The Medicare Death Spiral

The L.A. Times notes that only 3.6 million seniors have signed up for the botched Medicare prescription drug program on their own. (The remaining millions were automatically transferred from state Medicaid rolls or already had coverage through Medicare.) The same article points to this Kaiser Family Foundation study, which reminds us that unless healthy seniors sign up in droves, the program risks becoming even more useless than it has been thus far. Behold the Medicare death spiral: If few healthy seniors sign up, premiums will jump. If premiums jump, fewer healthy seniors will sign up. And so on.

It would be nice to think that at this point we could all give up, admit that the benefit was a uniquely terrible idea from its inception, and dull the pain of millions wasted with some cheap Canadian percocet. Instead, legislators are pushing for an extension to the May 15 sign-up deadline and begging seniors to jump onboard, desperate to unload slices of a billion-dollar giveaway no one much wants. Look for more bright ideas from this camp during tomorrow's State of the Union Address.

Reason commentary on Medicare Part D here and here.

Comments

SR | January 30, 2006, 3:20pm | #

With Matt Welch now working at the LAT, don't you guys have to put a disclaimer on links to it? (Just kidding!)

Mike | January 30, 2006, 3:25pm | #

If seniors can opt out of medicare drug coverage, why can't I opt out of social security?

joe | January 30, 2006, 3:34pm | #

Kerry, that line about cheap Canadian Percocet is gold!

LOL.

amazingdrx | January 30, 2006, 3:38pm | #

More smoking, more boozing, and legalizing drugs would save social security. Voluntary retirement to that big read state in the sky.

Captain Holly | January 30, 2006, 3:52pm | #

Here's a weird twist: My mom recently dropped her private prescription drug coverage because it was cheaper to pay for the drugs out-of-pocket than pay the premiums for the insurance.

Some people hear "all prescriptions paid" and they automatically assume they're going to save money.

Paul | January 30, 2006, 3:56pm | #

We're Europe, get over it. Stick a fork in us, we're done.

theCoach | January 30, 2006, 4:11pm | #

Paul,
Europeans would never allow there healthcare system to be this inefficient.

Mike | January 30, 2006, 4:20pm | #

Switzerland has an interesting healthcare system: mandatory private healthcare. Basically, if you go to rent an apartment, get a mortgage, etc, you have to prove that you have health insurance or you can't sign the contract. The private policies start at something like $50 a month for basic coverage. Would be interesting to see something like that here. Better than using tax dollars, at any rate.

Amy Phillips | January 30, 2006, 4:35pm | #

You can opt out of Social Security; you just can't opt out of paying for everyone else's benefits.

You can't, however, opt out of Medicare drug coverage without paying a large penalty, which is why legislators want to extend the deadline; they don't want a bunch of angry seniors storming their offices when they're notified of the penalties they'll have to pay.

You also can't opt out of the huge tax increase that will be necessary to cover the cost of everyone else's benefits. The cost of that new tax has been estimated at nearly 15 percent of the nation's total payroll.

In other words, we're all screwed.

Shawn Smith | January 30, 2006, 4:47pm | #

In other words, we're all screwed.

Unless, of course, you work for the government. I was thinking of adding, "or the police," but then realized that some of them also have to deal with too much crap.

Bob Smith | January 30, 2006, 4:53pm | #

>You can't, however, opt out of Medicare drug coverage without paying a large penalty

Which is?

neilpaul | January 30, 2006, 5:21pm | #

The solution is to void any and all intellectual property protection for all drugs whether now existing or to be made in the future. This may instantly bankrupt big pharma and insure that no new drugs are ever created. So what? We all live plenty long enough on average as it is and most people could extend their own lives quite a bit by changing their lifestyles in small ways. If you get cancer, that's rough. Maybe some charity research can be done to help you out. Probably there won't be a lot of charity impotence drug research. Too bad.

Then we can just have the government produce all the drugs for really cheap.

This may not be the libertarian soulution, but it has to save some money, right? Would we rather do this or raise payroll taxes to 30% down the road?

America needs, no, America deserves free healthcare. America demands free healthcare.

What other options do we have?

MP | January 30, 2006, 5:28pm | #

Then we can just have the government produce all the drugs for really cheap.

Now that's funny.

Isaac Bartram | January 30, 2006, 5:29pm | #

Then we can just have the government produce all the drugs for really cheap.

Yeah, along with all the other things the government produces really cheaply.

io1029 | January 30, 2006, 5:51pm | #

**boggle** @ neilpaul

My head hurts.

neilpaul | January 30, 2006, 6:03pm | #

Fine, have private enterprise produce the drugs. Absent intellectual property rights in them, they would have to cost little more than benedryl, right?

The point is that we protect drug companies' rights in these products for only a couple of reasons. One is basic fairness. Since these drug companies and their investors created the drug, they should have the rights to it. Most Americans really don't care about that. The other is that we don't want drug companies to cease research and we believe that the profit motive creates new drugs.

All I am saying is we don't really need new drugs. Frankly, I would rather have back all or most of my "free"-drugs-for-old-people money, in exchange for the hope that this system will generate and provide me with a drug that will cure some disease that I may someday suffer from.

dflynn | January 30, 2006, 6:20pm | #

"America needs, no, America deserves free healthcare. America demands free healthcare"

The only way you can have free healthcare is if healthcare workers are slave labor, and you have to forget replacing any plant or equipment. Having somebody else pay for something does not make it free.

neilpaul | January 30, 2006, 6:35pm | #

I guess "free" means "government paid, out of monies borrowed or collected in taxes." That fact only underscores my point.

If this government paid healthcare is going to be the rule going forward, wouldn't it be better if it was a whole lot cheaper?

FXKLM | January 30, 2006, 6:45pm | #

Neilpaul: In 20 years, all existing drug patents will have expired. If, as you claim, existing drugs are all we really need and we don't need to worry about drugs that haven't been invented yet, the issue will resolve itself by then anyway. Do you honestly believe that? Do you really think that pharmaceutical companies won't invent any new drugs in the next 20 years that won't have people like you demanding government expropriation? And do you really believe that there weren't people 20 years ago who thought that medical science had advanced far enough and we didn't need to worry about incentives for future development?

neilpaul | January 30, 2006, 7:04pm | #

Yes, I do beleive that once it is impossible to patent drugs, drug creation will all but cease.

The problem I see is while we are waiting for the current patents to expire and respecting intellectual property rights, some asswipe drug companies are going to invent new drugs with the idea that they will be allowed to profit thereby. THese new drugs will then be demanded by old people at exorbitant expense and presently working people will be fleeced to pay for it.

We need to limit the pain inflicted by our beserk policies by eliminating "excess" drug company profit. Then we can eliminate new drug development and finally get a handle on costs.

Either we expropriate from drug companies or we expropriate from all tax payers. Its cheaper in the long run to do the former, not the latter.

Not expropriating at all is an option that Americans will not tolerate.

science | January 30, 2006, 7:04pm | #

I think healthcare in general presents a challenge to the libertarian philosophy (more or less than others? I'm not sure). Many healthcare issues (such as contagion/prevention) require thinking of the group at the expense of the individual if they are to be addressed.

And market solutions don't do a good job of taking care of the poor (go ahead, try and provide me with an example of a society with free market healthcare that takes appropriate care of the poor... I would be very interested). But taking care of the poor is good for the society (to prevent contagion, reduce suffering, increase productivity, etc...).

And then there are those sticky "natural rights" which are said to include "life, liberty, and the pursuit of happiness" which just doesn't make sense without including a right of to access to healthcare.

Insurance is a good way to diffuse the cost of major healthcare expense across the group, but is a bad model for basic healtcare, while basic healthcare is the best way to avoid major medical expenses.

And around we go. I think some hybrid of private/public healthcare will end up being the best solution, but the current mish-mash doesn't take advantage of either resource well (despite the huge efficiency advantage shown by medicare/medicaid over private insurance... many more healthcare dollars in the public system actually go to healthcare than in the healthcare funded by private insurance).

Just random ramblings.
Thoughts by you thoughtful libertarians?

dflynn | January 30, 2006, 7:07pm | #

Free means not costing anything.

If we are going to discuss healthcare paid out of monies borrowed or collected in taxes, then we get back to the original poster's point: if the healthy, who don't need insurance, don't sign up in large numbers, then the unhealthy are SOL.

neilpaul | January 30, 2006, 7:20pm | #

science,

a hybrid is exactly what we don't need. Either private (reasonable cost because some people "choose" to forgo overly expensive healthcare) or public (full-blown socialized medicine like in Europe and other places where medical care is less bankrupting than in the USA).

What we now have is a system where the public pays and private businesses profit, quite massively in both instances. Its a stupid system. We will never move to a system where people pay for their own care. No one really wants that, not really. Sure it sounds fair in theory, but once you have one really sick person without means to pay, everyone breaks down and the fisc is on the hook.

Even if healthy old people sign up in droves (if there even really is such a thing) the system will still be one where healthy non-users subsidize users and abusers of the system. I don't see that its much better to coerce old people to pick up the tab with threats of penalties rather than screw the young with broad based taxes.

We need to spend less overall. I just nominate the drug companies to eat the first shit sandwich. People seem to like them a lot less than they like Grandma.

dflynn | January 30, 2006, 7:50pm | #

I disagree.

Americans want very high cost healthcare, but they want somebody else to pay for it, and politicians tell them they can have what they want. If you want to see what low cost healthcare is like in the USA, check into your local VA hospital.

Americans don't want to wait in line for anything; they don't care if a test costs thousands of dollars to deliver; they don't care if a drug therapy costs thousands of dollars for a 25% chance of a favorable outcome; they don't care how much it costs for Grandma to stay in intensive care no matter how unlikely it is Grandma will improve; they have zero regard for the value of a doctor's or a nurse's time -- unless the money comes out of their pocket instead of the pocket of somebody else.

Chad | January 30, 2006, 8:02pm | #

science

By many measures, a poor person in almost any industrialized nation today is far richer than the King of England was 200 years ago. Ergo, the US does a darned find job of taking care of its poor.

The problem of your argument is its shifting baseline and circular reasoning. If you define the bottom ten percent as "not well taken care of", then of course you will find ten percent are not well taken care of.

Jim | January 30, 2006, 8:29pm | #

A hybrid is not out of the question.

-- Individual-paid health care (not insurance) up to yearly and lifetime caps, with a tax-paid safety net for catastrophic care.

-- Tax credits (a la earned income) for those below a threshold.

-- Get business out of the picture entirely, with strong incentives to increase wages by something like the amount now spent on health insurance for employees. Make the true costs directly visible to the consumer and competition will flower.

And using the VA as an example of mismanagement or inefficency doesn't fly these days. The VA of 20 years ago, maybe. But today's VA, not so much.

science | January 30, 2006, 8:30pm | #

Chad,

I am not sure I am making an argument of any kind (rather posing a question), let alone positing a shifting baseline and circular reasoning (who said bottom 10% was poor? I would define poor as those without enough money to meet basic needs...).

I am asking you to think out loud for me regarding the issue. How do you balance the needs of the individual against that of the society in terms of healthcare? If we agree on a natural right to healthcare access, how do you avoid having the group pay for those who can't pay their own way. Charity ain't gonna meet the needs (I would say) so what options are there beyond taxing those with the means to fund those without?

NeilPaul

"Either private (reasonable cost because some people "choose" to forgo overly expensive healthcare) or public (full-blown socialized medicine like in Europe and other places where medical care is less bankrupting than in the USA)."

What is this private plan where people "choose" to forgo overly expensive healthcare. That seems like it leads to problems of poor public health which, I would think, is a drag on the society as a whole.

Why doesn't a hybrid that rewards innovation by serving the rich via the free market, while providing for those who can't afford basic care with a public program make no sense?

Your luddite solution of not providing insentives for innovation seems to me a poor solution.

science | January 30, 2006, 8:36pm | #

Jim,

That's along the lines I am thinking.
How do you handle retiree healthcare?
Given our current saving rate, it would require radical behavior mod for the populace. What would the transition have to look like?

What do the rest of the libertarians here think?

dflynn | January 30, 2006, 9:07pm | #

"And using the VA as an example of mismanagement or inefficency doesn't fly these days. The VA of 20 years ago, maybe. But today's VA, not so much."

I used the VA exactly as I said, an example of low cost healthcare in the USA. They are very efficient at what they do.

For example, if you are a veteran with lung disease who has FEV1 of 25% predicted, your healthcare will be 2 minutes with a PA every 6 months who will refill your prescriptions. When you have the misfortune of getting sick, as patients in this category inevitably do, and you end up in another ER, the VA will neither pay for transport to the VA nor find you a bed at the VA. The VA is very good at keeping VA costs low.

As long as healthcare is treated as a right, the cost of healthcare will continue to expand until, as currently predicted by the Federal Reserve Board, it eventually becomes the entire GNP. If you want sanity restored to the healthcare system, healthcare will have to be recognized by the public as goods and services provided by people who expect to get paid.

A word about insurance. Insurance is generally considered to be a pooling of risk so that everyone can afford the high cost of uncommon events. Healthcare for somebody with AIDS, an ejection fraction of 15%, on dialysis or any 75 year old person is not insurable. The costs are certain and should be considered maintenance. The public should stop viewing cost sharing in these circumstances as insurance. This gets back to the original poster's point of the healthy signing on in large numbers.

jeffiek | January 30, 2006, 9:31pm | #

I would define poor as those without enough money to meet basic needs

Only to find that "basic needs" is just as circular as defining "poor". The poor today have color tv's. Only the rich had them when I was a kid. "poor" is a moving target, so is basic needs.

How do you balance the needs of the individual against that of the society in terms of healthcare?

There is no such thing as "society". That's a macro definition subject to the whims of whoever is using it. It is a result of individual actions.

If we agree on a natural right to healthcare access

We do not. I do agree that everyone (almost) wants any medical care available. Natural survival instinct. That's not the question. The question is what are they willing to do to get it? Are they willing to peaceably obtain it? Or do they want to take it by force? Tough question. It's not easy to admit that you can't afford the care you desire and be moral enough not to just take it from someone else, especially when it's wrapped up in such pretty packages as "Medicare" and/or insurance that make it difficult to see that the real source of that care is money taken from someone else.

Given our current saving rate, it would require radical behavior mod for the populace.

Should the failure of the parent be paid for by the child? That's fine if the child is willing, but if that's the case then mandatory programs are unnecessary. Ok, so the descriptions "retiree" and "worker" break the direct genetic link. Morally, I think this is even worse because there's no sense of self-restraint towards someone else's children.

I have no idea what the transition would look like, no one but libertarians even consider it. But the way things are headed, it looks like an ugly crash. Unless the free market and technology work their magic. We do seem to make progress in spite of all the handicaps the government comes up with.

while providing for those who can't afford basic care

Again, you're missing the circular logic. More importantly, you're missing the fact that while you may have a reasonable definition of poor, the people that will administer such a program will certainly come up with a different definition. Isn't that what's happened/happening? It's not your definition that counts, it's theirs

Rick Barton | January 30, 2006, 9:42pm | #

We're Europe, get over it. Stick a fork in us, we're done.

No we aren't. Not yet. We shouldn't let em get us without a fight. We should work for the repeal of this monstrosity. And we should also work for a deregulatory freeing up of health care so it wil be less expensive. Health care is far too important to have the government involved.

science | January 31, 2006, 2:42am | #

Jeffiek

Re: "There is no such thing as "society". That's a macro definition subject to the whims of whoever is using it. It is a result of individual actions."

I'd say the English language works better than that. But that is one of the challenges Libertarians often face, using common language in ways that don't communicate to the rest of the world. Society is a very stable concept. Do not confuse levels of analysis here. Society is the result of individual actions, yes, but it is an entity that has needs that can be balanced against the individuals that make it up. An ant colony is a collection of individual actions. The needs of the colony differ from those of the individuals. Doesn't mean we can't define the colony or its needs. And, funny thing, the individuals don't do so well without the colony.

Re: Only to find that "basic needs" is just as circular as defining "poor". The poor today have color tv's. Only the rich had them when I was a kid. "poor" is a moving target, so is basic needs."

Nope, basic needs haven't changed. Food, water, shelter, healthcare, security, etc... Just cuz a color TV is cheaper than getting your teeth cleaned doesn't mean poverty is a moving target. Basic needs are still basic needs. Spend some time in the world and it is not hard to recognize poverty.

Re: "I have no idea what the transition would look like, no one but libertarians even consider it."

A strange response since I am certainly not a libertarian, and I was the one that raised the issue. Many people consider these things with more appreciation of the complexities than many libertarians (I'm gonna lump you in with the ones that fail to see the subtle nature of the problem--feel free to prove me wrong).

How can anyone who believes in natural rights not include a right to healtcare access. Do you really want me to believe that you hold the right to control a material possession higher than the right to be helped when you are sick? Think about it. Then consider it again the next time you have a broken limb or a cavity. Why did the founders change that last little bit from the "pursuit of property" to the "pursuit of happiness?" I'm gonna guess because they appreciated which one was more basic.

Like I said, healthcare is a challenge for the libertarian philosophy (and all the others, by the way). I was hoping to get more suggestions for solving the problem than criticism for claiming there is a problem. Maybe some of the folks around here smarter than me have some suggestions. I don't see a free market solution. I think a hybrid is the only way out. But not the one we've got.

dflynn | January 31, 2006, 9:00am | #

"How can anyone who believes in natural rights not include a right to healtcare access. Do you really want me to believe that you hold the right to control a material possession higher than the right to be helped when you are sick? "

The only way a sick person can be entitled to help is if the helper is obligated to do the helping without compensation. That is slave labor. In addition, the owners of medicines, medical supplies, and other tangible healthcare items must be obligated to give them away. That is theft. You are seeking a free market solution to the forcing of people into charitable organizations. You are right that it doesn't exist.

I am not a libertarian, but I do believe in private property and basic concepts of economics. If you want to place infinite demand in the hands of the public, you had best provide a solution for infinite supply, else you will need to soothe the public when they encounter shortages of service.

MP | January 31, 2006, 9:48am | #

How can anyone who believes in natural rights not include a right to healtcare access.

Natural rights are individualistic, not communitarian. They do not impose obligations on others.

R C Dean | January 31, 2006, 10:15am | #

How can anyone who believes in natural rights not include a right to healtcare access.

I think most libertarians would agree that you have the right to access all the healthcare someone will voluntarily provide you.

science | January 31, 2006, 11:22am | #

"The doctor must work without compensation or others must work to provide the money to pay the doctor. "

"The only way a sick person can be entitled to help is if the helper is obligated to do the helping without compensation. That is slave labor."

"the owners of medicines, medical supplies, and other tangible healthcare items must be obligated to give them away. "

Ok, so I understand why you don't see healthcare as a right... but I also see a solution here. Since libertarians see protection of property rights as basic, they (usually) support law enforcement to some degree (to keep me from taking your property). This is usually one of the roles that is (reluctantly) given to government. So, the police cannot provide you with a service unless they give away their service for free, or everyone agrees to pay them. This is not outside of the libertarian view of appropriate use of government. How can this principle be applied to healthcare. Pretty directly it seems to me. It is even hinted at above. Hence my idea that a hybrid is the solution.

"Basic Needs" -- sorry, they just ain't as fuzzy as you suggest. Nor is access. Access means the service is available if you want to utilize it. No one is gonna force you..

"basic concepts of economics. If you want to place infinite demand in the hands of the public, you had best provide a solution for infinite supply"

Basic economics. The need is not infinite, nor is the supply.

"By the way, I'm sick. I want you to sell your house to pay for my medical care. If you disagree, I'll just get the government to evict you and take it. How does it sound when the obfuscation of government programs is removed and the problem is stated in direct personal terms?"

Sorry that is just a silly strawman. Obfuscation in the other direction. Let's try again. I am sick, luckily we have all agreed to give a small portion of our income to support a community healthcare provider. You are free not to participate, but since our community provides you with a service, we are gonna have to ask you to pay up or find another place to live. Can't have you stealing the community property.

jeffiek | January 31, 2006, 11:34am | #

Sorry that is just a silly strawman. Obfuscation in the other direction.

Actually, it's not. An exaggertation certainly, but not a strawman.

Let's try again. I am sick, luckily we have all agreed to give a small portion of our income to support a community healthcare provider.

If the agreement is really there, then why is a law neccessary to enforce it? And who defines "small"? Isn't the definition of small the very reason for this thread? If it were small how could Medicare be in a death spiral?

You are free not to participate, but since our community provides you with a service,

If I don't participate then the community is not providing me with a service.

we are gonna have to ask you to pay up or find another place to live.

Which brings us right back to your accusation that I was using a strawman, only this time you're using it.

dflynn | January 31, 2006, 11:40am | #

Demand and need are not interchangeable terms.

A system where healthcare workers are employed by the state could lead to universal coverage, but not everyone wants their doctor to have no more incentive to treat their complaints than a postal worker. Government employees tend to be very creative at obtaining ever increasing levels of compensation for ever decreasing quality of service.

science | January 31, 2006, 11:57am | #

"If the agreement is really there, then why is a law neccessary to enforce it?"

To prevent theft of the community property. Living in a community is a balance between rights and responsibilities. Remember those taxes we were discussing above, those pay for many services ... law enforcement, fire department.... Can you choose never to use any of the services provided? Once you have voluntarily agreed to participate in society, they agree to protect your rights, but those rights come with obligations. Otherwise you are asking the society to provide for you without compensation... and I believe you called that theft.

Please give me concrete suggestions for how to solve this from your perspective. I don't see a free market solution... help me understand one. Difficulty in defining basic needs or poverty (from you stance) do not make those realities go away. How do we realistically deal with them from your view.

And yes, strawman = flimsy characterization of something more substantial... often done with exaggeration. An example would be "medicare death spiral." Usually used in an attempt to direct a debate towards a particular aspect of the issue at hand... not substantial enough to provide for a real solution.

science | January 31, 2006, 12:06pm | #

To be clear...

"You are free not to participate" means participate in society.

jeffiek | January 31, 2006, 12:12pm | #

Once you have voluntarily agreed to participate in society,

Haven't heard that one in a while. Please, tell me, when did I voluntarily agree to participate in this society? Do people sign some kind of contract? Is there an oath or something? I must have been out sick that day, or maybe the notice got lost in the mail.

Otherwise you are asking the society to provide for you without compensation... and I believe you called that theft.

I, and I believe all libertarians, are not asking the society (government) to provide health care. On the contrary, we want the government to stop taxing (remember, the thread is limited to the healthcare, we're not talking police here) us for something we don't want so that we can provide for ourselves.

Please give me concrete suggestions for how to solve this from your perspective. I don't see a free market solution... help me understand one.

I understand that many people have difficulty "unlearning" concepts that have been drummed into them since childhood (seriously, I'm not being sarcastic or judgemental). But it really is simple, free market is only two words.
Try mises.org or fee.org to learn (unlearn?).

As for suggestions as to how to get out of this tangled mess, I'm stumped. If I had them, I'd bottle them, sell them, and get rich.

dflynn | January 31, 2006, 12:28pm | #

If you believe that Medicare death spiral is a strawman, then I think you are in denial. Medicare, as the law currently exists, is headed for a fiscal cliff due largely to demographics.

What is the biggest problem for universal coverage? I will answer using my own example. I pay $24,000 per year for health insurance to cover me, my wife and my two children. I have $1,000 deductible per person as that was the most I could choose. If the government were to provide me a mechanism for obtaining the same quality of coverage and let you pay for it, why would I continue to pay out $24,000 per year? The problem is not finding a mechanism for the uninsured to obtain insurance. The problem is preventing the currently insured from bolting to the government solution at less cost to themselves and greater cost to the government.

The only path to universal coverage requires healthcare workers to be employees of the state. It also requires compulsory participation. Any free market solution will result in different coverage for different people depending on how important coverage is to them.

You are trying to pound a square peg into a round hole.

science | January 31, 2006, 1:09pm | #

Re:"If the government were to provide me a mechanism for obtaining the same quality of coverage and let you pay for it, why would I continue to pay out $24,000 per year? The problem is not finding a mechanism for the uninsured to obtain insurance. The problem is preventing the currently insured from bolting to the government solution at less cost to themselves and greater cost to the government."

I don't think that the government solution would need to provide you with the same level of healthcare, just the basics. And there are certainly mechanisms for determining eligibility for the government program that would discourage flight of those with the means (a sliding scale of some sort). I think it is a problem that can be solved. It can't be solved, as far as I see, without some sort of government action, however.

neilpaul | January 31, 2006, 1:27pm | #

Science,

most people just want the "basics" anyway. Or are you suggesting that life saving medicines not be provided to those on the dole? What king of non-basic healthcare will the gov't not be providing? Elective plastic surgury? That will save a bundle, I'm sure.

Socialized medicine may be slavery, but that's what we have already. We just have horribly inefficient socialized medicine. Just get over it and socialize it properly. Also AMericans wait in line for care all the time. It takes months to schedule many operations. That is a line you're waiting in. Get over that too.

dflynn | January 31, 2006, 1:36pm | #

"And there are certainly mechanisms for determining eligibility for the government program that would discourage flight of those with the means (a sliding scale of some sort). "

I thought we were talking about universal coverage. I guess not.

dflynn | January 31, 2006, 1:44pm | #

"Also AMericans wait in line for care all the time. It takes months to schedule many operations. That is a line you're waiting in. "

Would you give some examples? The only examples I can think of are organ transplants and the availability of donor organs are beyond even Ted Kennedy's magic wand. Coronary bypass, valve replacement, hip fractures, tumor resection or biopsies rarely take even a week to schedule in the USA.

science | January 31, 2006, 2:33pm | #

"I thought we were talking about universal coverage. I guess not."

Well I guess that depends on what you mean by universal. I am thinking is that if society agrees that everyone should be able to get their basic healtcare needs met, then their should be a mechanism for providing it to those whose private means are not up to the job (that's currently medicaid). The current problem comes from a gap between the government program and the need. Many people are making the economic decision to forgo insurance and hope they don't get hit with a health cost they can't afford. This creates a problem for everyone when they do get hit with such a cost.

I am thinking universal insurance style coverage for the hugely costly stuff that it makes sense to spread out the cost of, government support for well-care needs of the poor (usually pretty cheap). And let those who have the means use private mechanism for their well-care needs.

A modification of what we have, rather than elimination I guess. One that keeps people's eyes on the true costs by taking the employer out of the loop (avoiding GM/FORD type problems).

For medicare this would mean that those who have the means to provide their own healthcare don't get the government benefit. Medicare would be for the retired school teacher on a fixed income, and not the retired CEO with a still active porfolio of income generating investments.

"Or are you suggesting that life saving medicines not be provided to those on the dole?"

I am not sure people just want the basics. Life saving medicines count as basic. This gets us to a separate issue, that of evidence-based medicine which only pays for the treatment most appropriate to the condition. This is where the tough choices get made. Like I said, all models breakdown somewhere.

science | January 31, 2006, 2:43pm | #

This
http://www.msnbc.msn.com/id/11098797/

is quite tightly wound up in this issue. Particularly when it comes to defining basic needs.

jeffiek | January 31, 2006, 2:49pm | #

You agreed to participate upon reaching adulthood

This bothers me. Agreement is an action of the mind. Reaching adulthood is merely the passage of time. The two in the same sentence is meaningless. You might as well say I agree to die of old age.

Free market is an ideal

Agreed. But it is the only one that is actually obtainable. Perhaps not in our lifetime. All other solutions are doomed to failure.

It can't be solved, as far as I see, without some sort of government action

Here we disagree. I'll leave you with this. I agree to disagree. I will let you go your own way. I will not try, nor will I support anyone that tries, to force you to behave against your wishes or to pay for what you don't want. That is what I consider living peacefully.

Will you do the same for me?

MP | January 31, 2006, 3:10pm | #

Any inelasticity is in your own mind. There are plenty of times and reasons people choose to forgo certain medical procedures. Ever hear of "do not resusitate" orders?

Critical care is inelastic. When you are having a heart attack and are rushed to the hospital, what price are you not willing to pay to be kept alive? A DNR only covers the brain death or extreme organ failure.

And when you are having a heart attack, you are in no position to shop around for the best price.

There are laws that mandate that a hospital must treat all critical care patients. In a perfect laissez-faire world, these laws wouldn't exist. If you say "that's a good thing", well then you've just introduced a whole new level of class stratification to society.

It is much easier to make a case for a free market in elective health care than a free market in critical health care.

jeffiek | January 31, 2006, 3:33pm | #

A DNR only covers the brain death or extreme organ failure.

But my position still stands that there is elasticity in medical care.

And when you are having a heart attack, you are in no position to shop around for the best price.

And if it bothers you, I'm sure you'ld be willing to buy insurance. Which, by the way, would be much cheaper in a free market. Such a situation is what insurance is really for, risks that are relatively rare and may or may not occur. This is different from routine care.

There are laws that mandate that a hospital must treat all critical care patients.

Which creates a financial problem for the hospital. Which requires another law (taxes) to fix. Which causes more people to be too poor to afford insurance. Which requires another law .....

Read Mises for a better explanation.

MP | January 31, 2006, 3:43pm | #

jeffiek,

You are still dodging the tough issue of what to do with an uninsured critical care patient (or even the insufficiently insured patient). I guess the hardcore libertarian answer is "they should die". That's an answer I'm not able to accept. But I'm also not able to accept "cost is no object when saving a life", so I'm stuck with a problem that is unable to be solved based on my requirements.

Dar | January 31, 2006, 4:22pm | #

MP - Would you then just have a formula to determine how much value saving each person would be added to society should they live.

As in save the highly paid people since they paid the taxes that are funding saving them now that they need it. Or let the poor workng class or welfare peeps just die because they never really put anything into the system to begin with to cover their expenses now that they need it, nor in all likelyhood will they ever make much income to be taxed in the future.

Cost benefit analysis is all its about. Like taking someones property to try and better the good of the whole public at large. Saving a gang banger versus saving someone worth a damn is a no brainer. With which will the public be most rewarded for saving. Limitied resources will always be the norm not the exception.

science | January 31, 2006, 4:34pm | #

j

Re:"Free market is an ideal

Agreed. But it is the only one that is actually obtainable. Perhaps not in our lifetime. All other solutions are doomed to failure."

Here we can agree to disagree. It is not, I think, even theoretically obtainable, let alone the only ideal possible to obtain.

Again, I would say all complex adaptive systems have as part of their functioning, regulatory systems, which bias the operating conditions in ways that allow for as-optimum-as-possible functioning.

Some ideals are most applicable to one type of problem, while others work in others. I think your ideal is more applicable to issues that truly involve individual level choice and needs, but when a problem impacts the society as a whole, you get into problems (like healthcare). The solution that arises in the free market of ideas tends to be some form of government. The issue is how to keep mission creep from making government ineffective. This is the nature of our current debate.

as for:"I will not try, nor will I support anyone that tries, to force you to behave against your wishes or to pay for what you don't want. That is what I consider living peacefully."

In principle I am fine with this agreement. It requires, however, a way, a process, for determining if/when one of us is not living up to our side of the bargin. If you decide to interface with the society, which provides you with many things you want/need, it is important that you live up to your part of the contract and input resources that allow the society to function. It operates at a different level of complexity than you, so the interface is difficult to manage. The aggregated behavior of individuals will put pressure on the system to regulate unruly behavior that upsets the smooth operation of the system. If you are one of those unruly elements, the system will grind you up to meet its needs. That's why it is important to establish ground rules (bias the system) for both the behavior of the individuals and the behavior of the system in regards to those individuals-- to avoid the violent conflict that emerges and always favors the system. If a free market existed without government regulation, it would invent government regulation to improve its functioning.

Power is a real element of human interactions. Free market ideals often assume equal power in transactions, and rational behavior of the agents involved. A rare thing in real life.

jeffiek | January 31, 2006, 7:09pm | #

Oh yeah. I almost forgot. Any jerk that stands by and watches someone die is just that. Call him that on the 6 o'clock news, post his picture in the paper, shame him any way you want.

Fire him if you're his boss. Divorce him if he's your spouse. Disown him if he's your child.

Just don't steal his money.

science | January 31, 2006, 8:41pm | #

Just don't steal his money...

And that seems a perverse thing to place at the top of your moral ideology. At least to most people

jeffiek | January 31, 2006, 8:55pm | #

Being against theft is perverse? It's number eight in the Ten Commandments.

Healthcare didn't even make the list.