Wolf Blitzer: You’re a physician, Ron Paul, so you’re a doctor. You know something about this subject. Let me ask you this hypothetical question.
A healthy 30-year-old young man has a good job, makes a good living, but decides: “You know what? I’m not going to spend $200 or $300 a month for health insurance because I’m healthy, I don’t need it.” But something terrible happens, all of a sudden he needs it. Who’s going to pay if he goes into a coma, for example? Who pays for that?
This is the kind of question that libertarians usually give stupid answers to. Their first impulse is to stress that no one has the right to force other people to pay her medical bills – which is true enough, but a weird place to start. This answer in effect treats the free market as the present system minus welfare, and so takes for granted that the problem described is likely in a free market. It also casts the sick person as a threat to others’ liberty rather than as a person who can be better helped by libertarian methods than by statist ones. If someone is looking to smear libertarians as people who want to let sick people die, this hands them the opportunity on a platter. (Of course it doesn’t help if your alleged supporters are actually yelling in the background that the patient should die.)
Most libertarians’ second impulse is to mention charity. And their third impulse, if they ever get around to it, is to mention the point they should have led with – that the high cost of health care is a product of state regulation.
In the last Republican debate (transcript here), Ron Paul went through the three stages in depressingly predictable order. First, demonising the victim:
Ron Paul: Well, in a society that you accept welfarism and socialism, he expects the government to take care of him. … But what he should do is whatever he wants to do, and assume responsibility for himself. My advice to him would have a major medical policy, but not be forced …. That’s what freedom is all about, taking your own risks.
Next, he finds his way to charity (though with a bit of stage one still mixed in):
Ron Paul: I practiced medicine before we had Medicaid, in the early 1960s, when I got out of medical school. I practiced at Santa Rosa Hospital in San Antonio, and the churches took care of them. We never turned anybody away from the hospitals. … And we’ve given up on this whole concept that we might take care of ourselves and assume responsibility for ourselves. Our neighbors, our friends, our churches would do it.
And only then, finally, does he get around to talking about the structural problems caused by corporatist regulations. Now to his credit, he does actually get to stage three, where many libertarians would not. But leaving it to the end forces him to rush through it with no pause for explanation:
Ron Paul: This whole idea, that’s the reason the cost is so high. The cost is so high because they dump it on the government. It becomes a bureaucracy; it becomes special interests. It kowtows to the insurance companies and the drug companies, and then on top of that, you have the inflation. The inflation devalues the dollar; we have lack of competition. There’s no competition in medicine. Everybody is protected by licensing. And we should actually legalize alternative health care, allow people to practice what they want.
But when you lead with stage one, that’s what people will remember; adding stage three as an afterthought will leave far less trace in people’s thoughts.
The right way to answer a question like Blitzer’s is to proceed in precisely the opposite order. Start by asking what causes people like the hypothetical patient to be in the plight they’re in. In other words, lead with stage three. Why didn’t the patient buy insurance? Because the price was too high. Why is it so high? Talk about the specific ways in which corporatist policies drive up medical costs (and disempower the poor in other ways too).
Then, if you still have time, proceed to stage two. If someone doesn’t have insurance and needs care, what’s the most efficient way to get it to them? Talk about how charity and mutual aid are more efficient than government welfare, and how we therefore need to shift the venue of assistance from the latter to the former.
And then you can finish by pointing out that peaceful, voluntary solutions are not only pragmatically but morally superior to coercive ones.
I’m not saying that one should generally stress consequentialist over deontological considerations; it depends on the issue. But this is one of the issues where starting with the deontological issue is overwhelmingly likely to be heard as Scrooge-like, and that perception will colour and even obscure whatever you go on to say after that – which is, predictably, exactly what has happened in the aftermath of Paul’s answer in the debate.
This impulse to start with stage one is a strategic and rhetorical error on libertarians’ part; but I don’t think it’s solely that. I think it’s a symptom of incomplete emergence from a right-libertarian paradigm. The first impulse is to approach the issue as though our current system were a free market or close to it; and the left-libertarian point that it is no such thing is added as an afterthought because it is an afterthought. The problem is with the vision itself, not just with a strategy for conveying it.
I don’t mean this as a rant against Ron Paul. As I said, the fact that he does advert to anti-corporatist considerations at all is a point in his favour. (I have other problems with Paul, but sufficit malitia diei sua.) But his recent answer on medical care was a highly visible instance of a widespread libertarian problem.
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