September 03, 2007

posted by Frank Pasquale

Of course, you don't have to send your kid to a public school, or feed them from a vending machine or a lunch line. On the other hand, Edwards' program would be mandatory for all Americans, with no opt-out option.

Of course, we could do away with all public schools and with medicaid.

I suspect *one* part of the problem here is that Althouse relies on a rather attenuated if not unsophisticated conception of autonomy, one that has in fact held pride of place for some time now in the bioethical literature. For critiques of this conception that do not, at the same time, dispense with this important moral principle, please see, first, Carl E. Schneider, The Practice of Autonomy: Patients, Doctors, and Medical Decisions (New York: Oxford University Press, 1998), and then, Alfred I. Tauber, Patient Autonomy and the Ethics of Responsibility (Cambridge, MA: MIT Press, 2005).

[FWIW: I visit Ms. Althouse's blog for the photographs, which are typically first-rate, the other material rarely reaches such heights (and the comments are notoriously awful).]

From the article:

"It requires that everybody be covered. It requires that everybody get preventive care," he told a crowd sitting in lawn chairs in front of the Cedar County Courthouse. "If you are going to be in the system, you can't choose not to go to the doctor for 20 years. You have to go in and be checked and make sure that you are OK."

I would interpret that as meaning you're still allowed to buy your own private medical insurance, in which case you're perfectly free to neglect preventive care. That is, if you can afford that private insurance. And if you're on the dole, wouldn't conservatives prefer that the government not waste its money on treating preventable illnesses?

"I wonder if Althouse also opposes the Bush administration-supported West Virginia program that imposes all manner of paternalistic restrictions on Medicaid recipients?"

There is a fundamental and self-apparent difference between Medicaid and universal health care: Medicaid is not universal -- it is welfare. It is those who don't benefit from it paying for those who do. So there is of course a basis -- perhaps a heartless one, but a basis nonetheless -- for attaching strings to Medicaid eligibility that do not carry over to bona fide universal health care (including Medicare).

Socialized medicine (including Medicare) is different from Medicaid: it is taxing people to fund a compulsory universal scheme, then saying that because the health care is "free" (!), the government can attach strings on the very people who (involuntarily) paid for the coverage in the first place.

So the government takes my money, and then demands that I conform to its (i.e., politicians' and bureaucrats') standards of "correct" lifestyle choices in order to get my money back. All in the name of establishing a "compassionate" and "enlightened" paradigm.

This is what I have previously dubbed "The Krugman Lie."

Kip,
Given that people can buy supplemental insurance in Britain, and given the diversity of private insurance plans available to supplement public programs in countries like France and Germany, do you really think Edwards is planning to just nationalize the whole American system? Can't people supplement Medicare with Medigap plans and other policies?

As for Medicare & Medicaid: Is the deal really so 1-to-1 in Medicare? What about people who die before 65--they don't just get the money they put into it back. And if you have a condition while you're on Medicare that's a lot more expensive than mine, it's not like anyone says "wait a second--I don't want to subsidize him." No workable insurance system works like a dedicated HSA--and the latter can end up being a way to assure that the poor get close to no care at all.

Finally, Medicare also covers many disabled people, fitting more into the "welfare" paradigm you've articulated. see
http://www.ssa.gov/dibplan/dapproval4.htm

Finally: the U.S. government already massively subsidizes medical education and other parts of the health care infrastructure. I am just mystified by libertarian voices who think that if we somehow just got government out of the way, and cut taxes more, we'd somehow find a way to pay for all that.

Finally, some perspective from Woolhandler and Himmelstein:

"While national health insurance wouldn't cost Americans more, it would mean that taxes would pay a bigger share of health care costs and that private insurance and patients would pay a smaller share. Yet government now spends far more on health care-and national health insurance would require a smaller tax increase -than most Americans believe. The step from our current level of tax financing -59.8 percent-to Canada or Australia's 70 percent is less steep than the CMS figures on public spending imply. About $130 billion per year-the amount of the recent tax cuts-would get us from here to there."

from
http://www.pnhp.org/news/2002/july/paying_for_national_.php

Frank, I honestly don't understand your attack on me. You say "Althouse's lament is part of a more general libertarian pincer movement to erode social solidarity. The first step is to construct a class of undeserving sick who have failed to live up to their 'duty to be healthy.'" But it seems to me that it is Edwards who is trying to impose a duty to be healthy. It sounds as though you have to meet the conditions of going in for preventive care to be in the program. How could you enforce the requirement other than by disqualifying people who come in with something that could have been found earlier? I'm not the one recommending disqualification. Edwards is implying it, or is too short-sighted to see that it's implied by his proposal, as stated.

And I'm especially concerned about the requirement that we submit to screening for mental ailments. Why should we trust a candidate who comes up with such an idea? It's crazy. (He should be screened.)

Frank, I don't understand what you're trying to say in your post.

"Althouse's lament is part of a more general libertarian pincer movement to erode social solidarity."

The question is whether her criticism of Edwards's plan is valid. You haven't addressed that.

"Those who care about a functioning safety net then try to respond with programs like Edwards'"

"Care?" I'm sure they like to think they care, but if they really cared they wouldn't be supporting programs like Edwards's. Actually, when you read the last paragraph of your post, shouldn't you have said that "those who care. . . try to respond with programs like Newt's."
Anyway you still haven't addressed the mandatory aspect of coverage.

"I wonder if Althouse also opposes the Bush administration-supported West Virginia program that imposes all manner of paternalistic restrictions on Medicaid recipients."

You can wonder if you want to, but why would you want to? According to what you just wrote in an earlier paragraph, if she supports it she cares. If she doesn't support it then you'd have to say she's consistent. Either way you'd have an answer to what it seems you were trying to imply.

Ann,
I don't think of this as an attack on you. All I'm trying to do is to contextualize your post as part of a larger rhetorical effort to discredit efforts to insure the uninsured.

Every plan is going to have some component that someone dislikes. Does it really advance public debate to score points against one small corner of one candidate's plan without giving people a sense of a better alternative?

I think that anyone who criticizes a plan like Edwards's ought to advise readers of the plan that they prefer, and how that plan would deal with the problem of the 45 million uninsured. (see, e.g., http://lawprofessors.typepad.com/
healthlawprof_blog/2007/08/justice-oconnor.html

Good lord, what an odd way of viewing the suggestions (Ann's, not Frank's). I've said it before, but I will keep saying it: this country spends 95% of its health care dollars on acute care and 5% on preventive medicine and public health even though it is generally undisputed that the latter have a far greater effect on population health than the former.

If we are talking about a public subsidy of health care, a general proposal I am very much in favor of, we damn well better start by correcting the preposterous flow of health care dollars in this country. Moreover, it is precisely the libertarian predilections in American culture that Ann taps into that are in part responsible for the flow of dollars directed to acute care. As Callahan nicely pointed out in False Hopes, acute care generally deals with individual patients who need care promptly. This appeals to our individualist ethos, whereas the benefits of preventice care are more diffuse and are distal from the provision of care itself.

Far from being a reason to attack Edwards' plan, then, Ann's invocation of a libertarian ethos is actually part of the problem inasmuch as it is that kind of ethos which has contributed to the current health care state we are in, where the measures that would almost certainly improve health in the aggregate far more than any kind of acute care receive $1 for every $16 allocated to acute care.

Althouse's lament is part of a more general libertarian pincer movement to erode social solidarity.