Answering Wolf Blitzer

This is from a Republican presidential candidate debate:

Wolf Blitzer: You’re a physician, Ron Paul, so you’re a doctor. You know something about this subject. Let me ask you this hypothetical question.

A healthy 30-year-old young man has a good job, makes a good living, but decides: “You know what? I’m not going to spend $200 or $300 a month for health insurance because I’m healthy, I don’t need it.” But something terrible happens all of a sudden, he needs it. Who’s going to pay if he goes into a coma, for example? Who pays for that?

Most of the blogosphere — especially libertarians — thought Ron Paul’s answer left something to be desired. Check out suggested libertarian answers from Rod Long, Bryan Caplan, Robin Hanson, Arnold Kling and another answer from Scott Sumner. On the left, Ezra Klein sees the entire question as giving moral weight to the case for socializing health care, Austin Frakt says “your life is not your own,” and Paul Krugman (ever the intellectually dishonest attack dog) says that the “free to choose” crowd has morphed into the “free to die” brigade.

I’ll consider all this below. But first I want to make a point everyone else is missing: The best answer to this question has nothing to do with libertarianism. The problem Blitzer poses illustrates a defect in our current system that could and should be remedied without a great deal of effort.

A Non-Libertarian Practical Answer. Under the current system, you don’t get to be uninsured with impunity. Anyone who lacks employer-provided health insurance is forced to pay higher taxes than someone at the same income level who does acquire the insurance. Those higher taxes are a “penalty” for being uninsured; and the justification for this penalty, presumably, is that the uninsured may need health care that they cannot pay from their own resources. Either you buy private insurance or you pay taxes for implied public insurance.

What’s wrong with the current system is that it fails to formalize the system of subsidies and penalties in a rational way. For example, the penalty for being uninsured goes to Washington. But the free care delivered to those who cannot pay their medical bills is mainly funded by city and county governments. What should happen: The tax penalties the uninsured pay for being uninsured should be recycled back to safety net institutions in the communities where the uninsured live in order to pay for care that uninsured patients cannot pay themselves.

Let’s take some numbers. Since the man “makes a good living” let’s assume he is in the 25% federal income tax bracket and faces, say, a 5% state and local income tax. Like all other employees, he and his employer must pay a 15.3% (FICA) payroll tax. If his employer pays insurance premiums instead of paying taxable wages, the total subsidy will be about 45%. This implies that the tax subsidy for employer-provided insurance pays almost half the cost. The flip side of every subsidy is a penalty. The failure of the employer to pay premiums instead of wages means that (if insurance costs from $200 to $300 per month) the man will be effectively paying between $90 and $135 per month in extra taxes.

I would argue that these extra taxes ought to buy something. Specifically, they ought to buy access to a least some publicly provided care, if the man exhausts his own assets and cannot pay for all of the care he needs.

Turning the Practical Answer into More Fundamental Reform. Let’s take the answer I just gave and expand on it. The implicit premise is that society has a legitimate interest in whether you are insured. That’s why I called it a non-libertarian approach. Or, if you like, you can call it libertarian paternalism. Given that interest, we could take all of the tax and spending subsidies that encourage private insurance, including some of the new ones under ObamaCare, and give every family in America a refundable tax credit for the purchase of health insurance. This subsidy would be available regardless of how the insurance is obtained (through an employer, in an exchange, in the marketplace, etc.). Any extra premium for more expensive insurance would have to be paid by employees and employers with after-tax dollars.

In effect, the government would pledge to each individual adult, say, $3,000 and each family of four, say, $8,000. If people decide to get insurance, the tax credit would be applied against premiums owed. If they decide to be uninsured, the unclaimed credit would go to safety net institutions in the communities where uninsured people live. Money would follow people. If everyone in Dallas County opted to be uninsured, all the unclaimed credits for Dallas taxpayers would go to Dallas safety net institutions for unpaid care. If everyone changed his mind, and bought insurance, the government would use all the safety net subsidies to fund the tax credits for private health insurance.

This proposal is described more fully in “Characteristics of an Ideal Health Care System” and in “Applying the ‘Do No Harm’ Principle to Health Policy.”

My Libertarian Answer. I believe that a good society does not allow people to starve. A good society also does not allow people to go without basic health care. Or without reasonable shelter. If government does not get in the way, most human beings will help each other out. (Most libertarians seem to have trouble saying these things.) But as I have pointed out at some length, private sector charitable activities are never run like government entitlements. If you are away from home and lose your wallet, the local Salvation Army will give you a meal and a place to sleep and maybe even some cash. But they will not do this day after day, night after night. It’s probably fair to say that all private charities seek to give aid without encouraging dependency.

Non-libertarians sometimes ask: What if someone is in desperate need and nobody will help him. My response: Who among all these nobodies unwilling to help is going to offer to be taxed to help? Answer: Nobody. Neither public nor private aid will be forthcoming if the vast majority of people are indifferent to the suffering of others.

Some years ago the Council for Economic Advisors did a forecast of where the poverty rate would have been in the 1980s if the (Lyndon Johnson) War on Poverty programs had never been enacted. Answer: The predicted poverty rate based on economic growth alone was below the rate that we actually had (see chart below). In other words, after spending trillions of dollars combating poverty, it’s tempting to conclude that government intervention not only failed to make things better, it appears to have made things worse.

Ron Paul’s Answer. He has a three-part answer: (1) The young man should have been more responsible, and strangers shouldn’t be forced to bail him out; (2) private charity will help; and (3) regulation makes health insurance needlessly expensive.

Other Answers. Rod Long thinks Paul should have reversed his three points by (1) explaining that the lack of insurance is caused by government regulation that prices people out of the market, (2) arguing that private charity is more efficient than government and (3) asserting that peaceful, voluntary actions are morally superior to coercion. Bryan Caplan responds:

When you really think about it, Blitzer’s “gotcha” for Ron Paul was actually a “softball.”  Blitzer could have asked Paul about an unhealthy man. Or a man without a job. Or a child. Or an orphan.

I wish Rod’s Three-Step Program had credible solutions for all these cases. But it doesn’t. Free markets quickly make life better in some ways, and gradually make life better in almost all ways. But critics of libertarianism will never run out of empirically plausible “hard cases.” When faced with these hard cases, the best response we’ll ever have is, “Charity can probably provide for the deserving poor. Everyone else should live with the consequences of their actions — and stop blaming total strangers for failing to help them.”

Here’s Robin Hanson:

So everyone agrees that we heroically help some, and leave others to die. We only disagree on who falls into which category.

Here’s Arnold Kling:

People are naturally collectivist at the level of family and others in their immediate vicinity. And that’s fine. But to libertarians, national socialism is a mistake. The way to behave ethically with distant strangers is to trade honestly with them and don’t steal their stuff. There is no reason to treat distant strangers that live within one political boundary differently from distant strangers that live inside another boundary.

Now, it might be good for some of us to be particularly generous to some distant strangers. But libertarians would argue that this should be done voluntarily, and that it does not justify employing the coercive apparatus of the state.

I don’t disagree with any of this. I just wish libertarians would refrain from sounding as though they have “charity toward none.”

Comments (32)

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  1. Tom H. says:

    Very good. By far the most sensible thing that has been said on this issue.

  2. Vicki says:

    I agree with Tom. This is very good.

  3. Nancy says:

    I liked the practical answer.

  4. Devon Herrick says:

    The Libertarian argument for dealing with the uninsured does not translate well into a sound bite. In reality, we do numerous things each and every day that boosts our stock of health or detracts from it. Sixty percent of our health expenditures are on lifestyle-related conditions. Progressives believe society should be coerced into providing free health coverage for all. Yet I don’t hear arguments that society should be coerced into adopting healthier behaviors. If society has the responsibility to mitigate medical conditions such as diabetes, then why is society not responsible for mitigating behaviors that cause diabetes?

    When you get down to the nuts and bolts of health care, the issue is much more complicated than at first glance. There are also many inconsistencies. For example, if society funds medical care, it tends to under-provide care as a rationing tool. There are never enough resources to go around — partly because taxpayers don’t want their taxes high because they cannot realize all the benefits from their contributions. Thus, some people still suffer from a lack of needed care. This raises the question: if it’s wrong for individuals allow the sick to go without needed care, is it any less wrong for society to ration care so long as it’s equally rationed?

  5. Ken says:

    Excellent response. Best one in the blogosphere.

  6. Paul says:

    Devon Herrick – You don’t hear arguments that society should be coerced into adopting healthier behaviors? Don’t mandated school lunch purchases, banning toys in McDonald’s Happy Meals, and soda and cigarette taxes all fall into that category?

  7. Devon Herrick says:

    @ Paul
    That’s at the aggregate level. There’s no initiative to make obese diabetics pay higher premiums. There is just some mythical assumption that if sodas are taxed more heavily; if restaurants have to disclose calories; if jogging paths are built the obese will make better decisions. On the other hand, Medicare payroll taxes are very personal and very precise.

  8. Don McCanne says:

    Providing for the needs of others through voluntary charity is a policy weakness of the libertarian philosophy.

    Today In America we certainly have the freedom to help others, yet the need is so great and the resources that any individual or private institution controls are so meager, compared to the need, that private charity will always fall deplorably short. For those who would challenge this statement, just look around. The couple hundred million potential donors in this country, acting individually, are failing miserably to meet these needs.

    Even private institutions can never enlist the support of enough individuals with enough resources to make more than the tiniest dent in the various problems that need to be addressed.

    We do far better when we join together. Collectively, through the democratic process, we combine some of our discretionary resources and select elected delegates to determine how those resources are to be used. The process works very well.

    We still have much more to do, but with fewer wars and a reduction in the massive upward transfer of wealth, we can do far better. Although Paul Ryan again brings up the timeworn charge of class warfare (the rich are winning – big time), the Buffett Rule would still leave us with our own individual opportunities to become multimillionaires ourselves.

    Just as most libertarians do not support “charity for none,” most advocates of social justice do not support government confiscation of all private property. We will always have battle lines on where we should be, but most of us can agree that it should not be at either extreme.

  9. politicaldoc says:

    A not well known fact is that most large private hospitals, as well as county hospitals such as Parkland Hospital, are reimbursed for care given to uninsured/illegal immigrants by the federal government. So tax dollars are already used either way: to subsidize the healthcare of the uninsured or to subsidize employee healthcare insurance.

    Notably, there is no such fund to reimburse physicians and other providers for their “charity” care—not even a tax deduction is allowed.

  10. Andrew says:

    good post Dr. Goodman

  11. Norman Singleton says:

    Did you not listen to Dr. Paul? Because the list sentence of your article sounds like you did not, by implying he came off as having “charity toward none” when he talked about the charitable work he did –and he understated the case because as an OB-GYn he never took Medicaid but he never turned away a patient because the patient could not pay. Dr. Paul does not merely preach libertarianism he lives it.

  12. Frank Timmins says:

    This is of course the logical solution. Add the vouchers for the poor, eliminate Medicaid and we are well on the road to solving our national healthcare problem.

    There is one other issue here that seems to be the “third rail” healthcare problem for conservatives and libertarians. Insurance must play an important part in the solution, and it must be accessible. And we have to accept the premise that health insurance (or any other true insurance) is the process of pooling risks (good and bad) in order to create an affordable premium. Health insurance risks cannot be managed if unhealthy applicants are allowed to “select” against the carrier, by foregoing coverage until health conditions necessitate shifting costs to insurance. This drives the theory of “mandated” coverage. But we don’t want anything mandated. So what do we do?

    We conservatives can start by recognizing that insurance is and must be “pooled” and yes, it is a socialistic concept. Secondly, we can understand (and make sure everyone else understands) that the term “insurance” does not apply to “expected” or “predictable” losses such as most healthcare provider encounters and medications. Once we do this we can find ways to agree on uses of insurance that greatly minimize its cost as a percentage of our total healthcare expenses.

    Ron Paul is on the right track, but he will never be able to philosophically “close the deal” because he (nor it seems anyone else running for office) is willing to admit to and address the important role of insurance in healthcare, and how to make proper use of it.

    It can be done (quiet easily) if we could have intelligent discourse.

  13. John R. Graham says:

    I agree that Wolf Blitzer’s question was a softball, because cost of care for high-earning but uninsured 30-year olds is surely a rounding error in the national spending accounts. Rich 30-year olds do not have high health costs.

    I find Mr. McCanne’s comment astonishing. Every penny the government has comes from individuals or private institutions. So, to argue that “resources that any individual or private institution controls are so meager, compared to the need, that private charity will always fall deplorably short” cannot make any sense.

    Of course, the government does not finance all of its spending via taxes. An increasing share of it is funded by the central bank of communist China. But that central bank will have to be paid back by taxing our children.

    So, there is no getting around the fact that the “meager resources of individuals and private institutions” is all that the government can draw upon.

    Unless Mr. McCanne believes that the Chinese central bank will succumb to a monumental charitable impulse and forgive the U.S. debt.

  14. Virginia says:

    The typical criticism that libertarians are not charitable is the worst. It’s dishonest, and it shows a fundamental misunderstanding of the ideals of libertarian philosophies. What’s more charitable: letting people decide how they live their lives or compelling everyone to pay taxes for programs they may or may not support?

    Paul’s answer was pretty good given the allotted time. I would have liked to have seen him turn the tables. If Blitzer wants to talk about what the government needs to do to protect “national health,” then where do you draw the line? Regulating people’s diets? Forcing them to attend mental health screening? Making it illegal to sit on the couch and not exercise? Once you accept some governmental involvement, the line between “individual choice” and “best interest of society” becomes arbitrary at best.

  15. Don McCanne says:

    John Graham,

    My intent with the reference to “any individual or private institution” is clarified in the same paragraph when I wrote, “acting individually.” Collectively, the resources are there, but for each individual or institution, acting alone, charitable instincts are overwhelmed by the need that surrounds us. Voluntary charity on an individual basis continues to fall far short of the needs.

    (I agree that borrowing from the Chinese to pay for ill-advised wars and an unfunded Medicare drug benefit was unwise.)

    Virginia,

    It is not that lack of charity is limited to libertarians, but almost all of us demonstrate a lack of adequate charity when you examine how far short our combined voluntary charitable contributions fall when compared to the need. Again, the proof is that the need is everywhere (look at the skyrocketing poverty rates), and it is not being met by charity.

    I don’t understand the definition of charity as “letting people decide how they live their lives.” Charity is more commonly defined as individuals or organizations voluntarily giving help, often as money, to those in need. Using your leave-them-to-themselves definition, you do risk being accused of supporting “charity toward none.”

  16. wanda j. jones says:

    This series is he whole health reform debate in a nutshell. Some points:

    1)• The uninsured who need care are not only subsidized by the federal and state governments and counties, but by private providers who have a charitable obligation and who “cost-shift” these expenses to privately-covered patients. Doctors do not have this same obligation, but have provided much charity care in the past; especially to the elderly before Medicare. In the near future, the reductions in Medicare payments will have the unintended consequence of reducing the amount of charity care offered by providers, as they will already be cost-shifting to other plans. Those plans, if the Reform plan goes as designed, will have their premiums held down, so suppressing private charity care sources even further.

    • The notion of pooling society’s resources to allocate funds fairly fails the performance test. The Federal government, and now our state government, is the least reliable fiduciary agent in our society. Its programs skew the economics of all participants and stimulate work-arounds of it’s multiple micro-regula-tions. To me, many small mistakes made locally are better than a few huge mistakes made centrally that affect everyone and are hard to correct.

    • The “moral hazard of allowing people to opt out of insurance until they need it” is great. But the solution is not yet apparent, as many of those who do not obtain health insurance also do not obtain car insurance, or in other ways deal carefully with their lives. More rules mean more rule-breakers. We look around at our homeless mentally-ill, for example. Insurance will make not one spot of difference to them. Having a drop-in clinic or street medics will.

    I believe in market segmentation by what our public health leaders are calling “the Social Assets Ladder.” It’s most determining success factor is education. In this concept, those that are lowest on the social assets ladder would have healthcare provided by either public or private funds; those higher on the social ladder will pay for basic care and sign up for insurance. Let’s get a grip that it does not help us to be so politically correct that we imply that everyone is equal in competency, and that applies to competency to manage one’s own life.

    • There are two other formats for “insurance.” I refer to our concept of a “Healthcare Credit Union,” especially with those having HSA’s. In it, people would pool their funds for primary care, in effect, lending it to each other. It could arrange for primary care doctors, buy standard health coverage as a “Community of Interest.” And it could do the attitude -adjustment and mutual education to improve those important lifestyle problems that promote obesity, or that ignore genetically-linked conditions.

    The other one is, for employed people, a post-treatment payment schedule, under a bank’s management, so the patient can pay off a treatment as one would a new car. This would work for maybe one motorcycle accident, but not for two and not for a gunshot wound to the head. This brings up a form of linkage to consider: Require evidence of health insurance when applying for a marriage license, a car license (though 1/3 of drives are not covered) renting an apartment or buying a house. In fact, when buying into a life care facility, the healthcare is included in the price of the residence. For new towns, would that not be an incentive to home purchase? We have to think about more options as people are channeled into individual policies.

    Remember the early days of mass immigration from European countries? The first form of insurance was fraternal–paying into a fund that promised healthcare for those who could not access any pre-existing provider because of racial prejudice (Chinese Hospital) or language (French Hospital) or religion (Mount Zion Medical Center. One-third of the residents of our city are Chinese–they are in a position, should they want to do it, to purchase their own additional hospital capacity to augment that of the small hospital in Chinatown.

    Nationally, we try to compensate for those who choose to live in rural villages, an hour from the nearest hospital, or people who exist on a diet of pizza, or who physically abuse their family members. Once we agree that that cannot be done, we’ll get our expectations in line with what is actually possible. Those of us who live in well-established urban areas are blessed with well-developed healthcare systems and plenty of doctors; our biggest risk is that their life-blood will be sucked out by ignorance at the top.

    As to Paul Krugman–I think people are getting onto him About time.

    Wanda J. Jones
    San Francisco

  17. Robert says:

    “Again, the proof is that the need is everywhere (look at the skyrocketing poverty rates), and it is not being met by charity.”

    I don’t think Charity as private individuals or groups is meant too get people out of poverty, I don’t think it will ever be able to do it, even the forced “charity” (government) can’t do that.

    Poverty unfortutately will always be among us. Some people will choose to live there, some people will end up “poor” by things both inside and outside their control.

    Do we take those people and say – you don’t know what is good for you and make the choice for them? Do we take from people and give it to others or do we let them chose what to do with thier wares.

    Perhaps these people don’t even think of themselves as poor? Maybe they don’t want handouts, and doles. Why can’t what they want matter as well? We assume in our comfortable living spaces and cool internet linked computers that they want what we have, or want what we want, maybe they don’t.

    Poor is relative and charity by definition cannot be forceably taken it must be given.

  18. Alieta Eck, MD says:

    Rod Long said it best. Individual responsibility would dictate that the 30 year old be responsible for his own health care. Prudence would dictate that he buy an insurance policy for such an unforeseen event.

    But government has gotten in the middle and dictated things like community rating where the young man is forced to buy a policy that costs the same for him as an unhealthy 64 year old. The policy is unreasonably high for him and he often will choose to not buy it.

    So is the government the best vehicle to help him? Yes, and no. In the days before the big government programs, we had City Hospitals and County Hospitals. These were funded by tax dollars and were very efficient in caring for people with no funds or insurance. They had no bells and whistles, few amenities, but the care was adequate. Patient might find themselves in 12 bedded wards, but fewer nurses were needed to monitor the patients. Costs were kept down.

    Private charities are also very efficient in caring for the poor. They need to be encouraged, and simply providing medical malpractice protection would motivate more physicians to get involved.

    Patients ought to buy their own insurance. If they do, they will get top-notch care when a major illness occurs. If they do not, they will still get care, but there is no justification for forcing the taxpayers to pay for a two-bedded room with all the amenities. Care is one thing, luxurious care is another. Why not motivate, not coerce citizens to purchase health insurance? And why not elimiate all the mandates that would drive up the costs unnecessarily?

  19. Frank Timmins says:

    Wanda Jones writes, “But the solution is not yet apparent, as many of those who do not obtain health insurance also do not obtain car insurance, or in other ways deal carefully with their lives.”

    I think the answer to the insurance question actually “is apparent”. While it is true that many people opt out of auto insurance, the analogy to health insurance is not valid simply because there is no moral dictate to repair or replace our neighbor’s car.

    This doesn’t mean that we should mandate that everyone buy health insurance, but it certainly requires us to (as you say) “motivate” people to do so. After all is said and done, insurance viability is a numbers game. We don’t need 100% participation, but we do need “critical mass” in participation which neutralizes problems of “moral hazard”. This can be done recognizing there will always be a small percentage of the population that will be outside the process as some of the examples you have indicated – but not nearly as many as you presume.

    Like those below the often publicized “poverty line”, those who can’t (or won’t) finance or manage their own healthcare are in a dynamic class, and are not permanently assigned to that station in life. Our system should recognize that and have incentives to move out of it. Whereas you state that we should not assume that everyone is competent to manage their own life, I insist that is exactly what we should do. Everyone does not have to be “equal” to manage their lives (including their medical care). I think the the vast majority of Americans have the ability to do what is in their best interests if given the opportunity and tools to do so.

    It seems that instead of institutionalizing this “segmentation” of those we deem to be “incompetent” to manage their lives, we should be striving to reduce that percentage of people to as small a group as possible. To do anything else is to continue to try to validate the same thinking that has brought us to the mess we now have. Changing the name of the benevolent benefactor from the federal government to the state government (or some combination of private industry and government) does not change the failed concept.

    In short, we need to forget about solutions that involve third parties “managing” healthcare for individuals, and consider changing directions that don’t encourage and perpetuate the permanent underclass.

  20. Charles Johnsen says:

    A true market in health insurance would be able to give a healthy 30 year old good coverage for less that $500 a year. Way less if we make sure that ordinary medical expenses are paid out of pocket. Now maybe he would buy it. Deregulate, deregulate, deregulate.

    Too often we look for incentives for people to behave rationally instead of looking for the government screw ups that discourage rational action. We have tied the invisible hand behind our backs.

    Also, such a man would be more likely to purchase health insurance if he were married. It is looking like more and more of our problems as a society stem from the decline in marriage. This is how all human societies since we descended from the trees or left Eden, take your pick, have given males a stake in the society and a reason to behave like men. Social and market cheating (I mean in the reciprocal good sense) are worse when we lose our natural ties to each other as families and couples. Loners make poor soldiers and worse citizens.

  21. Charlotte Vick says:

    Very good piece, John. Thank you for a good clear answer. Keep pushing it out there. There must be some rational people left somewhere.

  22. Patrick Skinner says:

    John, Good post about the unfair tax differential, but don’t leave out the cost shifting from Medicare and Medicaid’s underpayment of providers, then add the gov’t regulations of insurance including mandated coverages. I’ll bet the 30 year old’s premiums would be 50% if the gov’t would just get out of the way.

  23. Jennie Fiedler says:

    Dr. Eck, thank you. I always appreciate an “inside” point of view and myself i would prefer a “bare bones” option I don’t care about amenities I think just getting what I need is enough. I don’t need “Cadillac” health insurance just a policy I can afford to pay that stays with me no matter what that I’m not dependent on an employer to provide.Too bad there isnothing national out there and too bad we can’t depend on our government to administer one like an expanded Medicare that is funded by and for every taxpayer in this country. So simple and streamlined but I guess that’s why it won’t happen.

  24. David R. Henderson says:

    John, See my blog post on this, where I point out that Austin Frakt’s answer (and he’s supposed to be a critic) doesn’t differ from Ron Paul’s except that Ron Paul explicitly advocated private charity.
    http://econlog.econlib.org/archives/2011/09/ron_paul_and_au.html

  25. Kent Lyon says:

    There is a problem omitted from all of this speculation, and that is that 3rd party insurance (private or public, employer provided or purchased by individuals, tax advantaged or not) per se drives up healthcare costs. All of these comments presume the validity of a third party payor system, with individuals who chose not to participate the exception and the irresponsible ones. That’s simply a specious presumption, shared by all the posts here. A third party payor system distorts the healthcare market and produces perverse incentives, such as for doctors and hospitals to do too much, and orient their actions to what pays the best, not what is best for the patient. The patient is distanced from paying the costs of care, and this reduces his or her interest in both the cost and quality of care. We have an opaque system of payment because it is a third party system. And that’s a disadvantage to all.
    What about a system in which everyone paid for healthcare out of pocket and there was no tax advantaging of healthcare, any more so than purchasing any consumer good, such as clothing. I dare say costs would be more transparent, and it is likely there would be advances in quality and reductions in cost as happens with consumer products such as ipods or laptops. We would then have a healthcare system that is both affordable for almost all, and much higher quality for everyone. Then charitable giving would be effective for those few who could not access care. Those in need of healthcare would likely have a much wider range of options about what healthcare to purchase. Everyone thinks healthcare is different. It isn’t. Healthcare value and importance has been vastly oversold, with the result that a lot of people are highly skeptical of the whole field. It’s still difficult to ascertain if more people are better off or worse off with heatlhcare. A famous study by an epidemiologist named Mendelsohn tracked mortality statistics in Los Angeles during the surgeons’ strike in Los Angeles in the early 1970’s. Surgeons stopped doing elective surgery, would only do emergency surgery like taking out inflamed appendices, or infected gall bladders, acute surgery that was life-saving. He showed clearly that mortality rates fell during the surgeon’s strike (called to protest rises in malpractice insurance) and rose to their formere\ higher baseline when the strike was called off. I submit, whether one is libertarian or not, we would all be much better off with much better healthcare if government stayed out of it altogether, and private insurers were instead savings banks for individuals.
    Consider that the “Golden Financial Age of Medicine” occurred right after Medicare was enacted, with healthcare inflation in the ensuing years rising to as high as 30% a year as physicians and hospitals took advantage of the lack of controls in Medicare reimbursement and jacked their fees through the roof. It was like taking free money out of an open ATM. And surgeons and hospitals were the ones that originated our third party payor system with the first Blue Cross program, established at the Baylor Hospital in Dallas, Texas, in a portenteous year, 1929, so that surgeons and hospitals could get paid in cash, instead of in kind. They made so much money that Blue Cross organizations were almost immediately set up in States across the nation. And healthcare inflation has ouotpaced general inflation ever since by a factor of at least 3, with few exceptions. Any thrid pary payor system will gradually collapse under the weight of it’s unaffordability, given enough time and vested interest behavior (which will always be extant in excess).

  26. Steve Trinward says:

    Blitzer’s insistence on conflating ‘society’ with ‘government program funded through taxation (or other theft)’ is the real problem here. In a sane society of free and enlightened individuals, nobody would go wanting for essential help in time of need. (There would also be a lot fewer truly ‘in need’ in such a society.) The intent among these evolved beings would be to restore health and self-reliance ASAP, and be more ongoing only with the very few truly unable to help themselves after whatever incident had disabled them for a time …

    As for how to pay for things, I’d point to some states that even have made car insurance semi-optional. In Virginia, forex, it is possible to get a driver’s license without showing proof of auto liability insurance — you just have to pay an extra $500 at the outset before you get the license. Aiming at health & wellness the same way (giving large discounts to those who are taking care of themselves, and hammering the rates for those who don’t?) might be a huge step in right direction.

  27. wanda j. jones says:

    To Frank: Actually, government programs themselves create a permanent underclass as we saw with welfare and as we see with Medicaid and as we will see with subsidized plans through state insurance exchanges. To plan for the actual care of people who are less able to manage their own affairs is not to assign them there or to consider that condition permanent, but it is to be kind enough to meet them where they are. We have a church in this City, Glide Memorial, a Methodist church, that has a food program that serves several hundred people a day, a free clinic, and its own housing program. The individuals they serve are not condemned to their state in life by the church, they are accepted, and given the kinds of services that they are glad to have. If a state insurance exchange staffer were to come up to them and ask “which private plan can we subsidize for you?” they would get a perfectly blank look. I strenuously object to being seen as not politically correct to recognizing that the public comes in all kinds of conditions and life situations. In America, that does not mean a permanent condition as it does in many countries of the world, as people can move both up and down the social ladder depending on a formula that includes family strength, personal initiative, community support and opportunities. To tacitly assume that the Reform plan will work well for everyone the way it is will lead to disappointment and yet one more cry for “single payer” as though not having single payer is THE reason why so many people will remain uninsured and cared for badly.
    In our work, we suggest learning the specific population groups in a service area, designing the kinds of delivery systems and programs they need and want, with a payment method devised to fit. The reform bill works backwards.

    Good discussion…

    Wanda J. Jones
    New Century Healthcare Institute

  28. Frank Timmins says:

    @ Wanda

    I understand your take on this, and in terms of how to take care of the those who truly cannot manage themselves I agree. It is just that I believe this segment of the population is very small, and that the majority of people on Medicaid are very capable of handling their healthcare issues and managing funds spent on same.

    Although I cannot cite statistics (it may be available), empirical evidence is everywhere. Waiting areas in Social Security offices are filled with working age individuals with Iphones who drove there in cars to apply for assistance. There is no reason they cannot become competent buyers of healthcare.

    If this is so, we should develop methods to make them part of the system that controls demand for medical services like the rest of us rather than allowing them to become (remain)dependent upon benevolent control of social planners.

  29. JDilegge says:

    Frank, you should Google, “define:empirical”.

    “There is no reason they cannot become competent buyers of healthcare.” Really? I put in over 500 resumes and applications before I finally got a job interview. Even with my job, the health care is subpar and purchasing a plan out of pocket is $900 a month. So, research before being high and mighty. Oh and while unemployed I reviewed XMas and BDay gifts, according to you I should have sold those, pissing off and offending the gift givers, in order to purchase insurance?

    I am so tired of morons that think that everyone should be like them and that every person should be exactly like them.

  30. JDilegge says:

    *recieved, not reviewed.

  31. Frank Timmins says:

    jDilegge, I think you missed the point, unless you are arguing with me about my assertion that you and others are resourceful and intelligent enough to manage your own healthcare. Or perhaps you are unaware of the meaning of the word “competent”.

    In any case perhaps you should follow the subject thread and the various posts before commenting with your silly platitudes and accusations.

  32. enseñanza a distancia says:

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