What’s Wrong with the World

Jeff - passing over all the non-responsive stuff: I gather that you think that it is more or less satanically evil for "the determination of care" to be "governed, in part, substantially, or in whole, by criteria extrinsic to the practice of sound medicine and the deliver of health services."

In other words: health care providers must be, always & only, selfless & charitable. There is no room for the profit motive in the provision of health care.

Have I understood you, so far?

Maximos says: "it would be no more, and no less, monstrous to say and believe the things in that post than to argue for the liceity of a government-run health system rationing on the basis of a politically-determined cost ceiling, or even a quality-of-life/quality-of-life-years "metric" devised by those satanists intellectuals called utilitarians. In each case, the determination of care is governed, in part, substantially, or in whole, by criteria extrinsic to the practice of sound medicine and the delivery of health services."

But one could say this about ALL goods and services that human beings might need. Take bread. I'm broke and walk into a bakery -- should the provision of bread be governed by my need ("the practice of sound eating and the delivery of warm, whole grain loaves of bread") or can the business owner suggest I go get some money before he gives me a loaf of bread.

As Maximos says himself, resources are finite -- so the question becomes how do we allocate these finite resources (bread, health-care, etc.) Those of us defending the market do so because it is the most effective system ever created by human beings to allocate scarce resources. No special pleading needed and I dare anyone to point to some other mechanism that allocates resources more effectively. Not everyone does well in a market system -- but that's O.K. because then we have charity, welfare programs, etc. to help out those we think don't get the resources they need.

That doesn't mean there is still room for individual acts of kindness and charity, even when we collectively decide the State should provide some minimal goods and services to the "unfit and poor." Tony gives some excellent suggestions for how a doctor might handle the case of someone walking in their door and needing help but having no money to pay for that help. And yes, these folks should be grateful for the goods and services they receive as we all should be grateful for living in a country that provides the level of freedom and wealth that this country has to offer.

Finally, what we all should be reminded of in a discussion of any good and service, is that when you take individuals out of decisions that influence the goods and services they think they need, you get situations in which someone like Maximos would like to see a chiropractor X number of times a year in lieu of an expensive drug and he cannot under his current health-care 'coverage'. Restoring more market power to individual consumers (and providers) would put the power to go see the doctors individuals think they need in the hands of those individuals (e.g. Medical Savings Accounts).

Here's a good follow-up on the question of rationing (Wilkinson argues the question should be put to the end-users of health-care, not the government):

http://www.willwilkinson.net/flybottle/2009/07/17/peter-singer-on-health-care-rationing/#disqus_thread

Ah, the tedium continues, beginning with the rote accusation of "non-responsive matter", a complaint that could be leveled at virtually anything posted on the internet, and a great deal besides, more or less whenever two or more interlocutors do not share presuppositions, interpretive frameworks, etc.

Am I to believe that no one "made a living" in health care prior to the conversion of the insurance industry from non-profit to for-profit status, and the subsequent introduction of the complicated metrics by which it is decided that you never need more than fifteen chiropractic treatments in a year, but do need expensive and risky injections of steroids that do have deleterious effects down the road, such as bone density loss, or that you need just so many chemotherapy sessions for breast cancer, or on and on ad nauseum? Please. People made fine livings in those days, and in fact general practitioners had an easier time of things; one of the many foreseeable and now realized consequences of this shift is that income in the industry has shifted to rich people called shareholders and richer people called CEOs, and away from physicians delivering primary care - who, incidentally, now labour under private sector bureacratic burdens fully equal to anything that Medicare imposes. They have that, too. But making a living does not equate to "big corporation earning massive profits and paying dividends to shareholders and bonuses to CEOs". So, the first non-responsive aspect of the "what's wrong with making a buck" argument is the assumption that any undertaking in the private sector that is not simply charitable must be profit-making. The second aspect would be the implicit dualism of market/state, with the individual left to choose between authority and the cash nexus.

But the most glaring aspect is simply the assumption that health care is a market good, a commodity, in the relevant sense, however one specifies it, of justifying the insurance system as it exists. This is not obvious. In fact, it is obvious that if one is making treatment and policy decisions, not on the basis of the good of the person, but on the basis of various actuarial tables and statistical measures engineered to ensure profits, one is treating the patient as something less than a person. One may go further. If one attempts to square the circle by appealing to charity, one runs afoul of what I think is the kernel of truth in something Frank posted in one of the other threads, something that can be expressed thusly: First, is the recourse to charity for the congenitally infirm and/or poor and/or unlucky the most efficient means of ensuring that these persons receive a standard of care commensurate with their dignity as persons; second, if not, is it even moral to make the suggestion that insurance companies be permitted to let 'er rip in the profit-making mode, instead of adequately socializing the risks of the less-fortunate? The answer to the first question is resoundingly negative, so the answer to the second must be negative as well. As gauche as it may seem, yes, it is immoral to tell someone like me, "Sorry about your cancer risk, but you can either go bankrupt paying a premium based not upon a socialization of risk, but upon an individual actuarial estimate, or rely upon such charity as you may chance to find. Now GTFU because I have money to make by taking insurance premiums from people so healthy they'll likely never need the coverage." If the person is not the touchstone of such determinations, there's not much point in attempting to parse the differences between Peter Singer and faceless, soulless bureaucrats at insurance companies throwing persons on their procrustean statistical beds in pursuit of profits.

Good job, Jeff Singer. Excellently well-put. It is no more treating the person as a "non-person" to try to make some sort of connection between his needs and his ability to pay for those needs in the area of healthcare than in the area of other actual _needs_, like food. Food is a real _need_. People die without it. But this urgent and important fact does not mean that third-parties should be paying for everyone's food nor, indeed, that this will be best for real, needy, people. It may be worst. And as Jeff Singer points out, the problems multiply when you "take individuals out of decisions that influence the goods and services they need." Exactly and precisely. This is what I have been trying to say about the problems with the over-standardization of medical services and the way that this has already begun in the HMO model.

Jeff Martin mentions

the subsequent introduction of the complicated metrics by which it is decided that you never need more than fifteen chiropractic treatments in a year, but do need expensive and risky injections of steroids that do have deleterious effects down the road, such as bone density loss, or that you need just so many chemotherapy sessions for breast cancer, or on and on ad nauseum?

I beg leave to point out, as I have repeatedly, that this didn't used to be the case, _not_ because the market had no place in medicine, but because the market had _more_ of a place, and insurance was insurance against _high-scale loss_ rather than a pseudo-insurance system that is actually a provider of all one's healthcare. Once it turned into that, you got all this messing around with control-freakish attempts at top-down price control. High-deductible _insurance_, on the other hand, would let you decide whether to spend your money on more chiropractor visits rather than on steroid shots, and it seems likely to me that the absence of artificial inflation of the fees themselves by third-party payer mechanisms would make the chiropractor visits (and for that matter probably the steroid shots, if you wanted them) less expensive.

And by the way, why in the world should you think Steve was baiting you by putting up a post of his own on healthcare? For goodness' sake, there are over 150 comments in my thread on health care, of which yours are only a few, and I myself was surprised to find that this subject, of all things, the desire to argue (apparently) in favor of more government healthcare and to say that there's no difference, no, none, between the present system and socialized medical rationing, would be the one thing that could bring you out of a self-imposed blog hiatus. But since it has, I can't imagine why you would take the fact that Steve chose to give his views on the subject as some sort of personal baiting. That makes no sense to me.

I for one am very glad that Steve chose to post. It makes me feel like I'm not the lone free-market enthusiast (without much Chester-Belloc sympathy, even) among the bloggers.

Lydia, I'm not disputing anything in your second paragraph. It is all contingent upon what qualifies as a high-scale loss or a high deductible, and whether the issuance of the policy itself is based upon risk-socialization or individualized risk assessments. MSAs likewise: it all depends upon what falls under the MSA legally, and what falls under the supplemental insurance, and the nature of the insurance.

As regards the first paragraph, well, objective need has precisely nothing to do with ability to pay, and the cases of food and health care are disanalogous by reason of the difference of fiscal magnitudes involved: it takes relatively little to sustain a person, food-wise, while it can take quite a bit medically.

Of course it was bait, Lydia. "Marty"? References to all of the maladies and risks I've mentioned as being specific to my situation? The statement that I should be a charity case so that insurance companies can remain flush? Come now. It was no dispassionate hypothetical, as though conceived for some journal of philosophy!

I was oblivious and honestly didn't notice those things, or did so only transiently, believe it or not. I still think it's the kind of thing that can be done quite legitimately in terms of give and take among people discussing ideas, as if we were all sitting around talking about this, but I see better now why you said what you did.

But the most glaring aspect is simply the assumption that health care is a market good, a commodity, in the relevant sense, however one specifies it, of justifying the insurance system as it exists. This is not obvious. In fact, it is obvious that if one is making treatment and policy decisions, not on the basis of the good of the person, but on the basis of various actuarial tables and statistical measures engineered to ensure profits, one is treating the patient as something less than a person.

Maximos, there really isn't much to say after that. Not sure what is more impersonal and demoralizing; a visit to the Motor Vehicles Dept, or trying to engage the harried and suspicious souls at my health insurance carrier.

We should focus on the Perfect Storm brewing between demographics, financial debt and spiritual decay, but we should also explore why modern medicine often feels like an institution onto itself and that strange, I really am a ghost in a machine feeling that follows any exposure to it.

and the cases of food and health care are disanalogous by reason of the difference of fiscal magnitudes involved: it takes relatively little to sustain a person, food-wise, while it can take quite a bit medically.

Well, no. Actually not. I spend just about the same on food for my family as for health care. I have budgeted for 18 years, and have the numbers to prove it. It takes relatively little in food to sustain a person at any one time , but it takes that amount of food over and over, every single day of the year. A medical expense may be several hundred times that small amount, but you may only need that once a year.

Governments should neither balance budgets - on the assumption of some sort of public provision - by rationing care, thus implicitly determining who lives and dies,

Perhaps I don't understand your point here, but it seems to me that you are pointing up a fundamental problem with a managed system: that it limits who gets how much by a criterion outside of the consideration of "how much do they need". That's intrinsically true of ANY system, public or private. So what? You said it yourself: resources are finite. Being finite, there is no way you can base decisions solely on "how much do you need?" and run the system. The only thing left then, is to decide WHICH of the available limiting methods best achieves all of the goals desired.

One of the goals desired is that ALL persons are treated as persons. This is neither morally or medically identical to "providing all the care that might make them live longer." Sometimes the personal decision is that additional intrusive medical care is inappropriate - like it was for my mother's brain cancer. Given that fact, and the fact that medical care is a finite resource, it CANNOT BUT be true that in some cases, the correct choice in respecting persons is to say "we are not going to supply the care for this need in front of us" because we have already allocated that care elsewhere, and nothing about this need in front of us gives us a reason to change than allocation decision.

For example, you are a pioneer with your brother and father. There is an accident that severely harms your brother and father. You can put one or the other on your back and carry him 20 miles to the doctor, but not both. Your father insists on your taking your brother, because he knows perfectly well that (a) all other things being equal, as the younger man, your brother is more likely to survive if treated, and (b) as the older man, your father has already lived a good length of life and has had his family, and he wants his son to have the same opportunity. This is a rationed care medical decision that is made on a basis OTHER than what medical care is needed. It is made on a basis of what care the finite resources will be applied to, given the personal realities.

EVERY system limits care, since it is a finite and valuable resource. If a market system rations care by your ability to pay, and co-exists with a voluntary system of charitable care, it is (I think), in principle, impossible to prove that if there are poor people falling through the cracks, then it is the market system itself must be a defective system, rather than that people simply ought to voluntarily give more to fill in those cracks.

Please note, though, that I say "in principle" because I don't think ALL market systems are equally viable. There are areas where our market system is unnecessarily skewed, and results in distortions that affect the combined market-voluntary whole. As, for example, the excess pay of large company CEOs, (including insurance and hospital CEOs). But such distortions merely prove that this particular market arrangement is imperfect, not that market system as such is a bad approach.

(Jeff, it would be interesting to see an argument about HOW and WHY these salaries are unjust, that applies specially to the health-care industry and not equally to cars manufacturers and power companies. Personally, I think that a board of directors, instead of saying "well, we can't get a qualified CEO without offering 3 million" instead should be saying "we wouldn't want a CEO that would accept 3 million, such a man isn't morally qualified." But I cannot find an argument that applies more to health-care than food or cars or power production.)

that the insufficiency of charity is one of the reasons for the present configuration of the health care system, and for the regulation, however often misguided in certain particulars, of the insurance industry.

And how did we get there? Precisely because people agitated for the government to provide for the needs of the public. Less money went into the church's hands, and more went into the government's treasury. It was inevitable.

No, people agitated for an overtly political provision of services/goods previously left to charity, both during the thirties (creation of Social Security) and the sixties (creation of Medicare) because antecedent developments in American political economy, ranging from the development of integrated national and regional markets, the ascension to political and cultural dominance of that fictive individual, the corporation, the instabilities of speculative financial markets, and the cycles of an economy increasingly dependent upon mass production and consumption, to the vagaries of macroeconomic policy (both pre- and post-Fed) destabilized - and to a significant degree incentivized the destabilization - families, communities, and the churches they sustained, thus undercutting the sociological basis for a decentralized, private provision of charity. Charity presupposes relatively cohesive communities, comprised of persons familiar with one another; and in the absence of such communities, the social and familial atomization, and geographic mobility, presupposed and encouraged by those previously mentioned politico-economic factors yield an insufficiency of charity. The economic system privileges a degree of individualized "rational" self-interest inimical to the stability and rootedness that encourage genuine charity. You cannot have a decentralized society of generous communities when your political economy incentivizes transience in connections among extended families, and detachment from one's given locality; the social networks upon which charity depends have already been attenuated by the scale and nature of our political economy.

Tony, I was not referring to the occasional, even annual health care expenses that may be roughly equivalent to a few hundred simple meals, for which one might conceivably budget, but to the larger expenses of ongoing screening for, and/or maintenance of inherited, congenital, or tragically-acquired medical conditions, and the treatment of catastrophic illnesses - expenses for which only the wealthiest among us could ever reasonable budget. It is for these reasons that, if the application of market logics to the provision of health care and health insurance is taken to entail the utilization of individualized actuarial principles in the issuance of insurance - with the consequence that insurance ends up being for the well and genetically blessed - that such a market system must be adjudged deficient in justice, for want of sufficient solidarity. Likewise for any system that rations principally on the basis of price, that is, ability to pay, leaving those unable reliant upon the vagaries of charity in a mass-consumerist/capitalist society. Part of the problem we have in thinking about these issues is the conflation of "market" with "private sector". We could easily have a system of regulated, non-profit, private entities offering insurance on a social/community rating basis, in order to avoid the problem of the exclusion of the sick and infirm, supplemented by some form of public provision, whether through direct subsidies, tax credits, or a parallel public system, for the impoverished. But it is difficult to perceive how a system, the effect of which would be to restrict insurance and care to the healthy and wealthy, leaving the remainder to contend with fortuna, could fulfill the solidarity requirements of justice.

As regards the salaries of for-profit healthcare executives, their injustice is a function of their origin, namely, the various metrics by which insurance companies contrive to deny needed care; CEOs are ostensibly compensated according to their ability to manage a company to profitability, and such pinching is a principal means by which insurance companies register their profits. Other industries, such as the financial sector, may be judged to pay unjust compensation according to the nature of their business models, for example, the exotic forms of usury dominant in our politically-protected banks.

No, people agitated for an overtly political provision of services/goods previously left to charity, both during the thirties (creation of Social Security) and the sixties (creation of Medicare) because antecedent developments in American political economy, ranging from the development of integrated national and regional markets, the ascension to political and cultural dominance of that fictive individual, the corporation, the instabilities of speculative financial markets, and the cycles of an economy increasingly dependent upon mass production and consumption, to the vagaries of macroeconomic policy (both pre- and post-Fed) destabilized - and to a significant degree incentivized the destabilization - families, communities, and the churches they sustained, thus undercutting the sociological basis for a decentralized, private provision of charity.

None of that has any bearing on the willingness and ability of local churches to do good and impact their communities. In fact, today it is more feasible than ever to efficiently allocate aid all across the country. Churches have the ability to coordinate help in a way that was simply not possible in the 1930s or any time before that. What has changed is the fact that the welfare-warfare state consumes a significant percentage of private capital making it extremely difficult for the non-wealthy to truly give to their community institutions.

and/or maintenance of inherited, congenital, or tragically-acquired medical conditions, and the treatment of catastrophic illnesses - expenses for which only the wealthiest among us could ever reasonable budget.

Jeff, I guess I misunderstood your point. Although, I still have questions about it. Continuing my anecdotal situation, I HAVE one of those "inherited, congenital, or tragically-acquired medical conditions" conditions which required regular visits, constant medication, etc. According to my estimates, the total health care expenditures I needed, including dealing with this condition, is roughly on a par with the amount of money I budgeted and actually spent directly (co-pays), semi-directly (my share of health insurance premiums, withheld from salary), and indirectly (my employer's share of group health premiums, which would have been part of my salary had we not had a group health plan). This rough equality has held for 24 years of work - with the exception of the costs of one expensive operation.

You are right that even normal middle-class folk cannot realistically pay for catastrophic care entirely on their own. Insurance handles that to some extent, but insurance is restricted in favor of those who work for the right employers or who are genetically or health favored. One question is, if we had primarily "catastrophic" insurance only (also referred in some older terms as "major medical"), would the rich be willing to buy such insurance so as to protect their assets? If so, would the necessary premiums for universal catastrophic coverage be brought to a level that middle classes could afford?

The other area in which I question assumptions is in cost. One of the reasons for the incredible sky-rocket of medical costs is the incredible increase in demand - by which I mean actual, real demand by people ready to pay, with cash, or with insurance, or with Medicare (which is a cross between insurance and controlled pricing). If we are imagining a total change in how to look at health care, one possible result is a change in how much catastrophic care is actually demanded when people don't have it automatically covered. Possibly the costs would come down greatly, I don't know. Suppose a 70-year old with nice house needs a heart transplant operation that will cost 500,000, and he is told: we'll pay for the excess over what you can pay, but "over what you can pay" includes entailing all of your assets so that when you die they go to us instead of to your kids - oh, and by the way, the life expectancy with a new heart is 5 years. He may just agree that it is not worth it, that he would rather pass the house on to his kids and forego the risks/benefits of the operation. But today if he has insurance (including Medicare) he gets the operation if they can find a donor heart for him.

So, 2 questions: is there any reason to believe that, a-priori, (that is, before we have really identified and modeled) a truly Godly system would end up providing just as MUCH total care as is now provided to people who are in doubt as to whether the care is worth it? If not, there any reason to be confident that the (possibly lower) market costs of catastrophic care could not be used as a valuable tool for helping people, including potential recipients, in making appropriately humane value judgments about whether such care is really beneficial to the human family? If it can be such a valuable tool, shielding people from all of the effects of such costs would obstruct that value.

One reality is that the most expensive forms of medical care are generally those on the leading edge of medicine, the things that were unimaginable 50 years ago, and were made practical only 15 years ago. It is hard to understand how someone who is poor or middle class can have a right to care today that 20 years ago could not have been had at any price. And we need to worry about whether that new medical concept wouldn't have been invented in the first place if the share of total health spending that is now used for research is cut in order to pay for the poor.

Likewise for any system that rations principally on the basis of price, that is, ability to pay, leaving those unable reliant upon the vagaries of charity in a mass-consumerist/capitalist society.

True. And one of the ways to envision a change in that is to get rid of a mass-consumerist society and replace it with a gratuitous market society, where people don't enjoy collecting more for the sake of having more, where they embrace the joys of giving generously, and the market works because people restrain it with higher values and principles.

If so, would the necessary premiums for universal catastrophic coverage be brought to a level that middle classes could afford?

That would seem to be an open question. As I stated in Dr. Liccione's thread, the middle classes are suffering the downward pressures of globalization, and, as such, experience a combination of declining standards of living and increased income instability; a sufficiently broad-based insurance system, however, one that spread the financial burdens of covering illness over the entire rate-paying public, could counterbalance the other trend, but it's impossible to determine a priori, or absent some sophisticated mathematics (probably on the basis of numerous guesses, at that).

Suppose a 70-year old with nice house needs a heart transplant operation that will cost 500,000, and he is told: we'll pay for the excess over what you can pay, but "over what you can pay" includes entailing all of your assets so that when you die they go to us instead of to your kids - oh, and by the way, the life expectancy with a new heart is 5 years.

Things of this nature happen routinely, as one may infer from the fact that in excess of 53,000 bankruptcies were declared last month solely for reason of medical expenses. But we should be exacting - or, at least as exacting as the subject permits - in distinguishing between extreme interventions undertaken at the end of life, on the one hand, and interventions that, by restoring normal physiological functioning, extend life appreciably, not to mention ordinary care such as food and water provided to the incapacitated.

is there any reason to believe that, a-priori, (that is, before we have really identified and modeled) a truly Godly system would end up providing just as MUCH total care as is now provided to people who are in doubt as to whether the care is worth it?

No, there is no a priori reason to expect a godly system, a system influenced by Catholic Social Doctrine, to provide more care in such circumstances; neither, however, is there is reason to suppose that it would provide dramatically less care: if an hypothetical ideal health care system established a minimum standard of care, and permitted those who wished to exceed that standard through insurance or private expenditure to do so, we might still see significant numbers of people willing to lay out 200K to purchase another year of life. But it seems to me that, given the nature of the hardships now confronted by many Americans, the imperative is establishing that minimum standard of care, and ensuring that it is consonant with the dignity of the person, and not a mere rationalization of crude utilitarianism.

If not, there any reason to be confident that the (possibly lower) market costs of catastrophic care could not be used as a valuable tool for helping people, including potential recipients, in making appropriately humane value judgments about whether such care is really beneficial to the human family?

We can indulge a (cautious) confidence on the matter, provided that we're clear on the distinction between catastrophic end-of-life interventions and expensive mid-life interventions, avoiding the trend of the insurance industry to declare "end of life!" whenever someone simply requires a costly treatment, but could live decades longer should he receive it.

It is hard to understand how someone who is poor or middle class can have a right to care today that 20 years ago could not have been had at any price.

Well, our hypothetical minimum standard of care, given the realities of technical progress, would have to be correlated to what technical progress occurs. It may be difficult to conceive of this as a matter of rights, but it is equally difficult to hypothesize a tiered medical system of 50's-style care for the proles, and cutting-edge services for the plutocracy, and square such an hypothetical system with justice.

a gratuitous market society, where people don't enjoy collecting more for the sake of having more, where they embrace the joys of giving generously, and the market works because people restrain it with higher values and principles.

At this stage of the discussion, I'll simply allude to the title of a favourite book of mine, and state that one of the purposes of the law is to make men moral, within the confines of the diversity of social goods government exists to secure.

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