Coyote Blog

Via Cafe Hayek, Paul Krugman says:

And surely the fact that the United States is the only major advanced nation without some form of universal health care is at least part of the reason life expectancy is much lower in America than in Canada or Western Europe.

If I were a cynical person, I might think that the tortured and overly coy syntax of this statement is due to the fact that Krugman knows very well that the causation he is implying here is simply not the case.  Rather than rehash this age-old issue here on Coyote Blog, let's roll tape from a post a few years ago:

Supporters of government medicine often quote a statistic that shows life expectancy in the US lower than most European nations with government-run health systems.  But what they never mention is that this ranking is mainly due to lifestyle and social factors that have nothing to do with health care.  Removing just two factors - death from accidents (mainly car crashes) and murders - vaults the US to the top of the list.  Here, via Carpe Diem, are the raw and corrected numbers:

And so I will fire back and say, "And surely the fact that the United States is the only major advanced nation without some form of universal health care is at least part of the reason life expectancy related to health care outcomes is so much higher in America than in Canada or Western Europe.

And check out the other chart in that post from that study:

US cancer survival rates dwarf, yes dwarf those of other western nations.    Even black males in the US, who one would suppose to be the victims of our rapacious health care system, have higher cancer survival rates than the average in most western nations (black American women seem to have uniquely poor cancer survival rates, I am not sure why.  Early detection issues?)

All this data came originally from a post at Carpe Diem, which I refer you to for source links and methodologies.

Megan McArdle has a great post on the CMS post. Bascially, there is no magic bullet to cut medical costs.  Benefits are going to get cut and costs are going to go up.

I really don't need the report to tell me this.   Here is the common sense answer -- before this administration embarked on the health care fiasco, we all pretty mich knew that Medicaire and Medicaid bankrupt and was going to blow a huge hole (McArdle's term) in the budget.  So, since this bill at its heart is really just an expansion of Medicaire/Medicaid to cover more people, how can we expect it to do anything but blow an even bigger hole in the budget.

By the way, years ago I wrote:

...health care is not like failed Great Society housing programs.  In those housing programs, only the poor got crappy government housing "” the rest of us kept what we had.  Universal health care is different, because it will effectively be like forcing everyone to move into the housing projects.

Now that we know what is in the actual bills, I stand by this prediction.  Here is the poll question I would still like to see:

Would you support a system of government-run universal health care that guaranteed health care access for all Americans, but would result in you personally getting inferior care than you get today in terms of longer wait times, more limited doctor choices, and with a higher probabilities of the government denying you certain procedures or medicines you have access to today.

Perhaps the scariest potential effect of the proposed health care bills is the negative effect they likely will have on innovation.  And if we adopt the bill, we will never know what we have lost.  Unlike budgets, which with near certainty will become overdrawn quickly, we will never be able to point to the health care innovation we didn't have.

I want to quote liberally from a Ronald Bailey post, but I encourage you to read the whole thing:

Yet, the elements of market competition that still manage to survive have had the salubrious effect of driving medical innovation and improving patient health outcomes. A new study by the free market Cato Institute, "Bending the Productivity Curve: Why America Leads the World in Medical Innovation" reports:

...In three of the four general categories of innovation examined in this paper "” basic science, diagnostics, and therapeutics "” the United States has contributed more than any other country, and in some cases, more than all other countries combined. In the last category, business models, we lack the data to say whether the United States has been more or less innovative than other nations; innovation in this area appears weak across nations....

...Harvard University economist Kenneth Rogoff observed:

"[I]f all countries squeezed profits in the health sector the way Europe and Canada do, there would be much less global innovation in medical technology. Today, the whole world benefits freely from advances in health technology that are driven largely by the allure of the profitable U.S. market. If the United States joins other nations in having more socialized medicine, the current pace of technology improvements might well grind to a halt."

In my column, "2005 Medical Care Forever," I suggested this thought experiment:

...what if the United States had nationalized its health care system in 1960? That would be the moral equivalent of freezing (or at least drastically slowing) medical innovation at 1960 levels. The private sector and governments would not now be spending so much more money on health care. There might well have been no organ transplants, no MRIs, no laparoscopic surgery, no cholesterol lowering drugs, hepatitis C vaccine, no in vitro fertilization, no HIV treatments and so forth. Even Canadians and Britons would not be satisfied with receiving the same quality of medical care that they got 45 years ago....

As Rogoff suggests, the nationalized health care systems extolled by progressives have been living off the innovations developed by the "only country without a universal health care system." I wonder how Americans would vote if they were asked if they would be happy freezing medical care at 2005 levels forever?

Previously, I used 1970s gas price lines as an example of a situation where the government, as Uwe Reinhardt puts it, "reduce[d] rationing on the basis of price and ability to pay."

Here is another example:  The Pruitt Igoe housing project in St. Louis, which was abused so badly by its occupants it had to be torn down less than 20 years after it was built.

I will remind you of my earlier comparison of universal health care to public housing:

Lyndon Johnson wants to embark on a futile attempt to try to provide public housing to the poor?  Our taxes go up, a lot of really bad housing is built, but at least my housing did not get any worse.  Ditto food programs "” the poor might get some moldy cheese from a warehouse, but my food did not get worse.  Ditto welfare.  Ditto social security, unemployment insurance,and work programs.

But health care is different.  The author above is probably correct that some crappy level of terribly run state health care will probably be an improvement for some of the poor.  But what is different about many of the health care proposals on the table is that everyone, not just the poor, will get this same crappy level of treatment.  It would be like a public housing program where everyone's house is torn down and every single person must move into public housing. That is universal state-run health care. Ten percent of America gets pulled up, 90% of America gets pulled down, possibly way down.

From Mickey Kaus:

Democratic blogger Ezra Klein appears to be positioning Dem health care reforms as a way to cut costs, on the grounds that a reformed system will be able to make "hard choices" and "rational" coverage decisions, by which Klein seems to mean "not providing" treatments that are unproven or too expensive--when "a person's life, or health, is not worth the price." Matthew Yglesias' recent post seems to be saying the same thing, though clarity isn't its strong suit. (He must have left it on Journolist.)

...

The "rational," cost-cutting, "hard-choices" pitch isn't just awful marketing--I don't even think it's accurate. Put it this way: I'm for universal health care in large part precisely because I think the government will be less tough-minded and cost-conscious when it comes to the inevitable rationing of care than for-profit insurance companies will be. Take Arnold Kling's example of a young patient with cancer, where "the best hope is a treatment that costs $100,000 and offers a chance of success of 1 in 200." No "rational bureaucracy" would spend $20 million to save a life, Kling argues. I doubt any private insurance company is going to write a policy that spends $20 million to save a life.  But I think the government--faced with demands from patient groups and disease lobbies and treatment providers and Oprah and run, ultimately, by politicians as terrified of being held responsible for denying treatment as they are quick to pander to the public's sentimental bias toward life--is less likely to be "rational" than the private sector.

That is to say, the government's more likely to pay for the treatment (assuming a doctor recommends it). So it's government for me.

He comes oh-so-close to getting it right, but then falls short.

Klein is right that the pressure will be to ration care -- we already see such rationing being seriously considered in Massachusetts (the model of choice for Democrats) under the weight of massive expenditures.

But Kaus is correct that if some high-powered and well-funded interest group gets behind a certain procedure, cost-effective or not, the government overlords of the program will likely approve it.   As a result, for example, no potential treatment for breast cancer will ever be denied given the proven strength of women's groups lobbying for breast cancer treatment (already, breast cancer research is hugely over-funded vs. other diseases given its mortality, due in large part to this powerful lobbying).

But it is not one dynamic or the other.  Both will exist.  There will be huge pressures to cut back somewhere, as costs skyrocket.  And there will be huge pressure from certain interest groups to fund treatment for certain diseases in unlimited amounts.  The result will not be, as Kaus posits,  that everything will be funded more than it is today -- the result will be that certain procedures and conditions with strong lobbying and political muscle will get funded more, with the difference being made up from cutting funding for conditions and procedures without a well-organized lobby.

Access to care will no longer be determined by money, but by political pull.  (Yeah, I know, it's Ayn Rand's world and we all just live in it).

I have argued for a while that one of the undiscussed problems with nationalized or universal health care is that by socializing the costs of individual lifestyle decisions (e.g. eating, drinking, smoking, wearing a bike helmet, etc) it creates a strong financial incentive for the government to micro-manage individual behavior.  I call this the health care trojan horse for fascism (other posts here).

Q&O has a good post, quoting from Paul Hsieh, on this very topic.

Here's how I understood freedom and liberty worked:

Of course healthy diet and exercise are good. But these are issues of personal "“ not government "“ responsibility. So long as they don't harm others, adults should have the right to eat and drink what they wish "“ and the corresponding responsibility to enjoy (or suffer) the consequences of their choices. Anyone who makes poor lifestyle choices should pay the price himself or rely on voluntary charity, not demand that the government pay for his choices.

Does anyone have a particular argument with that?

In fact, if you believe in freedom and liberty, there really isn't another choice, is there?

But here's what's being offered as the alternative:

Government attempts to regulate individual lifestyles are based on the claim that they must limit medical costs that would otherwise be a burden on "society." But this issue can arise only in "universal healthcare" systems where taxpayers must pay for everyone's medical expenses.

The article has a lot of good examples that follow.  Mr. Hsieh's op-ed is here.

As a side note, I was watching the movie "The Golden Compass"  the other day.  The author and the original book are quite critical of religion, at least of the organized kind, and the evil fascist entity against which the protagonists fight is a world-controlling church.  The movie actually purged most of the religion criticism (or at least made it more subtle) and made the bad buys more generically totalitarian, but hangover criticism of the book stuck to the movie as well.

It was not really a particularly good (or bad) movie, but it had one set of lines spoken by the Nicole Kidman character that I couldn't believe came out of Hollywood.  The protagonist, Lyra, asks Kidman about the contradiction between Kidman's unwillingness to let anyone tell her what to do and the rule-making and absolute obedience that her organization demands of all citizens.    I need to go back and watch the movie to get it exactly right (of course, no one on the movie sites found it memorable enough to post).  But it was something like "Only a few of us are capable of making good decisions for ourselves.  We few have to make decisions for everyone else.  It is really for their own good."  It was really a brilliant summary of the modern political mentality, and slipped through I think only because people in Hollywood took it as a criticism of the religious right, not recognizing it as an equally damning indictment of the left.  (if anyone has the exact quote or a link, please post.  It was on the dirigeable fairly early in the movie, I think).

Update: OK, the Golden Compass lines I wanted start about the 3:00 minute mark in this video [thanks to commenter for showing how to link to a specific point in a YouTube video].  Here is how I transcribed it:

Kidman (Mrs. Coulter):  The Magesterium [the world-girdling totalitarian organization] is what people need, to keep things working, by telling people what to do.

Lyra:  But you told the master that you do whatever you please

Kidman:  That's right, clever girl.  Well, some people know what's best for them, and some people don't.  Besides, they don't tell people what to do in a mean and petty way, they tell them in a kindly way, to keep them out of danger.

Its really hilarious to read through reviews, as I have trying to find this quote.  Apparently (though I missed it at the time) it became a left-right debate about the movie.  The hilarious part is all the left-leaning blogs criticising the right for not seeing how well the shoe fits, without for a second considering that this is a perfect recitation of their end game as well.

Again, about 3:00 into the below:

The looming federal government takeover of health care as proposed by most of the major presidential candidates will be far worse than anything we have seen yet from government programs.  Take this example:  In the 1960's, the federal government embarked on massive housing projects for the poor.  In the end, most of these projects became squalid failures.

With the government housing fiasco, only the poor had to live in these awful facilities.  The rest of us had to pay for them, but could continue to live in our own private homes.

Government health care will be different.  Under most of the plans being proposed, we all are going to be forced to participate.  Using the previous analogy, we all are going to have to give up our current homes and go live in government housing, or least the health care equivalent of these projects.

Think I am exaggerating?

One such case was Debbie Hirst's. Her breast cancer had metastasized, and the health service would not provide her with Avastin,
a drug that is widely used in the United States and Europe to keep such
cancers at bay. So, with her oncologist's support, she decided last
year to try to pay the $120,000 cost herself, while continuing with the
rest of her publicly financed treatment.

By December, she had
raised $20,000 and was preparing to sell her house to raise more. But
then the government, which had tacitly allowed such arrangements
before, put its foot down. Mrs. Hirst heard the news from her doctor.
"He looked at me and said: "˜I'm so sorry, Debbie. I've had my wrists
slapped from the people upstairs, and I can no longer offer you that
service,' " Mrs. Hirst said in an interview...

Officials said that allowing Mrs. Hirst and others like her to pay
for extra drugs to supplement government care would violate the
philosophy of the health service by giving richer patients an unfair
advantage over poorer ones.

Patients "cannot, in one episode
of treatment, be treated on the N.H.S. and then allowed, as part of the
same episode and the same treatment, to pay money for more drugs," the
health secretary, Alan Johnson, told Parliament.

Here is the poll question I would still love to see asked:

Would you support a system of
government-run universal health care that guaranteed health care
access for all Americans, but would result in you personally getting
inferior care than you get today in terms of longer wait times, more
limited doctor choices, and with a higher probabilities of the
government denying you certain procedures or medicines you have
access to today.

I was going back through my archives and I found a health care poll question I suggested about a year ago that I would still love to see asked.  I believe it accurately reflects the reality that most middle class Americans face with various universal health care plans:

Would you support a system of
government-run universal health care that guaranteed health care
access for all Americans, but would result in you personally getting
inferior care than you get today in terms of longer wait times, more
limited doctor choices, and with a higher probabilities of the
government denying you certain procedures or medicines you have
access to today.

I have said a number of times that health care is not like failed Great Society housing programs.  In those housing programs, only the poor got crappy government housing -- the rest of us kept what we had.  Universal health care is different, because it will effectively be like forcing everyone to move into the housing projects.

For a while now, I have been fascinated by the contrast between the Left's position on abortion and its position on universal health care. 

In the abortion debate, the Left was careful to try to establish a broader principal than just support for abortion.  Their position was (and still is) that the government should not interfere in a woman's decision-making about her own body.  Cool.  That's a general principal that any libertarian could love  (Note that there are many libertarians who accept this principal but argue that abortion is the one exception to it if one considers the fetus an independent life.)  The National Organization for Women have cleverly embodied this general principal in the T-Shirt below:

So now we come to universal health care.  And most every leftish plan has the government paying all of our health care bills.  Well I can absolutely assure you now, both via common sense and observance of practices in European countries with socialized medicine, that a couple of things follow from universal coverage:

1. The government will be the final decision maker for what care each person will or will not get, how procedures will be performed, and what drugs will be authorized.  If they did not take on these decisions, the system would simply implode financially.  The government cannot afford to pay the bills while allowing individuals to still make their own choices about their care.
2. The government will have a strong financial incentive to change people's individual lifestyles.  What they eat, how they exercise, their sexual practices, etc. all have a great influence on future health care costs.  Already, we see countries like Britain starting to meddle in these lifestyle choices in the name of reducing health costs.  It is why I have termed the health care Trojan horse for fascism.

I don't think even universal coverage supporters would refute these two points except to say maybe "yes, the government will do those things but we promise to be gentle."   Here is Jon Edwards:

"I'm mandating healthcare for every man woman and child in America and that's the only way to have real universal healthcare."

"Evertime you go into contact with the helathcare system or the govenment you will be signed up."

During a press avail following the event Edwards reiterated his mandate:

"Basically every time they come into contact with either the healthcare
system or the government, whether it's payment of taxes, school, going
to the library, whatever it is they will be signed up."

When asked by a reporter if an individual decided they didn't want healthcare Edwards quickly responded, "You don't get that choice."

So given that, how does the left hold universal coverage in their head at the same time as they argue that "a woman should make decisions for her own body"?  How can the NOW website sell "Keep your laws off my body" T-shirts while promoting universal coverage laws on their home page?  How do you reconcile "pro-choice" with Edward's "you don't get that choice."

I am really interested in someone taking a shot at this.  And don't tell me that the difference is that in universal coverage, the argument is just over what the government will and won't pay for.  I agree not having the government pay for something is not the same as banning it when there are plenty of private alternatives.  But in the systems being advocated by Democratic candidates like Edwards, there will be no "other system" -- the government will be the monopoly provider, or at least the monopoly rules-setter.  It will be what the government wants to give you or nothing.  And there won't even necessarily be another country to which one can run away to get her procedure, because America is that country today where victims of socialist medicine escape to get needed and timely care.

Via Q&O:

Again, the grand claim of such a system is it will be more efficient
and less costly. Nary a one of the systems in existence today that I've
read about has lived up to the "efficiency" claim, if access and
waiting times are a measure of efficiency. Every one of them seems to
suffer from lack of access.

Secondly, the "less costly" claim
seems to be accomplished by limiting access and limiting treatment. A
rigid structure with prescribed treatments which disallow deviation.
Imagine the sort of cancer treatment forced on the Japanese attempted
here. Now imagine it with any other chronic disease you can name.

What's the premise at work in a system like that?

Commenting
on the WSJ article, Craig Cantoni, a columnist in Scottsdale, Ariz.,
writes: "Like nationalized health care in other countries, the Japanese
system is based on the premise that the state owns your body."
Therefore, "the state can dictate what medical care can be withheld
from you, either by policy or by making you wait so long for care that
you die in the mean time."

We see all sorts of bloviation
by the left about attacks on our liberty. Yet, for the most part, they
are supportive of the most insidious attack on our liberty you can
imagine with their call for some form of universal health care system
here. And make no mistake, all of the leading Presidential candidates
are talking about an eventual government-run system despite their
obvious spin.

I've said something similar for years.  As one example, I have pointed out that the National Organization of Women's strong support for national health care just demonstrates their utter intellectual bankruptcy, as I wrote here:

What this article really shows is that by going with a single-payer
government system, each of us would be ceding the decisions about our
health care, our bodies, and even lifestyle to the government.  So
surely women's groups, who were at the forefront of fighting against
government intrusion into our decisions about our bodies, is out there
leading the fight against government health care.  WRONG!
Their privacy arguments stand out today as sham libertarian arguments
that applied only narrowly to abortion.  It's clear that as long as
they can get full access to abortion, women's groups are A-OK with
government intrusion into people's decisions about their bodies.

Don't miss their web site, which has sales offers for "Keep your laws of my body" T-shirts right next to appeals to "demand health care for all now."

I am always absolutely amazed when advocates of some form of national or single-payer health care argue that such a system would be more efficient.  For example, Kevin Drum argued:

A few days ago, during an email exchange with a
friend, I mentioned that I don't usually tout cost savings as a big
argument in favor of universal healthcare. It's true that a national
healthcare plan would almost certainly save money compared to our
current Rube Goldberg system, but I suspect the savings would be
modest. Rather, the real advantages of national healthcare are related
to things like access (getting everyone covered), efficiency (cutting down on useless -- or even deliberately counterproductive -- administrative bureaucracies), choice
(allowing people to choose and keep a family doctor instead of being
jerked around everytime their employer decides to switch health
providers), and social justice (providing decent, hassle-free healthcare for the poor).

I don't think any of these are true.  For example, let's take access.  Yes, everyone in a universal health care system would have a piece of paper that says they have health care, and the left seems really focused on that piece of paper.  But that paper has about as much value as my piece of paper that says I own a hundred shares of Enron.  Because someone has to redeem that piece of paper and actually provide the care, and there is the rub, is it not?  Canadian David Gratzer writes (vis Q&O):

My book's thesis was simple: to contain rising
costs, government-run health-care systems invariably restrict the
health-care supply. Thus, at a time when Canada's population was aging
and needed more care, not less, cost-crunching bureaucrats had reduced
the size of medical school classes, shuttered hospitals, and capped
physician fees, resulting in hundreds of thousands of patients waiting
for needed treatment"”patients who suffered and, in some cases, died
from the delays....

Nor were the problems I identified unique to
Canada"”they characterized all government-run health-care systems.
Consider the recent British controversy over a cancer patient who tried
to get an appointment with a specialist, only to have it canceled"”48
times. More than 1 million Britons must wait for some type of care,
with 200,000 in line for longer than six months. A while back, I toured
a public hospital in Washington, D.C., with Tim Evans, a senior fellow
at the Centre for the New Europe. The hospital was dark and dingy, but
Evans observed that it was cleaner than anything in his native England.
In France, the supply of doctors is so limited that during an August
2003 heat wave"”when many doctors were on vacation and hospitals were
stretched beyond capacity"”15,000 elderly citizens died. Across Europe,
state-of-the-art drugs aren't available. And so on.

I had forgotten about the heat wave.  Could you imagine backwards old America having 15,000 people die when the temperature got into the 90's?

As to efficiency, which Drum defines as "cutting down on useless -- or even deliberately counterproductive -- administrative bureaucracies," does anyone really ascribe these characteristics to the government?  Really?  Even European health care bureaucrats would not agree with this statement:

This privatizing trend is reaching Europe, too.
Britain's government-run health care dates back to the 1940s. Yet the
Labour Party"”which originally created the National Health Service and
used to bristle at the suggestion of private medicine, dismissing it as
"Americanization""”now openly favors privatization. Sir William Wells, a
senior British health official, recently said: "The big trouble with a
state monopoly is that it builds in massive inefficiencies and
inward-looking culture."

I won't get much into the last two, except to say that we actually have a ton of health care choice in the US today, far more than any other country.  And even if we did not, what does doctor choice mean if the best people are driven away from being doctors, as they are in socialized medicine.  And social justice?  Well, the poor get care in the US, the key is the "hassle-free" in his statement.  Would you immediately assume that a government-run service is going to involve less hassle than a private service?  Have you renewed your drivers license lately?  It may well be that the poorest 10% have such an awful health care experience that they will see things better.  But almost assuredly the other 90% are going to be worse off.

Remember this -- Universal health care is NOT a system in which the majority of us who are satisfied with our care can keep our current system, while the poor get a better one.  It is a system where all of us are thrown out of our current system and given the same care the poor get.  It is roughly equivalent to a Great Society housing program in which not just the homeless get housing, but everyone in the country are forced to give up their current house and live in public housing.

Postscript:  There is great improvement to be had in the health care system.  It revolves, though, around making the payer for health care the same person who receives the service, as it is for every other product and service we buy in this country.  We already have too much single-payer.  We need multi-payer.  I won't go there today, but I explained here.

Another Thought: A huge pillar of the women's movement was that the government should not make decisions for a woman and her body (e.g. by banning abortion).   All well and good.  But I have never understood how this was consistent with support, say, for the FDA, which tells women exactly what they can and can't put in their body.  And now women's groups are all for universal health care, where government will make all the medical decisions about what procedures one can and can't have, and when.  Consistency please?

Michael Canon has proposed for principles of an anti-universal health care coverage club:

1. Health policy should focus on making health care of ever-increasing quality available to an ever-increasing number of people.
2. To
   achieve "universal coverage" would require either having the government
   provide health insurance to everyone or forcing everyone to buy it.  Government provision is undesirable, because government does a poor job of improving quality or efficiency.  Forcing
   people to get insurance would lead to a worse health-care system for
   everyone, because it would necessitate so much more government
   intervention.
3. In a free country, people should have the right to refuse health insurance.
4. If governments must subsidize those who cannot afford medical care,
   they should be free to experiment with different types of subsidies
   (cash, vouchers, insurance, public clinics & hospitals,
   uncompensated care payments, etc.) and tax exemptions, rather than be
   forced by a policy of "universal coverage" to subsidize people via
   "insurance."

You know I'm in;  after all, I am the one that has said that "universal coverage is as if, in the Great Society public housing programs, everyone in the country, not just the poor, had been required to tear down their current houses and enter monolithic public housing structures."

However, I would have added a fifth principle:  Health care decision-making and tradeoffs amongst cost, quality, and
content of care should belong to the individual, except when an
individual delegates this decision in some way by his own choice (say
by joining a very structured HMO program).

I wrote about the joys of actually shopping for health care under a high-deductible policy here and here.  Michael Canon also has a new post on shopping and HSA's here.

Michael Canon has proposed for principles of an anti-universal health care coverage club:

1. Health policy should focus on making health care of ever-increasing quality available to an ever-increasing number of people.
2. To
   achieve "universal coverage" would require either having the government
   provide health insurance to everyone or forcing everyone to buy it.  Government provision is undesirable, because government does a poor job of improving quality or efficiency.  Forcing
   people to get insurance would lead to a worse health-care system for
   everyone, because it would necessitate so much more government
   intervention.
3. In a free country, people should have the right to refuse health insurance.
4. If governments must subsidize those who cannot afford medical care,
   they should be free to experiment with different types of subsidies
   (cash, vouchers, insurance, public clinics & hospitals,
   uncompensated care payments, etc.) and tax exemptions, rather than be
   forced by a policy of "universal coverage" to subsidize people via
   "insurance."

You know I'm in;  after all, I am the one that has said that "universal coverage is as if, in the Great Society public housing programs, everyone in the country, not just the poor, had been required to tear down their current houses and enter monolithic public housing structures."

However, I would have added a fifth principle:  Health care decision-making and tradeoffs amongst cost, quality, and
content of care should belong to the individual, except when an
individual delegates this decision in some way by his own choice (say
by joining a very structured HMO program).

I wrote about the joys of actually shopping for health care under a high-deductible policy here and here.  Michael Canon also has a new post on shopping and HSA's here.

Apparently, HMO's only have a 15% approval rate with Americans.  People don't like the waits, and the institutional service, but, more than anything, they don't like someone in the HMO back office rationing their care based on pre-set formulas about what care or test is appropriate in each given situation.

All well and good.  However, if this is so, then why does the idea of universal government health care appeal to so many people?  Because if universal health care turns out as well as it possibly could, then the best we could expect is that it will resemble... current HMO's.  And unfortunately, it will probably be worse.  Because today, the guy in the HMO back office who is setting up the allowed care formulas knows that if he cuts things back too far, you will go to another competitor.  No such threat or incentive will exist for the government bureaucrat, who will be setting the formulas based on stupid mindless rules and interst-group pressures and absolutely no concern about your satisfaction.

The USAToday published a front-page story today arguing that a health care "crisis" looks a lot like Houston, Texas.  I would argue, from their descriptions, that a health care "crisis" looks exactly like state-run medicine.

Ijeoma Onye awoke one day last month short of
breath, her head pounding. Her daughter, Ebere Hawkins, drove her 45
minutes from Katy, Texas, to Ben Taub General Hospital, where people
without health insurance pay little or nothing for treatment.

Onye, 62, waited four hours to be seen. Still,
going to the emergency room was faster than getting an appointment. For
that, "you have to wait months," Hawkins says....

The huge number of uninsured residents here means that health officials
must make tough decisions every day about who gets treated and when.
"Does this mean rationing? You bet it does," says Kenneth Mattox, chief
of staff at Ben Taub, the Houston area's pre-eminent trauma care
facility.

The article goes on and on like this.  The problem is delays and queuing in facilities that provide free care.   And the difference between this and state-run health care is what exactly?  When a product or service is free, people will tend to over-consume the supply, with rationing taking place via queuing rather than price.  This is how every state-run supply system works, from food in the Soviet Union to health care in Canada.  And by the way, exactly how upset should I be about people receiving an extraordinarily valuable and costly service for free but having to wait a while to get it?

This article is actually a great rebuttal of the inherent message in
the health care debate that "uninsured" means "denied health care."  In
fact, it is clear that even in the spot USAToday picked out as the worst in
the country, the uninsured are in fact getting health care.  It is tedious with long waits, but there are no examples in the long article of people going without.  Yes some people consume less than they might if it was free and convenient, but that is just the rationing at work.  Anyone who says that rationing goes away in a state-run system is bald-faced lying to you.

Remember that national health care does not eliminate queuing and waits for the poor -- it just institutionalizes these waits for the rest of us.   Universal Health Care is equivalent to a Great Society housing program where everyone, rich and poor, have to give up their house and move into a crappy public apartment block.

Postscript: By the way, I am sympathetic to certain hospital administrators who have a "crisis" on their hands because the mass of uninsured show up in their emergency rooms.  That, however, is a problem manageable far short of government-run health care.  They want to blame diversions of critical patients away from over-crowded emergency rooms on the "uninsured" but it is really a function of their own faulty triage.

Update: Michael Moore will soon argue that its better in Cuba.  Hah! That is funny.  If people really want to believe this, then it is another reason is is way past time to open up our relations to Cuba, so people can see for themselves what a lying sack of poop this filmmaker is.

For quite a while, I have been arguing that universal health care is a Trojan horse for freedom-robbing government interventions into our personal habits (and micro-habits).  Suddenly activities that used to be personal choices that affected only ourselves (e.g. unhealthy diet) become public interest questions affecting government-funded health care costs.

Jonah Goldberg, via Ronald Bailey, seems to agree:

The British government recently unveiled
plans for a massive crackdown on "excessive drinking," particularly
among the middle class. It will include all of the familiar tactics of
public health officials: dire new warnings on wine bottles,
public-awareness campaigns, scolding from men and women in lab coats...

Britain
still subscribes to a system where health care is for the most part
socialized. When the bureaucrat-priesthood of the National Health
Service decides that a certain behavior is unacceptable, the
consequences potentially involve more than scolding. For example, in
2005, Britain's health service started refusing certain surgeries for
fat people. An official behind the decision conceded that one of the
considerations was cost. Fat people would benefit from the surgery
less, and so they deserved it less. As Tony Harrison, a British
health-care expert, explained to the Toronto Sun at the time, "Rationing is a reality when funding is limited."

But
it's impossible to distinguish such cost-cutting judgments from moral
ones. The reasoning is obvious: Fat people, smokers and "” soon "”
drinkers deserve less health care because they bring their problems on
themselves. In short, they deserve it. This is a perfectly logical
perspective, and if I were in charge of everybody's health care, I
would probably resort to similar logic.

But I'm not in charge
of everybody's health care. Nor should anyone else be. In a free-market
system, bad behavior will still have high costs personally and
financially, but those costs are more likely to borne by you and you
alone. The more you socialize the costs of personal liberty, the more
license you give others to regulate it.

Universal health care,
once again all the rage in the United States, is an invitation for
scolds to become nannies. I think many Brits understand this all too
well, which is one reason why they want to fight the scolds here and
now.

I like his term "socializing the costs of personal liberty."  Its a good description of much of what is wrong with government today.

While it may have been unintentional, a quote in New York magazine helps make the point I have been trying to make about universal health care (HT: John Scalzi)

"With universal [health care], you'd get the same kind of
mediocre shittiness that you'd get in all other kinds of standardized
approaches. But for millions of people, that would be a big upgrade."

Americans are unbelievably charitable people, to the extent that they will put up with a lot of taxation and even losses of freedoms through government coercion to help people out.

However, in nearly every other case of government-coerced charity, the main effect is "just" an increase in taxes.  Lyndon Johnson wants to embark on a futile attempt to try to provide public housing to the poor?  Our taxes go up, a lot of really bad housing is built, but at least my housing did not get any worse.  Ditto food programs -- the poor might get some moldy cheese from a warehouse, but my food did not get worse.  Ditto welfare.  Ditto social security, unemployment insurance,and work programs. 

But health care is different.  The author above is probably correct that some crappy level of terribly run state health care will probably be an improvement for some of the poor.  But what is different about many of the health care proposals on the table is that everyone, not just the poor will get this same crappy level of treatment.  It would be like a public housing program where everyone's house is torn down and every single person must move into public housing.  That is universal state-run health care.  Ten percent of America gets pulled up, 90% of America gets pulled down, possibly way down. 

I don't think most Americans really know what they are signing up for.  Which is why it is so important for health care socialists to have people like Michael Moore running around trying to convince the middle class they will be getting better health care.  Because there is almost no possibility of this being true, and health care proposals will never pass if people realize it.

More here.

I was sitting here today, and was trying to discern why the government-run health care issue made me more nervous than other government welfare programs.  I get ticked off, for example, about the horrendous rates of return (think negative interest rates) paid out by Social Security on what are nominally our retirement account premiums.  But I don't get nervous.  Why?

I think because unlike other welfare proposals that [just] cost us a ridiculous amount of money, the current plans for providing universal health care imply that my personal health care and health care options will get much worse.  When government provided housing, my housing did not get worse.  When government provided a ripoff retirement plan, my personal non-government retirement savings did not take a hit.  In all these cases, we paid out tons of money to provide some terrible base-level services for the poor and the true-government-believers in the middle class, but my options did not get worse.

However, in the case of health care, most proposals on the table will very likely result not only in much higher taxes, but also in my personal health care options getting worse.  The government will not want to provide multiple levels of service, and can't afford anything beyond "crappy", so as a result we will all end up with crappy service (Insert Rush song "trees" here).  A lot of crap is written about how great all these other socialized medicine services are, but thousands of people travel from other countries to have medical procedures in the states, and about zero travel the other way.  More on the topic of closing coverage gaps at the price of making your own personal care worse here.  More on why these gaps are not as large as advertised here.

Update:  Quick proof -- My chosen health plan is now illegal in Massachussetts

A CBS poll says about 2/3 of Americans think the government should provide health care for all.  Many in the poll think the government would suck at it (about half said the government would do a worse job, and less than a third think it would do a better job). 

Given how important health care is to people, I find it hard to reconcile these two opinions.  If I had to guess, most people who say they are for government health care implicitly imagine a two-tier system, where they would still get the good care they have today, but poor people who people imagine are without care today (actually they tend to be without insurance, not without care) would get a suckier second tier of health care run by the government.

But I don't think this is a realistic view of what they will get with universal health care.  No government-run universal health care system is ever going to be politically stable with two tiers.  You are going to have to end up with a system that some poor people get better care but the rich and middle class end up with a worse system.  That is the reality of every government run health care system in the world.

I would love to see the answer to this poll question:

"Would you support a system of government-run universal health care that guaranteed health care access for all Americans, but would result in you personally getting inferior care than you get today in terms of longer wait times, more limited doctor choices, and with a higher probabilities of the government denying you certain procedures or medicines you have access to today."

The other night our local libertarian discussion group had a presentation by Larry Reed of the Mackinac Institute.  Mr. Reed discussed why he thought that individuals who are lone voices in the wilderness should not give up hope (a topic particularly relevant to us libertarians) and he used the William Wilberforce story as one example.  Wilberforce, who is profiled in the movie Amazing Grace, fought a nearly fifty year battle in the British Parliament first against slave trading, and then against slavery itself.   (Mr. Reed, who has written and spoken about the Wilberforce story for years, said he had seen the movie three times and highly recommended it).

Not surprisingly, the libertarians in the room found the story inspiring -- here was a man who successfully fought for protection of individual rights against great odds.  The Wilberforce story is part of the great 19th century liberal tradition that is bedrock for libertarians today.

However, what is interesting to me is how other parts of the political spectrum also look to the Wilberforce story as an essential part of their own history.  Conservatives see the Wilberforce story as an example of the beneficial effects of an activist religious fundamentalist (which Wilberforce was) bending law to fit his religious beliefs.  At the same time, progressives on the left can look to the story as an early example of the central government looking out for a downtrodden group, a precursor to modern "social justice" legislation.

In other words, libertarians see a direct line from Wilberforce to, say, fighting Kelo-type government takings or indefinite detainments at Gitmo.  Religious conservatives see a direct line from Wilberforce to reducing violence on TV and preventing gay marriage.  Progressive see a direct line from Wilberforce to universal health care and affirmative action. 

I'm not really sure I have a point here, except that Amazing Grace may find a pretty good audience if everyone thinks it is "their" movie.  The only other thing I would observe is that it is nice to know that for all our differences today, there are some things we can agree on.  Which causes me to wonder why modern slavery, which is still all-too-prevalent, does not get more attention (except perhaps because certain folks are so invested in the Westerners-as-bad-guys view of history that they are blind to exploitation from other directions).

Perhaps the central touchstone of the women's movement has been the ownership and decision-making for one's own body, starting of course with the freedom to choose an abortion, but extending into a number of other health and sex-related issues. 

What amazes me, though, is how quickly all this is chucked out the window when it comes to having the government take over health care.  Because many of the exact same people who have campaigned for the primacy of a person's decision-making for their own body are also strong supporters of government funded universal health care.  And I can't think of anything less compatible with individual decision-making for one's own body than having the government run health care. 

The demands for universal health care general come from two complaints:

1. Health care is too expensive and is more than I can afford
2. Health care quality is low.  In this category, by far the most common complaint is that "my insurance won't pay for X procedure that I want, or Y level of care, etc."

Neither is a surprising complaint, given how our health care system is currently set up, and both are highly related to one another.  The key problem in the US health care system is that, unlike just about any other product or service you and I purchase, the typical individual is not presented with a cost-quality tradeoff.   Since most of us have a fixed price insurance plan, we couldn't care less how much anything costs, and in fact, like an all-you-can-eat buffet, our incentive is to use as much as possible. 

This puts the insurance companies in the odd position of having to make cost-quality tradeoffs for us, via their coverage and treatment rules.  But when they try to cut costs by narrowing or limiting certain treatments, consumers tend to get the government involved to remove these limitations.  They either do this though legislation (many states now have onerous requirements on what procedures insurance companies must pay for in that state) or through litigation (the threat of lawsuits pushing doctors into expensive defensive medicine, asking that every conceivable test be conducted).  In other words, people take their dissatisfaction with #2 above to the government, who acts, pushing up costs and making problem #1 worse.

Until we find ourselves in a Strossian post-scarcity world, someone is going to have to make this cost-quality tradeoff for our health care.  Even if it is never discussed, this is the most important design factor in any health care system.  There are only three choices:

• Individuals make these choices for themselves, paying for their health care and making their own decisions about whether certain procedures are "worth it".  - OR -
• Insurance companies make these choices for us.  (I am not sure this is even a choice any more, as government micro-management seems to be pushing this de facto into the next choice). - OR -
• The government makes these choices for everyone

So, folks that are pushing for government-funded universal health care are in fact saying "I want the government to take over decision-making for my body."  Yuk!  Where are the feminists when we need them?

Beyond just ceding to the government decisions such as whether its really worth it for dad to get his new hip joint, there is another chilling factor, which I have written about a number of times.  Government health care will act as a Trojan Horse for nanny fascism.  Because, you see, if the government is paying to fix your body, then you can't be trusted to do whatever you want with your body.  By paying for your health care, the government has acquired an ownership interest in your body.  You want that Wendy's cheeseburger?  Sorry, but the government can't allow that if it is paying for your health care.  Likewise, it is not going to allow your kid to play dodge ball at all or to play soccer without a helmet -- can't afford to fix all those broken bones.   And no swing sets or monkey bars either!

Already, when its only affects us as individuals, the government is poking its nose into micro-managing our lives.  Just think what will happen when the government has a financial incentive, in the form of health care costs, to do so!  Eek! In fact, it is already happening:

People who are grossly overweight, who smoke heavily
or drink excessively could be denied surgery or drugs following a
decision by a Government agency yesterday.  The National Institute for Health and Clinical Excellence (Nice) which
advises on the clinical and cost effectiveness of treatments for the
NHS, said that in some cases the "self-inflicted" nature of an illness
should be taken into account.

Or here in the US:

New York City is at the forefront of this new public health movement. In
January, city health officials began
requiring
that medical testing labs report the results of blood sugar tests for all
the city's diabetics directly to the health department. This is first time
that any government has begun tracking people who have a chronic disease.
The New York City Department of Health will analyze the data to identify
those patients who are not adequately controlling their diabetes. They will
then receive letters or phone calls urging them to be more vigilant about
their medications, have more frequent checkups, or change their diet....

So what could be wrong with merely monitoring and reminding people to take
better care of themselves?  New York City Health Commissioner Thomas Friedan
has made it clear that it won't necessarily end there. If nagging is not
sufficient to reduce the health consequences of the disease, other steps
will be taken. Friedan
argues
that "modifications of the physical environment to promote physical
activity, or of the food environment to address obesity, are essential for
chronic disease prevention and control." Friedan envisions regulations for
chronic disease control including "local requirements on food pricing,
advertising, content, and labeling; regulations to facilitate physical
activity, including point-of-service reminders at elevators and safe,
accessible stairwells; tobacco and alcohol taxation and advertising and
sales restrictions; and regulations to ensure a minimal level of clinical
preventive services."

Read that last paragraph.  That's just the starting point for where the government will go when it starts paying for all our health care.

Postscript:   This is a very hard topic to discuss with people, because they are so ingrained with the way the market is set up today.  When I started working for myself, I told my wife that we needed a high-deductible medical plan, to protect us from a health disaster, but we would just self-pay for dental costs.  "What?"  She said.  "You can't pay for your own dental - you need insurance.  We can't go without insurance.  That's all you hear on TV, the problem of not having insurance.  We'll be one of those people!"  I patiently explained that it was almost impossible for us to face a dental problem that would bankrupt us, and that for any conceivable level of dental care, it was cheaper to just pay the bills than get dental insurance.  Eventually, she relented.

We have been paying our own dental bills for years now, and have saved thousands vs. the quotes I got for insurance.  The other day we had an issue that perfectly highlights why 3rd party payer systems cause problems.  My wife chipped a tooth.  She was presented with two choices:  To file it down for nominal cost, or to do a major repair which would cost $500.  She asked me my advice on which to do, and I said "its your mouth.  You know what else we might use $500.  You make the tradeoff."  I am not even sure what decision she made.  It is simply impossible to make this kind of decision for someone else.  Everyone will make it differently.  A government-payer system would only have two options:  1)  don't allow anyone to get the expensive fix or 2)  force taxpayers to pay for everyone to get the expensive fix.  Both solutions are wrong.  Such is the problem with all single-payer systems.