Thursday, November 26, 2009

The "uninsured Americans" Trojan horse

One of the main issues that allegedly motivates calls for health care "reform"- be it instituting single-payer, a "public option," insurance mandates, requiring insurance companies to accept all patients or charge the same amount regardless of risk, or some combination- is the problem of people who can't get insurance because they are poor or already too sick to get insurance. The problem, we are told, is that people with preexisting medical conditions can't get insured, and thus are either deprived of medical treatment or are impoverished paying for it. Similarly, people too poor to have insurance let problems fester untreated because of the expense. The extent of this problem is exaggerated greatly, since the most commonly cited statistics lump people who can't get insurance together with people who have simply chosen not to, but it does exist.

As is so often the case, this is a problem with roots in previous government interventions. The tax code and various government regulations encourage people to use insurance for everything medical-related, including routine and foreseeable expenses, which encourages greater consumption and less concern for cost, which drives up the price of medical services, which increases the amount of money the uninsured have to pay out of their own pocket. Another contribution to the plight of the uninsured comes from all the various conditions and treatments the law says insurance companies MUST cover, which outlaws stripped-down insurance polices that would be within the reach of more people.

Fixing that is out, needless to say, since the people who most loudly profess their concern for the uninsured are generally the same people who would scream bloody murder at the thought of people who can't afford gold-plated insurance buying a more modest version they can actually afford. To many people, actually getting the disadvantaged more access to medical care is less important than being able to boast about being the sort of big-hearted idealist who believes the disadvantaged should have access to the best medical care imaginable, and big-hearted idealists don't lower themselves to facing the unpleasant tradeoffs that exist in a world of scarce resources.

It's certainly a plight that ought to inspire sympathy, harming people whose lives are already harder than most. It's not surprising that this issue would loom large in any criticism of the existing system. There's a question that is almost never raised, however: What does any of this have to do with the proposed reforms?

As a libertarian, I think these people could be helped far more effectively and justly through market processes and civil society, if only the government would get out of the way, but what if I were a statist setting out to aid the uninsured? For a moment, let's take it as given that any sort of deregulation is off the table, and that this is a problem that requires a government solution. In that case, the solution to the problem is quite obvious: Set up a government assistance program, funded out of general tax revenues, for people who can't get insurance and have it buy them medical care as if it were an insurance company. It would, essentially, be a “public option” specifically for people who are currently shut out of private sector insurance due to poverty or illness.

Problem solved, and with far less government expense, distortion of the marketplace, inconvenience to the general public, or divisive political acrimony than any of the actual major proposals. There is potential for fraud and abuse, but no more so than any other welfare program and probably less than many. As government solutions go, this is relatively simple, and it's really just a logical extension of things the government already does now. It's modest size and consistency with the precedent set by existing forms of government assistance would make it far less controversial than what's actually being proposed.

Supporters of greater government involvement in health care have other arguments for their program, of course, but the issue of the involuntarily uninsured is simply irrelevant to the question of whether the health care system as a whole needs some sort of radical change imposed by the government. If you're really concerned about a small segment of the population being deprived of a resource and want the government to make sure they have access to it, give them the resource. When faced with the plight of people who can't afford food, liberals generally advocate giving them food stamps or monetary benefits. They don't use the needs of the desperately poor to argue that the government should nationalize agriculture or run Public Grocery Stores to compete with Wal-Mart and Safeway.

This ought to be a political slam dunk, winning support in Congress from every Democrat and many moderate Republicans. Libertarians and some fiscal conservatives might object, but there would be nothing like the storm of controversy that has raged. It wouldn't preclude further legislation creating other government interventions relevant to other problem areas of the health care system if they are needed. If Obama had proposed it upon taking office it would have almost certainly passed already; that is surely a selling point given how frequently we're told that getting help to the uninsured is a dire necessity that must be accomplished quickly, before more lives are lost. The need to help people who can't get insurance is cited by liberal supporters of health care reform more than any other issue, and this would address that problem quickly and without holding the issue hostage to far more intense arguments over proposals for more sweeping government intervention.

There are limitations to my proposed alternative It wouldn't turn every American into a captive customer of the insurance industry. It wouldn't allow the government to turn private insurance into a concealed welfare program where taxes paid to support beneficiaries are disguised as payments to supposedly private companies for their services. It wouldn't give the government greater control over everybody's personal health care choices. It wouldn't create a means for the government to crowd private insurance out of existence altogether.

It would, in short, solve (as well as a government solution can, anyway) the problem that provides the lion's share of the justification for a major increase in the government's involvement in medicine care without setting the stage for the destruction of private sector health insurance and total state control of medicine. And what “reformer” worth his salt would want that?

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Saturday, November 21, 2009

The Trotsky myth

Over at A Terrible Blogger is born, blogger rmangum has a post speculating about why Leon Trotsky's reputation has been so strong among so many Western intellectuals, given the ample evidence that the idealized image of a man who would have created a humane, non-repressive communist state if only he hadn't been outmaneuvered and exiled by Stalin is pure fantasy. He attributes this to the fact that Trotsky's image was far more intellectual than that of Joseph Stalin, making him easier for Western intellectuals to identify with.

I think there's something to that. It fits in with the Western intelligentsia’s attitude toward the crimes of Stalin- the Moscow Show Trials and purges of his own Party comrades like Kamenev and Zinoviev always loom much larger than horrors like the Ukrainian terror famine, even though the latter took far more lives. The famine killed millions of nobodies, peasants, whereas the Show Trials were directed at people Western intellectuals actually identified with and felt empathy for. There’s another reason I would place more emphasis on, however.

The state always disappoints, if judged according to its own promises and propaganda, and communist states tend to do so more dramatically than most. The Western Left always seems to be looking for a left-wing despot to idolize, but as a given tyrant’s crimes become harder and harder to hide or ignore admiring him becomes increasingly awkward and a new, less tarnished idol needs to be found. Stalin gave way to Trotsky, Mao, Castro, Ho Chi Min, and the like; now it's Che Guevara.
The advantage Trotsky has over most of these rivals is that – like Che Guevara- he was never a head of state, and thus offers far more open space to imagine what might have been.

The fact that he died violently- again, like Che Guevara- gives even more chance to ask, "What if?", as well as adding the sanctity of martyrdom and the romance of a life gloriously burning out instead of fading away. Death also saved him from living long enough to be associated with communism as it looked in its later days in Europe- dull, gray, crumbling, unromantic, uncool.

If we're knowledgeable of Trotsky and honest with ourselves about him and about communist regimes generally, we know that what might have been would have been horrible, but his lack of political power means that, unlike Joseph Stalin (or Mao Zedong, Pol Pot, etc.), there is no mountain of human corpses tied prominently, specifically, and unambiguously to him that can spoil our fantasy by forcibly directing our attention to his true nature.
Instead, communists and communist sympathizers can use him as a blank canvas to paint their own dreams.

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Friday, November 13, 2009

The Berlin Wall and the fruits of liberty

20 years ago as of Monday, the citizens of East Berlin penetrated the Berlin Wall and gained access to the West. The wall's physical destruction would not be completed for weeks, but its power was broken. My paternal grandmother was born in Germany, usually spent a few months out of the year staying with her sister in West Berlin, and had relatives who had escaped from East Germany. She lived just long enough to see the Wall destroyed before passing away in March 1990. One of her relatives gave me a piece of the Wall, which I still have.

At Econlog, David Henderson has a post about how he explained the event to his 4-year-old daughter back in 1989. I recommend the whole thing, but what jumped out at me the most was a brief aside. Recounting his discussion with his daughter about all the East Germans crossing the border for the first time, Henderson remarks in passing:

The media reported a few days later that the candy shops in West Berlin had sold out.
Something about this little detail was very striking to me. In my experience, most discussions of Communist oppression focuses heavily on a few specific areas, and above all on censorship and control of ideas. (Things that directly impinge on the psychological and material interests of intellectuals and journalists, in other words.) The material deprivation caused by Communism does get some attention, but much less. Acknowledgment of it, not surprisingly, mostly involves the striking, dramatic, and visual- people standing in line for hours to buy bread, the dull grayness of Eastern Bloc cities.

What doesn't get much attention is the day-in, day-out lack of things that make life in a wealthy country like the United States more pleasant for the great majority of the population. I do not use scratchy, sandpaper-like toilet paper. Barring natural disaster or freakishly cold winter temperatures, I take it for granted that water will come out of my sink's faucet when I turn the knob. If my shoes are worn out or my clothes are torn up, I'm confident that replacements will be readily available for me to buy. On Halloween, like the one that just passed, candy is so cheap and plentiful that children can go door to door asking to be given candy for free. and most households will cheerfully oblige them.

There are few things more revolting to me than the spectacle of some hyperprivileged Western leftist who enjoys a degree of wealth and material comfort that would be the envy of almost every human being who has ever lived pontificating on the evils of "greed" and "consumerism" and praising some oppressive, impoverished socialist hellhole for its superior spiritual values or sense of community or committment to "social justice" or whatever, and this is a big part of the reason why. The difference between a country with a comparatively free market and the sort of society they defend isn't just a matter of whether people have colossal gas-guzzling vehicles or plasma TVs or "McMansions" or the opportunity to buy, to use the sort of epithets anticapitalists like to trot out, "cheap junk" and "stuff they don't need." (It's depressing how much antimarket rhetoric boils down to whining that other people don't share your personal tastes and dressing it up as moral indignation.) It's about whether people beyond some small political elite get to enjoy the innumerable little improvements to their daily lives that free markets provide with such ease and abundance that we don't even stop to think about them.

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