• Gwai Lo, MD

    Interesting interview, but there are a few mischaracterizations here:
    1) Patients currently have full autonomy when it comes to medications. The doctor prescribed, the patient decides whether or not to fill it. It’s the role of doctor as consultant…this goes with the discussion of informed consent. We meet non-compliant (or non-adherent in nicer terms) patients every single day.
    2) Not all patients are the same. Drugs interact together. It’s not like Drug X cures Disease Y; go to store and buy Y. Modern medicine has moved SO much beyond that. Even within a specific class of drugs, there are variances. There is no substitute for a medical opinion. But, as stated here, if people want it, then release doctors and pharmacists of legal responsibility. I don’t think the majority of the population will do that.
    3) The free-market approach to healthcare is a challenge for many reasons. a) Bad things happen. You don’t need to eat Doritos and soda to get lupus. Or be born with asthma. Or just have bad genetics. Health is not a choice and it’s not predictable. Saying healthcare is not a right is literally condemning people to death for guessing wrong about completely unpredictable events in which they have no expertise.
    b) there are limited healthcare resources and they take decades to create. There will always be a shortage of human capital. Plus, healthcare is best when there is continuity, especially with chronic disease. Most doctors just want to be given the tools to meet expectations. That’s it. When there is unpredictability, a lack of information, multiple providers, etc., the patient’s health suffers. Everything about medicine lends itself to a centralized, structured approach. Even the most libertarian among us providers feel this.
    c) health as a commodity ALWAYS depreciates. Father Time is undefeated. Putting off a purchase of a car doesn’t have the same consequences as putting off the purchase of a medication or surgery. There is real lasting damage that can’t be recovered when the health good is ultimately purchased.

    So healthcare is a right. Now, if one were to provide everyone a UBI and the UBI could be used to purchase health insurance, that’s fine. People can make choices. It’s not significantly different from the ACA subsidy and the voucher system has been used in other countries. If people want the FDA to be an optional label, that’s fine. We already have that with the supplement industry. I’d expect physicians to not prescribe non-FDA-approved drugs, unless we’re given the free-market freedom of kickbacks (not ethical, of course) and patients surrender their legal rights.

    When it comes down to it, our current method of paying for healthcare is terrible. Our delivery is mediocre, and the biggest barrier is lack of coordination. As a liberty-minded insider, I will say the ACA has the right idea. The best model I’ve seen is Kaiser Permanente. They provide great care, provide excellent employee benefits, are highly-coordinated, and make the experience seamless. (I am not an employee at Kaiser.) THAT’S the model of the future.

    As for payment, most physicians don’t care where the paycheck comes from because there are very few individual practitioners left. Most form groups. The groups pool the money and allocate it in countless different ways that resemble socialism, capitalism, etc. So most providers are completely ignorant of the original source of the money (Medicare, self-pay, insurance, etc.); it’s been “laundered” through the group’s financial model.

    • DST

      >Health is not a choice and it’s not predictable. Saying healthcare is not a right is literally condemning people to death for guessing wrong about completely unpredictable events in which they have no expertise.

      But if healthcare is a right, then you’re entitled not to effective healthcare, but to whatever healthcare the government sees fit to give you, which often includes long wait lists and mediocre outcomes. And if you’ve taxed someone to provide them with healthcare, you’ve taken money out of their pocket that they could have used to pay for a preferred alternative to the government-sponsored systems.

      >there are limited healthcare resources and they take decades to create. There will always be a shortage of human capital.

      And government solutions are the best way to maximize the availability of human capital? If you want to entice more people into the medical field, wouldn’t you want to offer them the flexibility of a decentralized approach?

      >Everything about medicine lends itself to a centralized, structured approach. Even the most libertarian among us providers feel this.

      “People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices.”

      I won’t make any judgment about you as an individual, but I don’t trust the members of any profession to regulate that profession in a way that benefits consumers over themselves.

      >So healthcare is a right.

      Well, I’m glad we got that settled.

      >Now, if one were to provide everyone a UBI and the UBI could be used to purchase health insurance, that’s fine. People can make choices.

      So, it’s only a right so long as people choose to spend their welfare money on it?

      >The best model I’ve seen is Kaiser Permanente. They provide great care, provide excellent employee benefits, are highly-coordinated, and make the experience seamless. (I am not an employee at Kaiser.) THAT’S the model of the future.

      I’ve have good experiences with Kaiser as well. Is that model becoming more or less common?

      • Gwai Lo, MD

        The mistake people make when discussing “free-market” healthcare is that the free market actually leads to patient harm. If patients “doctor shop,” valuable health information is lost in the process. It’s also expensive to re-test for information we don’t have. In an ideal healthcare system, we are linked to our competitors, not in direct competition. For trauma, given limited resources, we all coordinate so that patients are directed to the hospital with the available resources. In other words, violation of the free-market is both essential and good. You have to treat the entire industry as a sort of utility.

        Also, government models in other countries DO work. It’s a myth that they’re worse than ours. Many also allow a secondary market to spring up for better care (New Zealand, for instance). You can work 3 days in the private sector, two in public. The flexibility we have is that we can hold many jobs at once should we care to. Doctors are also an unusual group in that most are not particularly entrepreneurial and would rather join something like Kaiser that removed the administrative headaches. It’s a VERY small-c conservative occupation. But there are some who want to make some bucks on the side and there are ample opportunities.

        EMTALA basically guarantees evaluation and stabilization of a patient. But that evaluation is, by definition, free labor that we should be paid for. That is an assertion we live under that healthcare is a right because, before that, people died in the streets. If we had our way, we would just treat everyone the same and not worry about the bills. Out current system is so convoluted that we have no idea which patient pays what.

        As to whether you can trust the medical cartel to act in the best interests of patients? You can. That was the whole point of medical ethics. There are plenty of laws on the books to prevent emoluments, kickbacks, etc. Those who do this get discovered and charged criminally, sued, or their license sanctioned. And each hospital has its own committee that can fire bad actors from their medical staffs. The many near fist-fights I’ve gotten into or seen between doctors are over what each feels is best for the patient. When you see something wrong, rest assured (?) that it’s likely incompetence, not greed. A Jewish surgeon and I, a Jewish anesthesiologist, resuscitated a Nazi (huge swastika tattoo) who t-boned an elderly woman without giving it a second thought. We are programmed to do the right thing; the last thing we want is for economics to undermine that.

        And, as I said before, we are truly neutral about where the money comes from. I don’t personally care if all healthcare is made part of Amazon Prime. We just care that money flows in and that we can do our jobs. The goal is to do our jobs as quickly as possible with as little headache as necessary. We’ve already been highly-programmed to do the medicine stuff..

        • DST

          >The mistake people make when discussing “free-market” healthcare is that the free market actually leads to patient harm. If patients “doctor shop,” valuable health information is lost in the process.

          Why would consumers in a free market for medical services not demand access to information about their care? You seem to assume that patient-hostile practices by doctors in our current cartelized system would continue in a free market.

          >Also, government models in other countries DO work. It’s a myth that they’re worse than ours.

          That depends on the metric. Many countries have long wait lists, and many procedures in socialized healthcare systems have worse outcomes than those in the US (which admittedly has higher costs). UK citizens who can afford to, will often buy into BUPA or some other system. People who have no other alternative might be glad that government-provided healthcare is available, but people who have alternatives generally prefer them.

          >As to whether you can trust the medical cartel to act in the best interests of patients? You can. That was the whole point of medical ethics.

          I agree with you when it comes to typical patient care, but I disagree with you when it comes to designing a healthcare system in the general sense. There’s no reason to expect that doctors wouldn’t be as self-interested as everyone else when it comes to their recommendations for how healthcare should be delivered. The past century that the AMA has spent trying to limit the supply of doctors, and to increase its control over the provision of medical care at the expense of patients is evidence of this.

          >A Jewish surgeon and I, a Jewish anesthesiologist, resuscitated a Nazi (huge swastika tattoo) who t-boned an elderly woman without giving it a second thought. We are programmed to do the right thing; the last thing we want is for economics to undermine that.

          Why would “economics” lead you to do anything other than provide good care to your patients, regardless of their personal beliefs/tattoos? Generally, market forces increase the likelihood that people do business with people they may disagree with.

          • Gwai Lo, MD

            People aren’t economically rational. It’s why bakers don’t bske cakes for gay weddings and people don’t work 80hr workweeks even if they could double their paycheck.

            Anyone can request their records, but the patient isn’t the one who needs them. The doctor needs them available at the exact time they’re necessary. And if something unexpected happens, they’re DEFINITELY not available.

            As for the AMA limiting supply of doctors, I don’t honestly think that’s the case. We’re getting outcompeted by other providers and literally can’t increase our numbers in response. And if there are more doctors, they won’t go to underserved areas; they go to the places they want to be. So the market there just gets tighter. Again, homo economicus doesn’t exist. Doctors have spouses with jobs and want their kids to attend strong schools. A 100-mile daily commute to the boonies just doesn’t work for almost any amount of money. I get continuous highly-paid job offers that never get filled because they’re in undesirable places.

            And, like you brought up, everyone needs to pay to subsidize the poor. Their care may be mediocre, but it’s care. The well-to-do can pay for better care above that. The important thing is that they’re already (1) guaranteed some form of healthcare if they lose their job or whatever, (2) are ensuring those who can’t are getting some. It’s not radically different than what we have now. It just simplifies the accounting.

          • DST

            >People aren’t economically rational. It’s why bakers don’t bske cakes for gay weddings and people don’t work 80hr workweeks even if they could double their paycheck.

            Not perfectly, no. That’s true of patients, doctors, and regulators. Which is why I would put my faith in large-scale distributed decision making, spread out over millions of people, rather than small group of regulators; I’d happily trade a system with a single point of failure for a more robust one where small sectors can succeed or fail independently.

            >Anyone can request their records, but the patient isn’t the one who needs them. The doctor needs them available at the exact time they’re necessary. And if something unexpected happens, they’re DEFINITELY not available.

            You’re thinking too narrowly here. Why would a consumer-driven healthcare system even continue with a system where one’s medical records stay only with their doctors, or are locked away somewhere? Why not a system where patients already have their records, or have the ability to access them remotely?

            >As for the AMA limiting supply of doctors, I don’t honestly think that’s the case.

            Oh, boy.

            http://www.motherjones.com/kevin-drum/2013/11/its-doctors-who-control-number-doctors-america-not-government/

            http://econlog.econlib.org/archives/2013/03/the_high_price.html

          • Gwai Lo, MD

            To your first point, the answer is somewhere in between. The endpoint of truly centralized healthcare would be the NHS, where everyone is directly employed. Healthcare “anarchy” with literally no regulation (caveat emptor) is at the other. Most patients would like a predictable experience. Most doctors would like a predictable experience. That requires coordination.

            As to medical records, I’m well-aware of the concept of a universal records system. I specifically helped create my hospital’s EPIC-based EMR. The problem here remains to guarantee records are accessible without unnecessary security or civil liberties risks. We’re trying to move toward that, but hospitals are spending billions of dollars on competing, incompatible EMR systems. It’s VHS vs. Beta, but with prohibitive migration costs. So this market would be necessarily limited. I don’t think we’ll achieve that point anytime soon.

            Toward the AMA, there was a miscalculation and we ended up short of doctors. But, understand, it takes DECADES to manufacture a physician. Medical schools are expensive to set up and residencies are as well. Plus, if the salary of doctors gets driven down, it will either reduce quality or reduce the number going in. I’d argue, the best plan is to maintain the number of doctors but treat them as the specialists they are (even GPs). lower-paid mid-level providers would do the routine stuff, physicians do the harder stuff. The “family doctor” model probably needs to go by the wayside, though they could still specialize in care-coordination.

          • Octavian

            “People aren’t economically rational. It’s why bakers don’t bake cakes for gay weddings and people don’t work 80hr workweeks even if they could double their paycheck.”
            This is just preposterous. Not working 80 hrs a week is perfectly rational. People work to earn money so that they can spend it in their free time. What’s the point of working to earn money if you don’t have any time to spend it? Working just to add numbers to your bank account would be irrational. Rationality means people work in order to consume.

            And <1% of bakers refuse to bake wedding cakes for gay people. Insipid analogy.

          • Gwai Lo, MD

            Your argument is exactly the point I’m making. People don’t always make the best economic choice. Decisions are more complex than dollars.

          • Sean II

            Buddy, if you think economic choice = “all about dollars”, you have utterly failed to understand the concept.

            That’s what people who haven’t studied the subject imagine it to be. And they’re wrong.

            Maximizing utility does not mean sacrificing everything for the sake of currency accumulation.

            If THAT is what you think you’ve defeated in homo economicus, you’re grappling with a straw man.

          • King Goat

            “if you think economic choice = “all about dollars”

            The discussion started with the good doctor’s disagreement with DST’s assertion that economics would *expect* that a Jewish doctor would give a Nazi patient good care *because* they’d make more money in doing so.

          • Gwai Lo, MD

            That’s cool. Not here to argue economic theory.

          • Sean II

            That’s a relief because you’re not very good at arguing, and you don’t seem to know much about Econ.

          • Gwai Lo, MD

            Ok. If it makes you feel better to belittle me like you do everyone else here, I’ll let you do so. Cheers!

          • Sean II

            Look, dude, you came in here rapid firing a bunch of economic arguments, or arguments with economic premises/implications.

            When I pointed out just one of MANY mistakes in those arguments, you said your were “not here to argue economic theory”.

            Disingenuous bullshit likes that deserves belittling.

    • Regarding your point # 1), under socialized medical schemes such as the one in Canada, therapeutic practices are tightly regulated. So, for example, a patient may be able to choose between Medicine A or no medicine at all. In order for a patient to choose Medicine B, she must first either prove that she has been non-responsive to Medicine A, or write a special letter to the minister. This is not what most people have in mind when they say “patient autonomy.” This is all the more important in light of your (correct) point # 2).

      Regarding your point # 3), you say,

      Saying healthcare is not a right is literally condemning people to
      death for guessing wrong about completely unpredictable events in which
      they have no expertise.

      You would probably agree with me if I said that there is no analogous right to tornado insurance, even though tornadoes are equally as destructive and unpredictable as unforeseen medical issues. Advocates of market-based health care prefer that people save for unexpected events, rather making them the burden of the tax code.

      I’ll also note that your two examples of health care at its best – Kaiser Permanente and doctor groups – meet most reasonable people’s criteria for being market-based care. My preference would be to clear away all legal and regulatory obstacles to the private sector’s coordinating in that way more often.

      • Gwai Lo, MD

        Kaiser, though, benefits for being the ideal concept of the ACA – a form of the ACO. Kaiser is highly-centralized and planned, which is my exact point. There are a few other mega-systems that also do as well. If those fit the criteria, then a free-market system would best function with maybe 3 major players with their own networks. Something like Medicare with a broad network probably provides more choice. That said, choice seems to be something that only politicians seem to want, not patients or providers.

        As to tornado insurance, that fails because one can choose to live in a tornado area or not. One cannot choose what diseases to get. And one’s health directly impacts he ability to save to protect one’s health. Unlike tornados, chronic disease decreases health every single second of every single day it’s untreated. It would be like buying flood insurance during a perpetual flood. It’s an unsustainable racket without some sort of subsidy. Contrary to the video’s talking points, healthy behaviors aren’t the be-all-end-all to medical ailments. And exercise can even CREATE its own problems (like injury).

        And the reason to choose Medicine A before Medicine B is because it’s been proven to be the most cost-effective. I do think patients should have the right to pay out of pocket for Medicine B if they want (most physicians would gladly do so if requested), but it wouldn’t be covered by insurance. A formulary is already a tenet of every healthcare system.

        The fundamental problem is that there will always be a shortage somewhere in the system. So do you give everyone a little access, or do you give most REALLY GOOD access and let the others die in the street? We’re at the latter while pretending to be the former. What we really need is the former, and those who can pay for better, should pay for it.

        • Kaiser is highly-centralized and planned, which is my exact point. There
          are a few other mega-systems that also do as well. If those fit the
          criteria, then a free-market system would best function with maybe 3
          major players with their own networks.

          I have two points here: First, I’m not naturally predisposed to a preference for centralization versus decentralization when it comes to industrial organization. My preferences involve efficiency (more = better) and competition (more = more efficiency). Whether the system that achieves competition and efficiency is centralized or decentralized is, in my book, irrelevant.

          Second, when you talk about how a free market system would best work, you’re speculating. Neither of us actually knows. I could speculate a bit in the opposite direction, and we could compare hypotheticals, but it would only ever be a comparison of hypotheticals.

          That said, choice seems to be something that only politicians seem to want, not patients or providers.

          This claim isn’t true. Allow me to introduce you to the wonderful and important world of patient advocacy and access to medicine: http://www.ijmedph.org/article/489

          As to tornado insurance, that fails because one can choose to live in a tornado area or not.

          Likewise, one can choose to live in a private health care area or not. More accurately, one can travel to where health care is cheaper, and purchase health care there. This is called “medical tourism,” and it’s a great way to save money on expensive treatments.

          And the reason to choose Medicine A before Medicine B is because it’s
          been proven to be the most cost-effective. I do think patients should
          have the right to pay out of pocket for Medicine B if they want (most
          physicians would gladly do so if requested), but it wouldn’t be covered
          by insurance.

          Patients in Canada do not have that right. This is precisely my point. In the United States, we have the ability to pay for medicines we want to try. In Canada, we’re stuck with what the province says we can have, whether we are prepared to pay for it or not. Thus, an important caveat to your point is that formularies and therapeutic practices retain important features of the American approach, versus the Canadian approach.

          • Gwai Lo, MD

            Pharmaceuticals is a totally separate issue from labor. I’m all for competition and choice at the pharmacy. That’s exactly what we have right now. There is no shortage of medications. There is a shortage of labor, so competition leads to poor resource use under those conditions.

            Medical tourism isn’t something one does except for elective procedures. No one is driving 200 miles to get their blood pressure checked. There are real world limitations to the ideological ideals.

            I was not intending to specify Canada as an ideal system. But my understanding is that only basic services are limited. Pharmaceuticals, room upgrades, etc., are part of supplemental private insurance. I would have no problem allowing someone to buy a better knee replacement or a more-convenient therapy. Either way, I’ll handwave a bit because I’m not married to any specific system. I only care that its rules and goals are clearly defined enough to plan around.

          • I’m all for competition and choice at the pharmacy…. I would have no problem allowing someone to buy a better knee replacement or a more-convenient therapy.

            Great! I’m glad we agree on that much.

            Medical tourism isn’t something one does except for elective procedures.

            As someone with a chronic condition who personally knows cancer, hearing impaired, and heart patients who have traveled to receive care, I must contradict you here. It might not influence your position much, but you should at least be aware that it is happening.

            No one is driving 200 miles to get their blood pressure checked. There
            are real world limitations to the ideological ideals.

            Blood pressure checks can be had for free at any for-profit drug store you can walk into, and home blood pressure machines can be purchased for the price of a shirt. This doesn’t seem like an ideological limitation.

          • Gwai Lo, MD

            Blood pressure was just a stand-in to represent the huge variety of routine care. It was meant to be an exaggeration. Maybe telemedicine and technology will eventually solve part of the distance problem, but it won’t address it in its entirety. Again, people will travel great distances for specialty care, but not necessarily routine or emergency care.

          • Of course. I only meant to suggest that the market is often capable of solving some of these routine care problems. 🙂

    • Peter from Oz

      Points 1) to 3) don’t go to prove the proposition that healthcare is a right.
      Things are either rights because no government has or can take away the unlimited personal rights we all have, or because the government or some other institution confers some advantage upon a person or entity. These latter rights are probably better labelled as ”privileges.”
      Healthcare requires someone else to do something for the patient. It is therefore not a pre-existing personal right. However, I think that there are moral and practical grounds for the right to health treatment to become a privilege bestowed upon the people.

      • Gwai Lo, MD

        That works for me. I wasn’t a humanities major.

    • Jeff R.

      If healthcare is a right, wouldn’t this imply that doctors should all give up their rights to decide which patients they want to see, and just treat all comers, regardless of whatever payment is on offer for treating them?

      • Gwai Lo, MD

        That is literally the system we have now.

        • Jeff R.

          That is not at all the system we have. A large fraction of physicians refuse to treat Medicare or Medicaid patients (or both) because they deem the reimbursement rates insufficient to make it worth their while, and they don’t treat uninsured patients at all.

          • Sean II

            I think he means to say “that’s what emergency rooms are” – i.e. places where doctors have no discretion, all comers are treated, etc.

            Hard to tell, though. This guy has a very strange communication style, with a knack for writing sentences which appear to mean the opposite of what he intends on a first reading.

          • Farstrider

            As you admit, they turn them away because rates are too low. I wonder how we could fix that….

      • King Goat

        Jeff, what do you think of the right to counsel as it exists in the US right now? Does it imply that defense lawyers should all give up their rights to decide which clients they want to see and just treat all comers regardless of whatever payment is on offer for representing them?

        • Jeff R.

          That’s slightly different, of course, in that you only have the right to counsel in the event that you’re charged with a crime and forced to stand trial, and not to, ya know, legal advice when negotiating your next employment contract or home sale, whereas this silly ‘right to healthcare’ meme seems to be some sort of blanket claim on the public till.

          But if you want to claim the two are equivalent, then I would say the answer is yes, it does indeed imply that. If a defendant has a right to criminal counsel, and you are the counsel, are you not obligated to step forward and do your thing? What else is meant by the term “right,” then, exactly?

          • King Goat

            Here’s another example: most US states have in their state constitutions a right of education for children in their state. That doesn’t seem to imply to most people that anyone who is a teacher must provide education to pupils for free. Instead it seems to imply that the government has a duty to provide some minimum of education to the children (with the teachers paid by the government). Likewise the right to counsel. So whatever your or my philosophical view of what a ‘right’ implies, empirically there’s a solid tradition of it meaning something like those two examples. I imagine when people talk about a right to health care they mean something similar, with similar implications (or lack of them as the case may be here).

          • Octavian

            Personally, I would say it’s absurd to postulate a right to education. That’s not to say there necessarily shouldn’t be public education, but the provision of certain public services shouldn’t be phrased in terms of rights. Others don’t violate your rights in any way by refusing to pay for your education.

          • Jeff R.

            Education is compulsory, and the state, having made it compulsory, has a duty to provide children with access to that service, because obviously one cannot be compelled to partake in some process that doesn’t exist. There may be a “solid tradition” of referring to this state of affairs as a right to education, but I’m skeptical, and in any case, this is some very sloppy thinking and an abuse of the language and concept of human rights. It’s commonality is no defense.

          • King Goat

            There were right to education clauses in Constitutions before education was made compulsory in those states. You and Octavian have the same point, it seems to me, which is ‘the concept of rights doesn’t allow for positive rights.’ But that’s only apparent to those who accept certain axioms common to some classical liberal formulations of rights. My point is there’s a long tradition that, not accepting these axioms, doesn’t accept the conclusion either. Maybe after great philosophical debate you’re correct and they’re wrong, but it’s certainly not obvious.

          • Jeff R.

            Well, the conundrum I see is that this Right to Healthcare represents a claim on the money or time or property of others, whether via tax and spend healthcare programs or telling healthcare providers they simply cannot turn people away, legally. If you accept the basic right of individuals to dispose of their time, money, and property as they see fit, though, then there would seem to be a clash of individual rights here, where my rights as a patient are in conflict with your rights as doctor to determine which patients you want to treat or your basic Lockean rights to enjoy the fruits of your own labor as a citizen.

            This conflict needs to be resolved, one way or another, and I don’t see anyone who advocates for these policies really making an honest attempt to do so. The depth of these people’s thinking doesn’t seem to go beyond “healthcare is expensive, but vital so let’s have it provided by the government and call it a ‘right’ so that everyone know we think it’s Very Important.”

          • R.Levine

            “so let’s have it provided by the government and call it a ‘right’ so that everyone know we think it’s Very Important.”

            I don’t think it’s even quite that sophisticated, but rather that most people understand “rights” to mean “legal rights” rather than “moral rights” (if they’re even aware of the latter as a distinct category). Of course, “legal rights” basically just amount to “privileges” or “entitlements” when they don’t overlap with moral rights, anyway.

            In fairness, I’m not sure that insisting on referring to them as “privileges” is any less of an orwellian language trick (though I can’t think of a more neutral term).

            In any case, as far as positive description goes I think Goat’s is accurate – doesn’t the average person think it’s perfectly consistent to talk about a “right” to being protected by the police/military, a “right” to adequate food, a “right” to a bystander throwing a drowning person a life preserver at negligible personal risk, etc.?

          • Sean II

            Yep, that’s about it.

            If you’re talking to someone who says “health care is a right”, there’s a 99% chance he doesn’t mean anything except “health care is a very important good I want the government to pay for”.

            Or to approach it from the other side, the chance is 1% or less that the person saying those words could follow-up with a coherent theory of rights that does include health care, but somehow doesn’t include food, shelter, clothing, employment, etc.

          • R.Levine

            Do you mean for “through no fault of their own” arguments to be satire? I suspect that’s what the people in question sincerely believe.

            I imagine you’d tend to get a response like “pshh, so you’re quibbling over the semantics of what ‘rights’ are… but since you mentioned it, yes – food and shelter and clothing and employment should be rights too. Nobody should have to forgo those things when it’s Through No Fault Of Their Own.”

            In other words, isn’t that reasoning (along with a healthy dose of the intention heuristic) exactly why “safety net” type programs are so generally appealing to the masses? Their worldview doesn’t want or need it to be specific in the first place.

          • Sean II

            No satire, I think that really is what people believe.

            I have this old friend who’s the least ideological person I’ve ever met. Fascinatingly hard to predict what he’ll say on a given political issue. I showed him a Nolan chart once, and he broke the thing just by staring at it.

            Anyway that guy is for universal health care, and once I asked him why:

            “No one chooses to get sick, and no one should go broke because they are.”

            It struck me immediately that, among people who are NOT socialists in any general sense, but who want various forms of socialized care, that’s probably the reason.

          • R.Levine

            Would you oblige me a bit of a tangent here?

            Among moderate / leftist arguments for “government-provided X”, this is one that I’m more sympathetic to, as far as it goes. I think the ideal case goes something like:

            1. X is something people “need”
            2. People’s need for X occurs through no fault of their own
            3a. X is reasonably cheap enough at scale that the inefficiency of not using markets, principal-agent problems, etc is negligible
            3b. The coordination issues involved in a market approach look challenging, at best

            (1) seems to be one of those points where libertarians overplay their hand. I’m sure you’ve seen the model argument a hundred times… “but we can’t know the preferences of other people… revealed preference re: health spending… etc etc”. The response to that (well-reasoned or not) always seems to be “oh, come on… *obviously* people need healthcare whether they realize it or not”

            (3a/3b) depend on some understanding of economics and are ultimately empirical points. It is least conceivable that there’s enough market failure to make some intervention defensible. In any case this is its own huge topic

            But we were talking about (2). My sense here is that the typical proponent is overusing the availability heuristic. When I (or you, or perhaps anyone here) engages the healthcare system, it’s generally only as a last resort after I’m convinced that whatever is wrong has passed some threshold of seriousness. If everyone used healthcare that way I could imagine (2) seeming more compelling. But as it happens, I volunteer as an EMT, which is great exposure to people who abuse the “free” healthcare already available to them at the drop of a hat, for stuff that by any reasonable stretch does not meet the criteria for (2). Off the top of my head I remember responding to a 911 call made by a mother whose kid was misbehaving, who basically wanted the cops/EMTs to show up and scare him straight. Similarly, I once asked an older EMT what was the most ridiculous reason someone gave for calling an ambulance. His response: “loneliness”. That’s people using healthcare for stuff that’s not only a “fault of their own”, but isn’t even healthcare in the first place.

            All that having been said, I suspect the examples that would get trotted out in defense of (2) are (a) things like children with expensive chronic conditions, which you’re expected to agree with lest you think that some 6 year old with bone cancer deserves to die, and (b) the elderly, since something like half the elderly population has hypertension and it’s a safe bet they’ll get sick at some point. Any chance you have numbers/references around “doesn’t describe all or really even most health problems”? Or more to the point – is it possible (if it’s desirable) to robustly figure out the minority of health problems that would qualify as “through no fault of their own” and have a different policy in place for them?

            This has been a not-just-academic talking point at least occasionally; I remember during the pre-ACA days some discussion of “well, let’s at least have mandatory publically-funded healthcare for children, since they lack the agency/ability to pay themselves for whatever befalls them.”

          • Peter from Oz

            I suspect that most apolitical people (who are by definition conservatives) probably think in the way you describe about a lot of government spending. But it is not really about healthcare, but about paying for it. The assumption is that the healthcare providers are there and that their services should be paid for by the government.
            We must remember that caring for the sick has always been, along with the propagation of religion, the provision of assistance to the needy and the advancement of education, one of the four pillars of charity.
            I think that we must acknowledge that apolitical people take the view that the government is in effect a giant charity that should meet the cost of healthcare, particularly as the need for treatment is mostly unexpected.

          • Farstrider

            there’s a 99% chance he doesn’t mean anything except “health care is a very important good I want the government to pay for”

            This reads like you think it is a “gotcha,” but it is actually something everyone already knows, as reflected by the ACA, medicare, medicaid, etc etc.

            Or to approach it from the other side, the chance is 1% or less that the person saying those words could follow-up with a coherent theory of rights that does include health care, but somehow doesn’t include food, shelter, clothing, employment, etc.

            Again, not a contentious view among many people, who do think the government should provide these to people who are concerned about their fellows’ welfare.

          • Sean II

            Yeah, but why use the word “right”?

            I noticed that elsewhere in this thread you – quite correctly – challenged someone on the hyperbole of using the word “slaves” to describe doctors under socialized medicine. Good point there. It is wrong to import the moral outrage we associate with chattel slavery into a discussion about the billing procedures of highly paid orthopedists, etc.

            But by the same token, it’s silly to invoke the language of universal human rights when we’re simply talking about whether some benefit should be paid for by the state or not.

            There are plenty of other non-hoorah words we can use here.

          • King Goat

            Why not use the term?

            Or, in other words, why use terms invoking universal human rights about whether free speech or freedom from unreasonable searches should be used or having counsel in criminal trials should be used, but not in cases of health care? The people who want health care, or some component of it, to be a right think it’s as critical for the government to satisfy that right as others think as it is as critical for the government to allow Neo-Nazi speeches in the park (that I, the park go-er, would have to hear) or not engage in unreasonable searches (though I, potential crime victim, might have a greater chance of justice re my crime occurring if such searches happened), or for the government to fund counsel for those finding themselves accused of crimes. You’d like them to play on your field, so to speak, and accept the axiom that the term rights can’t apply to ‘positive’ rights. Why should they?

          • Sean II

            Because negative rights got there first. Because equivocation is a tedious sheister’s trick. Because key parts in the concept of negative rights are absent from and indeed contradicted by the notion of positive rights, and typically when that happens we use different names.

            That’s why.

          • King Goat

            “Because negative rights got there first. ”

            Considering there’s also a very long tradition of using the term for ‘positive’ versions that’s kind of silly.

          • Really good, important point.

            This raises some interesting questions:

            1) What should be the parameters by which we make a decision about government benefits? Imagine there is some sort of test, with a set of criteria. If the proposed welfare addition meets the set of criteria, then we agree that the government should pay; otherwise, the government should not pay.

            2) Can such criteria be set out in such a way as to exclude anything if they are to include anything? To your point, Sean II, are there any criteria by which health care ought to be paid for, but food and shelter not? Free BCP, but you have to pay for bacon? We so often get hung up on whether it’s “fair” to have someone pay for BCP (or bacon), but the real question is what set of criteria outline a belief that BCP is a more worthy government subsidy than bacon? And if so, will bacon inevitably be paid for the very next election cycle after we agree to pay for BCP?

            3) Supposing we agree that the government ought to pay for X if it has the resources to do so, how ought the government obtain those resources? Yeah, I know: taxes. But now we have to repeat the same exercise all over again. By what criteria do we determine whether a tax is okay — and if the tax itself is okay, by what criteria do we determine what level of taxation is not okay? A 21% corporate tax rate is fleecing middle America; a 35% corporate tax rate was already too low. How about 50%? If not, why not? If so, why not 75%? Would that be okay? If not why not?

            Inevitably, I fear it always comes down to, “I don’t have a comprehensive theory about why the government should be paying for my blood pressure meds, I just think they ought to do it. Other people have money, I shouldn’t have to take on debt.”

            Why not???

          • Sean II

            Your “birth control today, bacon tomorrow?” reminds me that one of the first things I ever learned about politics was: leftists roll their eyes a lot.

            My older siblings would come home from college or grad school, and start arguments with my father. He was by no means a right winger, but he did like fucking with people. So a lot of arguments had a pattern where he’d say “Okay but if this, why not that?”, whereupon they’d roll their eyes and say “Oh, c’mon!” or “That’s ridiculous!” or something similar.

            This being the 1980s, it was stuff like: they’d say South Africa should be returned to its indigenous people, and he’s ask why not Canada and the U.S. Apparently the answer was “That’s ridiculous!”

            Or someone would say whaling had to be stopped, and he’d ask “What, is no one interested in saving the cows?” They’d demonstrate the state-of-the-art education he was paying for by coming back with an exasperated eye-roll. As though his question wasn’t just wrong, but embarrassingly stupid. Like preferring Glenn Miller to the Grateful Dead or something.

            It’s still a common practice today. “Oh, c’mon” remains the official left wing answer to a number of key questions.

            “If two men can get married, why not three?”

            “Oh, c’mon!”

            “If I can change my gender, why not my race?”

            “Oh, c’mon!”

            “If the government can force you to buy health insurance, what else can it force you to buy?”

            “Oh, c’mon!”

            “If breaking one window is good for the economy, wouldn’t breaking all of them be better

            “Oh, c’mon!”

            And of course: “If medicine is a right because we need it to survive, why not also food or shelter?

            “Oh, c’mon!”

            Anyway it’s a powerful technique, or else they wouldn’t keep using it.

            But I’m not sure why it’s such a characteristic lefty thing. Surely the right would like a stock method of bluffing its way out from inconvenient corners. Yet for some reason they can’t quite pull this one off. Hmmm.

          • R.Levine

            I recall a rightist deploying “oh, come on” back in ’08 against the charge that Sarah Palin was such a lowbrow hokey incompetent that she’d surely be totally incapable of understanding and meeting the demands of the vice presidency, should she end up there.

            But I take your larger point. Perhaps it’s because by nature leftists are typically trying to change the existing status quo to some new thing? A natural objection to a push for change is to make a slippery slope argument, and then the “oh come on” in response to that is a way of dismissing the slippery slope as so unrealistic that it doesn’t merit a serious response.

            Conversely, when you’re a small c conservative it’s probably harder for your political opponents to identify any sort of slope you might be slipping on. Rather, they can just wait until something undesirable happens (shootings, bad/overpriced healthcare outcomes, warmest summer on record somewhere, etc) and then accuse you of not wanting to change things like they do.

            We could test my theory by looking at situations where rightists or libertarians propose some major change to the status quo. This seems somewhat similar to a typical response when you propose markets in human organs: a lot of doomsday slippery slope scenarios, which (depending on the kind of person you are) you might at least consider dismissing with “oh, come on”.

          • Sean II

            That seems plausible. Another factor has to be that libertarians and paleo cons don’t mind biting bullets.

            “Oh, and after we privatize the railroads what’s nex? Private fire departments?”

            “Hey, great idea.”

            So maybe the “Oh, c’mon” thing is really about who is and who isn’t willing to own their particular utopia.

            Obvioud problem for the left, since there’s still looks like a cross between the Big Rock Candy Mountain and Magnitogorsk ’29.

          • R.Levine

            Interesting point. Maybe that is generally more true of libertarians and conservatives, but if it is I’m not sure it’s necessarily admirable (not sure if you meant to imply it should be).

            Because: it seems to me there’s a fine line between owning the “utopian, taken-to-its-logical-conclusion” version of your ideas and “inflexible adherence to principles, evidence and outcomes be damned”. You know the type; the libertarian who feels he has to defend your NAP-compliant negative right to let your infant child starve to death on a table (which the infant is free to leave, if it chooses) and charge people admission to watch… because principles. Those people do exist, but I’m glad that it seems to be a tiny minority of libertarians willing to bite that bullet.

            Of course maybe all of this is just a matter of degree. Presumably you’d have a better chance of getting “oh, come on” from a libertarian if you rode the slippery slope all the way to “so eventually what, we’re gonna privatize the air we all breathe? Because you know how poorly that worked out for Planet Spaceball…”

          • Sean II

            1) “but if it is I’m not sure it’s necessarily admirable (not sure if you meant to imply it should be).”

            I didn’t. Describe first, evaluate later.

            2) “…there’s a fine line between owning the “utopian, taken-to-its-logical-conclusion” version of your ideas and “inflexible adherence to principles, evidence and outcomes be damned”

            Yes. Always good to remember that the original appeal of this website was about not biting those baby-starver bullets they love so much over at Mises.

            3) “”so eventually what, we’re gonna privatize the air we all breathe? Because you know how poorly that worked out for Planet Spaceball…”

            “Comm’n, Cohagen! Dees peopre need ayuh!”

          • Farstrider

            Add to the statute: “No doctor shall be compelled to treat any person he or she does not want to treat.”

            Problem solved! Now we can get back to reality.

          • Jeff R.

            If the EMTALA has been struck down on the grounds that it violated the 13th Amendment, that would be news to me.

          • King Goat

            “If you accept the basic right of individuals to”

            See, that’s the axiom assumed here, that no right can make a claim on the money or time or property of others. But this is exactly how the right to counsel works (via a tax). Introducing the ‘well the government creates that exigency’ doesn’t help there…

          • Jeff R.

            I would accept that criticism, with the caveat that it is, at least, part of the public good of criminal justice, whereas healthcare is not, and so is in some sense justifiable, in the same way as other public goods are. In that sense I would probably say that referring to this practice as a right, in the same way that say free speech is a right, is also probably mistaken.

            I would also note that it has an inherent limit (ie, the length of a trial or appeal or what have you) whereas this right to healthcare is, again, kind of blank check, is it not? Or are there limits you have in mind on the obligations we have to provide healthcare services to our fellow citizens or non-citizens? I would be interested to know what they are and how you justify them.

          • Sean II

            The right to counsel wasn’t understood as a positive right until very recently in historic terms.

            Used to just mean “we won’t stop you bringing in a lawyer if you got one”.

          • King Goat

            “part of the public good of criminal justice, whereas healthcare is not”

            Are you using public good in the strict economists sense or in the sense that it’s sometimes used by political philosophers? If the latter I’m not sure this is obvious, if the former I’m not sure why, as a matter or political philosophy, one should care.

            “I would also note that it has an inherent limit (ie, the length of a trial or appeal or what have you)”

            In theory, I guess, but in actual practice many long trials-appeals cases would make one wish to have a bill for treating cancer instead.

            “whereas this right to healthcare is, again, kind of blank check, is it not?”

            Just as for over a hundred years the right to education hasn’t meant a right to unlimited tutoring and a ride to Harvard a right to health care wouldn’t entail what you’re ascribing to it.

            “By the way, are you saying you don’t accept my axiom?”

            The axiom, more generally, is that a ‘right’ cannot impinge on any other’s ‘rights.’ That’s blown out of the water by the right to counsel we’ve been discussing or education (where they come and take our property [money] to fund other people’s education, counsel needs).

          • Farstrider

            Obviously, it means that the state will pay someone to provide you with healthcare, not that the state will conscript someone to provide you with healthcare. I do not understand why people who make this argument seem to forget that the free market exists, such that the state can purchase things (like healthcare) with money.

          • R.Levine

            I’ve always found this particular example (EMTALA) to prompt an interesting reversal of left/right narratives regarding choice of employment.

            E.g., a response to Farstrider could be “… but for ER workers, they don’t get a choice. The government makes it illegal for them to say they don’t want to sell emergency care services to person X (even for reasons that we could all probably agree are not unfairly prejudicial; e.g. person X may show a high risk of being physically violent, have a dangerously communicable disease, etc.). I suspect Farstrider might reply to that “right, but nobody forced them to be an ER worker in the first place. They effectively agreed to be bound by EMTALA when they chose that career path.”

            That sounds like an awfully similar response to a boilerplate right-libertarian defense of (e.g.) sweatshops: nobody is forcing sweatshop workers to work there, and if they’re choosing it over any other available options one can similarly argue they implicitly agreed to the working conditions.

            The details are of course debatable since there are other ways in which these two examples differ, so it isn’t too difficult to find talking points to condemn one and not the other. My point is just that the top-level reasons to approve of both situations (people make basically rational choices about where to work, vs. the alternatives) or to disapprove (those choices are not rational and/or are unfairly constrained; also perhaps we can come up with a better overall arrangement) are basically the same.

        • Octavian

          This is entirely different: the necessity for counsel itself is imposed by the state. The state can’t punish you for not using a service it refuses to provide you. Doctors, on the other hand, don’t force patients to get cancer.

          And this right is basically a claim against the state, not against defense lawyers. If there are no available public defenders, it doesn’t mean the state can conscript one (nor should it). It means the state can’t try you until one is available.

          • King Goat

            “If there are no available public defenders it doesn’t mean the state can conscript one”

            The way the right to counsel actually works is that the state taxes all of us to pay (conscripts our dollars, so to speak) for counsel for all those who need it in criminal cases. Anyone in need of counsel in such a situation has, as a right, access to such conscripted money. So I fail to see much of a point you’re making here.

          • Octavian

            “Anyone in need of counsel in such a situation has, as a right, access to such conscripted money.”
            This is not the same as a right to counsel. If there is no defender willing to defend you for any price the state is willing to pay, would your right to counsel not be violated by them trying you despite the failure to obtain a voluntary attorney for you? Such a right would, imo, mean that they can’t try you unless and until someone is willing to defend you. That may be unlikely to happen, but it isn’t a theoretical impossibility.

            And even if it’s not a strict legal necessity, one could easily argue that the complexity of the process makes it a practical necessity, as you say, for the sake of fairness and avoidance of incorrect judgement. If, suppose, the state required you to solve a set of non-linear differential equations in order to enjoy your due process rights, sure it doesn’t make it a legal necessity to have the assistance of a mathematician, but practically, everyone who isn’t one would need one’s assistance to fully enjoy one’s due process rights.

          • King Goat

            “Such a right would, imo, mean that they can’t try you unless and until someone is willing to defend you.”

            A positive right might just mean ‘a right that some effort to procure X will be made.’ It’s not defeated by the possibility that the procurement won’t happen (unless, again, you’re smuggling some unspoken, not generally accepted axiom about the concept of what a right is into it).

            For example, many people would say a child has a ‘right’ to expect their parent to take care of them. The possibility (heck, reality here) that some parent might be unable to do so mean there is no such child’s right, does it?

      • Farstrider

        This is such a canard. No one who says “healthcare is a right” is saying “doctors should be slaves.”

        • Jeff R.

          I’m suggesting that this is the logical implication of that view, though. Consider an isolated village with one doctor on an island in the Pacific. If the villagers have a right to healthcare services, is he not violating their rights if he refuses to treat them? Does that sound as absurd to you as it does to me? How is it any better to kick the can down the road a piece and say that Peter is obligated to pay a doctor to treat Paul, otherwise he’s violated Paul’s civil rights?

    • Octavian

      Healthcare is not, and cannot, be a right, because health care is produced by other people. To say you have a right to a human-produced commodity is to say that someone (or everyone) has an obligation to produce it for them. To give one person a right to health care is to enslave someone else to the burden of having to provide it.

      If you get cancer to no fault of your own, that’s terrible, but no one is violating your rights by not paying for your care, just as no one violates your rights when you die in an avalanche to no faulty of your own. Otherwise, we are all guilty of murdering every African child that dies of malaria that we could’ve saved by donating all our disposable income to UNICEF.

      “Everything about medicine lends itself to a centralized, structured approach.”
      No, it doesn’t. Medicine, as with everything else, functions best when the consumer pays the cost of the good. Look at the CALpers study of joint replacements, or studies of healthcare quality in the UK as a function of the density of hospitals. People do shop for healthcare; when they are permitted by the system to discriminate by cost, costs go down; when they can’t discriminate by cost, quality goes up (regions in the UK with more hospitals per sq. km have higher quality because they have to compete more with each other for patients and therefore government funding)

      It’s worth noting even if a small minority of patients shop, it has a strong effect on cost and quality. All (indeed even a majority) of patients need not ‘shop’ for competition to work.

      Lastly, any attempt at universal care fails for supply reasons: giving everyone insurance while the supply of doctors, nurses, equipment, etc. saves no one; it just changes how care is rationed. The only way for more people to get health care – rather than just insurance – is to increase the supply, and the way to get supply is – guess what – to let markets do their work. Let services and products be charged according to the market value and eliminate barriers to entry so more people become doctors, build hospitals, etc. You can’t blame the current system on capitalism; the current system is more socialist than capitalist.

      Lastly, I don’t doubt most practicing physicians favor a centrally planned health care system: current physicians, through the AMA, are effectively a cartel that systematically impedes supply expansion at every turn. The AMA fights to prevent increased accreditation of medical schools, reductions in barriers to non-MDs providing care, streamlining of FDA restrictions. It’s a cartel that systematically suppresses opening up of markets to keep its own members’ salaries high. Of course they favor the continuation of a state-sponsored cartel based system. If we allow there to be more doctors, then existing doctors’ salaries might decline, and we can’t have that, can we.