Will Republicans eventually accept universal healthcare?

Great Debates
61

Like I said before, caricature. While you’re free to do so, these type of sweeping generalities of mental illness of those that disagree with you is off putting. It makes it more tedious and less interesting to engage.

That’s not a negative externality. Typically a negative externality is when decision makers do not pay the full cost of the choices they make. That’s a very general definition. Another way to phrase it would be:

I don’t think there is one perfect definition, but the gist is there. Because as a society we are not comfortable allowing people to suffer from their own poor choices, the cost of those choices is borne by not just the individual, but society as a whole and that creates a negative externality. Smoking would be a good example. Smoking is legal (for now), though the benefits of smoking are quite limited, and the costs can be very large. The negative health impacts and associated increase in medical costs of smoking would seem to indicate that non-smokers as a group are probably bearing some of the cost of the negative impacts of smoking.

It’s interesting that you bring up vaccinations because they are a good example of a negative externality. Now, I believe in vaccinations as the only choice, I’ve vaccinated all my kids and the science is iron clad. But as a thought experiment, if you knew for certain that 100% of everyone else was vaccinated, does it make sense for you to vaccinate? I’d say no. The non-zero risk of infection, poor reaction, etc. are greater than the risk of contracting certain diseases if 100% of everyone else is vaccinated. But that puts the costs of vaccination on everyone else, while still enjoying the benefits of the herd immunity. This is also a free rider problem.

Another example is helmet wearing when riding a motorcycle. In CA, a law was passed to require all motorcycle riders to wear helmets. In other states, helmet wearing is not required. In one of those states a person may decide that the utility they gain from the feeling of riding without a helmet, the cost of the helmet, inconvenience of wearing one, etc. is not worth the increased risk of injury or death when riding. Perhaps they weigh the choices, and decide for them, the relatively low chance of them needing a helmet is not worth the costs. But since we as a society are not comfortable allowing this helmet-less person to suffer or die in the street from head trauma, society incurs a cost of caring for this person in the event they suffer an injury. In making the decision to not wear a helmet, they may not bear the actual cost of their choice.

So what to do about that? CA decided that’s not a choice a person can make, so they passed a law requiring helmet use. Is that okay? A lot of people would say yes I think. And much of the justification I heard around that time is that the cost of people not wearing helmets is being borne by everyone else. I personally think wearing a helmet is an obvious choice, just like seatbelts, and the potential benefits vastly outweigh the potential costs. But using this rationale, the government could apply this in a variety of what I would consider terrible ways.

Ignore for a moment the differences in public road use, licenses to drive, etc. The rationale that the choice to wear a helmet should be eliminated because of the cost it imposes on others - that same rationale can be used to limit the diet of people. It can be used to force a minimum amount of exercise. Once the health costs are a justification for intercession, there really is no limit to the amount of intrusion that can happen in the name of reducing health care costs. So I think these things are on a spectrum of levels of invasiveness. Mandating seatbelts is not very invasive. Mandating a specific caloric intake and exercise regiment is much more invasive.

A principled position is that the level of invasiveness should be minimized to the barest extent whenever possible. The argument is over what that extent is. And it’s not mental illness to make these choices. Sometimes when evaluating what is more worthwhile, people’s lives, or money and freedom, the calculus falls on the side of money and freedom, in spite of the fact we know people will die as a result. A speed limit of 10mph would greatly reduce traffic fatalities. But we as a society have decided that’s not a good choice to make. We accept people dying as a tradeoff for more efficient commerce, among other things. If there are no negative externalities, and individuals bear the cost for their own choices, then there is hardly any reason for government to intercede.

So the question for Republicans, is UHC more like the 25mph speed limit, or is it more like seatbelt laws? Over the years, I have been sufficiently convinced that the market for healthcare is different enough that it justifies different approaches than other markets that are more free, more elastic, etc. I’d support the concept of UHC, depending on how it was implemented. The EMTLA as an example, and other choices society has made reflects the discomfort with letting people suffer for poor choices is part of the negative externalities that persuaded me.

I told a social worker friend who is a staunch liberal, to be a libertarian, you have to be comfortable with a certain level of people suffering for their poor choices. Poor choices should be punished, and good choices rewarded, in general. We disagreed of course.

Again, it’s not necessarily fantastic principles. I think society as a whole would be net better off in the long run with less government. In the short run, that may cause greater suffering, or worse outcomes, but that’s okay. It’s okay for two reasons - in the long run, it will be better. Second, maximizing individual liberty is its own goal.

62

This seems like a poor example. Isn’t part of the point of your political philosophy to move away from a system where society is uncomfortable letting people suffer for their poor choices? That you should be able to do whatever you want, even if it’s really, really bad for you, as long as it doesn’t negative affect others? I guess this just confuses me a bit, how this counts as an externality.

This fits quite well within my understanding of externalities. It also seems like a fairly exceptional case, one not easily or often mirrored - how often does your medical treatment directly influence the safety of others, and how often would everyone else getting treatment make you want the treatment less?

…But isn’t this precisely the kind of government decision you’re not okay with? I feel like if we’re trying to argue in favor of health care based on externalities, the people asking for that kind of argument are exactly the kind of people least swayed by arguments along the lines of “we need to protect you from yourself, otherwise your family might be sad at your funeral”.

…My point exactly.

I feel like at some point there’s such an extreme difference in scale to make it more of a difference in kind. Admittedly, this is just gut-feeling; I can’t put my finger on exactly what about this argument bugs me.

I don’t think that position is principled when the result is a society that necessarily has a more predatory, expensive, and harmful medical system. I think that looking at the theory behind actions rather than the consequences of actions is a terible idea. In theory, communism is great. In practice, it’s an absolute shitshow. In theory, government invasiveness should be limited as much as possible. In practice, it leads to the medical system we had back in 2006.

Of course, “choices” is always a matter of question. Poor children did not choose to be poor, and the child who dies of malaria did not choose to have parents who could not afford medical treatment or bed nets. The problem many liberals have with the republican conception of “choice” is that the republican conception of “choice” is often utterly disconnected from what really is a choice.

Your first point is interesting but is its entire separate discussion I don’t feel like getting into right here (although if you make a thread defending that thesis I’d gladly take part in it). But this… This bugs me. Roosevelt talks about “the four freedoms”, and I find that just talking about what you can do in theory doesn’t really work to maximize freedom. If I am technically free to color my hair, but doing so will almost certainly lead to me losing my job, I am not really free to color my hair. If I am technically free to seek medical attention, but am utterly ineffectual in doing so because I have no means with which to do it, I am not really free to seek medical attention. The freedoms one can have in theory must be balanced with the freedoms that one can have in practice. I find the latter far more meaningful, because it helps shine a spotlight on cases where shit’s gone tits-up and where we need to work towards a more just society for the sake of becoming more free.

63

I will paraphrase an economist because I think it’s important. An economist I follow said recently that economists favor free markets only because they are generally, but not always, more efficient.

I think many people see “free market” and think that’s a value statement rather than an attempted descriptor.

64

I am fine with other people smoking. I’d prefer to not pay the cost of their smoking either in increased health care costs that are spread generally or increased exposure to second hand smoke. I do believe people should be able to do whatever they want, even if it’s really bad for them. But we are talking about the negative impacts of those, some of which are externalities.

As to the last point, I don’t know. But I do think other people’s medical treatment will often influence the *cost *to others. Safety, cost, etc. are all just measures of various forms of utility.

And this is a fair point. I didn’t connect the dots as explicitly as I meant to. The rebuttal to that is that we already are doing it. We are just doing it badly. So in reality I’d prefer to move towards a place where we don’t protect people from themselves as much as we currently do, the reality is that we’ve set up a system that this is not the case, and we are already paying for and protecting people from themselves. Those are represented by those negative externalities that are unlikely to be changed. So it’s not persuasive to simply say, UHC is better because it has better outcomes, it costs less, etc. That’s not enough. But if that is coupled with the idea that we are in no way going to change to an extent necessary to reduce or remove those externalities, the least we should do is do what we do as best as possible. Skipping the part about externalities doesn’t bridge the gap sufficiently.

Person 1: We should pay for prenatal care because it leads to healthier and more productive children.
**Person 2: **It’s not society’s responsibility to pay for other people’s care
Person 1: If you don’t pay for prenatal care, you’ll pay orders of magnitude more for neo natal care, ongoing support care, and a lifetime of other support services that can be avoided with a smaller amount of prenatal care.

If those are the only options, then even though it’s not society’s responsibility to pay, it makes sense to do so. Once that decision is made, it should be done in the most efficient and effective way possible, while preserving the principle of least intrusion. The argument is whether the conclusions drawn by person 1 in the third statement are accurate, and are the only available choices. In the case of EMTLA, I don’t see it as ever possible to go back to a time when hospitals could refuse to treat an emergency situation in the ER.

Results aren’t germane to principles. That’s what makes them principles. We may be using the term differently. And I had much better medical coverage and care in 2006.

But I hope I’ve communicated well enough to highlight the objection. I don’t want a society where my caloric intake and exercise regiment is mandated by the government and I often do not see functional limits that would prevent that from happening in the case of proposals made that call for more intrusiveness.

Yes, those things suck. Due to luck of birth, a lot of suffering in the world exists. I think it’s debatable when efforts to reduce that suffering cause more suffering or not. Sterilizing indigent people would eliminate the issue of poor children being born poor, but that would be atrocious and a terrible approach to that problem. I think potential solutions should be evaluated on a case by case basis, with the principle of minimal intrusion always a part of the calculus.

I don’t subscribe to Roosevelt’s Four Freedoms (freedom from speech, worship, want, fear). Two of them are good. I’m not sure that these are directly on point for UHC though, so I’ll leave it alone.

65

I agree with this and it’s a good point. The focus on negative externalities is only one persuasive aspect for UHC. Health care and health insurance not operating in a free market, and/or not being efficient is also persuasive. Health care simply isn’t best described as a free market, and it doesn’t behave that way.

66

Can Medicare/Medicaid negotiate prices or is negotiating drug prices = “regulating prices”

67

No, that specifically was excluded when Dubya got Part D passed. The Free Market in action.

68

First of all, I’m glad to see you recognize that health care is radically different than commodities that can be thrown open to the free market laws of supply and demand, because it simply doesn’t work that way. EMTALA in my view is a costly and dysfunctional abomination that arises from the basic dichotomy of, on one hand, trying to pretend in the mainstream health care system that health care is something you can only get if you can afford to pay for it, and on the other hand, the realization that in any society with aspirations to be civilized you can’t throw people out of a hospital and let them die in the streets just because they don’t have the money for a crucial procedure. UHC, and specifically single-payer, addresses the problem by fully acknowledging health care for what it is: an essential of life, and therefore a basic human right and collective societal responsibility.

In that respect I want to address your attempt to justify your principled objection to UHC. Ironically for someone who was just objecting to caricatures above, ISTM that you’re using one yourself – specifically, the type of caricature that arises from the slippery slope argument. This is where one states that if we allow government to do “x”, then sooner or later it logically follows that government will do “y” – a characterization made in all seriousness even when everyone recognizes that “x” is very beneficial and “y” would be terrible, and the link between the two is an absurd stretch of logic whose real-world possibility is essentially zero.

I’ll give you a specific example in the exact terms that have just been raised. As a preamble, where I live as you know we have single-payer health care, which I’ve described as a system that is universal and provides unconditional coverage for everyone. It’s widely popular because what people primarily recognize in it is not the philosophical fact that they are responsible collectively for everyone else’s health care, but the more practically relevant fact that society collectively is responsible for theirs, and that as participants in this social contract their costs are far lower than they would be under a private insurance system, and that health care costs and fighting over claims denials will never be a problem in their lives.

Now let’s look at the terrible things that government might do, having now established this alleged slippery slope. They might insist that people eat only healthy foods, and exercise regularly, as a means of controlling health care costs, and back this up with force of law. They would certainly ban smoking, a proven major health risk. Now the question at hand on which this whole argument hinges is: have they done that? Has any such thing ever been seriously proposed? Is there any chance at all of any of these intrusive Orwellian things happening?

And the answer is “no”. It’s “no” because you and I also live in a democratic and free society, societies with constitutional protections and limits on government power. Consequently, single-payer health care is a threat to no one and a “slippery slope” to nowhere at all, while providing an immense benefit to society.

It’s true that the occasional misguided zealot has suggested that those who choose to smoke should be disqualified from receiving publicly funded health care if they get a smoking-related disease, or they should be charged a premium for being smokers, or some such nonsense which no one has ever taken seriously. But note why this could never work even if someone did take it seriously. First, it violates the fundamental principle of universality. Second and more basic, it violates even more foundational principles of single-payer in that it violates the community-rating model and imposes an entire adjudicatory bureaucracy on the health care system: is the patient a smoker? How long has he/she been a smoker? Is the disease provably smoking related? etc.

And here’s the thing. Single-payer fundamentally doesn’t work that way. It can’t work that way. It’s structured to be universal, unconditional, and non-discriminatory, with a community-based rating system structurally decoupled from any consideration of individual risk. If it were any other way it would be like private insurance, and lose all or most of its benefits. So none of those scary things are ever going to happen.

The whole fear-mongering exercise against single payer is also deeply ironic because the tremendous bureaucratic intrusions of private insurance are a greater threat to freedom than the benign bill-paying function of government will ever be. If my doctor recommends a particular medical procedure I can be certain that I will get it. Can you? Or might you have to deal with a meddling insurance company bureaucrat who prefers something cheaper, or maybe feels it’s “not necessary” at all?

69

Even in Medicare, which is occasionally held up as a model for single-payer in the US, there are procedures or devices or equipment that are not covered.

For those who want single payer, I think this article lays out some issues that really must be considered: https://www.thenation.com/article/medicare-for-all-isnt-the-solution-for-universal-health-care/

70

But as the article also points out, Medicare is not the same as what is meant by “single payer” in other countries. For example (my observation, not from the article) one of the fundamental principles enshrined in the Canada Health Act is the guaranteed universal coverage of medically necessary procedures, something that does not exist as a fundamental principle either in Medicare or in any private insurance. So yes, there are things that are not covered, but they tend to be nickel-and-dime things. Need crutches for a while for that post-operative knee? You may have to pay for it yourself if you don’t have supplemental insurance. Need a million-dollar heart transplant? No problem. No one is even going to try to second-guess a medical recommendation.

The article mentions part of the reason why this sort of unconditional coverage is possible at low cost. Countries that have UHC have long been able to control costs systematically through a centralized system of uniform fee negotiation, whereas no such agency exists in the US private insurance system, where fees have continued to soar. It will really be a challenge to deal with this retroactively. It’s one thing for UHC to reduce providers’ operating costs, but politically quite another to get them to accept lower fees.

71

Medicare covers medically necessary procedures.

72

I think you are conflating single payer with UHC. UHC doesn’t have to be single payer. It could be but doesn’t have to be. UHC could be providing a minimum basic insurance coverage. It could take lots of other forms.

I’m unconvinced of the idea that health care is a basic human right. Not even close. In any event, I don’t think it’s a caricature to say that rationale applied in one instance can be used in others. I’m not saying it’s necessarily so, but I don’t see anything that would prevent it from happening. I would say the things you identify have not happened exactly, but things close to them have. Smoking has been banned in various locations, mostly private businesses but also pretty much all government buildings. Large size soda drinks have been banned in NY, though overturned by courts. Many employers have plans where tobacco users pay higher premiums, or even obese people, etc. Yes these are private businesses, but the idea is there. If the government is paying, then it stands to reason they would want a say in what they are paying for. So are large intrusive things right around the corner? I don’t know. We have seatbelt laws, vaccination laws, helmet laws, smoking bans, and soda cup size bans (reversed). Does that mean that the government is about to tell me I need to run 5 miles/day? I’d say no. But it becomes less far fetched the more intrusive government becomes.

73

This would seem to suggest that if, say, a private business doesn’t allow you to watch TV on the job, the government is coming for your TV.

74

It’s a weakness, I know. I could have not included these examples, but they were meant to respond to the idea that you couldn’t charge people different amounts for different behaviors.

75

I don’t think that is what was claimed. The poster claimed that universal insurance does not work that way despite private insurance working that way.

Your pointing out something about private business does nothing to rebut this claim. It comes closer to reinforcing it.

76

There’s that phrase again, and to me it sounds like doublespeak.

So far, we’ve established that the free market won’t work. But you don’t want government intervention.

What are these ‘negative externalities’ that are so important that resolving them would be anything more than slapping cosmetic band-aids on a balloon that’s destined to explode? (And I’m not just talking about Obamacare here, I mean the entire ‘system,’ such as it is.)

77

Not sure where you’re getting that. I mentioned it be okay with UHC.

Again, i think youve misunderstood or i hvent communicated it well enough. The negative externalities are not the focus to resolve, but a catalyst of acceptance.

78

Correct, it could. But most other forms of UHC are what I’ve called de facto single payer systems, in sense that even if there are multiple payers, there is a regulated system and a uniformity that makes little if any practical difference for the majority of the population that there are multiple payers because they’re functionally all the same. What matters is that everyone gets essential health care. And let’s be clear that in all these systems “minimum basic coverage” is nothing like EMTALA, which is essentially “do something so that we don’t let the patient die on our premises” and actually extends to first-class medical care that often has better outcomes than for the majority of insured patients in the US.

You’ll notice that the major disconnect in your argument is that you’re citing government actions that you consider intrusive but which are occurring throughout the US where there is no UHC, yet in Canada where there IS UHC, in the form of single-payer, there are no more and arguably fewer of those intrusive actions (like the silly NYC soda ban, for instance). So you’ve failed to establish any kind of correlation between UHC or a humanitarian view of health care and “intrusive government”.

Needless to say, in the big picture I reject your view that health care is not a human right because ISTM the logical consequence is that you must be fine with letting the poor and uninsured die in the streets. I know you’re not, but it’s unclear how you propose to resolve this. You surely cannot believe, like Ron Paul, that the sick should be left to the luck of the draw of churches and charities to fund serious health care emergencies and ongoing care, as opposed to a binding societal responsibility. Only government can administer such a social contract.

Yes, exactly. Risk-rating health insurance is right back to the failed free market model of health care – terrific for cars and home appliances, useless for human health care.

79

No, you were clear, except for what those externalities are. But being against drug price regulation sure sounds anti-interventionist to me.

80

This (and the paragraph I snipped) both make perfect sense, thank you. But wouldn’t this in theory make any demand for a limited good contain the externality, “will make this limited good more expensive for everyone else as well”?

Just to see if I get the gist here: basically, we’re already doing a form of socialized health care, but we’re just doing it really really stupidly and there’s no way we’re going to let emergency rooms turn away dying people, so we have to logically proceed to some form of UHC to minimize those externalities. Is that about right? I guess that makes sense, but it seems like an odd and flimsy way to justify it, and I feel like most affected by this argument would go precisely the other direction with it.

Yeah okay that sounds about right, but I stand by my objection.

If by your definition results aren’t germane to principles, then I reject the concept of principles as you define them as useful or meaningful, and find them to be a colossal waste of time, energy, money, life, and presumably several other things we all value. I’m reminded of that catholic hospital who refused to perform an abortion on a septic miscarriage because they had a firm principle to never perform abortions - even if the chance of survival for the child was 0%, and the treatment was necessary for the mother to survive.

I’m very firmly of the consequentialist bend, because the consequences of what you do matter far more than the intent when it comes to what actually happens. If what you do results in my quality of life increasing threefold, I honestly don’t care that your goal was killing me (although I might be wary of what you attempt in the future). If what you do results in millions dying and a massive step backwards for humanity, I don’t care that your goal was noble (hello, Marx and Engel) or that you followed good principles, because millions are dead and you fucked up real bad.

I’m pretty sure I get your objection, I just don’t agree with it. Thanks to wolfpup for answering this. I’m not 100% on board with his answer, because I could in theory imagine a democratic society where people voted to regulate our eating and exercise, which really just kicks the problem one step further down, but I could imagine that society with or without universal health care, so that doesn’t really seem quite as relevant.

The key point I take away from thinking about this is that the freedom from want is important and somewhat necessary to be able to exercise the other freedoms in any meaningful way as well.

(Also thank you for trying and mostly succeeding in dragging us away from partisan bickering. This is much nicer. I should keep that in mind more often.)