To avoid excessive quote frisking and repetition, I’ll lay out a few general thematic problems with Goodman’s proposal, which by itself is a good stand-in for all anarco-capitalist plans for health care.

First, the way he talks about the uninsured and their access to the emergency wards, he seems to think that the predominant medical concern in the country is re-attaching severed hands from lawn mower accidents. This is by no means unique to fringe libertarians - mainstream Right wingers from Bush to apparently every single Republican 2008 hopeful (though I’ll admit to having only watched the recapped version of the debates) believes that the uninsured can get medical care ‘if they really need it’ - by which they mean access to the emergency ward. (Note that this would also necessarily mean that any time anyone procures care in a manner not available to the uninsured, they must not ‘really need it’.) Well, as far as the big picture and valid international comparisons are concerned, emergency care only makes up a part, and a comparatively unimportant one at that, of overall health care. Genuinely effective health care requires regular checkups, a regular doctor with whom the patient is comfortable, regular screenings, regular appointments; by the time most people realize they need health care, it’s already too late in many cases. Good health care also requires that this regularity be built up into someone’s year in year out routine, which is why alternating periods of being insured and uninsured is often not much better than being uninsured all the time. The uninsured do not get this with the current American system and they’d only fare worse under a system like Goodman’s.

Second, like all libertarians, he doesn’t seem to realize that there’s such a thing in the world as an economic dependent, and that this group actually outnumbers the working population by quite a bit. It’s easy enough to say that a working age man gets a time limit to buy the private insurance that he can’t afford before BOOM! the state Initiates Force on him, levies a tax penalty (further hindering his ability to obtain private insurance), and relegates unto him a vastly inferior standard of care. What of his children, who in any world close to this one could only hope to be bundled in with whatever plan he can get? While we’re in Republican Heaven, what of his wife who doesn’t work? What of his elder relatives who’ve been newly ‘liberated’ from Medicare? Even if the guy’s inability to afford private insurance is entirely his fault, it’ll still be his children and his parents who won’t get regular appointments, treatment, checkups, and care. His children and his parents, who actually need them a lot more.

This isn’t just about health care. Any politically pleasing and nice sounding move toward ‘economic independence’ (read:lower taxes on the rich) so often has this effect on those whose only crime is being of an economically dependent demographic. Look at the poor in America, and what do you see? By far, mostly minors, elderly, single mothers, those with medically and/or mentally debilitating conditions, etc. To Right wingers, of course, the poor consist of nothing but middle aged white male vagabonds with scruffy beards and an empty bottle of hooch, or whatever group is politically most convenient to villify*.

Third, both he and Jamila nervously sidestep the obvious fact that the ’safety net’ you generously provide for will be just plain worse than anything else in a civilized country today - it will be horrendously underfunded, will fund nothing but most ‘needed’, or otherwise cheapest, procedures, and won’t even be available at all hospitals. Given that Jamila already acknowledged that there’s such a thing as victims of circumstance, I think even libertarians realize that plans like these are non-starters; they are thrown out there when it is required of them in a debate, that is all. As I’ve alluded to before, most Right wingers do not seriously, sincerely want an overhaul of the American health care system, and their interest in the topic is purely in reaction to the Left, which is the only reliable and consistent voice for true reform - in the past couple of decades before 2006 when Republicans virtually had ideological reign, their complete inaction on health care made Managed Care look downright revolutionary.

“Those who don’t buy insurance will still be using hospitals for emergency treatment and they should be charged a tax that is used to fund and pay for those public hospitals ( and reimburse private hospitals for care given to the uninsured). Even those who choose to go without insurance can still have a sudden unforseen illness and end up needing treatment somewhere–these people should be forced to fund the public hospitals and clinics that they are using as a back-up plan.”

The second statement slipped in a phrase that wasn’t supported. Can you spot it? There’s a difference between those who “don’t buy insurance” (first statement) and those who “choose to go without insurance” (second statement); the former encompasses the latter, but the latter is a subset of the former. To whom does the tax penalty apply, specifically?

“Many of the uninsured in America are only temporarily without insurance. ( I think that something like 85% of the uninsured are without insurance for a year or less, primarily due to job changes or job loss. )”

If you got that 85% from the Manhatten Institute or something, I’ll save you the trouble and just tell you it’s wrong. According to the CBO, between 50% to 75% are uninsured at least for the entire year. (Strictly speaking, the longest duration of time they measured was a year. But unless between two-thirds to four-fifths of those who remained uninsured at the end of that year magically obtained insurance within, say, a week or two after they stopped measuring, when they hadn’t been able to all year, my ‘at least’ is mathematically warranted.)

By the same token, many of the currently insured in America are not far from dropping out themselves - many live on a cycle of insured/uninsured. If you count those along with the uninsured, the number goes substantially up; recurrent periods lacking coverage present their own problems to regular, consistent care.

“What exactly to do you mean by “relief”?”

For your sake, I’ll continue to stay here in the wealthy white bubble of Right-Libertopia where it’s not a moral calamity to not provide for the care for the uinsured. By the somewhat alarmist libertarian reasoning employed earlier, there’d be an ‘avalanche’ of private hospital bankruptcies if the uninsured were provided care that wasn’t paid for. And since Goodman’s plan doesn’t do away with the law that everyone who’s hurt or sick must be cared for at a hospital - mind you, merely because it’s *politically* infeasible for some impossible, inscrutable reason - this care for the uninsured must be paid for. The only fund that’s paying for them are the tax penalties of those who choose to go without insurance, correct? These same tax penalties must also pay for the tax breaks for everyone who actually did obtain private insurance. Just how much remuneration, then, are private hospitals receiving, when we know perfectly well they need it to prevent an ‘avalanche’ of failure?

“I believe that anarchists are the only ones who oppose all taxes.”

It is not necessary to believe all taxation should be abolished for my earlier point to hold. If you believe that taxation is a necessary evil, a form of coercion, something that’s only above base robbery - whatever you consider its practical merits to be - then it follows that *selective* taxation is a form of punishment. Your tax penalty is an example of selective taxation.

Adding that to the tax *break* that the privately insured get, which would be state favouritism even if you didn’t believe the above, it’s not at all true that your system is ‘neutral’ and that the government does not care what option you pick. But hold onto this notion if you wish; by the same standard, the rich aren’t forced to pay taxes, because if they don’t all that happens is a surtax penalty – which apparently is not a mark of state disapproval.

Under my Medicare for All, by contrast, the government has no preference whether you sign up for Medicare, private insurance, or neither.

“The intent is not for the government to punish those who go without insurance but the public hospitals that the uninsured use as a form of back-up in case of catastrophic injury must be funded somehow.”

We’ve entered a very curious land if intent, not outcome, solely determines the rightness or wrongness of any action, by the state or by anyone. Didn’t we leave deontological ethics back in the 19th century?

Then again, given how so many libertarians and wingnuts want us to return to the 19th century, perhaps that’s not such a pejorative when applied to them.

“The way that I see things now there are 3 choices: 1) private insurance, either through an employer or purchased on your own; 2) public insurance, such as Medicaid or Medicare and 3) no insurance, you use public hospitals and clinics if need be but for the most part you get by however you can. The plan I am proposing gets rid of options number 2 and 3 by combining them into one option. In essence, there would be the private option and the public option with the government remaining neutral on which option you choose.”

Actually, I think all it does is take (2) off the block and subject all those who are dependent on it currently, which includes nearly the entire senior population, to the horrors of (3) as it is currently.

“If you had insurance for 9 months or more of the previous fiscal year then you don’t have to pay the penalty. I just pulled the figure of 9 months out of my head, but I think 9 or 10 months sounds like a reasonable amount of time.”

So, in other words, you get a grace period of 2-3 months to get private insurance and *keep it*, or else the state sends Men With Guns in to rob you of more of your hard-earned money that you earned all by yourself - which is all taxation amounts to, isn’t it?

“1) Most small businesses don’t offer insurance to their employees now and they wouldn’t be forced to do so under this plan.”

Small businesses are made up of small business owners and employees. If the latter suffer, the former does as well. Also, many small businesses aren’t even incorporated, so you can’t always differentiate between small businesses and their owners.

“2) Self-employed people will continue to do what they have been doing: pay for their own insurance or go without it.”

Except you’re taking away Medicaid and any other form of state health care plan from them.

“There is no extra burden on small businesses or the self-employed.”

On the contrary, they are burdened with the following:

1. The removal of Medicaid or similar government programs, with their only option being the basest of safety nets that is sure to provide insufficient care.

2. The tax penalty that’s being applied to those who ‘choose’ to go without insurance.

“The problem is this: once you start giving people something from the government, it is very hard to get people to accept that the government should stop giving it.”

Jamila, this is a problem when people get used to anything above the most basic Stone Age necessities. For instance, if you give people junk food and reality TV, it’s very hard to get people to accept that you should stop giving it. And if you give some people certain luxuries such as same day care to remove little Suzie’s tonsils (at the expense of same year care for some uninsured guy with lymphoma), it’s very hard to get them to accept them that you should stop giving it; and if you try and stop giving it, they cry foul, pay off a few political reps, and fund crackpot think tanks like CATO and Heritage Foundation to churn out whatever their rich donors want them to.

*To a more aged, conservative audience, this group in question becomes younger, female, blacker.

[Rest of post cut by Amp.

Don't post on this thread again. Period. If you have something more you must say, find an open thread or a different thread about universal health care and insurance to say it on, or say it on your own blog. If you have any actual respect for the folks here, demonstrate it by respecting our rules. --Amp]

As Jake already said, joe: wrong.

Imagine if lawyers insisted that, in any trial involving a malpractice suit or other claim for wrongdoing against a lawyer, the jury ought to be composed of lawyers and paralegals. Or if a CEO brought up on a stock scandal said that a real ‘jury of my peers’ meant everybody in the jury ought to have an MBA. You’d go apeshit, because you’d realize that the intent was not to make sure the jury got it but to try and get a biased group that would close ranks.

99% of what’s going on here is that doctors and lawyers just plain can’t stand each other. The rest of it is that doctors are clueless about the business aspects of medical practice, meaning they’re stick-and-stone stupid about how badly they’re getting screwed by their malpractice insurers. But, like a dog obediently chasing a tennis ball, they go haring off after lawyers while their insurers count their profits.

You may understand how the medical profession works, but you really have no idea how the legal profession works. Lawyers who take malpractice cases essentially do so on commission. Which means that if a frivolous malpractice case “makes it all the way to trial”, and the plaintiff loses, the lawyer eats 100% of the costs of bringing that case to trial.

You’ll be glad to know that if you or one of your colleagues hurt Uncle Marty, you probably won’t have to worry about being sued at all. Because Uncle Marty is 85 and doesn’t have an income, the economic damages are very low, and the doctors’ lawyer is going to argue that he was old and would have died soon anyway. Meaning that Aunt Martina is going to be told by a lawyer “Sorry, I can’t take your case. Even if we win, you won’t make enough money to pay for the costs, and I won’t make any money either.”

You may also be gratified to learn that both sides get to pick a jury. So if your lawyer would like to pack a jury with doctors and nurses who think patients are all greedy, lying sacks of shit squeezing money out of those poor dedicated medical professionals, that’s something your lawyer has some ability to do.

If you really care about malpractice reform, I suggest you take a hard look at your insurers. You might notice that your premiums don’t actually drop when lawsuits or legal awards do. They are, however, a convenient excuse for insurers to cover up the fact that they took a hit in bad investments–not on jackpot lawsuits.

I’m leaving this comment up because it seems to reflect a lot of labor. However, you’re not welcome to post more here. If you’ll look above, this thread has been closed to people who [don't] accept universal health care as a good.

First, what I believe to be wrong with the system. In a nutshell: insurance companies, including government programs. Actually, the medicare/medicaid system is probably the biggest offender here. Every hospital I’ve ever worked at has had to have a number of people on staff whose full-time job it was to “deal with” insurance issues. I am not referring to the accounting and billing people, these are clinical people (nurses, social workers, etc), who spend their entire day talking to insurance companies about why a patient is still in the hospital, why they’re still in ICU, etc. We have insurance adjusters picking apart the patients medical condition and attempting to micro-manage their medical care. On a daily basis, the nurses and physicians involved in the patients care are asked to explain and justify why we’re doing what we’re doing. I understand the need for accountability, however, when physicians are spending a couple of hours everyday justifying their actions to an insurance adjuster, how are they compensated for this time? Further, how can a nurse provide appropriate care when they know that every action is going to be torn apart for billing purposes? People often wonder why a visit to the doctor costs hundreds of dollars yet they only see the doctor for 5-10 minutes. Because that 5-10 minute visit results in 1-2 hours of additional work for the doctor, the nurses and the office staff. Some of this time is due to legal paperwork having to do with licensing requirements in the sense of “we may need to defend a complaint over this visit to keep my license”. Even greater is making sure paperwork is in order enough to withstand being torn apart by an attorney in a malpractice suit, justified or not. I have experienced this same problem in my own family. When I made the decision to step down from a staff position as a nurse and begin to travel, it resulted in a change in employer, hence a change in insurance. My 3 year old son is on a couple of different medications for severe allergies. We were unable to keep him on his established medicines because the insurance would not pay for one until another, cheaper, alternative had been tried. Of course, we had already done this previously, but this documentation wasn’t good enough. He had to spend 3 months in agony ‘trying’ this other medication because the insurance would not pay for the one that we had already established worked for him. In speaking with the insurance company myself, I asked the adjuster I was speaking to (who had the power to approve the correct medication) what type of college degree she held. I was shocked to learn that she had no degree at all. I have since asked this question anytime I have had to deal with an insurance company professionally and found that commonly, the people at insurance companies deciding whether to approve or deny coverage either have no degree at all or have a degree in business or accounting. In my opinion, these people are making medical decisions with no medical training whatsoever. My question regarding insurance companies is this: Why should someone with no medical training or background at all decide what medical care someone should receive? We have people with no more than a high school education second guessing medical specialists in their care of their patients. Does this make any sense at all? I have witnessed this and can tell many more stories in great detail if you would be interested in listening.

I work in an ICU where split-second life or death decisions are made. i.e. the patient is dying and we must save them…do something in the next 15 seconds or they are dead. If you have ever watched an episode of ER when they are scrambling to save someone and doing many things very quickly, remember that all those actions must be documented to defend against an insurance company’s examination days later, calmly sitting at a desk somewhere with all the time in the world to sit and think. Worse yet, to defend against a lawsuit up to 10 years later being microscopically examined by attorneys with all the time in the world. I am sure you have seen episodes of different attorney shows where the attorneys are dissecting a physician’s action on the witness stand. Keep in mind the statute of limitations for malpractice suits is 10 years, longer if the patient is a child. They have until they turn 28 to file a suit. We as healthcare professionals always must keep in mind as we do our “charting” that we must write enough information so we can confidently defend our actions 10 or 20 years and hundreds to thousands of patients later. I make a point of remembering my patient’s names while I am caring for them, but I am just not good enough to remember them all by name forever. Even a few months later, I am sorry to say I remember them better by their medical course than by name. Therefore, in addition to changes in how insurance operates, the court system as relates to malpractice must be changed. You do realize that malpractice insurance costs more for physicians than a lot of people make in a year? For physicians that I work with, their malpractice insurance costs up to $100,000/year. This money must come out of their billing rates. Hence another reason why your 5-10 minute visit costs hundreds of dollars. People tend to think of doctors as rich. Nothing could be further from the truth. Yes, they make a good living, but they literally make life and death decisions on a daily basis. Remember, I work in a Pediatric ICU, so if your child were critically ill or injured, how much is it worth to you for the doctors and nurses who save your child’s life? Thinking about it from that perspective, how much should they make? And keep in mind, the doctors to make quite a bit more than us nurses. Add to this equation that most of the doctor’s decisions are made based upon information they receive from the nurses and we get into a whole other argument regarding nursing salaries.

I could ramble on more and more about the problems, but it does not fix anything. Solutions are needed and I have a few thoughts in that area as well. You may think I would be in favor of nationalized healthcare. Actually, I think nationalized healthcare would be even worse than what we already have. As I stated earlier, the government programs are the worst offenders when it comes to what I call insurance meddling in medical care. They say no the most often and have no avenue to make a more detailed argument to attempt to prove the necessity of a needed treatment. Talk to anyone, especially someone in the medical field, who has emigrated from Canada and they will tell you how poor the healthcare is in Canada. Sure, everyone is covered and all healthcare is essentially free, but what level of healthcare do they have. I have worked with many nurses from Canada who have stated without reservation that the medical care provided in Canada is vastly inferior to that of the care here. The principle of free enterprise and competition improving the quality of a product applies in healthcare as much as it does anywhere else.

I sincerely feel and believe with all my being that the insurance industry as it exists is the very foundation of the problems in the healthcare system. How to fix that? Somehow create a system whereby decisions on coverage are made based on sound medical grounds, not financial considerations. Perhaps a law requiring physicians in the appropriate specialty making decisions regarding coverage and authorizations without regard to costs. Insurance companies always complain about the high cost of healthcare, yet they are the primary reason for it. Perhaps a standard form whereby the physician can state “this is the patients condition, this is what we need to do”, and then get a yes or no without multiple requests for more information. This would result in the physician performing much more efficiently, thus enabling the billing rate to be more reasonable. There are other ways to address this as well.

In combination with this must be some kind of reform of the malpractice laws. There are much too many frivolous lawsuits being filed and making it all the way to trial. There has to be a way to hold attorneys accountable for clogging the system with cases that should not even see the light of day. I have encountered respected attorneys who have medical personnel on their staff who research cases for merit before deciding to even take a case. The burden in medical malpractice is “acceptable medical practice”. This perhaps needs a more specific definition. Also, not to put a value on a life, but is “uncle john”, who dies at 85 due to complications after surgery really worth $100 million? This seems outrageous to me. The constitution states “a jury of peers” in criminal cases. Should a doctor or nurse in a malpractice case not be afforded the same protection? Perhaps a jury composed of doctors or nurses who actually have the training and experience to judge the actions taken in the case?

I do not claim to have all the answers to this problem, but I do feel I am extremely qualified to pinpoint the causes of the problem. I would be happy to answer any questions and/or discuss further with anyone who is interested in discussing this issue with an open mind. Bottom line is this: show me a government run program in ANY AREA that works, and I may rethink my position somewhat.

Marty G., RN

You’ve had enough time on this thread. I appreciate your willingness to express and argue for your opinions — and I hope you’ll be willing to write on other threads of mine — but I think these particular lines of debate have now been about played out.

I’m leaving the thread open for people to discuss differences of philosophy within an acceptance of universal health care as a good. Anyone interested in arguing within those terms is welcome.

Even if I were to accept the premise that government intervention in health care is bad, it is not true that Goodman’s plan, as you describe it, would decrease government involvement, for the simple reason that taxation is a form of government involvement.

Government involvement necessitates more and more government involvement to correct for the problems created by the initial government involvement. What I mean by that is this: In America, hospitals are legally forced to treat patients needing emergency care regardless of ability to pay–the law forcing hospitals to treat all comers is the initial government involvement; because people know that they can get treatment at the hospital if something tragic and unforeseeen happens to them, even if they don’t have insurance, this provides an incentive for them to save their money and not pay for insurance. Voila! You now have a free-rider problem because there will people who won’t pay for insurance, yet they will still get treatment, and the hospital is left to foot the bills. The only way to remedy this problem is to revoke the law requiring private hospitals to treat all patients. But, because it is not palatable to most people to allow a hospital to refuse to treat a patient who can’t pay ( thereby forcing the person to go without treatment or go to a public hospital) the only way to remedy the problem of private hospitals being burdened with unpaid medical bills–bills that will eventually get passed onto paying customers in the form in increased prices for treatment–you now have to have more government involvement to remedy the situation so that there won’t be an avalanche of hospitals going out of business due to unpaid bills.
You can remedy this situation by revoking the initial law that intruded on how private hospitals operate or you can attempt to solve it by some form of taxation. Goodman knows that trying to get rid of that law requiring treatment is probably futile so he–and I–advocate minimizing the damage while still keeping the government away from attempting to institute a UHC scheme. The plan would also eventually get rid of Medicare and Medicaid.

You say that those who choose not to buy private insurance will be taxed extra to pay for care for the uninsured, while those who do buy it will be given tax breaks

Those who don’t buy insurance will still be using hospitals for emergency treatment and they should be charged a tax that is used to fund and pay for those public hospitals ( and reimburse private hospitals for care given to the uninsured). Even those who choose to go without insurance can still have a sudden unforseen illness and end up needing treatment somewhere–these people should be forced to fund the public hospitals and clinics that they are using as a back-up plan.

If Medicare and Medicaid were to be done away with, many, many more Americans will be left uninsured. This greatly increases the tax strain that will have to be put on those who opt to go without insurance - and without slogging a debate on just how many otherwise able Americans regularly choose to go without insurance, wouldn’t be safe to say that those who WOULD choose insurance would greatly outnumber the former?

Yes.

Taking into account the tax break that’s assigned to each and every individual or family who buys insurance (which by itself would probably override the extra funding obtained by tax penalties), I don’t see much relief being given to the uninsured.

Many of the uninsured in America are only temporarily without insurance. ( I think that something like 85% of the uninsured are without insurance for a year or less, primarily due to job changes or job loss. )
And there are many people who really do perform a cost-benefit analysis and opt to go without health insurance.
What exactly to do you mean by “relief”?

At best, all I see is a means for the government to substantially punish those who choose to go without insurance when they otherwise could - perhaps justifiably, but aren’t taxes, according to libertarians, a form of coercion?

I believe that anarchists are the only ones who oppose all taxes. For instance, the military and a small federal government must be funded and those funds would have to come from some form of taxation. Of course, I believe that most libertarians would get rid of the vast majority of government programs and departments that currently exist so the tax burden would be substantially lower than it is now.
The intent is not for the government to punish those who go without insurance but the public hospitals that the uninsured use as a form of back-up in case of catastrophic injury must be funded somehow.

If so, how is this any different from those systems you mention where people are ‘forced to get insurance’? No similar mechanism exists in my Medicare for All* proposal; your primary complaint about it was actually groundless.

Because under this system no one is forced to get insurance. If you want private insurance than you get your own private insurance. If you choose to go without insurance, no problem, but there is still the possibility that you might get sick and since the hospitals won’t throw you out on the streets for not paying someone has to fund your care.
The plan is designed so that the government will be neutral on the choice of citizens to get insurance or not; the government won’t be trying to take in more taxes than necessary to fund the public safety net.

But that’s not the biggest conceptual problem with the plan. The weak point, as I see it, hinges on the word ‘choose’. Who decides who has ‘chosen’ to go without health insurance, and who has been merely hit hard by circumstance?The government, obviously; and THIS is what I consider to be unacceptable government instrusion into people’s private health.

Those who don’t “choose,” in the usual sense of the word, to go without insurance, but instead end up the victim of circumstance, will be using the public hospitals and clinics.
Government will not be choosing anything for you or making decisions about who can or can’t afford health care. The public safety net will still be there, funded by the people who are using it.

An income or wealth cutoff would be the simplest, most humane method; above a certain income floor, being without insurance, regardless of cause, means that the tax penalty applies. This would largely recreate Medicaid, in which case I don’t see the point in axeing the former in the first place, but at least the plan is still somewhat sensible.

The way that I see things now there are 3 choices: 1) private insurance, either through an employer or purchased on your own; 2) public insurance, such as Medicaid or Medicare and 3) no insurance, you use public hospitals and clinics if need be but for the most part you get by however you can. The plan I am proposing gets rid of options number 2 and 3 by combining them into one option. In essence, there would be the private option and the public option with the government remaining neutral on which option you choose.

If we choose to go beyond a crude income cutoff and start parsing which middle-class families ‘chose’ uninsurance and which had it thrust upon them, we run into more problems.

The system I’m proposing won’t be concerned with whether people chose to go without insurance or had it thrust upon them; their only option would be to use the public system if they can’t afford the private one.

For most Americans with private coverage, it is their employers who have direct control over their insurance plan; if their employer decides to drop it, what recourse do they have?

They can purchase private insurance or use the public system.

Or say, they recently switched jobs, which is another major cause. At this point, they’d have to purchase private insurance for themselves to avoid the tax penalty, but how will this be enforced?

If you had insurance for 9 months or more of the previous fiscal year then you don’t have to pay the penalty. I just pulled the figure of 9 months out of my head, but I think 9 or 10 months sounds like a reasonable amount of time.
It would be enforced the same way taxes are currently enforced: people figure their own taxes and pay accordingly. Just like the government currently goes after people for tax evasion, it can go after people for avoiding this tax too.

Not to mention the added strain this will give to the self-employed and to small businesses. Are we to count everyone who works for a small business as having ‘chosen’ to go without health insurance**? Is that the new right libertarian credo? Tax small businesses to pay for care for the uninsured?

1) Most small businesses don’t offer insurance to their employees now and they wouldn’t be forced to do so under this plan.
2) Self-employed people will continue to do what they have been doing: pay for their own insurance or go without it.
There is no extra burden on small businesses or the self-employed.

Essentially, then, the uninsured are on their own as a group - but since they’re all paying for each other’s health care by state fiat (taxes), isn’t this now basically a mandatory insurance plan of sorts? A very limited, and honestly quite crappy one, but some of the same principles apply.

In a way, yes. However I prefer the term “safety net” to “mandatory insurance plan”. The other alternative is to completely eliminate government involvement in health care–no clinics or hospitals funded by the federal government–and make the entire system private. There would still be public hospitals funded by schools to teach health care professionals and public facilities funded by philanthropists and public facilities that are paid for at the state level.

It seems to me that the end result of this is that the poor do get some sort of ‘insurance’, but by state command it is of the flimsiest, most worthless variety. There’s no upside to this, from any ideological angle.

You get what you pay for. The public system is meant to be a safety net in case of a severe sudden illnesss or, in the case of clinics, to take care of cheap routine needs like a yearly pap smear or flu shots.

This plan seems thoroughly flawed from every angle, but if in some inconceivable way all these problems could be rectified, I wouldn’t be averse to an entirely private, non-state solution to health care, provided it solve the problems of equity and access in the current system. But do libertarians themselves sincerely believe this can be done?

I don’t believe that a non-state solution could completely solve the problem of equity or ensure that everyone received care. I think it could come close but I’m not enough of an expert on health care to tell you exactly what that system would look like or how it would work.
I think many libertarians believe that an excellent private health care system could be accomplished in this country, but I am not the best person to explain such as system in detail.

So are health care libertarians up front about plans like these, laying them down on the table at the start of a debate?

I don’t know if they do so at the beginning of a debate but I know that whenever I’ve asked one what his/her plan was they were able to lay it out for me.

Do they contact their representatives, the RNC, and the Wall Street Journal, with point-by-point abstracts of plans such as the one above?

I think they do. Goodman has been publishing books about health care since the 80’s and he has a blog. Goodman lays out is plan pretty well in his book. There are plenty of libertarian and classical liberals with websites who have been writing books and talking about their health care ideas but since they are in the minority few are listening.

In my experience, they do not; they first and foremost support the current American system, which is by no stretch of the imagination a stateless system.*** If prodded for consistency, they conjure up some anarcho-capitalist plan, but they never bother with the details and for the most part don’t seem particularly attached to them.

I’ve read papers and books explaining how health care would operate in the absence of government interverntion so I know that such plans do exist for those that want to read them.

The problem is this: once you start giving people something from the government, it is very hard to get people to accept that the government should stop giving it. It’s much easier to modify the currenty system than to throw it out and start a new one. Which is partly why once countries start moving toward a UHC they don’t turn back; people get accustomed to government ensuring care, then they expect the government to ensure care and any suggestion that the government should stop ensuring care is going to be automatically met with intense hostility. (See the comment by Mandolin about how I’m “on the side of suffering” and I supposedly want people in the streets dying.)

Most people also know very little about the various UHC systems around the world (I read tons of books and I still feel like it’s a drop in the bucket) and how those systems work compared to our own system. It is much easier to get people to understand that the government will provide everyone with health care than to explain in detail the intricacy of a complete free-market health care system. I think free market ideas stir up far more skepticism from the starting gate than does the simple explanation of ” government will take care it.”

And back we are again to health care as a cookie for Right Livelihood.

Even if I were to accept the premise that government intervention in health care is bad, it is not true that Goodman’s plan, as you describe it, would decrease government involvement, for the simple reason that taxation is a form of government involvement. You say that those who choose not to buy private insurance will be taxed extra to pay for care for the uninsured, while those who do buy it will be given tax breaks.

If Medicare and Medicaid were to be done away with, many, many more Americans will be left uninsured. This greatly increases the tax strain that will have to be put on those who opt to go without insurance - and without slogging a debate on just how many otherwise able Americans regularly choose to go without insurance, wouldn’t be safe to say that those who WOULD choose insurance would greatly outnumber the former? Taking into account the tax break that’s assigned to each and every individual or family who buys insurance (which by itself would probably override the extra funding obtained by tax penalties), I don’t see much relief being given to the uninsured. At best, all I see is a means for the government to substantially punish those who choose to go without insurance when they otherwise could - perhaps justifiably, but aren’t taxes, according to libertarians, a form of coercion? If so, how is this any different from those systems you mention where people are ‘forced to get insurance’? No similar mechanism exists in my Medicare for All* proposal; your primary complaint about it was actually groundless.

But that’s not the biggest conceptual problem with the plan. The weak point, as I see it, hinges on the word ‘choose’. Who decides who has ‘chosen’ to go without health insurance, and who has been merely hit hard by circumstance? The government, obviously; and THIS is what I consider to be unacceptable government instrusion into people’s private health. An income or wealth cutoff would be the simplest, most humane method; above a certain income floor, being without insurance, regardless of cause, means that the tax penalty applies. This would largely recreate Medicaid, in which case I don’t see the point in axeing the former in the first place, but at least the plan is still somewhat sensible.

If we choose to go beyond a crude income cutoff and start parsing which middle-class families ‘chose’ uninsurance and which had it thrust upon them, we run into more problems. We have to remember that many who are otherwise reasonably well off have perfectly valid reasons for not having health insurance. For most Americans with private coverage, it is their employers who have direct control over their insurance plan; if their employer decides to drop it, what recourse do they have? Or say, they recently switched jobs, which is another major cause. At this point, they’d have to purchase private insurance for themselves to avoid the tax penalty, but how will this be enforced? Who decides the point at which they are uninsured no longer out of circumstances beyond their control, but from their ‘choice’? They could conceivably be given a grace period, but that would make this identical to the Swiss method that you denounced earlier.

Not to mention the added strain this will give to the self-employed and to small businesses. Are we to count everyone who works for a small business as having ‘chosen’ to go without health insurance**? Is that the new right libertarian credo? Tax small businesses to pay for care for the uninsured?

The government could decide who has ‘chosen’ to go without health insurance and who has not by other means, of course. It could be entirely arbitrary, but I doubt that would be an arrangement that would have anyone’s support. It could tautologically define anyone who’s uninsured, at any level, to have ‘chosen’ their predicament. Given that most of the presently uninsured are too poor to be taxed, this would not be much different from the income cutoff method. Essentially, then, the uninsured are on their own as a group - but since they’re all paying for each other’s health care by state fiat (taxes), isn’t this now basically a mandatory insurance plan of sorts? A very limited, and honestly quite crappy one, but some of the same principles apply. It seems to me that the end result of this is that the poor do get some sort of ‘insurance’, but by state command it is of the flimsiest, most worthless variety. There’s no upside to this, from any ideological angle.

This plan seems thoroughly flawed from every angle, but if in some inconceivable way all these problems could be rectified, I wouldn’t be averse to an entirely private, non-state solution to health care, provided it solve the problems of equity and access in the current system. But do libertarians themselves sincerely believe this can be done? There is inhumanity in Goodman’s plan, to be sure, but for the most part I’d say that is unintentional (though by no means unsubstantial). So are health care libertarians up front about plans like these, laying them down on the table at the start of a debate? Do they contact their representatives, the RNC, and the Wall Street Journal, with point-by-point abstracts of plans such as the one above? In my experience, they do not; they first and foremost support the current American system, which is by no stretch of the imagination a stateless system.*** If prodded for consistency, they conjure up some anarcho-capitalist plan, but they never bother with the details and for the most part don’t seem particularly attached to them.

* Medicare for All isn’t *my* idea, but I specifically use the first person possessive to distinguish the one describe in this thread between the many other proposals called Medicare for All put forth by many other advocates, politicians, and interest groups. Some of them may contain provisos that I don’t agree with, such as mandatory enrollment or prohibition of private care.

** I realize that small businesses aren’t literally being taxed for the sake of the uninsured, and if the small business is incorporated, there’d be no corresponding corporate tax penalty necessary to say that the business *itself* is being taxed. But small business owners and employees disproportionately fill the ranks of the middle class uninsured, and any attempt to tax the latter group necessarily taxes the former. For all intents and purposes, small businesses are being taxed for the sake of the uninsured, and I’m sure many conservatives sincere in their concern for small businesses would agree with me.

*** In fact by the most important measure, government involvement in American health care is ‘worse’, if we are to accept that taxation is theft. Non-universal does not mean the same thing as less government involvement, and in fact the simplicity of removing age restrictions to Medicare could decrease government involvement elsewhere.

(BTW the infant mortality link w/r/t Canada adopting UHC was mentioned in an article I linked to on post 209.)

America already pays more taxes than any other industrialized nation, and this isn’t an arrangement most of them explicitly object to - most, like Jamila, accept Medicare and Medicaid and use them to defend the American system, since understandably they don’t pine for having to defend an American system where the number of uninsured may possibly be tripled the number it is now.

Ideally I would like for America to get rid of Medicaid and Medicare by adopting the plan I spoke of in #308 or some similar plan.

Are these bureaus depriving people of government-offered services without cause? Why is the BC government so ineffectual at clamping down on these bureaus? What does this tell us about national health care systems?”

You’re reading more into this than there is. As a general rule, people don’t like faceless bureaucracies, and they don’t like being turned down for anything, for whatever reason. They especially don’t like being turned down for anything BY a faceless bureaucracy. Perhaps some of it is due to the BC system facing some massive spending cuts almost a decade ago, owing to the election of the Liberal party (an idiosyncracy of BC politics is while the federal Liberal party is a left-ish centrist caucus slightly left of the Dems in the US, the provincial Liberals are hard right wing and can be best described as “Liberals” in the European sense of the word) that wanted to create, for political reasons, an artificial spending crisis a la Bush with Social Security. Yes, Virginia, that kind of thing happens all the time in Canada too, it’s not an unshifting lefttopia. But I’d expect most of it comes from people being people.

There’s a similar situation occurring right now with higher education, which in Canada is almost always public. (The best Canadian schools, such as McGill’s and Queen’s, are all public.) UBC still accepts as many students as it can, but now it’s finding perfunctory reasons to drop students and decrease its enrollment, simply because there’s a set limit on how many students it can take without decreasing quality significantly for all. Thanks to immigration and more competitive students from all across Canada, more and more qualified students are applying there at a rate much faster than it can possibly hope to expand. The BC government responded by creating two more universities (one of the few things the Liberals did right): Thompson Rivers University and UBC Okanagan - but people have been slow to embrace these new schools because of the intractable issue of prestige, instead continuing to complain about the unfairness and tyranny of UBC. As I myself chose to go to a school with considerable prestige, I don’t mean to fault the parents who think this way; I’m just pointing out that sometimes, even if a bureaucracy is partly at fault, human nature just guarantees that there’s going to be problems. No manmade system gleams with a spitless shine.

“… citizens of BC are blaming bureaucrats for a dynamic that arises in any health insurance system?”

Perhaps. But citizens of America - and to a lesser extent Canada - blame bureaucrats for a dynamic that arises in basic large scale organization. That’s why commensensical measures of fairness and decency can be scarequoted as the work of “bureacrats” and “politicians” and so many are baited, at least for a while.

“Again, the purpose of the system is to reduce the extent to which government makes decisions for you – specifically, the extent to which government decides how much you will subsidize my lifestyle decisions.”

With the method you propose, someone else is making my decisions for me. By making me pay more to live a certain way, what they are doing is no different than saying, “you like to close your eyes in the bathtub - that’s a tax”, “your hair’s long, it occasionally obstructs your vision - that’s a tax”. If a random policeman on the street started barking out fines for things such as this, we’d rightly consider it tyrannical. What makes it okay if it’s done with a stamped signature on a monthly bill?* I don’t give a tosh if my life is being directed and controlled by a government health bureau, a government accounting office, or a private corporation. It demeans the very idea of freedom if the immorality of its curtailment is contingent on who is doing the curtailing, and those who believe so must truly not value freedom.

It’s interesting, because so much of anti-government sentiment rests on not what power is intended for, but it could potentially be used for. What’s next - the company starts streamlining their processes by designating a ‘most watched’ list for those who take out too many books about skydiving at a library? Watch too many movies starring extreme sports stars? Wow. I cannot in good conscience support anything of the sort.

I do agree with your circumcision example - that is already policy in many UHC systems. Elective procedures are often not covered under government plans, and are considered extremely low priority (hence the waiting lists associated with them).

“Conceptually, I like school vouchers – a “single payer system” for primary education.”

I am open to the idea of introducing competition to our schools. I’d want significant government regulation, however, to prevent segregation from occurring by class, race, or gender. School isn’t just where we learn our ABC’s, it’s also where kids first learn to relate socially to the outside world. Also, I’d still insist on a standard curriculum - the freedom for cultist parents to send their children to the L. Ron Hubbard Academy is one, being the freedom-hating commie that I am, that I can do without.

That being said…

I’d like to highlight a problem common in straight “anti-government” bombast. A single payer education system ensures choice, whereas single payer health care is One Size Fits All? Essential control of the food industry by large, private companies, but with myriad government safeguards for quality, is unspeakable big government intrusion? The same situation for utility companies is Liberty with a capital ‘l’ (given that the alternative in many other countries is state owned enterprise). And so forth.

Now, I understand the “One Size Fits All” claims for health care, for instance, are meant in a directional sense, but still, the difference between single payer health care and ’socialized medicine’ is identical to the difference between school vouchers and current public education. And I’m not saying the level of regulation should be identical for each and every industry - that’s as laughably simplistic as saying there should no regulation for each and every industry. So many are just unwilling to admit out loud that natural monopolies exist, though, as if admitting so presents drastic complications for the rest of their ideology.

It’s the same with my Medicare-for-all proposal. Jamila’s response to this was unexpected, because as I made clear, NO ONE is forced to sign on to this program, anymore so than they for existing government health plans in America such as Medicaid (and, reading through the thread, she has no problems with existing programs such as these, insofar as she incorporates them in a defense of the American system). If someone, god forbid, wants to go without either public or private insurance, let’s just let them - I think it’s fair to say, though, that the vast majority of the currently uninsured would prefer to be insured, and for them an expanded Medicare option should exist, without limitations on age or disability. Perhaps she was talking about my caveat with children, but I really don’t get this - do libertarian parents let their children drive motorcycles when they say they want to?

The response I was actually expecting, and the one I’ve gotten before, amidst much sidestepping and nervous evasion, was that I was being too optimistic on how it will impact tax rates - expanded Medicare would actually increase taxes by quite a bit. Let’s just suppose for the sake of argument that this is true, though I vehemently protest. America already pays more taxes than any other industrialized nation, and this isn’t an arrangement most of them explicitly object to - most, like Jamila, accept Medicare and Medicaid and use them to defend the American system, since understandably they don’t pine for having to defend an American system where the number of uninsured may possibly be tripled the number it is now. Can you imagine if America paid more taxes for *unemployment insurance* than any other industrialized nation? Or *public transportation*? Look, either taxes are theft, carried out by Men With Guns wielding a Monopoly On Force, or they aren’t. A position along the lines of “being ROBBED by state coercion to pay for health care more than any other industrialized nation is acceptable, but paying just a little more ISN’T” to oppose Medicare for All, isn’t strictly disprovable in the standard sense, but it does strike as remarkably inconsistent, shallow, opportunistic, and dishonest. I think you’d agree.

Yes, this was the answer I was expecting Jamila to give, and yes, the latter was a prepared, if disjointed, response.

* Don’t bother pointing out that this mirrors standard anti-tax arguments. It’s meant to, it’s tongue-in-cheek, and not 110% serious.

The reduction in heart disease seems to be due to both decreasing risk factors and better treatment. This is true in both the US and other countries studied, including Holland, New Zealand, and Finland. If that helps.

Some of you here say that you don’t want something like government intruding into our personal lives through health care, and I want to believe you, but really, I can’t imagine a more pervasive way than this convoluted sin tax method for allowing higher institutions to make personal decisions for us….

Again, the purpose of the system is to reduce the extent to which government makes decisions for you – specifically, the extent to which government decides how much you will subsidize my lifestyle decisions. And my neighbor’s. And her neighbor’s. And roughly 300 million other people’s. I have yet to hear of any other UHC system that accomplishes this.

If at all possible, put aside the whole “sin” aspect and simply look at the issue of choice: Right now, if I am willing to accept a generic drug to fill my prescription, my insurer will cover it (ok, with a co-payment). If I choose the name-brand equivalent instead, that’s ok too, but I have to pay the difference between the cost of the name brand and the generic equivalent. The same policy applies to everyone else in my health plan. So my insurance premiums don’t subsidize anyone else’s choice to buy a name-brand drug, and their premiums don’t subsidize mine. Does this policy intrude upon my autonomy or vindicate it?

Similarly, imagine that there are insufficient medical merits to conducting routine circumcisions, tonsillectomies or chin-lifts. I wouldn’t expect a UHC system to prohibit me from having these discretionary procedures done; I just wouldn’t expect a UHC system to compel you to pay for them. If I choose them, then I should pay for them. Again, would such a policy intrude upon my autonomy or vindicate it?

So how different are these choices and the choice to smoke? To me, “sin” is not the relevant feature. It is only people who choose to burden their neighbor that are acting sinfully. By providing a means for people to pay for their own choices, on the other hand, I offer forgiveness, absolution and fullness of grace!

That said, the devil’s in the details. Yes, such a system could get complex.

In industrial organization law, we have the Essential Facilities doctrine. Your railroad company cannot refuse to let a competing rail road use your tracks, but you may charge the competitor for the cost the competitor imposes on your system. It’s a good doctrine, although calculating those costs can get extremely involved.

Telephone Company A cannot refuse to let Telephone Company B complete a call on A’s lines, or otherwise use A’s “network elements,” but A may charge B for its costs. Again, fights about costs can get quite detailed.

Electric Utility A cannot refuse to let Electric Utility B transmit electricity across A’s lines, although A may charge for its costs. Today regional transmission organizations calculate these costs; the calculations are mind-numbing.

Similarly, Electric Utility A cannot refuse to permit people in its service area to generate their own electricity, and even to sell this electricity back to the utility at the utility’s avoided costs. Calculating those costs, as well establishing the interconnection requirements, is not simple.

Conceptually, I like school vouchers – a “single payer system” for primary education. But before government should implement such a system, government would need to identify with particularity what it was buying, and how to measure that it was getting it. Again, a lot of complexity, both in establishing the standards and in verifying the performance.

I should probably include examples involving the tax code or Net Neutrality, but they provoke more controversy.

Clearly, indisputably, undeniably, the simplest system is one-size-fits-all. One railway. One phone company. One electric utility. One school. One level of web access. One level of taxation. Whatever. We’ve been moving away from these one-size-fits-all systems for a while now. The extent to which we can achieve the same thing with a national health care system remains to be seen.