Tyler Cowen, A libertarian case for expanding Medicaid.

I have next to no views about health care funding policy. I can tell you horror stories about Canada but I also know plenty of horror stories about the U.S., and I don’t believe that those two countries’ systems are useful synecdoches for “state” and “market” respectively. I know enough to know that figuring out how to improve a few pieces at a time of a vast complicated patchwork like the US health care system requires knowledge that is way outside my competence, and that no particular good is served if I pretend that my ideological priors count as useful substitutes for policy knowledge in a domain in which I have zero decision-making authority.

But I do think Tyler’s post is relevant to what we do here. I take one of the BHL ideas to be this application of the theorem of the second-best:

When Libertaria is not an option and when libertarian first-best policy choices are not available, selective and piecemeal spending cuts will often make things morally worse not better. If, for example, the features of active state policy that make life worst for the disadvantaged or vulnerable are sticky and durable, then taking easy chops at the state expenditures that mitigate disadvantage and vulnerability makes things morally worse. “Cut poor relief last, not first” is one way to think of this. Holding constant a world of immigration restrictions, mass incarceration, occupational licensing, corporate welfare, agricultural subsidies, and upward redistribution of all kinds, large-scale state action to mitigate absolute material suffering among the poor is a necessary offset; cutting that state action first is immoral, and there will often be an obligation to increase it in the meantime. If libertarians are right about the poverty-reducing potential of the rest of our policy goals, great; once we’ve checked them off the list, then we can remove these no-longer-necessary programs. But in the meantime, selective spending cuts are as beset by public choice dilemmas as any other piecemeal state action, and it’s all too easy for them to be focussed on the politically weak. Likewise, in some particular mixed-economy sector like health care, even if there’s a clear libertarian first-best situation, the theorem of the second-best will hold. One has to be very careful about just ratcheting back state spending that supports the poor on the grounds that in the first-best situation such spending would be very low. And– I think, and this is one of the ways in which I’m a BHL– “careful” here definitely includes “attentive to distributive consequences, and not doing the things that take away support for the poor as an early part of the transition to an optimal end-state.”

I also happen to think that Tyler’s prisoners analogy is of potentially very widespread applicability; a thought for another day. For now I’ll just note that his post represents the kind of inquiry that I think BHL demands.

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  • AP

    I think that I largely agree with you, but there’s a worry I have that intervention leads to intervention leads to intervention, with each being justified on the grounds on the previous one. e.g. The state restricts entry to the medical profession; this leads to higher prices. The state uses this as a justification for large subsidies and transfers. Now that people are not paying the full cost of their own healthcare, they have a reduced incentive to stay healthy; the state uses this as a justification for paternalism, restricting or banning smoking and various unhealthy foods. (“By not looking after your health, you inflict an exernality upon those of us paying for your healthcare!”)

    In each of these situations the new intervention might be a reasonable response to the problem at hand, but the combined effect of them is to make the situation worse and worse. If we wish to stop the rot instead of allowing an endless chain of new interventions, then some people will be hurt by the problem we leave unsolved, but perhaps we just have to accept those people being hurt in order to avoid making the whole situation worse.

    • Aeon Skoble

      This. If there’s one crushing blow against state-run health care, even given your theorem of second-best, this is it. “If we’re paying for your health care, we have the right to dictate your choices.”

    • PTT

      Sounds like wishful thinking. When has only preventing the wasteful/interventionist policies that help the poor from passing ever helped to unwind the process?

    • Jerome Bigge

      The history of American health care shows that prior to the involvement of government in the health care system, the cost of health care was both reasonable and affordable for most Americans. The driving force for government intervention in health care from the start was the AMA, who like any labor union, understood that restricting the supply of medical providers was the best route to increasing their incomes. With the passage of prescription laws in 1938, the AMA achieved the objective of giving doctors a legal monopoly over access to medical drugs. Prior to this time, people could purchase most medical drugs from their local drug store, and the druggist generally could assist them if needed. Needless to say, with prescription laws, doctors had much more power over access to medical drugs, and they quickly turned this to their own economic advantage. Prior to this, becoming a doctor really didn’t pay that well, with a middle class level income the best that could be expected for having that MD after your name.

      Today, the law does not permit any prescription to be valid for more than one year. which means that the doctor holds a great deal of power over you. This no doubt is one reason among others that the US has the world’s highest health care costs. Our drug companies also enjoy a great deal of economic “protection”, which allows them to charge Americans far more for medicine than what the rest of the developed world pays for the same product.

      • Damien S.

        “Prior to this time, people could purchase most medical drugs from their local drug store”

        Whether they worked or not! Which most of them didn’t, because 1938 medicine wasn’t all that great.

        • Jerome Bigge

          Not everyone was unemployed in 1938. And medicine was not as “backward” as all that. Druggists often compounded medicines (this where the symbol of the mortar and pestle comes from). The theory of bacteria causing disease was known. The practice of sanitation was well known. Iodine was used as an antiseptic. Ether was used for control of pain in operations. X-ray was used, oxygen was used to aid breathing with people who were hospitalized. The first antibiotics were in use. We still use some of the sulfa drugs yet today.

          • Damien S.

            ‘Whether they worked’ referred to the drugs.

            Soap and iodine and I think ether are still cheap today. Unless you get them from a hospital, but that’s true of basic bandaids, too.

          • Jerome Bigge

            There is still a lot of “trial and error” in medicine today. Part of the problem is human genetic variation. The same drug will not work the same on everyone. The cholesterol drug I take does not work on my wife. All the FDA does is to determine that the drug in question is “safe to use”. And even there sometimes a drug will be later withdrawn from the market because the side effects on some people can cause all sorts of problems. While others take the exact same drug and experience only benefits.

          • Joshua Holmes

            “All the FDA does is to determine that the drug in question is “safe to use”.”

            Incorrect. New drugs must be proven safe *and* effective. Google “FDA New Drug Application” and see.

          • Jerome Bigge

            Define “effective”… Effective on what percentage of users? For my wife only Lipitor was effective in reducing her cholesterol. The generic lovastatin that works on me didn’t work on her.

            WebMD has “user reviews” of various medications. Which also show that the same drug does not work the same on everyone. There is no such thing as a drug that has the same effect at the same dosage levels on everyone. This is why the doctor has to start you at a lower level and work up if needed.

      • Damien S.

        “Today, the law does not permit any prescription to be valid for more
        than one year. which means that the doctor holds a great deal of power
        over you. This no doubt is one reason among others that the US has the
        world’s highest health care costs.”

        How does that compare with prescription law in other countries?

        “which allows them to charge Americans far more for medicine than what the rest of the developed world pays for the same product.”

        The developed world pays much less because their governments bargain drug prices on behalf of the entire country.

        • Jerome Bigge

          The governments of these countries, unlike ours, place the interests of the people ahead of the interests of business. Whether or not this is the best way is an open question that everyone will have to decide for themselves.

          Very few businesses get to set their prices where they want due to competition from other businesses. It is only those who have the “protection” of the government that can do so. Everyone else has to face competition from other businesses. This is why the free market is more effective in setting affordable prices than is the government. The free market also tends to produce better consumer goods than government. The Soviets could build things, but their consumer goods left a lot to be desired.

    • ThaomasH

      It seems to me that the proper response is an intervention that removes-ameliorates one of the interventions causing the problem. In the case of health care finance, breaking the link of subsidizing health insurance only through employers.

  • jahouse

    To me this is just the flipside of the argument that open borders would be good in a free society – but because we don’t have an optimal end-state we should enforce immigration restrictions.
    I think libertarians need to, at some point, declare that the state may no longer grow, no matter how ameliorative the intentions behind expansion may be.

    • jahouse

      And if I may just aniticipate a response, I understand that Cowen would probably respond that immigration restrictions hurt the poor whereas medicaid purpots to help the poor. But plenty of closed-borders proponents believe that the poor will be benefited by the lower tax burden that may result from limiting those eligible for social services.
      And to those who say, “well, empirically closed-border proponents are empirically wrong about its effects,” I think that is tenuous position to hold. Similar to AP’s sentiments, what if various state expansions create effects where one apparently pro-freedom policy is actually hurting people? In other words, what if opening borders affected some policy which affected some policy which affected another policy that results in state oppression somewhere else?

      Interventions can build upon eachother. At some point one needs to simply say “stop, enough.”

    • Aeon Skoble

      Yep.

  • John Ash

    There is no “libertarian argument” for statist policies. There are just people who either desperately want to be libertarian, but aren’t, or increasingly ex libertarians so desperate for love and affection in the media that they can’t help but throw libertarianism under the bus any chance they get.

  • jdkolassa

    “yak-yak-yak” is a tag?

    • John Ash

      #donttalkback

  • Common Progress

    Good commentary… Libertarians of the BHL mindset would be more respected and more effective by focusing on eliminating government regulation and red tape that holds down the poor from moving up the socio-economic ladder, simplifying the tax code to reduce bureaucratic costs and pass cost savings on to the poor, and streamlining the welfare bureacracy and passing those cost savings on to the poor.

    • Libertymike

      They do.

      • Common Progress

        RIght, and we should continue… This style of libertarianism is better than the militant absolutist barbarist libertarianism that the masses usually hear..

        • John Ash

          It’s not libertarianism at all. At best, it’s utilitarianism. You think the tradeoff is logical and has utility, but freedom isn’t a significant factor. Time for you guys to rename yourself and stop flinging inappropriate, poorly thought out, illogical names at us. Learn word definitions.

          • Common Progress

            If a public policy streamlines costs and shrinks government, then isn’t that at least incrementally libertarian? For example, if a public policy streamlines welfare spending, gives more aid to the poor, then doesn’t that minimize the role of the state and maximize the liberty of the individual? Anything that minimizes the role of the state, and maximizes the liberty of the individual, compared to its prior state, is incrementally more libertarian by definition.

            However, some libertarians would get too caught up in the “Why should I have to pay for someone else’s welfare?” argument, and reject the public policy outright; rather than paying recognition to the fact that it streamlines government (minimizes the state), and saves money (maximizing economic freedom of the taxpayer).

            I understand the definitions… I just don’t hold a strict absolutist view of the meaning as others.

          • John Ash

            No. You’re geting into relativism. Libertarianism may have various flavors, based on how to implement any kind of enforcement of contracts, but none include forced wealth redistribution.

            So, since you’re engaging in liberal thought, why not just own up and say “I’m a liberal”? You can be a small government liberal. It’s rare, but it’s possible. You can’t be a wealth distributing libertarian, however.

          • Common Progress

            Small government liberal is fair. However, with the wealth redistribution… fixing that is like rebuilding an airplane as it’s flying in midair.

            The broken airplane in midair is symbolic of wealth redistribution.

            The absolutist libertarian like yourself is sitting in this airplane arguing why it shouldn’t be in the air in the first place. You never asked to be on-board. You feel like you’ve been held hostage and forced to board this plane that’s about to crash.

            A practical libertarian, like myself, says “Well, we’re in the air, and it’s falling apart… Why not fix it up a little and bring it to a gradual landing.” Then you come back and argue, “Oh my god, you’re fixing the airplane.. you’re not a libertarian”

          • John Ash

            A libertarian plan isn’t to fix broken government, it’s to create private institutions that can take over the role of government, not to fix the unfixable, let alone expand it. The current obsession with sex and race and “social justice” and trying to take over the libertarian name is about as non-libertarian as non-libertarian gets.

            If you want to be a small government liberal, we will only oppose your ideas. If you try to call yourself a libertarian while doing it, then we will oppose you.

          • Common Progress

            You sound like the protector of some “clique” or “tribe” that is being “infiltrated” by “outsiders” and “posers”… reminds me of the high school cafeteria “cliques” in different tables…it’s cute…

            Controlling this “libertarian” label is essential to your personal identity…

            So I’ll back off…

          • Libertymike

            Regarding your broken airplane analogy, I just do not see the connection to wealth re-distribution.
            I agree with you that once an aircraft is aloft and develops a problem which requires in-flight fixing, it matters not whether one is aboard the flight of one’s own volition. For purposes of your analogy, I am assuming that failure to fix the broken plane while in-flight will result in a crash and burn ending.
            However, with regard to addressing wealth inequalities, your analogy fails, in my view, because: (1) wealth inequality, in and of itself, does not present some immediate danger requiring some remedy the failure of which will bring about an imminent crash and burn as with the plane; and (2) fixing the plane does not require some centrally planned, one size fits all approach to be implemented only through coercion.

          • John Ash

            Aside from this, the libertarian option still allows the plane to fly and costs a whole lot less than allegedly fixing it. Income redistrubtion is more like the idea that there is first class and coach and it bothers CP that people have money to fly first class. It really has no bearing on the plane’s flight, except that the wealthier passengers help subsidize the flight for everyone, voluntarily, simply by possessing and then spending their money in their own self-interest, helping make a better flight for all in the end.

          • Common Progress

            The longer term solution is employee ownership of businesses. Businesses should stop treating workers like Wage Slaves, who earn the same amount of money regardless of their level of productivity, and start treating them like business partners who own equity in the company.

            With that being said, I believe that reform needs to happen from the bottom-up from the grassroots. It can’t, and should not, be created from the top-down by government.

            Let me repeat that again! It should not be created by government.. One more time, IT SHOULD NOT BE CREATED BY GOVERNMENT…

          • John Ash

            Employee owned business is just great. We have a private mechanism for that, called the stock market.

            But you don’t just get to say nice things “on one hand, but on the other hand”……you owe someone else for no reason other reason than you have more stuff. Saying some libertarian aligned things doesn’t make you a libertarian. In fact, it is the non-libertarian things you say that proves you are not.

          • Common Progress

            Another “private mechanism” would be an Employee Stock Ownership Plan (ESOP) or Workers’ Cooperative… They aren’t government owned or controlled…

            About liberty… there’s negative liberty and positive liberty… Freedom from interference from government or other individuals doesn’t necessarily make one free (negative liberty). I have some negative liberty in my thinking too.. And that is ALSO very libertarian…

            Cato Institute, Positive and Negative Liberty: http://tinyurl.com/lw78umq

          • John Ash

            “non-libertarian liberal points to non-libertarian liberal article written by non-libertarian in support of non-libertarian agenda”

            There is no such thing as positive or negative liberty, it is an invention.

          • Guest

            Who sets this so called “libertarian agenda”? Who gets to decide this?

          • John Ash

            Reason and word definitions. The idea of state intervention to ‘clear a path’ is nice in theory, but it comes with it the necessity of control, of theft and other anti-libertarian concepts. It is a nice thought exercise and nothing more. If there were some mechanism that, without negative consequence to any other, removed limitations to your self-actualization, it might be said to have significance, but there is no such mechanism and even if there were, we would quickly find out that positive freedom as controlled by outside sources is simply a guilded cage.

          • Common Progress

            You’re losing me with the state intervention accusations.. When everything I’ve suggested either requires less government than the status quo, or little to no government…

          • jdkolassa

            “I can’t think of anyone who calls himself a libertarian that is further from libertarianism than Jason Brennan. What a fraud.”

            Sarcasm or serious?

          • John Ash

            Well, maybe Matt Zwolinski.

          • Common Progress

            “To me there’s something innately twisted about people who try to make money off of being “libertarian”.”

            Who’s making a lot of money by being a libertarian? Seriously!!! Most of the academics who write at BHL probably make a decent living as professors in their respective fields. But whatever money they’re making isn’t due to the fact that they’re libertarian.

            The editors of the various libertarian blogs on the web don’t make much money; compared to what they could be making promoting the political establishment’s status quo.

            Most iibertarian books are not New York Times Bestsellers selling millions of copies. Especially libertarian books that are academic and abstract. There’s a very small audience for that type of literature.

            Television? The only libertarian on TV making a decent salary is John Stossel…. But he’s not making anything near what Bill O’Reilley, Shawn Hannity, or Rush Limbaugh is getting paid…

            Most “libertarian” candidates running for public office have the HARDEST time raising campaign money… Which is a big reason why they’re always the “underdog” in virtually every political election in America known the man…

            Nobody steps into the libertarain world to make lots of money…. You’ve made a lot of silly comments on here, but THAT ONE takes the cake… smh

          • Damien S.

            I’m baffled at the idea of finding it twisted to make money off of right-libertarianism.

          • http://www.sandiego.edu/~mzwolinski Matt Zwolinski

            Coming soon, on Amazon, “What Libertarianism Is, According to Me” by John Ash.
            Check out these advance reviews:
            “The definitive philosophical, historical, and sociological account.” – John Ash
            “There is, simply put, nothing more to be said on this subject.” – Ohn Jash
            “If you only read one book on libertarianism, ever, welcome to the club.” – Not John Ash

          • Libertymike

            I agree with everything in your post except I am not convinced that CP is bothered by the fact that some people have the money to fly first class and others do not.
            BTW, you may have noticed that I am as consistent as any person you may find on this board with regard to my fidelity to anarcho-free enterprise-individualism principles, including Sean II, who, I will admit, is wicked smaaaarter than me.

          • Common Progress

            Your assumption is correct about the broken plane analogy resulting in a crash and burn ending if it’s not
            fixed.

            You’re correct that wealth inequality doesn’t result in a crash and burn ending. However, higher unemployment and higher poverty does. When too many people can no longer feed themselves, there will be theft, murder, arson, and riots. Throwing people in jail costs more than giving them welfare.

            You’re absolutely correct about “fixing the plane”, or fixing poverty, not requiring a centrally planned economy. Personally, I propose a Negative Income Tax, cramming all welfare spending inside it, and guaranteeing a Basic Income up to 100% of the Federal Poverty Line (FPL), and tax free income up to 200% FPL. It would cost about 10% less than current welfare spending (over $90 Billion in savings).

          • John Ash

            No….it’s essential to preserving its essence. This is exactly what happened to the term “liberal”. It was appropriated by big government socialists and damaged so badly that it is unusable in its original form. So real liberals started using “libertarian” and here you guys come again, trying to crash the party and destroy the libertarian movement.

          • Common Progress

            Here’s a wikipedia article about Libertarianism… You’ll quickly find that the word has MANY meanings and philosophies. (http://tinyurl.com/y3c8cs)

            Nobody is “crashing” anything… Left-libertarianism has been around for a long time..

          • John Ash

            Left libertarianism is an oxymoron. Libertarianism means personal freedom, that you are not for others to control. Leftism is all about control. There is “civil libertarianism” which is not libertarianism, but the concept that government needs to fulfill and provide the “rights” that it has promised you. And no more. But that still is the concept that the state essentially owns your existence as defined by those that created the terms for you.

          • AP²

            Left anarchism is also part of left libertarianism, but it has no concept of the State providing “rights”. Of course, that includes the State not providing property “rights” as well, unlike some other “libertarian” theories.

          • John Ash

            Well, really, certain kinds of property rights are utilitarian, not libertarian. A libertarian property rights scheme really only applies to the creation of someone’s labor, so if someone plants tomatos, you can’t just come in and build a house. in theory, if you’re not using your land, it would be unlibertarian to claim that you have a right to it. The only thing is that now….most land is something you had to pay for with your money, so the system protects that investment. But if I make a or buy a hammer, then that hammer is mine.

          • Damien S.

            Actually, y’all stole ‘libertarian’ from the “property is theft” anarchists and anarcho-communists.

          • John Ash

            I wouldn’t be so sure about that. “Libertarian” has been around for hundreds of years and essentially means that you serve no purpose for others nor have a specific fate, that your purpose and life is yours to define.

          • Jerome Bigge

            Winning over people is the only way we are ever going to be “more” than just a “debating society” getting at best 1% of the vote. We need to show people that they are better off with us than with the Democrats or the Republicans. I have a blog on “WordPress” under “muskegonlibertarian.wordpress.com” where I express my views upon these sort of topics.

            For example, neither of the two major political parties is effectively offering anything that lowers the actual cost of health care here in the US. Taking money from some people through taxes to give to others doesn’t really lower the cost of care, it is just a transfer process that does nothing to actually reduce total cost. This is really “ALL” Obamacare does. The Republican offerings here involve some sort of tax credits which realistically end up doing the same thing. Getting an actual “reduction” in the cost of US health care is apparently beyond the ability of either of our major political parties. Both subscribe to the same ideology of making medicine into a “protected monopoly” and almost completely excluding the free market in the process. It is interesting to note that in the field of visual correction by laser, which is not covered by any insurance plan I know of, the cost of the service has actually declined over time (allowing for the effects of inflation). Proof if any is needed that health care costs are controllable by a free market in health if one is allowed to exist. The only political party that supports a free market in health care is the Libertarian Party. No other political party is willing to do this.

          • Damien S.

            There’s lots of cost control measures in the ACA bill, on top of the basic universality mechanism. Plus it was hoped that shifting care from emergency rooms to regular doctors — and providing more preventive care — would lower total costs. Either way, US health care spending growth has slowed down a lot since ACA was passed.

            Laser eye surgery is elective, almost cosmetic, and thus not subject to the reasons Kenneth Arrow gave for why health care was an inherently bad market.

  • John Ash

    “For now I’ll just note that his post represents the kind of inquiry that I think BHL demands.”

    Why? Does making evil simpler and more streamlined make it less evil? Should libertarians argue for burglars that are more efficient with their theft? Should libertarians propose ways rapists can do less physical damage? Should libertarians advocate murder by a single shot to the head over stabbings?

  • Libertymike

    One of the flies in the ointment of Jacob’s position is the erroneous assumption that “state expenditures mitigate disadvantage and vulnerability”. To the contrary, state expenditures aggravate disadvantage and vulnerability.
    If we hold constant a “world of immigration restrictions, mass incarceration, occupational licensing, corporate welfare, agricultural subsidies and upward redistribution of all kinds”, how is more state spending going to ameliorate all of the concrete, real suffering of the “disadvantage[d] and vulnerabl[e]” who are daily victimized by the very state expenditures which finance and sustain the police state?

  • Kevin Vallier

    I think you’re absolutely right. Here’s a more specific case that works based on the same logic. There are lots of mentally ill people in poverty. Many are homeless simply because their behavior is so unusual that they either can’t handle the ordinary confines of homeless shelters or simply aren’t stable enough to stick around. There are drugs that will help many of them (not just anti-depressants, but anti-psychotics, etc.). These drugs are very expensive due to patent laws that libertarians think are illegitimate and the fact that other countries bargain down drug prices for drugs developed in the US due to their single-payer systems, which leads the companies to pass the costs down onto US consumers.

    There are also social programs that help pay for these drugs, but in many cases, as I understand it, they’re non-functional save for trial packets that psychiatrists and nurse practitioners can give out to anyone they evaluate. I support redistributive efforts to provide people with these potentially life saving medications for precisely the reasons you suggest. Anti-libertarian laws make the drugs extremely expensive, and the weakest of the weak are severely harmed as a result. The tiny amount of redistribution required to provide them with these drugs should be balanced out by taxing the corporations that produce them, but in lieu of that, taxes on people who can more easily bear the burden is definitely morally superior to them not getting the drugs.

    • Libertymike

      The gravamen of your post: more statism because, without it, the impoverished mentally ill will suffer.

      • Kevin Vallier

        I’m talking about a corrective for statism, not statism for its own sake.

    • Homeless

      Your compassion is admirable. But I would not feel confident in psych solutions if I were you. As an on/off again homeless person, shelter volunteer and employee– I will back up your observation that some homeless need forceful intervention for their own good. But the Progressive means you advocate is often results in the very opposite of what you might want it to be.

      Like Eisenhower said of the military and state relationship– there is an enormous psych-state-pharmacological industrial complex. Psychiatrists are often the spearheads of this perversity– and homeless people, some of the easiest to victimize, are the guinea pigs. False imprisonment and poisoning via “anti-psychotics” describes a significant portion of what you are calling proper drug treatment. This is not to say that drugs– maybe future drugs– should not play a role in helping people.

      Psychiatrists are sometimes as dangerous as pedophile priests and sadistic police-state interrogators– and for similar reasons. Yet the bulk of damage done to people– like chemical lobotomies with irreversible physiological consequences– consequences of solitary confinements and/or denial of sustenance– and the power/ torture games played by psych staffs at lock-up facilities– is all part and parcel: of psychiatrists (and other psych profs) just doing there jobs.

      Again, yes people need help. I appreciate your compassion. But interventions should not be monopolized in government psychiatry. Rather, innovations– like accepting homeless transience while intervening covertly in the environment to make sure “bum” areas are safe, hygienic– can only be brought about and sustained via competitive cooperation i.e. the market.

      There is much more to this. I have anecdotes aplenty– about psych abuse, ptsd ghosts wandering Cambridge MA, drunks living down by the river, a destruction of brand new state mental health housing by residents equaling hundreds of thousands of dollars down the drain, and so on…

      Anyway, I guess I only want to implore you to question your assumptions about the psychiatric-homeless paradigm.

      • Kevin Vallier

        My goodness am I not advocating forced psychiatric anything. I simply think that the drugs should be available to people who need and want them.

        • Homeless

          That’s all you are saying?

          Needs and wants… Whose needs and wants? It is doctor perceived needs and wants that assume priority among at risk and homeless populations– because doctors can influence people’s fates– incarceration or street, the rough public “wet” shelter or the private charity safe shelter, welfare benefits or no.

          “Take the drugs or X.” Do you know for certain that these chemicals are “needs”? Have you even entertained the notion that these chemicals might merely be dehumanizing control mechanisms? In other words, the Progressive angle shines through in action: utilitarian state goals over individual rights. We will call this drugging a service to these individuals but really that is ancillary….

  • Al Bundy

    There is a difference between arguing that a particular interventionist policy should be the last to go, and arguing for even more of that intervention.

    I definitely agree that the massive policies that harm the poor should be cut before the smaller policies that mitigate this harm, such as welfare.

    But I won’t go as far as to advocate for MORE welfare in the meantime. Then we are just making the statists’ arguments for them.

    • jdkolassa

      Agreed completely. Let’s start cutting corporate welfare and other policies that drive up the costs of goods and services, THEN we can talk about reforming welfare.

  • jdkolassa

    I still say eliminate Medicaid and Medicare, privatize Social Security, turn the tax system into a Negative Income Tax, have tax-exempt health savings accounts, and pursue reforms that open up the supply of doctors and nurses and break down the accredition monopoly.

    Of course, these will hardly get done (and not all at once) but it is lightyears more libertarian than smearing bureaucratic effluvia over more poor people.

    • Common Progress

      The Negative Income Tax is BRILLIANT! I just wrote a piece on that…

      • jdkolassa

        Indeed. Its one of the few things I can look at and feel like it’s a sure shot to fix a lot of our problems, on both left and right, which also makes me a little worried I’m being overconfident. But I really do want to get it implemented and I think we’re reaching a point soon where it will be politically feasible.

        • Common Progress

          Rand Paul is talking about a flat tax, but hasn’t went though any real details… If he decides to run for president in 2016, then it would be good if his flat tax plan is a Negative Income Tax…

        • K.P.

          You think we’re reaching a point where the elimination of Medicare and Medicaid is politically feasible?

          Particularly from the left, I think the most support you’d get is for a minimum income… on top of the current system in place.

          • John Ash

            5% of the way there and inching along!

          • Common Progress

            A minimum income is a good idea if it REPLACES current welfare. Money can be saved by eliminating the micro-managing Nanny State bureaucracy, and giving the poor straight cash up to 100% of the Federal Poverty Line.

          • jdkolassa

            I mean, I think we’re coming to a point where a Negative Income Tax to replace our current system will become politically feasible. Obviously we’re not there yet – it will probably take another decade – but we’re getting there.

            As for gutting Medicare and Medicaid, that will take longer, but I if we can derive some great alternatives (such as NIT) I think it will pick up steam. And as for privatizing social security, well, I actually think that will be easier than most people think. It’s just everyone is too afraid to actually be bold on the issue.

          • Damien S.

            The fact that the star country for Social Security privatization, Chile, regrets it is a bit of a problem.

      • John Ash

        ….of course you did.

    • John Ash

      Not a libertarian idea but could actually slowly lead to dissolving all of the requirements when it works – http://www.policymic.com/articles/13057/universal-savings-accounts-the-path-to-freedom-in-health-wealth-and-retirement

  • Joshua Holmes

    It is not libertarian for subsidized cartels to enjoy profit without limit, whether those profits come from “public” or “private” spending. We pay 50% more, cover an 1/8th fewer, and generate no better outcomes from a system that is not (and never will be) remotely libertarian. No libertarian principle is lost by moving from subsidized cartels to single-payer, and we know from every other developed nation that costs will be lower and outcomes will be no worse. Medicaid for all.

    • John Ash

      Uhhh, false dichotomy. Libertarians are for removing subsidies and “cartels”.

    • CT

      Do you really believe it would be “Medicaid for all”? Allow me to offer a few examples (from a Canadian) of how single payer actually works.

      The only way to keep costs down is to cap prices and salaries. This has led to shortages. My mother, for example, had to wait in pain for almost 6 months to get knee surgery. People have to wait hours in clinics and emergency rooms for basic care. That means a poor single mother can lose an entire day of pay because her kid is sick. You want to see a specialist (for a colonoscopy for example)? Get in line. You don’t even know when you’ll get one (this happened to me so I paid the have one in the now legal private sector). If you have a problem you get to wait 18 months to find out what is wrong with you. As the boomers get older, its pretty obvious that the problem is about to get a lot worse.

      To make matters worse, the for-profit system in the U.S. acts as an overflow valve for wealthy Canadians. Go to single-payer and your system won’t look like Canada’s because where will the American valve be? And obviously, from a Canadian perspective, the line-ups will just increase.

      The ONLY solution libertarians should be pushing is an end to the regulatory disgrace which has led to the current situation.

      • Joshua Holmes

        The US system also suffers shortages and wait times. We don’t have hard statistics on them, as you do, because they mostly happen to the uninsured, 1/8th of our people. The delay is no different; it’s just harder to quantify here. That’s probably why, despite your quite visible wait lists, your health outcomes are basically the same as ours. If you like, you can think of the American overflow valve as kicking the poor in the teeth, a treasured American tradition.

        Note that we *double* your per capita spending with nothing to show for it. That’s the ultimate regulatory disgrace.

      • Damien S.

        There are two dozen countries with some form of universal health care, including others with Canada’s single-payer socialized insurance Medicare model (Australia and Taiwan, at the least.) Long waiting lists is a *Canadian* problem, not a UHC problem. Possibly because you have even fewer doctors per capita than the US, while European countries tend to have 50% more doctors.

  • Les Kyle Nearhood

    “when libertarian first-best policy choices are not available, selective
    and piecemeal spending cuts will often make things morally worse not
    better.”

    In order for me to buy that, you would first have to convince me that government programs actually in the long term really help people more than they harm them.

    • Common Progress

      Some people only collect government assistance for a short period of time before bounching back into stable jobs. Single mothers at young ages (18-23) require government assistance, and have been able to finish school, get a job, and earn a steady income. In these situations, one can say that government programs have helped in the short term AND long term.

      Of course, there’s people who live on government assistence indefinitely and never achieve economic independence. In these situations, one can say that government programs aren’t working in the long term.

      At least with government welfare, it’s not completely black and white. There’s shades of gray.

      • Damien S.

        “Of course, there’s people who live on government assistence
        indefinitely and never achieve economic dependence. In these
        situations, one can say that government programs aren’t working in the long term.”

        Lots of those people have real physical or psychological problems that would make them not good workers — or colleagues! — anyway. I don’t think there’s very many able but idle pure moochers, given that (a) welfare kind of sucks and (b) it sucks even more after Clinton’s reform; you can only be on it for five years.

  • Storewars News

    Nice
    read! Very informative. Did you know that Tesco trials ‘multichannel’ staffroom
    concept in Lincoln. Full story here: http://bit.ly/1oAgs8r.

  • Wheylous

    How easy it is to forget Bastiat’s words of caution:

    “Socialism, like the old policy from which it emanates, confounds Government and society. And so, every time we object to a thing being done by Government, it concludes that we object to its being done at all. We disapprove of education by the State – then we are against education altogether. We object to a State religion – then we would have no religion at all. We object to an equality which is brought about by the State then we are against equality, etc., etc. They might as well accuse us of wishing men not to eat, because we object to the cultivation of corn by the State.”

    Going back to the question: “Given a red button to end government funding of healthcare in prisons, would you press it?”

    It’s easy to forget that if we do cut it, this doesn’t actually mean *they won’t be getting healthcare*. It means the state won’t be funding it. Seems like a good opportunity for all the bleeding hearts to start opening their wallets, putting the money where their mouth is, and paying for their healthcare voluntarily.

    To reiterate – just because we’re cutting out the government, it doesn’t mean other people (including ourselves) won’t take action. Am I advocating this over the extension of government healthcare services to prisoners? That is not the point of this post. The point is to remind everyone that if something is a well-known policy under democracy, that implies enough people favor it. As long as it’s not a public goods problem, voluntary actions can often replicate the same effect.

  • DavidBernstein

    The problem is that Medicaid is entirely free, while other options cost money. If you expand Medicaid without doing it carefully (say with a sliding scale of costs), you wind up placing HUGE marginal tax rates on individuals who are just over the Medicaid threshold. And then you keep them stuck in bad circumstances because they can’t afford to make more money.

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