent.

If you do believe that there is no right to a decent standard of living, then I won't argue with you. That doesn't mean I think you're right; I disagree rather vehemently. But I'm pretty sure I'm not going to persuade you that you have moral obligations you don't feel, and you're not going to persuade me that the American taxpayer should let babies die because they made the mistake of having the wrong parents. How about wandering over to the music thread and making some suggestions? Some of my favourite bands have come via anarchocapitalists.

But what decent minimum standard of living? Liberals, it is safe to say, believe that this should be much more generous than do libertarians; I lean closer to the P.J. O'Rourke axiom that "the biblical injunction is to clothe the poor, not style them".

The question is easiest in the case of children. They have a right to good schools, nutritious and tasty food, safe neighbourhoods, a home where they are not terrorized by crazy or drug-addled parents, top-notch health care, and any social services they need to overcome whatever familial handicaps they started out with. I am not under the delusion that they will get all of these things, but I think they ought to, and would be willing to plow in pretty much any amount of tax money to cover the cost.

Disabled adults are the next easiest. If you can't work, for reasons of physical or cognitive handicap, you are entitled to a warm dry abode, decent food and clothes, excellent health care, such occupational therapy as may make you able to lead a fuller, more participatory life, and premium cable if you're bedridden. No, I'm serious. If you have to lie in bed all day, you should get the deluxe cable package at the taxpayer's expense.

If you're an able-bodied adult, I think a minimum decent standard of living involves making your work pay enough to support a warm dry abode, adequate food, basic clothing, electricity and gas, and the other basic accouterments of a basic life. Cable television is your own responsibility. However, I think you are also entitled not to die or become crippled from lack of health care.

Yes, I'm sorry, my libertarian brethren just started screaming at the monitor. Yes, I'll turn in my membership card and secret decoder ring at the Cato Institute. But there you are: I think along with crime prevention and courts and public health, society should keep people from dying.

How can I believe this, and not support the welfare state? My liberal readers are thinking. Well, several reasons. For one, I think government is, on average, a more comprehensive but less efficient provider of social services than private charity; fewer people slip through the cracks, but government agencies generally do a worse job with their clients than private ones, for a variety of reasons that I will elaborate elsewhere. Because of that, I want to see private charity bear as much of the burden for social service provision as possible, while realizing that the government will nonetheless have to provide fallback services.

The second is that I prefer a system which interferes as little in the lives of the poor as possible. I don't think the government should be providing vouchers for food and housing; I think the government should be giving poor people money, and letting them decide what they want to spend it on. I support the elimination of almost all government benefit programs, except those targeted at children and the disabled, and a more comprehensive version of the earned income tax credit. In fact, I'd like to see a tax system which has positive and negative rates in a continuously increasing function, zeroing out somewhere around $28,000 a year.

However, I think that schools and health care will be important exceptions to that general rule. Schools, because not all parents are responsible, and the state has a compelling interest in seeing that children are well educated even if their parents would rather spend the money on cigarettes; and health care, because of high variance in costs, and moral hazard.

You can't just give people money and say "Buy the health care you need to make sure you don't suffer and die", because unlike the other items in the package of basic goods--food, shelter, clothing, maybe a car--the costs each person will bear can vary from $0 to several hundred thousand dollars. And you can't just tell them to buy insurance, first, because their insurance costs may also vary much more widely than those of the other basic goods; and second, because many of them won't do it, relying on the fact that we will not let them die. Unless you can make a credible committment to not treat someone who shows up at the emergency room without insurance (and I certainly hope we can't make that kind of committment credible), relying on remedies that work very well for the other basic goods will not work.

I think--I think--that single-payer advocates and I share basically the same moral intuition, which is that society should not let people die from hunger, cold, or lack of medicine. They would go on to argue that for various reasons of administrative efficiency, social failure, or political difficulty, we should realize these intuitions by having the government provide massive amounts of these services. I disagree even in cases that I regard as special, such as health care and educatio, for reasons that I will lay out in future posts. But I find the moral intuition that they are trying to realize correct. And having finished describing which moral intuitions I don't find compelling as a rationale for single payer, I wanted to go on record elaborating the ends that I support, even if we disagree about the means.

This article available online at:

http://www.theatlantic.com/business/archive/2007/09/back-to-health-care-blogging/2001/