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Joseph's avatar

Asking libertarians “How do sick people afford healthcare?” is like asking progressives “What is a woman?” or conservatives “Who won the 2020 presidential election?”

If you want to save capitalism, your answer can’t suck for everyone except the ultra-rich. We all get old. Any of us can get cancer, suffer a terrible accident, or develop a costly illness.

The practical libertarian answer is too often: beg for charity, be financially ruined, or die. They talk about regulations making insurance expensive while ignoring that many of those rules exist to make insurers cover sick people. See all of Michael Cannons writing on healthcare.

The conservative movement and Republican Party are mostly in the same “get sick and die” camp if you’re the undeserving poor. They will cut Medicaid and taxes, but rarely confront the stationary bandits extracting the money: hospitals, drug companies, specialist cartels, licensing regimes, and other protected incumbents. Cutting benefits for poor people and taxes for rich people is easier than taking on entrenched healthcare interests.

The better libertarian message is abundance, not austerity. Make healthcare radically cheaper by attacking the regulations, cartels, supply restrictions, and incumbent protections that make doctors, drugs, hospitals, and insurance so expensive. Don’t tell voters sick people consume too many resources. Tell them capitalism can make healthcare cheap enough that getting cancer does not mean financial ruin. That is a political argument for capitalism.

Brian Moore's avatar

"Don’t tell voters sick people consume too many resources. Tell them capitalism can make healthcare cheap enough that getting cancer does not mean financial ruin. That is a political argument for capitalism."

This is a good political message, and one I personally endorse (via curing T2 diabetes), but... the Michael Cannons have a point.

A huge amount of the cost in everyone's (including paradoxically the poor) healthcare comes from the regulations and rules and price limits and coding systems and administration and counter-rules that are designed to prevent that scenario of "poor people get sick and die", among others. Because "poor people get (unexpectedly, emergently) sick and die" is not actually that common a category and " because they can't afford healthcare" is not that expensive, and doesn't describe most healthcare spending.

Medicaid and medicare are not just some kind of food stamps program for healthcare that just subsidizes (otherwise commercially available and subject to price competition, like other industries) healthcare for the poor. It regulates (and heavily affects the entire system, even completely "private" commercial healthcare insurance) with the effect (among others) of heavily increasing the costs of nearly all parts of the system. The subsidy enacted by this system is not “rich people pay more so that poor people can afford healthcare” it is “massive amounts of regulation is added to the system that increases everyone’s costs, to subsidize a specific category of patient: old, chronic disease, on average richer, votes”

"The practical libertarian answer is too often: beg for charity, be financially ruined, or die. "

That's your perceived answer to a hypothetical scenario that doesn't exist. Anyone in this country can go into any hospital and get life saving care - doctors are in fact legally obliged to - and won't have to pay for it because there is no mechanism for forcing you to. You can literally just ignore the bills that arrive, yes really. The question is not "how will you pay for it", it is how do we pay the doctors who provided that care enough to keep them in business. And in fact the govt has a huge apparatus for reimbursing those hospitals for uncompensated care, both explicit and implicitly.

The question, on which you're completely right, is why is this all so expensive? And capitalism - which mostly does not exist in our healthcare system - provides a lot of the solution to that.

Daniel Sz's avatar

My libertarian-ish answer to “How do sick people afford healthcare?” requires decomposing sick people (or rather healthcare) into a few separate categories categories:

-Lifelong or quasi lifelong invalids/handicapped people: these are the only people who require socialized healthcare or some form of charity. This is a real category but the percentage of Medicare/Medicaid spending going to these people is small yet it is always them who pro-socialized healthcare people bring up. A reasonable compromise would be to have a reduced Medicaid going mostly towards these people.

-Normally healthy people who get sudden bad news (car accident, cancer diagnosis). This should be covered by private catastrophic health insurance which kicks in after a deductible that people should be free to choose, although we can have some regulation to have that deductible not be unrealistically high. We can make this insurance obligatory if necessary but no government spending going towards it.

-Normally healthy people getting checkups or minor not overly expensive treatments should pay that out of pocket up to their deductible same as groceries or rent.

-Old people who worked their whole lives and just need increasing levels of healthcare due to aging: this is almost all of Medicare spending and an increasing share of Medicaid as well. There is no justification for having a huge socialist program for this category of person, they had all their lives to save money and having to spend more money on healthcare when you get old is extremely predictable. At most, you can have individual healthcare saving accounts like in Singapore that work like payroll taxes but where it is still you saving for your own healthcare instead of the old people leeching of the young Ponzi scheme that most Western countries currently have in place.

There, sick people get healthcare and we don’t bankrupt the US with multi-trillion dollar healthcare programs for wealthy Boomers.

BucketofFried's avatar

You appear to be treating Republicans and Libertarians as one and same. While there is some overlap, I would say under Trump, this is loose at best.

Regarding Libertarians, Milton Friedman criticizing medical licensure regimes as early as the 1960s and compared it to medieval guilds that drove up costs and had negligible effects on quality. Of course, everybody laughed at him deferring to whatever their local medical licensure board dictated.

Alex Tabarrok, of Marginal Revolution, has beat the drum about the “hidden graveyard” due to the FDA’s bureaucratization of the drug and device approval process for years.

There’s many other libertarian critiques that are very different than focusing on insurance companies.

Dave92f1's avatar

Yes. The best answer to “How do sick people afford healthcare?” is the same way sick people afford food and housing - that these things are affordable to normal people. Healthcare would be affordable (is, in most other countries) if not for Our System.

I've never understood why people treat healthcare (and labor) as different from all other markets. Traditionally the essentials of life are food, clothing and shelter - we let people buy those on the market. But not healthcare, and not selling their labor.

Jon Stokes's avatar

If you want to be taken seriously by people outside your echo chamber, you can’t dismiss anything that conflicts with your assumptions by declaring that it “suck[s] for everyone except the ultra-rich.”

Or rely on embarrassingly obvious straw-manning like “the practical libertarian answer is…”.

Argentus's avatar

"How do sick people afford healthcare?" - Simple - by forcing everyone else to pay some kind of "I failed to get cancer/hit by a bus this year" tax. It's basically compelling me to use my good health dividend to pay for other people's bad health instead of getting to invest that good health dividend in myself or my family.

This is the underlying truth. It's no less a form of aggressive redistribution than any other taxes are. I'm not even categorically opposed to redistribution, but I am opposed to obfuscating what the actual mechanism is. Sick people don't afford healthcare by taxing billionaires. Sick people afford healthcare by extracting payments out of healthy people.

Cutting edge & highly complex healthcare will still be expensive even if you get rid of regs, and innovation just pushes the frontier of what constitutes cutting edge and complex. Sick dying people will still want the cutting edge no matter how cheap "regular" healthcare becomes.

Leslie MacMilla's avatar

Two minor demurrals:

1) Someone who has assets but can't (because of not having insurance) pay a large medical bill can be forced into bankruptcy where those assets could be forfeited. Someone who has no assets can declare bankruptcy and get off scot-free. I don't know how often this actually happens. The claim that medical bankruptcy is the most common cause of bankruptcy doesn't tell us how often bankruptcy occurs over-all, and much of the bankruptcy could be just people with no assets to lose telling the hospital, "You can't get blood out of a stone." Most hospitals and almost all doctors would just write off these uncollectable bills as bad debts, a cost of doing business.

2) An indigent uninsured person will certainly receive life-saving emergency care without regard to his expected inability to pay. Where it gets harder is for care for chronic diseases that aren't immediately life-threatening. Doctors have understandable incentives to limit the number of patients they take on whom they know won't or can't pay their bills for maintenance care. Unfortunately, expensive chronic disease is concentrated in low-income people, both by the distribution of the determinants of health working in the forward direction and the tendency of chronically sick people to drop out of the labour force working in the backward direction. There just aren't enough sick people who remain wealthy enough to pay their doctor bills and keep the medical workforce in the style it has become accustomed to after decades of insurance reimbursement for everything it wants to do. That's why so much primary medical care involves "preventive" care of the worried well who are more likely to be insured because working.

Over-all, you're right: medical care is expensive largely because of rent-seeking in an environment of market failure from asymmetric information. Even in Canada with its mandatory single-payer system that bans any private payment for medically necessary services, health care is the second-most expensive in terms of percentage of GDP spent on it, in the world.

Dave92f1's avatar

"old people will be more likely to give up their money and power if they can rely on the government to take care of them". I'm guessing he doesn't know many old people personally. Age grants experience - very few old people would take that deal.

And you say Moyn supports "a dynamic and innovative society" but also wants to take capital away from its owners and give it to the government. And government is going to use it to create "a dynamic and innovative society"? Like Amtrak? Or the Post Office?

Tolu's avatar

Towards the end of Derek Thompson's podcast with Samuel Moyn, he validates Moyn's argument that capitalism is the problem and will "run rampant in a way that produces negative consequences" without regulation (neither Derek nor Moyn acknowledge how gerontocracy exists largely due to existing government regulations). Between this and Ezra Klein's support of Mamdani, can we also admit that the Abundance Movement™ is itself a trojan horse for socialism? How is it that local republican politicians who haven't read a book in their life produce more abundance than the Abundance Movement™?

Argentus's avatar

Take away my ability to be free when I'm old and I'll basically just commit to being a freeloading bum. "I will finally get to spend 10-20 years doing what I want, when I want most days" is my only remaining motivation for working. This may make me contemptible but it's the unalloyed truth.

You can take both money and status and stick it where the sun don't shine. What I want is freedom. I'm also militantly pro assisted suicide on these same grounds. The instant I am becoming a prisoner of my failing body and losing my freedom is the instant I check out.

Ed Powell's avatar

My mom is in a nursing home. Every dime of money, every asset my parents saved, has gone to pay for the nursing home. All the money my parents hoped to hand down to my disabled sister and me is gone now, and we are on our own. The nursing home is not bad, and she gets fair care, but $15,000 per month is so expensive that only by dying would she not have been impoverished. How is that any different from what the author writes about in his socialist utopia?

Yinran Huang's avatar

Moyn is projecting.

Spouting Thomas's avatar

For a brief moment, I somehow allowed myself to hope that the one silver lining of the DSA's rise was that all these young socialists might give some power to anti-gerontocracy as a movement. But no, I've quickly come to realize they only want to expand gerontocracy in practical terms. The youthful faces are just there for marketing.

mariposa's avatar

almost liked a hate tweet

mariposa's avatar

this obsession with the right to paint socialists as the greeks in the odyssey seems like maybe a misguided communication strategy. but we’ll take it!

CleverBeast's avatar

Have you read the Iliad? It’s not at all clear that the Greeks are the good guys. Certainly Hector and Paris are more sympathetic. Achilles is a brute.

alina_pereslav's avatar

I mean, have you? I find it hard to believe, because essentially the only true statement here is that the Iliad (like the Odyssey and basically the totality of classical myths) depicts Hector positively, in contrast to Paris, who is explicitly described as a self centered coward despised by his own side. It's not as if this requires any cognitive ability to comprehend, the source material is not exactly subtle, one doesn't have to read between the lines, or indeed to read much of the book, to get the drift. Just up to chapter 3 or 6 to see Helen refuse to sleep with him because she is revolted by his shameless cowardice, and being forced to do so by Aphrodites, or Hector being appalled by him messing around at home while others dying for his self centered whims, and remarking that the Trojans hated him to death.

Everyone involved, from the Greeks to the Trojans to the Gods themselves (who are largely manipulating things to lead to Troy's destruction) had the same religion and mores. The Trojans at no point view the Greeks' military actions an unjustified: they were aware the war was started by Paris going on a diplomatic mission to Sparta and running off with that country's queen and a good chunk of its treasure, taking them back to Troy and thus predictably creating a conflict (I will stress the obvious fact that they were not peasants, they were royalty representing their respective countries, thus their actions had political and diplomatic consequences, for the same reason that me insulting a random dude in traffic is not the same as, even in an hypothetical modern day universe, Trump insulting Xi Jinpin to his face and stealing his mineral resources), and were all for returning them and ending this mess, it was Paris who sabotaged those attempts and kept the war going, and he was rightfully despised for it by his own side, because he let his genitalia to do his thinking for him and essentially didn't care as long as he got what he wanted.

To elaborate, and introduce some basic facts, everyone involved was a bronze age warlord, including the Trojans. Shacking a city and taking slaves were the normal, expected behavior for all those involved, contrary to what Mr. Nolan would have us believe, as evidenced by the fact they all had armies and surrounded their cities with giant walls, with Troy itself having already been shacked multiple times by the time the Iliad rolled around. Absolutely nowhere in either side was there the modern, totally anachronistic concept of "civilian casualties", nor could the gods have cared one iota about that: Zeus' most favourite hobby was rape, the gods took issue with the Greeks for desecrating their temples, they didn't care about the shacking of the city, which was predestined and that they largely caused anyway, thwarting multiple attempts of the two sides to resolve this without a full scale war.

As a matter of fact, arguably the Trojans were the ones seen in universe as the "barbarians" and certainly as the Xenia violators, though frankly they (particularly Hector), contrary to what one might expect, are not demonized and are largely portrayed positively, with the obvious exception of Paris, who was famously despised even by his own side. In other words, despite the fact that in this particular occasion they were on the defensive, again, we are not talking about ISIS vs modern day London, but about two societies inhabiting the same shared moral universe, even sharing the same religion, and it is in any case idiotic and ridiculous to apply modern day morality to civilizations that existed thousands of years ago.

And while it is undeniably true that Hector is portrayed positively, the same is most definitely not true of Paris, in fact the latter is used as a foil to highlight Hector's sense of civic duty. In the Iliad, Odyssey and most if not all classical myths, this is neither subtle nor controversial: his own brother, Hector, tells him it would have been better if he had never been born. After Aphrotides helps him escape Menelaus in the one to one fight they were meant to have to avoid all out war, Helen refuses to sleep with him, telling the goddess that if she wants, she can become his slave or wife herself, at which point Aphrodites literally threatens to use her powers to turn both Greeks and Trojans against her to force Helen to sleep with Paris, and before she does, she mocks his bragging and wishes Menelaus had killed him. Later, she tells his brother that she wishes that if the gods had decided to mess her like that, they would have at least given her to a decent man who could feel a shred of shame. Both of them at numerous points express their disgust at him and his behavior.

And of course, famously, and as Hector notes, the Trojans themselves absolutely despised Paris, because he was a self centered coward who went on a diplomatic mission to Sparta and ran off with the king's wife (either forcibly abducting her or having her follow him thanks to the intervention of Aphrodite, all because he had exchanged her for a vote in a bet, without having even met her, solely because she was hot) and a good chunk of Sparta's treasury, predictably starting a war (predictably not just because it was obvious to everyone involved that would have been he obvious consequence, but also because there were literal prophecies). Then he insisted on taking the spoils to Troy, and held on to his "prize", sabotaging any attempt to solve this whole mess. He bragged about meeting the Greeks in single combat, and when Menelaus accepts, he got scared and had to be shamed by Hector into fighting, then he escaped with divine intervention and proceeded to basically sleep around (with Aphrodite having to threaten his partner) and lay about at home while everyone else was involved in a war he himself had caused (I have already talked above about Hector's appalled discovery of him at home, and about his and Helen's revulsion).

In the same vein, Achilles is basically no more of a brute than anyone else involved, mortal or divine alike. He was a bronze age warrior doing what a bronze age warrior was supposed to do. There were exceptions, such as the human sacrifices and desecration of Hector's corpse, but those were explicitly connected to his grief at the death of his lover, though he ultimately relents and changes his mind after Priam's visit, weeping together with him. Actually, it is not at all clear the extent to which, if at all, the human sacrifices are condemned, they are certainly treated as far less important than the desecration of the corpse, which receives divine protection, with Zeus eventually asking Achilles to give the body back in exchange for ransom, and Achilles ultimately being persuaded by Priam's grief. Aside from him going beyond the limits of heroic vengeance in his grief, none of his other behavior is condemned, because it would not have been recognizably more savage or unacceptable in the Greek, or Trojan, or for that matter divine moral worldview. All the characters involved, human or divine, Greek or Trojan, lived in the same moral universe, we are not talking about Al Qaeda invading modern day New York.

A far less banal presentation of the subject, relative to Nolan's, would have been something similar to the show Vikings, where the cultural differences between the Christian world and the Viking practice of human sacrifice, for example, are explored, and that was already a world where there were significant differences in the cultures, religions and code of ethics of the two civilizations involved. This was most definitely not the case with the Greeks and Trojans, it was a conflict between tho societies at the same level of moral development.

延续存在's avatar

I agree that the intergenerational conflict here goes deeper than capitalism versus socialism.

It makes me think about what happens when two group structures depend on the same limited resources. Older generations seek to preserve the income, healthcare, property, and political arrangements that sustain their existing lives. Younger generations need many of those same resources to build what comes next.

Both naturally push resources toward the conditions that support their own continuation. The conflict begins when maintaining one structure increasingly reduces the resources available for the continuation and expansion of the other.

This is where the Structural Expansion Mechanism becomes interesting: when two structures can no longer be fully sustained at the same time, whose continuation gets priority?