What’s Wrong with the World

Anti-genetic discrimination bill approved -- Bush expected to sign measure preventing hiring or insurance use of data

Health provision is a "natural commons"? Uhboy. I think I can tell we're going to disagree about this one. A service provided by specific people, who have gone through long, hard, expensive, and specialized people, is a "commons"? It should be commonly owned, in other words? The labor of doctors and nurses? In other words, either everyone has a right to it, or all healthcare workers should be public employees. Heaven preserve us from that outcome. You wouldn't like it if you saw it, and it would make the lot of virtually everybody, including plenty of poor people, worse in the not-so-long run.

Not exactly: the risk-pooling of health insurance provision is a natural commons; otherwise, vast numbers of people will be priced out of the market. I'm hardly claiming that the provision of specific health services constitutes a natural commons, merely that some means of socializing risks is; this stuff will be socialized somehow, without question, unless we propose to let the sick go untreated when they cannot afford medical attention.

I'm hardly claiming that the provision of specific health services constitutes a natural commons, merely that some means of socializing risks is; this stuff will be socialized somehow, without question, unless we propose to let the sick go untreated when they cannot afford medical attention.

Taking on this burden used to be the burden of the church, not the state, and we were better off for it. By conceding that socialization has a role, except for those who are injured or maimed in the line of duty (military and police, for example), is to concede fundamental ground to liberalism in this area. What is needed is for conservatives to actually start demanding that the church shoulder this burden again, as that would not only help it accomplish its mission, but would also provide a firmer foundation for dismantling the socialist structures in our government.

There are already numerous socialized structures in our society for this. Medicare and the unfunded mandate on emergency rooms come to mind. Plus various free clinics and other private initiatives. There is no question of a poor person's being hit by a truck and being left to die on the street because he doesn't have insurance. In true emergencies the care is funded, and the risk is socialized. I could wish myself that this were done in some more efficient way with fewer mandates and less socialization, but we already have a mixed and partially socialized medical system.

The real issue is making what are, if you think about it, fairly high standards of health care into a right for all. Massachusetts demanded that everybody have health insurance, with the gov. picking up the tab for those who couldn't afford it. Now they have a doctor shortage, with waiting lists for getting a new primary care doctor. If you make bananas a universal right, you will have a banana shortage. This is simple common sense.

When it comes to the economy, Maximos (and most paleos) operate under the same misguided ideas our friends on the Left use when thinking about economic matters. Exhibit one is his thinking about health insurance:

"the risk-pooling of health insurance provision is a natural commons; otherwise, vast numbers of people will be priced out of the market"

AND even worse there is this from the previous post:

“Privatization of profits/socialization of costs is a dominant motif of political economy in our times, from immigration to the war, and it is thoroughly disreputable and corrupting.”

Shorter Maximos – I don’t like the outcome of a free market (“privatization of profits”?! as if there were such a thing as public profits!) and would prefer to use the heavy hand of the State to regulate markets to get my desired outcome. Why not suggest to your fellow citizens that they have an obligation to those “priced out of the market” for a particular good or service and should help those in need (as MikeT suggests, this could be a role for the church or other charitable organizations – this is how many hospitals were started in the first place).

And as usual, Maximos likes to pepper his moral jeremiads with factual claims that seem suspect to this reader. For example, is it really true that with better actuarial risk-pooling “vast numbers of people will be priced out of the market”? As McCain’s health care proposals suggest, the heavy hand of the State (or more accurately the 50 States) already distorts the health care market (here is a nice summary: http://cafehayek.typepad.com/hayek/2004/11/the_unfettered_.html) and as we have discovered time and time again, when the State gets out of the way, the market does an excellent job of providing folks with the goods and services they need at ALL income levels. Here is just a little excerpt from David Frum’s new book “Comeback” on this subject matter:

“It is state governments, not consumers or insurers, who determine what and who must be insured. If the acupuncture lobby is strong in your state, every policy must cover acupuncture. Ditto marriage counseling. Ditto hairpieces. One industry trade group estimates that the fifty state governments impose a total of some 1,843 must-insure mandates altogether as of mid-2006. The combined impact of these mandates thrusts health insurance costs up to nightmare heights. A health insurance policy for a single twenty-five-year-old man can be bought for less than $1,000 in low-regulation Kentucky. The equivalent policy costs more than $5,800 in high-regulation New Jersey.”

Frum goes on to suggest some of the same reforms McCain is proposing (i.e. allow Americans to buy insurance across state lines, break the link between insurance and employment, etc.) I’d recommend the book to all my conservative friends.

Finally, even if you are inclined to use the State to help those “priced out of the market”, it is just bizarre to assume that regulating a business is the only way to do so. Why not redistribute wealth (i.e. give a subsidy to those “priced out of the market”)? For some reason, Maximos thinks an insurance company can make too much money (I wonder at what level of profit will the Maximos “trigger” take effect – is a 9% return on investment? A 12% return? Maybe 4% returns are too high – I wonder if Maximos has calculated a trigger for each and every industry in America?) Or perhaps like the acupuncture lobby, he knows better than insurance companies do, as to how they should run their business.

I’ve said it before and I’ll say it again - this type of thinking just seems out of place in the long tradition of Anglo-American conservative love of private property and well-ordered liberty.

"...an insurance company can make too much money..."
Is that not true for individuals and organizations? Does one need to establish a mathematical formula or a plan for government intervention to validate ancient moral wisdom on this matter?

"...the long tradition of Anglo-American conservative love of private property and well-ordered liberty."

It is impossible to have the latter without a wide-distribution of the former. It is the apparent lack of emphasis on this basic truth by so many "main-stream" conservatives that is troubling.

Perhaps, after conservatives receive their electoral punishment this November, they can compose a program more compelling than; "let them eat cake, because the government solution is worse", and rescue capitalism from it's more ignoble practitioners. They will have plenty of time to do so.

A three hundred million person commons, now that's something to think about.
No sense thinking small, maybe we can get the same people who have gifted us with our energy policy to run the commons. Look what they have done for the production of corn for example, a miracle !

Admittedly I've never thought of health care as a free market, a sort of giant car dealership. Maybe if I was subsidizing auto purchases through CarAid and CarCare federal transfers and giving free autos to recently arrived immigrants, never mind how they got here, the free market distinction would blur.

Come to think of it why don't we have a Car Commons? But maybe we shouldn't spoil the fun by contemplating the administrative possibilities based on past and current performance. Why spoil a noble idea?

What has to be realized is that a huge amount of the health care that goes on in the U.S. nowadays is for healthy people. It isn't a matter of a "risk" of "needing" yearly checkups, twice-yearly teeth cleanings, and a jillion cancer screenings when you have no symptoms whatsoever, unless we can speak meaningfully of the risk of being a human being. Much health insurance money doesn't go to taking care of people when they are sick but to paying for non-emergency care and preventative testing when they are well. And then there are all the grey areas; the sinus infection or minor ear infection that might or might not resolve itself without antibiotics and where it is a judgement call whether to go to the doctor. It's not that I'm saying that all of this stuff is bad. I'm saying it's optional. All the more reason not to make it an entitlement.

There are already numerous socialized structures in our society for this.

Yes, there are; they are just extraordinarily inefficient, layering various forms of state involvement over the private insurance system, meaning that a)the public at large pays higher taxes, and b)holders of private insurance pay somewhat higher premiums when those state-funded systems compensate physicians and institutions below cost. In effect, and in this regard, those public systems offload onto the public the financial responsibility for those unserved by the market; and just as surely as the social costs of mass immigration are borne by the public, while the profits accrue to those employing low-wage immigrants, so also the social costs of health coverage are borne by the public, while the profits accrue to principals and investors in the insurance industry. Hence, contrary to Mr. Singer, who complains that

I don’t like the outcome of a free market (“privatization of profits”?! as if there were such a thing as public profits!)

For example, is it really true that with better actuarial risk-pooling “vast numbers of people will be priced out of the market”?

Yes, it is, particularly with the increasing accuracy and efficiency of screening procedures. Those suffering from inherited ailments, chronic conditions, or susceptible to the development of certain conditions, will not, unless they are wealthy, be able to purchase coverage on a fee-for-service, or cash-swap basis, since the costs of care routinely exceed, often by many orders of magnitude, the patient's ability to pay. What follows is that risk-pooling, which is to say, some mode of socialization, which is to say further, some form of commons, is inescapable.

As McCain’s health care proposals suggest, the heavy hand of the State (or more accurately the 50 States) already distorts the health care market...

I would be more than willing to concede this, if and only if it is further conceded that what is distorted is an unreal image of how health-provision can function; the reasons health care cannot be treated as a pure market good are both manifest and intrinsic, and the attempt to envision a pure market system for the delivery of health services is an act of ideological fantasy. This is a sphere of human endeavour calling for prudential judgment in particular, contingent circumstances, and not for attempts to instantiate some sort of theoretical model of how things would function in the absence of the state. Hence, we should be considering such matters as hairpieces and acupuncture, along with other mandates, under the auspices of prudential reason; while it seems obvious, at least, that toupees ought not be covered, the reason for some of the mandates is also obvious: in their absence, coverage for certain procedures and ailments would be excluded from risk-pooling for most, and would therefore be inaccessible to some who would require them, necessitating direct state provision in those cases. Unless we propose to permit people to go untreated, many health risks will be socialized; we're merely disputing the details of the socialization process.

Taking on this burden used to be the burden of the church, not the state, and we were better off for it.

In a broad, historical sense, this is perfectly true. Moreover, since the origin of any thing is, at a minimum, a clue to its nature or essence, we ought to attend to the fact that widespread health provision was originally a ministry of the Church, and founded as a charitable endeavour. Nevertheless, the Church or, more broadly, charitable institutions, can only assume such a tremendous burden - particularly in a more complex modern society - if they can command vastly more social authority than they do presently, exercise more overt social power on the basis of that authority, and command a greater percentage of adherents' resources than those adherents presently provide under our purely voluntaristic models of giving. One cannot recreate a social form without first recreating its conditions of existence. As a long-term project of cultural reclamation, I've no objection to the aspiration; nevertheless, in the meantime, those objectives will be ill-served by the pretense that health provision can be legally and socially structured in a manner inconsistent with its nature. We ought not succumb to the error - the equivocation - of holding that because the Church is a private institution, in the sense of being a non-state institution, that privatization under the rubrics of the market, conceived as a set of property-relations outside the bounds of the state, will also safeguard the essential goods of medicine. The Church is not a market institution, a place for profit-taking; the Kingdom of God is not a haven for moneychangers. We ought never assume that the appellation "non-state" embodies the essence of the Church, not least because this would be transparently false (the question is oblique to that of the nature of the Church), but also because such assumptions elide the differences between divergent non-state institutions, permitting some to conflate opposition to the state (an abstraction too often reified in these discussions) with support for the mission of the Church, and, consequently, to imagine that marketizing a domain of human endeavour - even one which, by nature, cannot be fully exposed to market logics - is equivalent to returning it to the Church. Too many of these discussions tacitly identify the heterogeneous contents of the box, "non-state", just as they subtly equate the Church, or "that which is consistent with the ecclesial, Christian ideal", with what is thus regarded as "non-state", and identify this category with market institutions and rubrics.

It's not that I'm saying that all of this stuff is bad. I'm saying it's optional. All the more reason not to make it an entitlement.

This must be considered on a case-by-case basis (I'm not certain that you would disagree...), inasmuch as preventative care for cancer is only expensive when considered in abstraction from the costs of treating the cancer, should it be diagnosed. Some people will require such routine screening more than others; nonetheless, even where it is provided, risks and costs remain socialized. Screening me for colon cancer is less expensive than attempting to cure me, once the cancer has metastasized to such an extent that I feel appreciable symptoms of some unspecified ailment, let alone feel dreadfully ill. In this light, some of these procedures must be covered generally, lest those manifestly more susceptible (ie., me, in the present example) be lumped together in a group of high-risk patients who are effectively priced out of the market; otherwise, there really doesn't occur any risk pooling, which is pretty much the only way the sick receive coverage.

I know that's the common wisdom: "Oh, but in the long run, if we screen everybody and his uncle, we'll actually save money over the cost of treatment." I remain highly dubious. The vast majority of people test negative, and the false positive rate in many types of testing is high. Sometimes treatment is recommended after early scanning comes back positive where that treatment is questionably effective anyway and would not have taken place at all if the screening hadn't taken place. I have real doubts about the entire "health maintenance" model, and those doubts about the claims of economic efficiency. I also think it tends to burden doctors and patients as well with time-consuming and unnecessary visits and lab work when people are in perfectly good health. It also has a cost in needless anxiety and discomfort from further testing when false positives occur. How many woman-hours are spent in unnecessary mental agony and fear caused by a false positive mammogram, followed by a highly unpleasant needle biopsy? It seems to me almost bizarre to say that everyone is _entitled_ to be put through all of that, and that society should bear the cost for those who are too poor to afford it. And the entire attitude has vast swathes of other applications: Yearly general physicals for every single perfectly healthy person in the country. Routine cholesterol screenings. "Well-baby" visits even beyond those at which routine vaccinations take place. And on, and on and on.

When I was in graduate school I had no dental insurance and little money. I didn't go to a dentist for routine teeth cleaning for several years. Now that I have better insurance, I do. I survived just fine. We really need to consider what a high, even a pampered, standard of care we have in this country. If we try to socialize that standard of care for everyone, we will only lose it for virtually everyone in the long run, and the poor will not be better off, either.

I also sense a strange ambiguity on the term "socialize" here. Do I understand correctly, Maximos, that you are referring to everybody who has insurance as having his risk "socialized" just because his risk is pooled with other people? Doesn't this unnecessarily blur the distinction between government-provided "socialized" care and risk-pooling paid by employer-purchased insurance?

And is this, or isn't this, a commercial for some form of further socialized medicine in America? Or is it really just about genetic testing? I can't even tell.

The vast majority of people test negative, and the false positive rate in many types of testing is high. Sometimes treatment is recommended after early scanning comes back positive where that treatment is questionably effective anyway and would not have taken place at all if the screening hadn't taken place.

All these things, and more, are incontestably true. All I'm arguing is that it is also incontestably true that removing certain insurance mandates will shunt identifiable at-risk groups into relatively more discrete higher-risk categories, effectively reducing the risk pool used to cover... more treatment. That's bad economics. We've no choice but to examine legions of procedures prudentially, with a variety of parameters in mind. And, yes, well-visits are pointless, as are annual physicals for most people, along with quite a number of things some mandates impose. And dental insurance is a rip-off, whether purchased separately or included as part of a broader package.

I also sense a strange ambiguity on the term "socialize" here.

I'm utilizing the term to refer to any social structure or arrangement in which risks and rewards are distributed across the population, or subsets thererof, as opposed to being attached solely or primarily to individuals, without mediation. In other words, I'm using it in a neutral, social-scientific sort of sense.

And is this, or isn't this, a commercial for some form of further socialized medicine in America?

No, it isn't; unlike Morning's Minion, I'm not an advocate of single-payer health care in America. If anything, I consider my posts PSAs warning against the naive idea that something which, by nature, requires risk-pooling (socialization in my generic sense) can be reconfigured on a pure market basis, such that the individual confronts health risks and burdens solely, or primarily, as an individual. Genetic testing affords a window onto the larger question.

But isn't this in a sense warning people against the last thing they need to be warned against? Aren't we already very far from a purely market basis for healthcare, and isn't that part of the economic problem?

For example: As I've pointed out before, the involvement of governmental and quasi-governmental entities prevents doctors from engaging in discretionary cost-shifting. If Joe needs his car fixed and is poor, the mechanic can take pity on him and charge him a lower rate, passing on the cost of that if necessary to Bill Millionaire by charging Bill full cost. But if we're talking about healthcare, regulations by government and by groups like Blue Cross prevent such ad hoc cost shifting or freebie-giving.

For another example: Suppose that the vast majority of people had to pay the doctor directly if they went in for a cold that had been going on too long and that they suspected might have gone into a secondary infection. I suspect that the cost of such ordinary healthcare visits is inflated by the fact that most of them are paid for by third party payers--insurance companies. If most people had something more like old-fashioned catastrophic-only health insurance, sure, lots of people would just tough it out with the cold-maybe-sinus-infection. But market forces would act more directly than they presently do on the cost for those who did go to the doctor, and I suspect the overall cost would come down to something that no longer required a third-party payer. Something like this often happens when prescription drugs go OTC. First they are very expensive, then eventually they begin to be sold at something people can buy directly with their own money, which is much less than the companies were getting for them when the patient was paying a co-pay for the prescription _and_ the insurance company was paying more as well. Zyrtec has come down in price with astonishing speed since going OTC just in the past year. Now you can buy it for the $25 you used to pay just as a co-pay or even for less if you buy generic. The same thing happened with Claritin a couple of years ago. Where part of the economic problem comes in now is that healthcare costs are inflated by insurance payments and that people who don't have insurance thus get socked with the inflated prices when they need to go to the doctor. Something similar (I know I've said this before) happens with body work on a car. If you don't have comprehensive auto insurance and get a dent you want to repair, you're likely to decide just to drive around with the dent, because the body work charges are outrageous. Why? Because most of them are paid by insurance companies, which drives up the prices.

Lydia,

I think part of the problem here is that we are debating a problem that is entirely of our own making. Let's not forget why, for example, that Massachusetts has its doctor shortage in the first place: government regulations.

1) It costs an arm and a leg to go to one of the few schools that have been certified to teach medicine. We need greater freedom to educate people to join the medical profession.

2) Insurance premiums for doctors are far too high because of dubious malpractice lawsuits.

3) No jurisdiction is willing to seriously reform the way that doctors can be punished for making honest, human mistakes and to tighten the evidentiary standards used to prove that a doctor's actions resulted in harm in the first place.

Maximos doesn't seem to appreciate just how toxic the government's intervention has been in just the area of limiting the number of doctors, let alone the other areas that artificially increase the cost of healthcare.

But isn't this in a sense warning people against the last thing they need to be warned against? Aren't we already very far from a purely market basis for healthcare, and isn't that part of the economic problem?

In some respects, yes; in others, no. My argument is that too many conservative discussions of health care are insufficiently nuanced. We need to have discussions of precisely what should be covered under ordinary health insurance plans, for the very reasons you suggest; we don't need to have discussions about transitioning from risk-pooling to actuarial insurance, as this would be, in the short term, the path to a great deal of misery, and, in the medium term, the path to overt socialized (government-administered) medicine. One thing worth mentioning is that, in the case of nagging little ailments which (perhaps) drive people to the doctor's office for unnecessary consultations, what motivates them is, in a sense, ignorance: they don't know whether that persistent condition might be symptomatic of something more serious, so they act on a precautionary principle.

It costs an arm and a leg to go to one of the few schools that have been certified to teach medicine. We need greater freedom to educate people to join the medical profession.

I'd need to know quite a bit more about the artificial constraints on supply in this case, as most of the people I've personally heard broach the subject believe that there ought not be any sort of official certification, and that the operative principle for patients should be caveat emptor - and that's just daft.

As regards malpractice lawsuits, tightening evidentiary standards would be well advised, depending upon the details (as always); imposing a ceiling on damages would be ill advised, as the state has no legitimate business establishing a price ceiling on incompetence and negligence, when these might result in the loss of life. Life ought not be treated cheaply, for when it is, it becomes a cost of doing business.

But actually, MikeT, Massachusetts only got the doctor shortage after they mandated that everyone be covered. So the system is pretty resilient even to the high costs of medical school, etc. What overburdens it is government-driven increase in demand. When you give everybody coverage, everybody suddenly has to have a doctor, including people who never had to have a doctor before, never bothered with it, etc. Then you get a doctor shortage.

The thing is, Maximos, I'm not saying that people's visits to the doctor in the cases I'm talking about are strictly unnecessary. I'm saying there isn't a sharp line between necessary and unecessary. It's as you say a prudential judgement. And inevitably the amount one pays oneself figures into one's decision whether to wait a few more weeks or go. I've gone myself at times when I would not have gone if I had to pay $45 or more for the visit. The $15 co-pay is one factor I consider along with the prudential considerations. That's why mandating coverage for everyone does drive shortages.

I have a question for the group, based on Maximos' idea that there is a tension between "risk-pooling" and "actuarial" insurance. Last I heard, despite all the state mandates in place forcing insurance companies to pool risk, these insurance companies still employ a lot of actuaries. Which suggests to this econ major (although it's been awhile since I took micro) that while mandates will make insurance cheaper for those who fall into high risk categories, the insurance companies will still earn their return on capital by charging everyone else a higher premium for the increased risk and attendant loss associated with taking on this risk. In other words, mandates on insurance companies act just like a tax on all of us by raising the cost of the average policy. So now we aren't talking about insurance company profits or the mythical "social costs" -- we are talking about a technical question -- what is the best way to provide health insurance/care for those priced out of the market if it were to operate without government constraints. Perhaps Maximos is right -- we should force insurance companies to pool us all. But is this the most efficient way to provide coverage/care to those who have "inherited ailments, chronic conditions, or [are] susceptible to the development of certain conditions"? From what I remember of my econ studies, regulations/mandates are usually a more INEFFICIENT way of taxing consumers -- it would be easier to simply directly tax everyone and pay for the care of the genetically unlucky directly. Assuming, of course, that you are all O.K. with forcing people to be charitable.

That's why mandating coverage for everyone does drive shortages.

Certainly mandates can drive shortages; I'd not gainsay it as a generalization. However, removing certain coverage mandates will create price-induced shortages of care for many people who require it. Pick your poison. My point is that the latter option gets you to politically-socialized medicine much faster, through the vehicle of justifiable political discontent.

...Maximos' idea that there is a tension between "risk-pooling" and "actuarial" insurance.

There is a tension, which can either be maintained through creative, prudent policymaking, or sharpened to the point of contradiction.

...while mandates will make insurance cheaper for those who fall into high risk categories, the insurance companies will still earn their return on capital by charging everyone else a higher premium for the increased risk and attendant loss associated with taking on this risk. In other words, mandates on insurance companies act just like a tax on all of us by raising the cost of the average policy.

I wouldn't call it a 'tax', because I think that this is an equivocation on the meaning of 'tax', but, yes, that is how the system operates.

But is this the most efficient way to provide coverage/care to those who have "inherited ailments, chronic conditions, or [are] susceptible to the development of certain conditions"?

Well, if it were more efficient to directly tax the public in order to finance the care of those excluded by the private system, we'd be pretty close to Morning's Minion's own argument in favour of single-payer: cut out the middleman. However, in my judgment, there are considerations other than those of optimal efficiency that ought to be taken into account; and the overt stratification of the population along the axes of wealth/poverty and genetic fitness/genetic weakness would be enormously corrosive. In any event, if this would not result in a distinct public sector health care system for the poorer and sicker, it would result in the imposition of another (dense) layer of bureaucracy over the existing private system, an arrangement with which we already have generations of experience in America. I cannot see the efficiency gains in that. The multiplication of middlemen never really increases the efficiency of anything.

Assuming, of course, that you are all O.K. with forcing people to be charitable.

At some level, I am OK with this; otherwise, charitable contributions will be insufficient to the need, leaving people hungry, sick, and worse - people who will then demand, and receive, socialism. I'll reconcile myself to the imperfection I've got, rather than pursue a chimerical perfection that leads to disaster.

As regards malpractice lawsuits, tightening evidentiary standards would be well advised, depending upon the details (as always); imposing a ceiling on damages would be ill advised, as the state has no legitimate business establishing a price ceiling on incompetence and negligence, when these might result in the loss of life. Life ought not be treated cheaply, for when it is, it becomes a cost of doing business.

The state should only be able to award someone enough to compensate them for the costs incurred, not make them independently wealthy on top of that. When you combine the ease with which patients can simply point a finger at a doctor and say "muh baby wuz hurt by him!" with the ability of juries to effectively designate someone a lottery winner, you have a recipe for disaster.

While life ought to not be treated lightly, an individual life, for the purpose of public policy, has a fixed price, and one that is significantly smaller than "priceless."

...an individual life, for the purpose of public policy, has a fixed price, and one that is significantly smaller than "priceless."

I cannot say that I concur in this, if it means that someone victimized by negligence or malpractice should only be compensated for specified costs incurred up to a certain expense. If through someone's negligence or incompetence or malice, an injury requiring ongoing, possibly life-long care is inflicted, the culpable party(ies) ought not be able wriggle out of responsibility for several hundred thousand (let's stipulate) when caring for the injured party might cost an estimated fifty thousand per annum, indefinitely. Responsibility should be proportionate to the offense, and victims should not be expected to be human sacrifices to efficiency. Needless to say, I don't believe that this entails Powerball-size jackpots; but those wronged in such cases ought not be told by the law that they must be worse off, as a function of some arbitrary limit on a settlement, so that some unspecified others can be better off.

The lax standards are not a theoretical problem either. It is a well-established problem with many specialities. New Jersey, for example, has serious shortage of OB/GYNs who will deliver babies, and Florida only has a handful of neurosurgeons who will operate on children now. Last news report on the latter I saw said that only 5 neurosurgeons in the state will operate on children now because of the way that many of the previous ones were running the risk of or sued for serious damages.

All I can say is, if only lawyers were held to the same exacting standards that doctors and engineers are held to. That would certainly do wonders for cleaning out the corruption in the criminal justice system that is far more likely to affect many Americans in a life-damaging or destroying way, than a simple screw up by a doctor.

I cannot say that I concur in this, if it means that someone victimized by negligence or malpractice should only be compensated for specified costs incurred up to a certain expense. If through someone's negligence or incompetence or malice, an injury requiring ongoing, possibly life-long care is inflicted, the culpable party(ies) ought not be able wriggle out of responsibility for several hundred thousand (let's stipulate) when caring for the injured party might cost an estimated fifty thousand per annum, indefinitely. Responsibility should be proportionate to the offense, and victims should not be expected to be human sacrifices to efficiency. Needless to say, I don't believe that this entails Powerball-size jackpots; but those wronged in such cases ought not be told by the law that they must be worse off, as a function of some arbitrary limit on a settlement, so that some unspecified others can be better off.

I think we agree on this. By covering costs, I meant that any medical cost, and a reasonable amount to make up for lost income due to the injury, should be incurred to the doctor (too bad we don't punish lawyers whose actions result in court rulings that damage innocent lives this badly, but I digress). The problem is, no human life is worth a $20M ruling, unless they are very young, and that $20M is the calculated cost to keep them from being a ward of the state for the rest of their life, assuming that their injury is so bad that they cannot care for themselves. Otherwise, I say pay for their medical costs, a little something for the grief imposed on them, and tell them to shut the hell up, and get back in the job market like a normal person.

Perhaps we should note that every other industrialized country has some form of national health care and they all provide better overall care at less per capita cost than our system.

Our present "system" is inefficient and a drag on productivity.

"...and they all provide better overall care at less per capita cost than our system..."

Cue hysterical laughter. Actually, the UK's system does not offer anything _like_ better overall care than ours. It's...got problems. Read Wesley J. Smith's blog for instances. (People pulling their own teeth. Patients waiting in ambulances for hours to get around the rule that you must be seen within two hours of arriving at the hospital. Rationing galore.)

Perhaps we should note that every other industrialized country has some form of national health care and they all provide better overall care at less per capita cost than our system.

That's what happens when you institute price controls, ration healthcare, and don't have to spend much money on researching your own medical technology. The rest of the industrialized world is largely parasitic on the technology that is produced by the two market-based healthcare systems: the United States and Switzerland.

My wife's family is friends with a woman who is Canadian. She chooses to have her children in American hospitals because they are better than what Canada provides. In Canada, pregnant women are typically herded into a large room where they go into labor. You know, to save costs since individual rooms are decadent, bourgeois luxuries.

Of course, the reason the rest of the world has a lower infant mortality rate is that they employ different statistical standards. The United States counts the death of premature babies into its infant mortality rates, and also tries to save a lot more babies than most industrialized countries do. If we adopted the same utilitarian ethos that the rest of the world uses, we would look a lot better. If not in the eyes of God, at least on paper.

A few things.
* Of the studies I'm aware, malpractice adds anywhere up to 3% to the costs of medicine in this country. I think the CBO said it was 1.5%. This is the cost of malpractice period, including phony and dubious lawsuits.
* It takes a lot of preventative care to add costs to the system. At the small company I worked, we managed about 50,000 lives and had about $200 mil in claim payments, roughly $4,000/live. A number of screenings are for $250 or less and in the world of medical payments, that is like penny candy.
* People are right that the savings available through early detection are not the be all and end all to savings. This is where medical research comes into play. There are really no incentives for insurance companies to pay for medical research, and they almost always won't pay for experimental surgeries, etc. The reason of course is that even if Aetna could develop a process that saves half on breast cancer treatment, BCBS could use that same treatment without having to have spent the money researching it.

* Of the studies I'm aware, malpractice adds anywhere up to 3% to the costs of medicine in this country. I think the CBO said it was 1.5%. This is the cost of malpractice period, including phony and dubious lawsuits.

I don't think it is particularly accurate to look at the cost of malpractice insurance as a part of the total cost of medicine in America, when the issue really is how much an individual doctor or a practice must pay for it, which can turn it into a serious cost of doing business for them.

An analogy of sorts for what you did here would be to say that labor rates in IT account for only 25% of the cost of IT industry costs in America, therefore a consulting firm shouldn't have to worry about its rates, when all a consulting firm sells is labor. All a doctor sells is labor. The cost of buying insurance may not be high to the medical industry in America, but the cost to the doctor of buying malpractice insurance might be very high. Enough so that the doctor cannot charge rates that make him or her competitive anymore. Some specialities like pediatric neurosurgery are apparently extremely expensive in this respect.

If the question is how to reduce medical expenditures, it is a perfectly valid question. If the question is how do we get more ob/gyns in West Virginia, then it is a bad question. Even if we removed malpractice completely, the most we could expect to save is 3%. Much of the malpractice cost is real as in the money is being used to pay for actual mistakes.

Since someone brought up the NHS...

If the question is how to reduce medical expenditures, it is a perfectly valid question. If the question is how do we get more ob/gyns in West Virginia, then it is a bad question. Even if we removed malpractice completely, the most we could expect to save is 3%. Much of the malpractice cost is real as in the money is being used to pay for actual mistakes.

Malpractice insurance increases not only raise the cost of doing business, they raise the cost of entry into the medical profession. Malpractice lawsuits also have the tendency to scare many people out of particular professions in the first place, which I doubt you would argue has little effect on the price of medical treatments (supply and demand, and all that, you know).

That is precisely what is being argued. When you get your peer reviewed study published by the CBO showing that there are vast savings available by addressing malpractice, I'll look at it.

http://www.hsph.harvard.edu/news/press-releases/2006-releases/press05102006.html

Whether it "works better" for "more people" to legally require that insurance work in a way other than the free market would provide is, definitively, a secondary question. The first question is, does the state even have the right to make such a mandate. It is clearly a state taking to do this. So the question is, does the state have a right to impose such a taking?

The fundamental and True principle of subsidiarity declares that a higher order shall not take over that which a lower order can accomplish. The reality is that personal and community organizations can distribute health care as well as the state, or better, at least in some cases. If you wish to argue that the state has a role here, you must first argue that health care distribution cannot be accomplished without the state controlling it. Clearly that case cannot be made. A more qualified case can be made potentially: health care distribution cannot be accomplished so that poor people get all the health care that well-off people get, without the state to control it. Then this resolves to a further question: Is such an outcome even within the state's proper goals? I don't mean is such an outcome desirable. I mean is it specifically a goal proper to statehood as such?

I find it impossible to support any claim of that sort. Health care is a good, but it is not a good of a nature belonging to the state's proper sphere, as is community justice, for example, or defense. Also, health care is a good, but 95% of its development and delivery are a matter of individual efforts rather than a matter of intelligent political order. Of necessity you impede individual free choices to have the state control the system, choices that people as a general matter have a right to. Thus any system of state control over health care would have to have an OVERWHELMING state need to justify removing from individual choice what by nature ought to be free options left to individuals and lower-order communities.

Hopes (even fully correct anticipation) of efficiencies of scale, or of similar benefits, could never, never create such an overwhelming state need. These are just of the wrong order of need.

The only justification which even SOUNDS like it might work is that with state control some poor people would get care that otherwise they would have to do without. (This is difficult to substantiate, in the face of (a) reduced resources because of an induced shortage of doctors and nurses, and (b) the counter-example of charity and community aid which would have served some of those poor people without state interference. But aside from that difficulty...) You are still left trying to make the argument that "getting health care to those poor people" is a basic state role.

Sorry, it won't fly. Defense and justice are state roles by nature. Health care is not. It cannot be made into a political right. Attempts to gloss over this fact are detrimental to subsidiarity, which is what protects us from tyranny. (Defense and justice are primarily a matter of preventing someone from taking what you hold away from you. The state never CREATES the "what you hold" that it protects. To posit health care as a state role means having the state CREATE a new good. It doesn't know how to do that, because this is not its natural sphere. See: Downfall of Communism)

If you wish to argue that the state has a role here, you must first argue that health care distribution cannot be accomplished without the state controlling it.

There is an elision here, from "having a role" to "controlling". Nevertheless, I am not arguing in favour of single-payer health provision, merely that certain mandates and prohibitions are warranted; moreover, some of these provisions actually support supply, inasmuch as they insure broader access to specialized health services that would otherwise be priced beyond the reach of many people.

merely that certain mandates and prohibitions are warranted; moreover, some of these provisions actually support supply, inasmuch as they insure broader access to specialized health services that would otherwise be priced beyond the reach of many people.

making certain legal mandates is the same thing as prescribing by law something other than free market decisions about providing or obtaining health care. To the extent of the mandate, this is state control - at least of those decisions.

You must have a different idea of supply than I. Greater supply means more doctors, more nurses, and more medicines in existence. It does NOT mean more doctors in poor areas, etc. You are referring to a different distribution of the same amount of goods.

You could in theory, over the long term, increase the supply of health care by simply having the state purchase such goods for poor people out of general funds. This would of course alter the market by increasing DEMAND, but eventually that would even out with more people encouraged to get into health care to grab some of the money available - thus increasing supply. During the interim, though, health care would cost more FOR EVERYONE, but that's OK. Having the state simply purchase from the existing market the health care it wants for poor people is far less damaging to the system than having the state control distribution through unnatural market manipulation.

...making certain legal mandates is the same thing as prescribing by law something other than free market decisions about providing or obtaining health care. To the extent of the mandate, this is state control - at least of those decisions.

As a pure free market is an artifact of theory, incapable of realization in any sphere of human endeavour, let alone in the area of health provision, and presupposes an untenable methodological individualism, I am untroubled by this.

Having the state simply purchase from the existing market the health care it wants for poor people is far less damaging to the system than having the state control distribution through unnatural market manipulation.

This is theory, not the complexity of existing institutions. Mandating that general health insurance policies cover cancer treatment, or proscribing the use of genetic testing as a screening mechanism, is more efficient that maintaining two health care systems - one for the relatively wealthy and well, the other for the less well-off and ill - inasmuch as the inevitable interface between the two will be fraught with inefficiencies. See: Medicare. Moreover, if an untrammeled free market in health care were to be imposed, and vast numbers of people found themselves priced out of the market - under such a system, insurance rates would be established on the basis of an increasingly fine-grained actuarial analysis - the risk pool would be reduced, leading to either of two consequences for the provision of care to those excluded: the government would be compelled to purchase care for the excluded at the higher rates established by the private, actuarial system, or would establish the rates by bureaucratic diktat, or legislatively, effectively overruling the operations of the private system. The irony, of course, is that the former course would instantiate a de facto indirect subsidy to the private system, while the latter course would be more interventionist than the present ad hoc arrangement of mandates, exclusions, and so forth. The attempt to realize the chimera of a pure market system would engender the all-too real contrary of such ideals, a dialectic which has been, itself, the history of modern political economy.

Greater supply means more doctors, more nurses, and more medicines in existence. It does NOT mean more doctors in poor areas, etc. You are referring to a different distribution of the same amount of goods.

Insofar as the distribution of health services to the poor is concerned, that may well be true; but I've not been discussing the provision of services to the needy, but to those who would be excluded from the private system by an actuarial/ala carte model of insurance. There will be, of course, some degree of overlap of these problems, and there, the point is twofold: first, an actuarial model of insurance will exclude many non-poor who suffer from certain conditions, environmental or inherited; second, any scheme of social provision extended to the poor will, by socializing those risks, augment the supply of health services, in a manner analogous to the way the risk-pooling of private insurance increases supply. If substantial numbers of people are priced out of a market, and cannot by any means purchase the goods of that market, the supply of those goods will be correspondingly reduced.

As a pure free market is an artifact of theory, incapable of realization in any sphere of human endeavour, let alone in the area of health provision, and presupposes an untenable methodological individualism,...

Indeed, there is something close to and perhaps even actually contradictory in the very notion of a 'free market' understood as exchange of goods and services absent any authority which establishes, prior and precedent to exchange, based on moral understandings independent of the market, the positive rules governing market exchange. In highly contrived circumstances bearing no discernable relation to the practice of modern large-scale industrial capitalism, that a priori rule-making authority may be largely implicit. But the capability of demonstrating a vacuum in the laboratory, and the existence of a vacuum in some uninhabited parts of nature, does not in any way imply that we actually can or ought to live and breathe in a vacuum.

I've been meaning to say this briefly, but Maximos, I don't think I understand fully the distinction you're drawing between an actuarial model and risk-pooling. How is it possible to pool risk if risk is not estimated? Aren't actuarial data required for any sort of insurance at all?

Certainly actuarial data are required for insurance; the requirements that coverage be extended to cover certain conditions and treatments, and that certain data be excluded from the screening procedures, do not guarantee that higher risk policy-holders will pay no more than the lowest risks, merely that they will receive coverage - the actuarial data are pertinent to the assessment of risk, not to mention the calculation of policy premiums, but those risks are then averaged against the risk assessments of many other policyholders. I've mentioned, somewhere upthread, that there obtain tensions in the provision of health insurance, tensions which are maintained fruitfully by the application of prudential reasoning to contingent circumstances, so this is, in my mind, a both/and situation. My objection is that too many conservative discussions tilt it towards either/or.

There are few things combining together. Before joyful computers, one was really dependent upon the natural truth that cost converges with the more samples taken. I'll make the numbers up here. Say you have 10 25-year-old men that you are insuring against death for 15 years for $1,000. The odds that you will have expended $0 or $10,000 at the end of 15 years is low but within the realm of possibility. If you have 10,000 25-year-old men, the odds that you will have expended $0 or $10,000,000 are significantly less.

The problem that can develop with applying actuarial modeling on a smaller and smaller scale, which modern computing allows, is that markets can stop functioning. It is the difference between custom fabrication and assembling common components.

M.Z., I don't believe you are correct. The general result of being in a higher risk category is having to pay more for insurance, not being unable to get insurance. You won't be able to get insurance from those limited companies who ONLY like to deal in the low-risk categories, but there are other companies who (for an extra buck related to extra risk) are willing to insure high-risk persons. Try Lloyds.

Maximos, the concern about availability of insurance to those who have high risk is not that there simply won't be insurance companies who will sell to them, it is that such insurance will cost a lot of money. If by pricing such insurance beyond their means you point out that they will be out of the insurance market, well, that's true, but it's true by the normal market force of not being able to afford a service they would like to purchase. I cannot afford a large-screen TV, either. The people who are willing to pay 4 times as much for insurance can get it.

Furthermore, the only reason we are talking about managing the "rules" for insurance is to modify who can get health care when they wish to get it. Health care is the real commodity being regulated. It remains true (for the moment) that people who are not insured can purchase health care directly, without the interference of an insurance company. Thus they are not forced out of the market that really matters. Nor are they charged more for their care than the insured are charged, in general (though there are exceptions).

The fact that we do not now have a level playing field in which market forces operate without any legal involvement says nothing about whether it is a good idea to impose still more involvement. I am not opposed to the concept of certain legal involvement establishing ground rules for the free market system (I am not a libertarian, for example), because human nature is such that men will frequently be found to take unreasonable advantage and skew the playing field where he can. But those limits have to be justified by something more than "if we don't control the market then people who want a marketable service but can't afford it won't be able to get it." And it has to be more than just that the natural market price for a product is too high for some people. So far I have seen nothing toward an argument suggesting that charging more to insure someone in a higher risk category is somehow an exploitation rather than natural market force. The fact that it makes it more difficult for a high risk person to afford health care does not constitute exploitation - in the long run these high-risk people will cost the insurance company more money.

In reality, you are saying that low risk people SHOULD shoulder some of the cost of health care for others, and that this SHOULD stands as a social obligation that SHOULD be established and regulated by law. But you have nothing to support such a view.

Lloyd's will insure most anything, but not everything. Technically they aren't an insurance company; they are a clearing house.

The more work that has to go into assessing the risk, the more money is sunk into the policy. It isn't like we are lacking empirical evidence on this. In a number of states there is a compulsory pool for high risk drivers. Many of them also have compulsory pools on the health side.

In reality, you are saying that low risk people SHOULD shoulder some of the cost of health care for others, and that this SHOULD stands as a social obligation that SHOULD be established and regulated by law. But you have nothing to support such a view.

This is precisely what I am arguing, inasmuch as it would be IMMORAL to permit people to suffer the denial of necessary care, whether by means of market mechanisms or otherwise, given that charity is insufficient to the degree of need (indeed, the charity model of health provision presupposes an entirely different social order, as I have argued, I believe, in the preceding thread; the effort to recreate, in altered circumstances, social modalities which have receded into the mists of history is an act of ideological nostalgia, of performative anachronism...); unless one is desirous of arguing, explicitly, that it is licit to permit such grotesqueries, all in the pursuit of some illusory market purism, such health risks will be socialized by some means or other. And I believed that conservatives were wont to laud to the heavens our private health care system; now, it appears as though they are content to connive, indirectly, at the creation of a state system, albeit for the poor and sick, if only the profit margins of that industry may be preserved, and the costs to the well may be minimized. Ahem. Priorities are tremendously warped, if indeed this is the case; apparently, it wasn't the private health care system per se, but gross receipts that concerned them. Once again, I seem to intuit that so-called conservatism aims, not at the preservation of humane traditions and institutions, flawed as they may be (as are all institutions on this earth), through the exercise of prudence, but the conservation of mammon. Pardon me if I perceive in this a microcosm of everything that has gone awry with postwar conservatism, now reduced to ritualistic chanting about tax cuts, free trade, and privatization, regardless of the evidence.

And it has to be more than just that the natural market price for a product is too high for some people.

The point is being evaded: insofar as market institutions are always artifactual, there is no natural market price; there are only prices reflective of the intersection of legions of considerations, some of which are pragmatic (acknowledgment of the operations of supply and demand, etc.), others of which are moral (sick people should not go untreated merely because the market prices them out of the market for care and/or insurance), yet others of which are prudential (the balancing of competing claims for the socialization of risk, the balancing of these with the necessity of cost containment), still others of which are personal. All of these are mutually contextualizing, and not even 'supply and demand' obtains in the absence of a broader social network within which supply is generated and demand stimulated, and both conditioned by the other categories.

insofar as market institutions are always artifactual, there is no natural market price This is a bad economics theory matched to poor social philosophy, as far as I can tell.

If I hold a garage sale, there is a background of social context that creates a meaning to money - other than that, whatever I get for an item is its market value. I can even barter goods at times, and this does not depend on the money context. This shows that there is indeed a natural market price considered of itself.

I admit that we live in a very complex system, and part of the complexity is in defining the playing field. Yet, part of the reason for politics being capable of being honorable in principle is that the work of a law-maker is to make that playing field level, insofar as it can be. We all know the root meaning of justice, even if we cannot agree on an exact just price in the concrete. The fact that we can identify a playing field tilted means that tilting is understandable, and level should be too.

now, it appears as though they are content to connive, indirectly, at the creation of a state system, albeit for the poor and sick, if only the profit margins of that industry may be preserved, and the costs to the well may be minimized. Ahem. Puhleeeze. I am one of the people who are greatly advantaged by a system which relieves the cost of high risk and spreads it around, and I always will be. So my arguing for a system that will do the reverse could hardly be self-serving. Please don't ascribe my motives in such a way.

unless one is desirous of arguing, explicitly, that it is licit to permit such grotesqueries, all in the pursuit of some illusory market purism What about in pursuit of true and essential principles of social order, like subsidiarity. Principled conservatism suggests that ignoring the underlying principles which make social interaction work will in the long run create more problems that it solves.

For example (slight digression): Take Social Security. Ignore for the moment that it was sold as a "retirement" system - it is really a welfare system with current revenue paying for current costs. When it was started, it was explained as a way to share out a social cost between many, so that the old people who had no means of support would be taken care of. This of necessity took a responsibility that was, at that time, being met in MOST cases by family, friends, and local community, (by persons known to the old folks being helped), sometimes as simple due (from children) and sometimes as generous gift. We moved it to "government" as an "entitlement", thus creating a myth that "everyone" owes it to those old folks where, the day before, they did not.

Now, look at the social effect: before the change, most people knew that they would be relying on their own kids to support them in their old age, so they (in part) put up with the heavy costs of bearing those children and raising them with that expectation in mind. After the change, people know they will receive basic support from good ole gov, and they stopped having more than a couple of kids. This is a natural, unavoidable consequence of changing the cost/benefit ratio. But, of course, it is IMPOSSIBLE for a system which bases current payments on current revenue to work with 2 kids replacing 2 seniors - unless you use a whopping high Social security tax. The utterly natural effect of changing the cost/benefit ratio away from the natural one of personal responsibility is what ruins the system. (By the way, I built my current house with room for my parents, they moved in with me, and all their kids are helping to support them, so I am not just talking the talk).

social modalities which have receded into the mists of history is an act of ideological nostalgia I don't know whether to be insulted or pleased. You get carried away a bit, don't you? I do not suggest that we MUST return to exactly one model, that of the 1600's, or anything of the sort. I am suggesting that any model which flies in the face of valid principles of social order will (a) NOT WORK, and (b) run roughshod over rights and freedoms which people who want to take their personal responsibilities seriously should be able to act on. God gave us human creativity not to say " I have a problem so you are going to solve it for me" but to solve them in ways that make sense with human nature. Taking away personal responsibility and personal freedom is not normally that right way.

If you come up with a model which increases the personal responsibilities being met by personal action, that I'll go for. The fact that an older model had more of it than the proposed one does not mean I am pushing specifically to go back to that older model.

This shows that there is indeed a natural market price considered of itself.

It always astonishes me that people actually believe this.

...other than that, whatever I get for an item is its market value.

This is an exercise in abstraction, inasmuch as the concept of a good, subject to supply and demand in the marketplace, is not univocal; no one is greatly concerned to regulate the social conditions of secondhand china sold at garage sales, whereas the provision of health services is manifestly fraught with moral considerations, as I have argued. Aside from this consideration, there is no more a market valuation, considered in itself, any more than there is such a thing as a person, considered in himself, in abstraction from all social and familial relations; it is precisely in these thickly-constituted relations that the moral differentiation of goods transpires. Those who are arguing for the attempt to approximate the ideological figment of a pure market discipline in health care are doing so against the accumulated weight of our cultural norms, which have never known such a thing.

Please don't ascribe my motives in such a way.

I'm not. I employed plural pronouns, in order to generalize over certain segments of American conservatism.

What about in pursuit of true and essential principles of social order, like subsidiarity.

Nothing I have argued is incongruous in the slightest with the principles of subsidiarity; those principles do not forbid higher levels of authority from assuming a given responsibility, but rather condition such an absorption upon the demonstrated incapacity of the lower order to effectively provide for some social good. In the case of health care, neither families nor small communities, nor voluntaristic charities, would be capable of assuming the risks of any number of ailments; the average family could not, for example, shoulder the cost of treatment for colon cancer in a pure market system. Socializing the risk by mandating the inclusion of such an ailment in insurance coverage programme is a reasonable response to this incapacity; certainly, I'd rather receive treatment from Blue Cross PA then from some governmental bureaucracy.

Taking away personal responsibility and personal freedom is not normally that right way.

Personal responsibility has little or nothing to do with the specific questions which motivated my posts, unless one is arguing that a)those who have inherited genetic afflictions, or tendencies to the development of certain diseases, or have suffered personal misfortunes, are responsible for such weaknesses, and b)that any persons so affected who are incapable of providing for their own care, out of their own expenditures, are irresponsible in virtue of that fact. No one argues as much, since an inability to afford something does not demonstrate improvidence, except perhaps to the worst sort of Calvinists.

Leaving people bereft of requisite care, merely because the market has priced them out of it, is not a vindication of subsidiarity; neither is it a vindication of personal responsibility. This can be justified either by an argument that physical health is not a good, or by an argument that, even if it is a good, there obtains no claim upon the conditions of its pursuit. Even controlling for the cultural norming of such matters, I'm dubious of such arguments.

Backing up: Maximos, I think I must be misunderstanding you. You applaud a bill making discrimination on the basis of genetic testing illegal, yet you _seemed_ in a recent comment to be saying that you understand that it may be necessary for higher risk people to pay higher premiums. But that would be a form of discrimination on that basis and would surely be illegal under such a bill. Again, you express concern about high-risk people being priced out of the market, yet you seemed to say it would be okay to charge them more. Is it just that they shouldn't, on your view, be charged "too much" more? Or did I misunderstand something?

Those who present higher risks will, of necessity, pay premiums somewhat higher than the average among those who do not present such elevated risks; nevertheless, by means of coverage inclusion mandates, and the proscription of certain screening criteria, those higher risks are to a substantial extent socialized across the category of all those paying insurance premiums, thus reducing the costs to the higher-risk group by orders of magnitude, by comparison to what they would be in a pure actuarial/diminished risk-pool model. That, in part, is the function of any insurance scheme worthy of the appellation; higher-risk policyholders pay a little more, relative to what they would be compelled to pay in the absence of the risk-socialization function of insurance, which is a lot more.

First you say upon the demonstrated incapacity of the lower order to effectively provide for some social good

Then you say In the case of health care, neither families nor small communities, nor voluntaristic charities, would be capable of assuming the risks of any number of ailments

Ummm, "neither... would be capable" pretty much implies "has not yet been demonstrated", doesn't it? So by your own criterion, we shouldn't be resorting to the government mechanism yet. The fact that I cannot afford high insurance premiums under the CURRENT system does not determine (a) that I would not be able to get health care, or (b) whether I would be able to afford insurance if the government were not already screwing up the system with its intrusion.

Further, my health care is a personal good to me. You have yet to show how my health care is a social good. This can be justified either by an argument that physical health is not a good, or by an argument that, even if it is a good, there obtains no claim upon the conditions of its pursuit. I don't see why the fact that Joe down the street cannot afford health insurance creates a social mandate on my money that should be mandatory. Why can't Joe ask the church or community chest, which then asks for donations, which I give to this month because I happen to have it but last month I didn't because I had an emergency room visit to pay for of my own. I have seen advertisements for medical mutual aid societies which operate as entirely voluntary bodies for helping each other to find donative support for major health care when needed. Are you saying this kind of thing is unacceptable? Or that it CAN'T work?

You are just assuming that a society in which everyone has medical care for a modest direct cost is a natural right, or a socially necessary good. I am saying that I don't see how a person who cannot afford to have colon cancer surgery on his own nickel (whether through insurance or not) creates an absolute mandate on my money. Good health care is not a governmental obligation. It is not an eternal good. It is not a common good in the ordinary sense of the word. Not providing it on our nickel is not equivalent to denying them a human right.

Those who present higher risks will, of necessity, pay premiums somewhat higher than the average among those who do not present such elevated risks; nevertheless, by means of coverage inclusion mandates, and the proscription of certain screening criteria, those higher risks are to a substantial extent socialized across the category of all those paying insurance premiums, thus reducing the costs to the higher-risk group by orders of magnitude

So, you basically want the government to use what amounts to fairly large machete (across the board banning of genetic testing in setting insurance rates) to accomplish a result that is more like heart surgery - that most people who present higher risk to pay SOME more, but not so much more that they cannot be part of the standard market. And this means government will be establishing by fiat how much "more" is OK, how many high-risk people must be able to remain covered for it to be "most" of them, and so on, how to decide whether and when a high-risk person going off insurance because of OTHER costs is OK. All decisions manipulating a natural market for non-governmental objectives. I don't want bureaucrats deciding this for me, and I sure don't want politicians doing so. Putting power in the government's hands and taking it out of mine. No thank you.

Taking the health care costs out of the hands of the individuals who need it (in first instance) or the people who are willing to pay voluntarily (as individual donations) means you automatically get systemic stupid health care decisions - stupid because they are disconnected to appropriate cost/benefit ratios. If medicare says you can get hip replacement surgery when your hip mobility is impaired by 70%, then people will get this expensive surgery who, had they had to pay for it themselves, they would have declined (even if they had the money available): Grandpa who is 85, and will probably be blind or need a wheelchair in 2 years regardless of his hip.

A system can survive a few of these stupid decisions at a time. It cannot survive such decisions being systemic. But they cannot but become systemic when the benefits behind the decisions are largely unrelated to the costs.

And yet I sure don't want a government wonk in charge of setting a policy that says health care for these people is acceptable, but the same care for those people is unreasonable. Such a situation will become a tyranny in short order.

I am saying that I don't see how a person who cannot afford to have colon cancer surgery on his own nickel (whether through insurance or not) creates an absolute mandate on my money.

Ah, finally, we cut to the chase: there should exist no laws requiring the inclusion of certain coverages in health insurance programmes, and perhaps no laws forbidding the employment of exotic screening techniques, such that all insurance policies are tailored specifically for the individual, with all that this would entail for those afflicted with costly ailments (and of this, no demonstration is required, inasmuch as it is a matter of simple economic logic: if the cost of cancer treatment is not distributed among all policyholders, it will be borne solely by the patient and his heirs; charity is insufficient, since few churches could afford even one or two multi-hundred-thousand-dollar treatments, let alone an indeterminate number), because, by God, I have a right to the disposal of all of my money, and all of the claims of the needy are contingent upon the fiat of my will.

Glad to have that cleared up, as it means this discussion can be considered closed. There is no common good; all good is refracted through the voluntaristic movements of individual wills, and it's acceptable to let the poor and ill die, because it's my right to let them die if I don't want to spend a few extra bucks every month for my insurance policy. And this will be justified by the argument that regulation takes power out of the hands of the individual, regardless of the manifest fact that the sick individual would be virtually powerless in such a purified marketplace. God Almighty, if this is capitalism, it is no wonder the welfare state obtains pretty much everywhere.

charity is insufficient, since few churches could afford even one or two multi-hundred-thousand-dollar treatments,

This is a totally assumed premise, without a shred of proof. Furthermore, sooner or later the government will be doling out those multi-hundred-thousand-dollar treatments with some limited-availability model of its own. Why prefer the gov's over one with freedom and voluntary choices?

There are other models than charity. I mentioned one: VOLUNTARY medical mutual aid societies, for example. Prove first that there is no other model than government fiat.

all of the claims of the needy are contingent upon the fiat of my will.

Finally we get to the crux of the matter. According to you the needy not only have a claim on my money, but the claim is one that automatically justifies a law which mandates that I give the money. According to me, there is a difference between an obligation in justice and and obligation in charity. The government's role is to enforce justice, NOT charity. I should be perfectly free to say to Joe down the street: I acknowledge your need, and I would like to give to you if I had the means, but I just spent 3,000 last week helping Bill whose house burned down. In other words, I can choose of my own will WHICH needs I will help meet. (Please note that I accept the notion that such need presents an obligation on those around. It is the nature of the obligation that is at issue.) You are saying that by virtue of being sick Joe not only has a CALL on my money, but an actual RIGHT to my money. Prove it.

Finally we get to the crux of the matter.

It isn't a mystery. This discussion always comes down to the libertarian version of the autonomous self-created free and equal superman, with his voluntarist conception of charity and his tinpot god plenary concept of 'property'.