22 August 2007

The Morality of Single Payer

Damn. You all really are going to think I am a single payer advocate, when I wind up defending it from the absurd conservative attacks out there. But I just can't help myself restrain the impulse to rebut the rampant stupidity and disingenuous arguments out there. Kevin approvingly links to the Atlantic's new blogger, Megan McArdle and her argument that a single payer system is immoral.

So, Megan, I "get" the distinction you are making between efficiency and morality. And you're still wrong. As Bucky Katt said, you are so wrong philosophers weep at the sound of your voice.

Her argument is well summarized thusly in her words (combined from both of her posts):
This isn't really insurance we're arguing about; insurance is voluntary. What we're really talking about is a tax. Single payer advocates are looking for the most politically palatable way to tax the young and healthy in order to pay for the health care of the old and sick. [...] A gigantic single-payer system is a pretty blunt instrument; it transfers money from one group, the young and healthy, to another group, the old and sick. It does not distinguish much more finely than that between the deserving and undeserving within that class. [...] What we need to know is whether the class of old and sick people as a whole are much more deserving than the class of young and healthy people; whether our transfers do more good than harm. [...] Are the old and sick needier than the young and healthy? No they are not. They have more assets and less poverty than any other group. [...] Are the old and sick unluckier than the young and healthy? Considering people as beings with duration in both time and space, no they are not. The overwhelming majority of old and sick people were once young and healthy. They got to be young and healthy, and old and sick.

I think this fairly encompasses the heart of her argument, and the bulk of her errors.

Most egregious is her complete inability to understand (or willful distortion of) the fact that health insurance is just that: INSURANCE. The goal of insurance to minimize risk by spreading the risk out among a large population. She attempts, wrongly, to recast the debate as simply that of wealth transfer, and arbitrarily defines the transfer as from the young to the old.

She seems to base her rejection of the risk pooling model on the unsupported statement that "Insurance is voluntary. This is a tax." What crap. Insurance can be, and in many cases is, compulsory. Automobile insurance is required in most states. In my locale, professional liability insurance is required of physicians. Are these also then taxes? The fact that is it required in no wise changes the nature of the program nor invalidates the concept of risk pooling.

Then, having redefined mandatory insurance as a liberal plot to transfer money from one class to another she defines the supposed beneficiary demographic as: old people. Damn old people, always wearing hats and driving slow in the left lane and bursting into congressional hearings and forcing Tom Delay to pay for their lisinopril! Easy to scapegoat, I suppose, but it's a specious association. Sure, there is a transfer of money from all premium-payers to those who sustain losses; that's how insurance works. I pay USAA my auto premium and it goes to someone who gets in an accident. In the case of health insurance, the assets are transferred from the healthy to the sick. It is, however, inaccurate to conflate that with the young and the old. Sure, young people are on the whole healthier than old people. But why not portray this as a transfer from men to women (women have significantly higher utilization of health care? Or from white to minorities (who have disproportionate rates of chronic illness)? Or from the wealthy (who tend to be healthier) to the poor? The demographics associated with illness are only poor and partial approximations of the actual target demographic: the sick.

Which leads us to Ms McArdle's next logical error: the failure to understand the concept of risk. By conflating youth with health and age with illness, she creates a sense of inevitability to illness which would, if that were quite true, lend some support to her follow-up arguments. But she conveniently neglects the fact that there are large numbers of young people who are sick and old people who are healthy. That's the reason we buy insurance: we don't know in advance whether we are going to get sick. Sure, we'll all die eventually. But morbidity and mortality are not completely parallel. I am going to die, but I probably will never need a kidney transplant. Or maybe I will be on dialysis for three decades and get two transplants which fail. Or maybe I'll ski off a cliff and be killed instantly. No way to know in advance what my fate will be (other than the grave promised to us all), so there is risk.

There's not much left to her argument once the above points have been established. But let's pick off the straggling errors, while we're at it, just for the sake of completeness. The other point she seems to not get is risk pooling. She implies that old and sick people, the perfidious parasites sucking off the teat of the virtuous and productive young, fail the 'moral test' of neediness. Old people are rich, right? For the sake of argument I'll buy the tenuous notion that old people are on average wealthier than young people, since it is entirely irrelevant! The reason we pool our risk is that when you become ill, the expense is far beyond what any one individual can bear (regardless of age). A week's stay in the ICU is a staggering cost. Dialysis, bypasses, chemotherapy, any large-scale surgery -- any of these things is beyond the financial capacity of anyone this side of William McGuire. With modern health costs, any ill person (regardless of age) is needy beyond the means of private payment.

And finally, she cannot resist, like the moth to the flame, the conservative tendency to blame the ill for their illness. I'll give her credit, though, she backs off of that point a bit, and at least does not use it as the entire foundation of her argument. And she also concedes that national health insurance just might be preferable to allowing poor people to die by the side of the road. So she's got that in her favor, and I will go on the record as saying she's not evil (as she accuses liberals of labeling her). Not evil, just terribly terribly misguided and profoundly wrong.


  1. I never thought I would be an advocate for the single payer system but it seems like it is the only way to fix the horrible state of health care.

    I would like to point out that tax dollars already pay for the very poor and those 65 and up, with Medicaid and Medicare. We also have state health insurance programs that covers children from families above the poverty level. Now it is time to make sure that the middle-class doesn't go broke trying to pay rising insurance premiums or with self-pay for health care.

    I enjoyed your thought provoking take on the situation.

  2. In my locale, professional liability insurance is required of physicians. Are these also then taxes?


  3. She attempts, wrongly, to recast the debate as simply that of wealth transfer...

    Shadow, any type of single-payer plan is an overall transfer-of-wealth from the "rich" to the poor. All people would get the same thing, but the "rich" would pay a lot more for it in the form of higher income taxes and higher overall payments in terms of dollar amounts. If there was no transfer-of-wealth, then how would the unemployed mamas with 6 kids get their health insurance under a single-payer plan?

    While we'll never agree, I feel that anything that needlessly restricts our freedom, such as forcing us to be in a health insurance plan that the government runs when we're perfectly happy with our private plan and private system, is immoral.

  4. I guess I've reached that post-Watergate post-Libertarian age where when I read 'private' or 'market' I don't think 'efficient', I think 'corrupt, but with no oversight or recourse.' Maybe it's just the past six years, I don't know.

    Whether single-payer is the right answer will be determined by the details; frankly, I don't have enough invested in the day-to-day of it to get all dogmatic (I'm a health care consumer, not provider.) My concern is that in an affluent, literate, industrialized country many people who need health care cannot get it at a reasonable price in the current market and it would not be an onerous burden to provide a basic universal level of care. Compare the level of defense spending to domestic programs or all non-defense spending combined and it's blatantly obvious that this country can afford to provide care - it chooses not to.

    I have faith that Americans can, if allowed, create an equitable, effective, and well-managed system of care that suits the unique character of this nation.

    The morality argument against single payer is specious for the reasons you've outlined; I think a more pressing ethical question is whether health care should be a for-profit industry. I'm all for reducing costs and improving efficiency but I question the ethics of deriving profit from denying care whether by 'preexisting condition', bureaucratic hoop-jumping, or the legal waiting game where - right or wrong - the party with the deeper pockets can bankrupt the other simply by running the clock.

    I have a hard time sympathizing with nurse_k's mythical rich whose freedoms are onerously and 'unnecessarily' impinged by having a very small fraction of their income siphoned off to provide care to people not as happy & healthy who don't have access to care at whim.

    I pay for guns I'll never shoot, planes I'll never fly, highways I'll never drive, land I'll never visit, schools that will never educate my nonexistent kids, and prisoners who'll never victimize me. Consequently, I don't complain too loudly about the nation's defense, the transportation network, the education system, and the rule of law. This isn't a matter of being a big flame-o liberal - this is about basic human decency, or failing that, the notion that a rising tide lifts all ships. Given how many families are one major health care incident away from bankruptcy and the ongoing economic cost of that, doesn't everyone (especially the rich) get richer if more people are happy and healthy, able to work and pay their debts and contribute to society?

    Morality my ass. It's all about greedy entitled white people justifying their shitty treatment of others less white or entitled than themselves with the threadbare spectre of socialism. In certain moods I loves me some Ayn Rand but that doesn't mean she's right.

  5. Single payer is wealth transfer and it is socialism and it is nothing more than a different sort of rationing.

    Kids, invalids, and the elderly are already covered (or can be) under our present socialistic single-payer systems of Medicaid and Medicare. You want to cover the "not so rich" middle class too? By providing them with some nebulous basic level of healthcare? I'm not completely opposed to that concept, but I think many will complain just as obnoxiously as they do now when they see that their basic healthcare doesn't cover _________ (fill in the ever-expanding blank):

    Coronary stents? Sorry, those aren't covered. Recent studies show minimal benefit over medical therapy. MRI? Nope...how about a CT instead? Come back next month, we have a slot open then. Back surgery? Afraid not...how about some physical therapy instead; sign up on on this waiting list. Knee replacement? Try some Motrin and get in line. Liver transplant? Are you kidding? Hemodialysis? How old are you? Zofran? Sorry, you'll have to take Phenergan suppositories instead (like the Medicaid folks do now). Remicade? No way, Jose. Provigil? Try some caffeine pills instead.

    The socialists won't be happy until we all have the same level of care, because to offer otherwise lacks "basic human decency." How dare the "rich" have access to knee replacement surgery while the average citizen suffers needlessly? Barf.

    I suspect that we ER docs might make more money in a single payer system than we do now, because the demand for our services will increase and we'll get reimbursed at least some amount from everyone we treat. I'm more skeptical about single payer from a healthcare consumer perspective than from a healthcare provider perspective.

  6. Can't resist this one:

    Insurance IS a form of wealth transfer between statistically "expensive" insureds and statistically "cheap" insureds, unless they pay different rates based on risk assessment.

    Most health insurance programs charge people more for (or excludes coverage in response to) higher risk. Thus, it is not technically a transfer of wealth from sick to poor but is, as you claim, a risk sharing arrangement.

    However, most UHC systems don't include exclusions or added costs for high risk. And if you charge everyone an equal amount for health insurance nationwide, you ARE effectively transferring wealth from the low risk people to the high risk people.

    (I don't understand where you're going with the "kids get sick, too!" argument. Generally speaking, the elderly are quite expensive to treat in comparison to younger adults. Exceptions don't change the general rule.)

    However, there is a way to view UHC as an accurate risk sharing arrangement and not a wealth transfer arrangement. That requires making a lifelong assessment of contribution and coverage, not a year by year one.

    Even if you assume that, say, infants and elderly are much more expensive to insure than the rest of us... that doesn't matter. It doesn't matter so long as we know that we are guaranteed coverage for our own lives. if EVERYONE is paying "too little" as an infant or an 80 year old, and EVERYONE is paying "too much" when they're 25, then there is no effective transfer from one class to another.

    The obvious problem is that this makes the currently-healthy, middle aged, folks nervous. We'll be asked to absorb the increased costs for kids (which we can no longer take advantage of.) And we'll be asked to absorb the increased costs for the elderly.

    But given the vagaries of government, we are not sure that we'll get back what we put in. It certainly didn't work for Social Security, did it? And if I end up subsidizing elderly health care for 30 years, only to have it become less available as I age and need it more, then that IS a tax, not a sharing of risk.

  7. it's blatantly obvious that this country can afford to provide care - it chooses not to.

    apthorpe, in my opinion, hits the nail on the head with this comment. I am far less knowledgeable than most of the people who have commented so far, so my interest is not in debating the details of one system over another (although there is great value in that).

    This is what it boils down to: if those of us at the top (which probably includes the vast majority reading these words) are willing to help this much (imagine my fingers about half an inch apart), it will help those at the bottom this much (imagine my hands about six feet apart).

    It's kind of like, you give the homeless guy on the street $1, but magically that $1 morphs into $5,000. Now he can rent an apartment, buy new clothes, etc. You have changed his life by giving him something that you really will never miss (and please, I know that this analogy breaks down if taken far enough...what if he's a drunk, what if he's an axe murderer blahblahblah)

    So when I read comments like Nurse K's (I feel that anything that needlessly restricts our freedom...is immoral. I just want to give her a hug and say, but there IS a need. The fact that it's not YOUR need doesn't make it go away. Addressing that need is important enough that I personally don't mind the inconvenience it causes me.

    If anyone is interested, I'll be out by the campfire hugging trees in my birkenstocks later. Everyone's invited (even nurse K and scalpel :)

  8. Or you could give a junkie $1 and it might magically turn into a $5000 down payment towards his rehab bill.

    Ya think?

    La, la la, lala.

  9. "Insurance is voluntary. This is a tax."

    We pretend all too easily that food, shelter, transportation and, yes, the care of a doctor are somehow optional.

    Threat of dire financial consequences is a form of duress. Threat of injury or death because of a lack of monetary resources is cruel.

    Pity is not optional. When we deny that, we are savages.

    I pay taxes gladly when it goes to the greater good. Civilization is founded on a shared risk and a shared protection.

    We can afford this. We choose, every day, to partake in this lie: that money = worthiness. We pretend it's the money making the choice. That this is just a cold business decision, based on shifting numbers. It isn't. It is we who decide.

  10. Threat of injury or death because of a lack of monetary resources is cruel.

    Voila! EMTALA is born.


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