Health Care: A Lesson in Practical Philosophy

John Holbo writes a long post asking me to clarify whether I'm against national health care as a matter of principle, or against national health care as a matter of pragmatics.  To some extent, this is a meaningless question.  Whatever practical objections I have must be judged on some principle.  There's a fairly difficult philisophical question involved in whether we should permit a system that serves some current people badly in tangible ways, merely because it will probably save the lives of other unknown people in some unspecified way in the future.

I suspect that Holbo, and many of my interlocutors, are made intensely uncomfortable by the idea that their root assumption--that they are on the side of reducing human suffering and lengthening lifespans--might be wrong.  There are a bunch of ways you can deal with this disturbing possibility.  You can scream at me.  You can posit a highly speculative world in which government and academia suddenly, and for no apparent reason, get a lot better a inventing devices and mass-market drugs than they have so far proven.  You can claim, falsely, that government and academia already do all the work producing useful drugs.  You can assume that slashing pharma profits 80% will have no impact on their behavior, or at least, only change the behavior you want to change.

Or you can bite the bullet and say, we should save lives now at the expense of lives later.  There's philisophic justification for that choice. But that opens up a whole can of worms about things like global warming.  It helps if you phrase it aggressively:  "How dare you suggest that someone should suffer now when we can treat them, so that someone who's not even born yet can live?" and don't think much about the equally inflammatory alternative formulation:  "How dare you suggest that billions and billions of people suffer and die for the sake of a few uninsured Americans right now?"  Geometric progressions are a bitch.  So is figuring out the right discount rate for the lives of future world citizens, as William Nordhaus and Nicholas Stern can attest.

As far as I can tell what Holbo means is, am I basing this on an ideological belief that he considers illegitimate, or at least fairly trivial, like respect for property rights.  I suspect that what he is looking for out of this exchange is a reason to can dismiss my objections as so much rationalization of my unreasonable priors.  It would be nice if our opponents were always wrong for the wrong reasons, weren't it?

I have no doubt that I place a much, much higher value on property rights than does John Holbo.  But I am not one of those libertarians who takes the sanctity and inviolability of property rights as their most important first principle.  Property rights exist only in the context of society, and not only are they far more contingent and flexible than I think many libertarians acknowledge, I believe they have to be.  Property rights are an evolved institution that happens to work better than the alternatives for enhancing human welfare*.

My libertarianism is somewhere between 80-90% what Holbo calls practical objections.  I think government programs, and regulations, usually cause more harm than good, and always have costs to liberty and "practical" considerations like national wealth.  In some cases I think those costs are justified, as when there are massive free-rider problems or negative externalities--defense, environmental protections,  crime, auto insurance, and arguably in rich cultures, mandated health insurance and forced retirement savings.  In some cases, I don't think there are free-rider problems, but I'm nonetheless okay with creating government programs, because I can't think of another way to do something I consider morally necessary, while accepting ahead of time that they will be wasteful, inefficient, and nowhere near as good as their creators promise: care for children and the disabled, unemployment assistance.  I also believe that, whatever its drawbacks, government enforcement of transparency has far greater benefits than costs.  I'm broadly willing to use a negative income tax to top off the incomes of those whose labor is not sufficiently productive to support themselves in minimally decent style. My most "principled" libertarian stands are against paternalistic tinkering with the habits of the poor on the government dime, either from left or right, and a categorical unwillingness to give much of anything to able-bodied adults who won't work.

In principle, if it did everything the creators promise, would I support universal health care and generous national pensions?  No.  But that's because I don't think they add a lot of value.  I would support an incomes policy for seniors who can't work, and subsidies for seniors who can't afford health insurance.  I might sign on to some sort of reinsurance for excessive health costs.  I might sign onto a proposal I made years ago, whereby the government covers all healthcare expenses that exceed 15% of your income.  I expect that this would be very expensive, but also probably worth it.

Obviously, there's a lot of principle and practical packed in there.  John Holbo, I imagine, gets a great deal of value of knowing that we're all in this together, getting the same thing at the same time.  Unlike left or right, libertarians don't see great value in feeling like a cell.  I part company with my libertarian brethren in many ways (and I'm sure that lots of them are even now once again disclaiming my libertarianism, on the grounds that I am willing to steal from other people in order to feed the poor).  But I agree with them on that.  Likewise, I think that taking someone's money is a real violation of property rights that shouldn't be done unless you're achieving major good.  I think keeping people alive is a major good.  I don't think keeping people equal merits the case--though I also recognize that this is not a pure principle, as a society's "decent minimum" rises along with its wealth.

I'll close by returning to the practical question.  If my objection is just "practical", he says, then why don't I include the good that could be done by a national health care program if it worked?  Well, I have.  I've acknowledged that at least some people would have to be better off under such a system (and others worse off, and I can't begin to calculate which group is larger) But as I said at the beginning, geometric progressions are a bitch.  If the innovation spurred by the private sector could save 1% of the people who currently die each year, the number of people we'd be killing along with the private sector would necessarily be hugely larger than the number of people we'd save by implementing such insurance, since the most grotesquely exaggerated estimates released by interest groups pin the latter figure at around 0.8% of deaths in America (a much smaller number than the number who are estimated to be killed by access to the system--nosocomial infections and treatment side effects).  That's even before you consider the people in other countries who would be saved by these advances. When I talk about the utilitarian calculus of weighing the good of current uninsured against the good to people who are currently, and in the future, untreatable without further innovation.

Now, obviously, there's a possibility that I'm wrong.  But how high a probability of that would I need to change my mind?

It's got to be pretty high.  There are 45 million uninsured people in Americans.  But there are 300 million people who are going to die of something we can't cure.  The uninsured also benefit from health care innovation--many of them will be insured by the time they need care.  The number of chronically uninsured American citizens with serious health problems is not large; chronic uninsurance is concentrated among immigrants and young adults.  When you factor in the anti-immigration political pressure that national health systems create, the case becomes even more murky.  Those immigrants, no matter how sick, would probably not be better off back in Chiapas.

I would probably need a better than 50% chance that I'm wrong.  And I sort of definitionally don't think it's that high.  I'm extrapolating from government behavior that's already happened in the other countries with single payer.  From our own government's behavior in other utilities.  And from the progressive advocates of a health care plan, most of whom lionize international drug pricing, and spend a significant amount of time complaining that they can't use Medicare's clout to force down pharmaceutical prices.  I'm frankly a little stunned that they've all suddenly started demanding to know why I'm worried that the government's going to start slapping price controls on drugs.

So let me turn it around on John Holbo, et. al.  Put aside your ideological committments, and seriously consider the possibility that I might be right.   What P(less innovation) would it take for you to abandon the quest for single payer?  How many billions of lives would you be willing to gamble on your speculation about alternative innovation mechanisms?  I submit that as a practical matter, it shouldn't take a very large possibility that you're wrong to make you at least pause a moment, and reconsider.

Imagine, arguendo, that I am right, and the US is basically providing most of the incentive for innovation.  Imagine further that Nixon had succeeded in passing a national health care plan.  Would more, or fewer, people be suffering and dying today?

So let me offer another hypothetical.  If liberals can build an alternative to the profit model that's at least as productive, in dollars spent, as the private sector, and looks reasonably likely to scale, I'll probably cave.  (I reserve the right to worry about rationing, but I find that worry less pressing.)  At the very least, my worries about the issue will move it to the back burner for me.  But the thing is, you have to do it first.  Use prizes, non-profits, the research agency Dean Baker's proposed, or any combination of the above.  You just have to do it first.  Right now, it's just too much of a gamble.

*  No one is allowed to talk about how much more wonderful hunter gatherer life is unless they are speaking to an anthropologist from the doorway of their thatch hut