Wednesday, August 19, 2009

OOC: Health Care

Neil Gaiman (@neilhimself on Twitter) summarized what I think of as the "well-intentioned but fuzzy-thinking Left" position when he tweeted: "For the record, perhaps because I'm from the UK, I think healthcare is a human right, like education . Not something to make companies rich."

For the record, I respect Neil Gaiman's talents as an author immensely. But calling something a "human right" does not make it so. We can debate the level of _____ that the better-off members of a society should make available to those less fortunate, and we can even debate whether the private sector or the government is a better provider of _____ to the poor. One cannot have an intelligent debate about whether something that uses scarce resources is a "right." Rights cannot depend on the wealth of a nation.

Here's a thought experiment. Let's say that food, shelter, health care, and, God help us, education are "rights." How much of each is guaranteed to all? Let us suppose that a nation - call it Caledon, for the sake of this paragraph - decided on a guaranteed level of each such that these "rights" encompassed the entire income of the nation. That is, add together all the earnings of all Caledonians, and suppose that this amount equalled the total expenditure on food, shelter, health care, and education. Obviously, the wealthier would be subsidizing the poorer, but that's fine. Now suppose that Caledon suddenly became half as wealthy as it was yesterday. Its expenditures on "rights" necessarily must fall in half. Have its citizens lost half their rights? How can that be?

The emptiness of the "health care is a right" position is twofold, because, not only is the word "right" being misused, but "health care" is so amorphous as to be meaningless. Does health care encompass preventive care? Minor treatments? Major surgery? Organ transplants? Does Mr. Gaiman want to claim that plastic surgery is a human right? Probably not, but one can't tell from his phrase.

The Declaration of Independence claims that man is "endowed by his Creator with certain inalienable rights" - among these, "life, liberty, and the pursuit of happiness." Poor or rich, we retain these rights. These rights do not require the wealthy man to reach into his pocket to provide for the tenant farmer, nor do they change when the former loses his wealth. Not so for goods and services that require the wealthy man to reduce his consumption, or to reduce his investments in new goods and services, in order to serve the poorer man.

I want to emphasize that I am not saying individuals and nations alike have no moral obligation to help the less affluent with basic needs (and I play no word games with the word "needs"). I think the U.S health care system, while generally good, can be improved. But to use the words "human right" is to shut down debate; anything argued in opposition becomes morally indefensible. Anyone who wants to argue for greater health care spending on the poor is welcome to do so, but don't try to claim the moral high ground by inventing phony rights. It's a sign of intellectual weakness.


Edward Pearse, Duke of Argylle said...

I'd have to side with Neil on this one. So far the anti-Healthcare debate in the US seems to be focusing on the scare tactic of universal healthcare being a Socialist tool (with several idiot people claiming universal healthcare as a Nazi programme.

Personally I've never understood how exactly Socialist automatically equals Bad in American English.

Universal healthcare (or government sponsored healthcare is a key part of the majority of western countries throughout the world. Canada, the UK, Australia, France, Germany, Norway, Sweden and Italy all have public health care. Even countries like Japan, South Korea and Singapore have it. Even where private health cover is available to supplement those items not covered under public health, you have the option of choosing your own provider.

The American system of tying your health benefits to your employer, and then only the one your employer wishes to deal with is rather bizarre to my eyes.

Basic health care SHOULD be a right. If you're too poor to afford to see a doctor to help you get better to find a better job and get Employee medical cover (assuming they touch you with a pre-existing illness) it just continues the cycle.

Yes the finer details of whether Universal healthcare should cover things like cosmetic surgery or sex change operations (no to both) or whether dental should be on the same level as a GP appointment (yes I think) need to be thrashed out. But that people are even debating the need for it boggles my mind.

Dio said...


I agree that the question of looking at health care as a "right" obscures many other important aspects of this debate. Likewise, saying that this is just about health care for the "poor" also directs the discussion into certain narrow ideological constraints.

From the perspective of people like me, the problem is not just a philosophical one, but it is also very much an economic one. It is not just the "poor" who do not have health insurance. Increasingly that is the case for many of us, even if we are employed, and particularly if we are self-employed.

Simply put, when you have workers who do not have good health care, they are less productive, and consequently the businesses they are involved in are less productive.

But the cost for companies to provide health insurance for their employees is getting more and more of a burden. It is an ongoing reality that American companies close down or send their manufacturing operations overseas, because of the costs doing business. And one of the biggest uncontrollable costs is health insurance.

Depending on whose numbers you are using, the US spends approximately 40% more on health care per capita than other industrialized nations, including Britian. Much of that burden falls on employers, making it very difficilt to compete with their counterparts in other nations.

And to be honest it's a personal issue as well for me. I'm one of those people who can't get insurance at all because I am a diabetic and don't have insurance offered by an employer in a a group plan where they have to take you. So it's not an issue of "I have to pay more for insurance," it's a matter of the bastards won't give it to me, period. A number of my self-employed friends are in the same boat...

Now of course I can save up my shekels and try to find a Doctor who will take me as a pay-as-you-go patient, which works for some stuff, but if I have a catastrophic situation, then I'm screwed. I'll probably go into an emergency room and probably get taken care of, but the institution or the public is going to end up footing the bill because I won't be able to pay. It's not like I haven't tried to get a job with health benefits. But with the way the economy is doing lately, it hasn't worked out so well. Free-lancing is what I can get right now, and I'll live with that (at least until I get sick and die).

So I really can't tell you if the US health care system is "generally good" or not. I haven't seen enough of it up close in the last few years to know. But one thing is clear, the way we provide and pay for health care in this country cripples our nation as an economic power.

To be honest, I'm not sure how the concept of a "right to health care" intersects with or might possibly be an aspect of the right to "life, liberty and the pursuit of happiness." I guess it kind of depends on how you define life, liberty and happy.

But I would agree that those things being a "right" just means that we shoulkd all be able to strive for them. It doesn't mean that Big Daddy government is obligated to provide them. A right is different from a guarantee.

But to me this isn't about rights. I'm one of the many people who think that the primary role of the Federal government should be limited to national defense and facilitation and support of commerce and industry (which it does with things like the interstate highway system, the Army Corps of Engineers system of navigation locks and dams, air traffic controllers, the U.S. Treasury, etc.). And within that essentially conservative world view I think one could argue that doing something to ensure a healthy work force and facilitating the ability of American businesses to survive and compete internationally falls into the category of supporting the nation's commerce and industry.

And to do so is going to take some substantial changes, not just cosmetic ones.

So is that what you meant by "while generally good, can be improved?"

Rhianon Jameson said...

I write a fairly inflammatory piece and it generates only two comments? I must not have tried hard enough! *grins*

Miz Dio, you left me red-faced, as I did leave out two huge issues: individual insurance and portability. The former is largely unaffordable because of a huge adverse selection problem and a small-ish pool; the latter, as you note, shafts those with pre-existing conditions. In my defense, I was motivated to write by Mr. Gaiman's comment, rather than try my amateur rehash of the whole health care debate.

I think we could have made real progress had the "reform" debate centered around a handful of serious but correctable problems with the system: high expenditures (generally thought of as arising from the lack of linkage between patient and payment), a health care safety net for the poor, individual coverage, and portability. (I could be forgetting one or two important items, but these strike me as the big ones.)

Two problems stem from the tax treatment of employer-provided health benefits. I get wonderful health benefits from my employer, but that causes me to overconsume health care and, indirectly, to screw over the self-employed. (Sorry, ma'am, I didn't mean to do it.) If everyone bought an individual policy, just as we generally buy individual life insurance policies, I'd consume less and the pool would be big enough to better spread risks. The adverse selection problem would remain, which is why some advocate mandatory coverage. I'm not sure enough of my facts to have an opinion on that one.

Not to go on so much about my preferences, my point is that there is a serious debate to be had, with changes ranging from small ones that would have widespread support to big ones that would be controversial and divisive, but may yield big benefits at modest (net) cost. But to start the debate by calling health care a right instantly polarizes the debate for no good reason. (See also the insistance on the so-called "public option" - those folks are so focused on the means by which reform is achieved that they've lost sight of the objective.)

Rhianon Jameson said...

Your Grace, perhaps we just have a semantic difference, but I see a right as something entirely different than a moral obligation. In a developed country, where we think it's uncivilized to let people starve to death, we might also think it's uncivilized not to provide health care. Just as we don't seem to think that our obligation to feed requires us to serve steak and lobster, presumably we think the obligation is limited to some basic level of health care services (where reasonable people can and no doubt will debate what "basic" means).

But the political Left in the U.S. has insisted that everyone is entitled to the same level of care (hence the love of the public option), which is silly, but it's also why the proposals are so expensive.

As for why so many in the U.S. think "socialism" is a bad word... I'll say that, from my perspective, socialism has been practiced to varying degrees in many places in the world, and the results aren't particularly happy. No doubt many would disagree, and that's a debate worth having, but to me it comes down to two things. First, socialism it inherently at odds with individual liberty. When the guys with the guns also provide the services, they tend to get their way. Second, not to speak ill of my typist's employer, the U.S. government, it's not terribly good at many things. FedEx delivers packages much better than the postal service; local motor vehicle departments are legendarily horrible places to visit, and so on. Markets just work better than centralized planning - not because the planners are stupid or evil, but because they have no way of adequately understanding the preferences of millions of individuals.

But we agree about the bizarre nature of employer-provided health insurance, even if we agree about nothing else. :)

My frustration with the process is not that I have a different point of view and different preferences than the thoughtful people who read my little Aetheric Journal; I would be delighted to sit in a cafe and have a friendly back-and-forth about the issues (as I have with some of my friends and colleagues at work). Rather, the political process is not working out terribly well, and the prospects for decent reform are being drowned out in the noise. Then again, that has ceased to surprise me. :)

Mako Magellan said...

We all seem to agree that we have moral cause to look after those unfortunate enough to suffer disease or debilitating conditions. However, in this particular debate the crux seems to be the definition of 'right'. It is therefore doomed to become a philosophical semantic argument, I'm afraid, based on assumptions about the real meaning of Mr Gaiman's tweet. Given that the only gentlemanly course in debate is to give the most sympathetic reading possible to one's opponent's propositions, and given that the proposition is a mere tweet, I propose an alternative debate in which people say which country's health system they admire, and why.

Breezy Carver said...

semantic Difference is putting it most eloquent ..
You see what other nations and countries do not realize or perhaps understand is the United States has this bit of Paper called a Constitution !
No it does not make us the Greatest .. But it does make us just what it intended to be .. One Nation under God !
It seems to have become more and more of a goal of some far left to continue to poke and tear down what our four fathers created ..
Now some might say " Oh please get over it" ... Ah no I am not . I have worked and paid into my "Quote Benefits "
Health Care is a Privilege Not a Right ! We have programs to take care of the less privileged (( Those that are disables , Those that have legitimate reasons who can not provide for or are not able to work ))
We are not neglecting to meet any call ... It is not a Christan duty or a moral obligation to provide health care for our neighbors !
Perhaps some of our Youth should get off their duffs and join the Military and stand up for their country !!
Health Care inflation is a problem !!! Portability also a Problem I agree .. That has to change and that needs to be addressed !!
Blue Cross Blue Shield (( that I personally Have )) is off the hook, out of control .. But funny thing I have to pay for my health insurance .. We all do some how some well in this country (except for those who say "Oh i can't afford it ":. But somehow now all of a sudden we should redo the whole system in the middle of 2011 and spend money we as a nation and people do not have to provide for people that could be working towards obtaining health insurance and then Yeah lets go to Social Medicine, No Sir , not in my life time !! Does the system need to be looked at .. Yes it does . But I am sorry You can not take a nation back to the 30's when some of these programs where created !!!
We have free education !! We have freedom !!!
Again in this country where Health Care is not a right it is a Privilege, If we give this up , we are simply going back as a nation .. Undoing what so many have fought for ..
Over haul and restructure of Health Care should not include call it what ya like govt medicine, coop .social Medicine !!!
Health Care Inflation is an issue and yes should be addressed . But the land of the free and brave is not a welfare State .
with respect !!!

Dio said...

Thank you for your thoughtful reply to Edward and me. I agree that a calm give and take discussion of the subject would be beneficial. However, Breezy's highly emotional and largely irrational reaction gives you an indication of why this debate is going nowhere on a massive scale and you get people saying things like "keep your government hands off my Medicare."

I did want to comment on a point in your well considered response--I understand how as a federal employee you would have a sense that the government doesn't do a lot of things very well. I would counter, though, as someone who has worked on a contract basis for the US Army, the New York National Guard, other federal agencies, a number of state and local governments, various non-profits, AND several major private companies, I can say down that the people who had their heads shoved farthest up their own asses were folks running the private companies.

You haven't seen mismanagement, bad planning, and horrendous waste until you've worked for a major American corporation that is dominated by its bloated legal department and led by self-serving over-compensated executives.

Yes, you look at the Federal government's track record, and there is waste and failure, but still there are agencies that are doing remarkable jobs that could not be accomplished by private enterprise on the same scale or with a similar success rate, including The Navy, Army, the Air Force, the Coast Guard, NASA, NTSB, and the FAA. Yeah they ain't perfect, but I can just imagine how badly private enterprise would screw up the tasks such agencies are charged with.

And people seem to forget that the government is already in the health care business and has been for a long time. The VA, while not perfect, does a pretty respectable job, considering the size of its task. Yes, it has a lot of failures and struggles with waste and inefficiency and the growing demands of the expanding pool of damaged humanity generated by our recent wars, but compared from the purely anecdotal perspective provided by my Father and his WWII era buddies who rely on VA health care, they're pretty happy with it.
Would the government really do a worse job of managing health care than the private companies that have created the current crisis situation?

I'm also glad that you brought up the issue of over-consumption, speaking of waste, but that's another discussion for another time perhaps.

And finaly, I'll say that Breezy completely missed one of the key points in my situation, which isn't that I don't want to pay for my insurance, it's that I can't fucking get it. I am glad that he, she or it has BlueCross and is cheerfully overpaying for it. I don't want you to pay for my insurance. I just want insurance. You can keep your money. In fact I WANT you to keep your money, and maybe if we had a rational, reasonable system where you weren't getting screwed by Blue Cross, you WOULD get to keep more of it.

Breezy Carver said...

Breezy's highly emotional and largely irrational reaction gives you an indication of why this debate is going nowhere on a massive scale and you get people saying things like "keep your government hands off my Medicare."
Warm Smile I am sorry you do not like my reaction to call me irrational and highly emotional .. As it seems to state insults is your idea of a debate ,...
smiles bottom line when a person pays into a program and works hard and has seen what an out of control governments results can do ..Yes it does become personal.
Yes my health care is personal as i am fortunate right now I don't really use it !! Think about that .. (( how painful it is to pay for something I do not use but I still pay because if I do not I won't be able to get it or have it when I need it . That is what Insurance is ... again not a right . sigh .. ))
Same thing with life Insurance we pay into it for the next person not ourselves and some choose to have and some not !
Perhaps you can not understand these things I wish I could type I shall not reply again, but smiles that just would not be me ...
as i don't wish to insult your tender means .. lack of information and knowledge is quite sad really !
If you read I said that reform is needed and the system needs help Just not govt help in total take over .. I am sorry you can not get insured !!
I am not some heartless person as you may think !!
But you know what again I pay a lot of money in taxes .. in fact it a wicked rip off but I don't believe the answer is to give the govt more power !!
Would the government really do a worse job of managing health care than the private companies that have created the current crisis situation?
YES they would !!! oh is that irrational to you for me to type that or perhaps emotional because I do not agree with you !!
again warm smile read your reaction and read mine !!
I am sorry You can not get insured! It is not fair and it should be addressed Not an entire system changed to go gov't because that is an extreme ...
The problem really is this is becoming a wicked political matter and it really should not be .
It is just plain wrong !!!
why is it a political matter because like it or not our sens and congress people ( i call them people because it is not men anymore ) are supported by insurance companies ..
these people are suppose to represent us and work for us but they are our for themselves isn't that evident !!

Edward Pearse, Duke of Argylle said...

Far be it for me to criticise an American about their own history Breezy, but in this case I have to pull you up short. Yes the US has a Constitution. I will forgive many Americans for their apparent belief that they are the only country to have one or that they were first. However claiming that constitution intended to create "One Nation under God" is an enormous misreading. That the Constitution existed for 116 years without the Pledge of Allegiance and the Pledge existed for 62 years before becoming a religious commentary shows that nearly 180 years without being "under God".

As for the inference that nations that do provide basic healthcare to its citizens are backward or retrogressive, I think you need to look long and hard at what you're saying.

Breezy Carver said...

nods ok Edward ...
I still stand by my words and posts..It might not be popular and it can be disected as lovely as you like .. Be it for the people by the people , we are still one nation built on for the people by the people with standards to protect us from ruling powers ie gov't but this is an issue that is not going away anytime soon .
One more thing
I just feel as an American I just keep paying ... I could say I don't get anything in return except whew I paid that bill !!
But that would be wicked negative.
Its just the way it is ..
The older I get the more I pay and this whole system is going to make me have to pay more and get less !
How will be it less . doctor visits where I live are nightmares!
We have a shortage of Doctors and Nurses as it is !
We also have a very high senior population (perhaps one of the highest in the nation) !
We also only have one hospital !
None of this matters to you I am sure but they are all mood points ..
I have a husband who works in New York and I can not get coverage because I am in another state ..
Please understand I am not sitting pretty oh pfft to the uninsured !!
I am independent contractor and therefore I pay .
I am quite frustrated myself the difference is right now .. I am paying in fear that say (( fingers crossed)) when my time comes I am covered !!
I have always paid .. and that's just the way it is .. for all the people that do not pay (( not because they can not because they choose not to it ticks me off !! ))
For your citation It is heartbreaking and not fair alas if you think gov't insurance is going to save the day .with socialized medicine (( please don't be insulted )) alas it is delusional
just like if there is a bad storm the govt is not coming in and making it all better !!
What I see with Obama Care is a country giving up !!
People giving in and giving up thinking the govt is the answer and will save the day !!
Heck they can't even be by partisan and handle what we all really need and want and that is Health reform . please see my side not as irrational and emotional but as the valid points that I am living in my part of the country k ?

Rhianon Jameson said...

Just another example of the Law of Unintended Consequences: although my goal was to stir up thoughts, it was not to point friends at one another. Oops, sorry about that.

Mr. Magellan: as amusing as I would find a poll of favorite health care systems across countries, I don't have any first-hand experience with non-U.S. systems and, thank goodness, not much U.S. experience either. Although I have seen and experienced second-hand emergency care (lousy), hip replacement surgery (good), end-of-life care (mediocre), kidney stone removal (fairly bad), spinal surgery (excellent), and so on, I have no idea whether it's representative of U.S. health care. Nor do I know much about the problems of the uninsured, except what I read - and everything written on the subject has one slant or another. We hear cautionary tales of the NHS, or of Canadian health care. Those stories are hardly representative, either. I will say that small steps seem a better idea than wholesale change - and a great many nervous people seem to agree.

Miss Breezy makes the good point that the law prohibiting insurers to compete across state lines creates problems for no good reason at all. I'd love to see that law repealed.

Miss Dio: I wasn't suggesting that private companies are paragons of efficiency, or that the government lacks dedicated employees. (Heck, I'd like to think I'm one of them!) And I certainly don't want the armed forces to be privatized! (We could debate NASA - one of my neighbors is a big-shot engineer with Orbital Sciences, and they seem to get crap into space on a regular basis - or certain responsibilities of the FAA. The VA is a necessary part of government, but I've long wondered why it wouldn't be better served by (mainly) getting out of the hospital business and just reimbursing hospitals for veterans' care.) The problem is that government regulations are so byzantine that you get the fabled $500 hammer and $1000 toilet seats. Even well-intentioned regulations create unanticipated problems. You can't fire the ten lazy idiots in the office that drag down the morale of the 90 bright, energetic sorts. Pay is almost entirely disconnected from performance. And as crazy as are many private business decisions, the pursuit of profits at least focuses the mind. My political bosses are motivated by keeping the morons in Congress happy, which leads to all sorts of mushy thinking.

I guess that sums up my thinking: I'm old, and cynical, and don't trust the intelligence or integrity of our elected officials. Not that they've ever let me down before. :)

Dio said...

"Would the government really do a worse job of managing health care than the private companies that have created the current crisis situation?
YES they would !!! oh is that irrational to you for me to type that or perhaps emotional because I do not agree with you !!
again warm smile read your reaction and read mine !!"

All right deary, settle down and unbunch your knickers. I wasn't insulting you, I was merely stating that your are looking at this from an emotional and irrational perspective. Rational discussion requires something other than mere opinion. Let's talk actual numbers. You like many other folks say automatically, that the government would not run health care as efficiently as the private sector. Yet you have no actual data this base this opinion on. I would direct you to this article from Fortune:

In it you will find that the Veterans Administration provides
care for our veterans at an average annual per capita cost of $5,000 per person. For the general population, health care spending is $6,300 per person year.

So clearly, the government run system of the VA is spending less, and providing decent care. Is it perfect? No of course not. Do patients have to wait for a specialist appointment and things that, , yes, sometimes. But to automatically assume government will do a worse job than the private sector is simply not borne out by the numbers.

Speaking of irrational, in your first screed, you said something about "young people getting of their duffs and joining the military", I assume so they wouldn't have to get private health care. Well gee, then wouldn't they be getting government health care? You're going to be paying for it. Good thing it's more efficient than the private sector care.

No, if I was insulting you it would be with terms that are a bit nastier than emotional and irrational. And save your fake warm smiles for your children.

Dio said...
This comment has been removed by the author.
Dio said...

Oh and I should have clarified that that my last reply was directed at Breezy. I think that was obvious, but I neglected to put @Breezy on the top end.

@ Rhianon, I agree with your point that NASA is not always efficient or effective. They have a couple of shuttle disasters and significant casualties to prove otherwise. However, on the whole, they succeed at what they are supposed to do and they carry out an exercise that simply could not be executed successfully on the scale that is by private enterprise. Yes there are private rockets and satellites put up by private companies, but the usually rely on NASA or Russian, or French government support and facilities to get there.

Breezy Carver said...

Points taken .. Dio
We shall see what happens ..
My closing point is this
I am not some neo con and I do not believe you to be some left radical!
I do have some issues as I see you do also,
(A perfectly healthy generation not working (on a resort island was one of *my issues excuse me for not explaining that better )
I admit I am not pleased ..
I am concerned about various issues as I see you are too ..
I do not think the solutions are simple ones to achieve . This is not our fault. But this does effect each of us ..
Sort of a huge paradox .
What I think gets lost so often is how fast and young our country is .. (( not a cop out honest ))
We have grown so fast...and it has now become if one does not fit into class ... a b or c ..d..e. ??
( a person is screwed ) ... Humble view its not all going to get asap ..Fix
As corporations continue to lay off * in what ever decade* their experienced staff and continue to hire (( @ less cost to them)) either free agents (not having to pay for coverage)) Or younger less experienced and cheaper to insure people ..
We now have a new said "Group" of independents to Insure not ignore !
It is almost like Health care and lack of it create a new demographic of working poor .
Health care for some has become some sort of right to passage (( So Wrong))
its almost like Cobra was created to weed people off health plans . I do not know !
As for my smiles that is me (( attempting not to sound and give another my direct anger ok ? ))

Rhianon Jameson said...

This thread has completely changed the targeted ads I receive on Gmail. :)

Mako Magellan said...

I certainly wasn't attempting to make light of this issue in my last comment, or to suggest a waste of time. What I hoped for was some selected models of what individuals might like to see, constructive suggestions, considered proposals.

Rhianon Jameson said...

Although your dry wit is well known, Mr. Magellan, I did not interpret your comment in that way. I did, however, think you were suggesting the impossible - which was merely my misreading of your intent.

I confess that I have perhaps not been as positive as I am normally - you there, the one who coughed, don't think I didn't hear that! - and the topic perhaps deserves some constructive suggestions.

In the interest of organizational clarity, I will attempt to do so, and to invite further or alternative suggestions, in a separate post.