[Cross-posted to In Medias Res]

Wichita, KS

Over the past couple of weeks, I’ve written a few things on the current debate over health care reform. A couple of smart commenters on those posts got me thinking–or rather, forced to the front of my mind a question I was already thinking about: if, when it comes to public policy, I’m continually balancing between my socialist/egalitarian/establish-a-just-and-equal-context and my localist/populist/empower-communities-in-their-differences sides, on which side do I think that efforts to reform health care should come down on? National coverage, or local control? Baseline justice, or state-level variety? And might there be some ideal way for it to straddle both?

I have, for a long time, basically been of the mind that populism–which I take to mean politically and economically empowering people in the places they live–and egalitarianism–which I take to mean arranging politics and economics so that all people enjoy basically equal recognition and opportunities–while clearly different ideological projects, overlap more than they diverge. What they have been common, as a starting point if not as an ultimate goal, is solidarity and a grounding in “affectivity.” As I put it in the above-linked post, nearly five years ago:

It is affection, specifically that which arises from and depends upon a shared life, a defined (and therefore somewhat limited) life, that makes possible real social concern, a concern which is not restricted to a needs-tested distribution of a few select goods (which at best can only result in the just treatment of those who accept the terms of choice which the market–and those who are lucky/hard-working/well-connected enough to dominate it!–imposes), but which actually seeks make the distribution of and decisions about goods a component of one’s participation in the community. Not for nothing did late 19th-century populism often merge with socialism, and not for nothing are social democrats today often the most responsive to the diverse demands of distinct communities, whether in neighborhood design, public schooling, welfare provision, or a dozen other areas. To talk about populist justice means to talk about “the people” not in the abstract, whether behind a veil of ignorance (John Rawls) or as individual choosers confident in their holdings (Robert Nozick), but to begin where they live, in their various (culturally or historically or religiously defined) communities. The goal is not some rigorously Marxist collectivizing of the material and economic and social life of all communities in the name of uniting everyone’s species-being….[but rather to] limit and constrain the meritocracy in the name of civic equality….by granting recognition and opportunity to communities and people’s identities as they are.

I don’t want to pretend that I had figured out answers to all the questions I’m taking on today a half-decade ago: I hadn’t (and no doubt I will continue to work on these same and new questions far into the future, whatever I might happen to conclude today). But I do feel some confidence in saying that the “conservative” (or maybe better, the “communitarian“) essentials of any populist or localist or socialist alternative to modern liberal capitalist/consumerist/individualist lifestyles and destinies can be, by and large, much benefited by certain broad egalitarian actions–by certain progressive compromises, you might say.

What sort of compromises? Some are so obvious to the majority of Americans that their careful balancing act goes unnoticed. The guarantee of universal and basically equal public education, for example, often results in massive bureaucracies and headaches, it’s true, but it also serves as a vital way-station between the principled goal of providing all children with an education and a taste of civic life, on the one hand, and the necessity of keeping those children grounded in the communities and families that shape the lives they actually live, on the other. Other compromises, though, for a variety of reasons, have never struck the majority of the American people as particularly crucial: despite all the obvious ways in which an up-front investment in public transportation and bike paths would help local communities to thrive by building pedestrian and rider friendly (read: not overly automobile-dependent) residential and commercial zones, thus avoiding as much as possible the isolating and environmentally unhealthy costs of suburbia, Americans by and large instead seem to figure that only poor people ride the bus, and the rest of us just want to pour on the gas.

That brings us to the current, huge question over another potential compromise–health care. While the majority of Americans (including me) have health insurance and are, despite our regular complaints, generally satisfied with the coverage they receive, almost everyone is aware of the injustices and inefficiencies of our current patchwork of hospitals, emergency rooms, government programs and private insurers. If the moment for reform has truly come–as even many anti-government conservative thinkers have come to acknowledge–how should we understand our options? Is the proposal to create an ostensibly more equitable and coherent system of providing and paying for medical care going to result in an oppressive bureaucratic monstrosity? Or can we see broad, egalitarian reforms as part of an effort to put people on a similar level, discouraging dependence and injustice and enabling more people to feel security and affection for their local places? And would variations in delivery make all the difference?

It’s not hard to come up examples of variations that hardly anyone, no matter how convinced a localist they may be, would be willing to endorse: the just look at the many poverty-stricken societies around the world, where basic nutrition, immunizations, and simple emergency medical care are nearly absent, and where as a result infant mortality is high, pregnancies with complications are often a death sentence, diseases like measles or bronchitis routinely kill, and a compound fracture or head trauma will often mean a life of disability or death from resulting infections. I’m not setting up some puerile claim about the “march of progress” here: this was simply the way of the world for nearly everybody, even in some of the wealthiest and most scientifically advanced parts of the globe, as recently as the end of the 19th century, and people accepted and flourished in the midst of and built their lives around such expectations. However, given a chance to escape all that, through the various blessings of specialized and concentrated technological advances (think of penicillin, sterilization, or artificial limbs), only the most determined of Luddites decline the opportunity, and not even all of them. (For what it’s worth, there is nothing in the Amish Ordnung that speaks out against modern medicine, and the Amish will patronize neighborhood doctors and hospitals just as anyone else might.) That such resources ought to be reasonably available, without the interference of bankrupting paperwork and arbitrary exclusions, seems to be something that practically anyone who desires that the inhabitants of local communities be able to maintain themselves should hope for.

What about variations on the other end of the scale? A friend of mine, who works at and has health insurance through one of America’s top universities, recently shared this story with me:

[W]e had to rush our 3-1/2-year-old daughter to the emergency room last Friday night. She was admitted and spent the next four days being run through a torturous string of tests….The hospital we brought our daughter to was…[one of the] best children’s hospitals in the world….It’s an extraordinary place….Once admitted, you’re assigned to a “team,” like on the “House” TV show, led by one star doctor and about a dozen “fellows” i.e., med “students” about 10 years out of school. They hover around the lead doc as they do rounds on the floor, having little ten-minutes lectures, as the doc stands at a rolling computer-cart, about each patient before entering the room….Because my daughter’s problems are GI-related, we were on the GI floor–25 rooms, with everyone there having somewhat similar problems; the other floors of the high-rise were also arranged by malady. The hospital also employs special nurses who organize activities for the kids to get their minds off their hospitalizations, and counselors to help them cope with their illnesses….

During our first meeting with the doc, he asked about our insurance. We told him we had…the most expensive of the three options [their university] offers. He was delighted. It meant we could get anything we needed. He scheduled the battery of tests after he heard this good news. He also transferred us to another doctor–his mentor–who’s the world’s leading expert on precisely the problems our daughter is having. He’ll be handling everything from here on out. So, leaving aside the awful bad luck of our daughter’s health problems, it seems like we really got lucky….[W]e have basically unlimited access to what is literally the best care in the world for our daughter. If we had inferior insurance, let alone no insurance, we couldn’t possibly be enjoying these benefits. We’d be at a lesser hospital in the area and potentially facing catastrophic medical bills. And that’s assuming we were [in their home urban area], where most of the hospitals are very good. But what if, say, we were in or near my wife’s home town in rural Ohio? The hospital in the town itself is pathetically bad, and the one in the nearest city is merely OK. Why is that? Well, part of it is the simple fact that we are a huge country with a huge number of hospitals and a limited supply of super-smart people: the best medical students, from the best schools, all want residencies and then permanent jobs at [top university hospitals], and if not there, then at the other good hospitals, etc….[M]y wife’s hometown hospital way down below that.

This is meritocracy in action, in other words. And it makes we wonder about what health-care reform in the country could ever achieve as far as equality and fairness are concerned. Give every person in America open access to health care–and yet most people will not be living five miles away from [a top university hospital], and they will never be able to see many patients who travel there from rural Ohio, since if everyone did that, they’d be swamped in about half an hour. So the worth of that open access to health care will vary enormously depending on where people live. And there’s nothing that can possibly be done to change it–unless we decapitate the top by getting rid of the [top university hospitals]. Then there’d be much more equality and fairness. But not fairness for me and my daughter. And to the extent that the super-docs develop procedures that are then applied elsewhere, everyone would lose as well.

That’s a powerful story, one that just about every parent can sympathize with, as I imagine that just about every parent would be willing to do whatever it took to be able to get their desperately sick child to the best medical care available. Faced with that, very, very few of us would qualm at or complain about the expansive, sometimes invasive, structures that concentrate the resources and expertise which produce the occasional medical miracle. I certainly wouldn’t.

So there are two almost undeniable observations that can be derived from my friend’s story. First, that we will want, in at least extreme and emergency cases, for “big medicine”–with its teams of doctors and expensive tests–to exist. Second, that, absent some sort of Harrison Bergeron-type of wholly centralized and strictly controlled system, there will always be a some randomness and unevenness in the availability of different much-needed goods, because the people who provide them are following paths and setting goals and making decisions that can’t necessarily be directly aligned with egalitarian principles. So where does that leave us? The relative injustices and inefficiencies of our current ramshackle system are undeniable, but neither do we want health care to become the property of some inhuman redistributor of resources. There is already plenty of market-forced rationing of the diverse forms of care out there (and by that, I mean everything from insurance companies denying coverage to select segments of the population, to mostly overwhelmed and often underfunded urban or rural medical practices and hospitals being forced to close their doors) and some of that rationing already leaves some families and communities without the ability to care for their own needs. Is there some way in which egalitarian reforms can address this, if not ever resolve it entirely to every person’s satisfaction? Forget utopia; can we at least strike a better balance than the one we currently have?

Probably, if you open your mind to all the options. Consider the much maligned single-payer option, which the Democratic party took off the bargaining table right from the beginning. Of course, we already have a single-payer-type system in place in this country where people can choose for themselves the care they best need out of all that which is locally available to them, and don’t have to worry about negotiating through various financially-invested and profit-hungry intermediaries, instead trusting their medical providers to tally up the costs straightforwardly: it’s called Medicare, it’s been around for seven decades, and seniors love it. Moreover, that notorious, Canada-style, single-payer approach is actually more amenable to the American passion for choice than our current system. Opponents of reform often make a big deal about being able to choose your own insurer, which a single-payer system would of course make obsolete…but I suspect that what really matters for the great majority of us is being able to seek out your preferred doctor–and today our HMOs and whatnot give us a specific controlled list (worked out through backroom negotiations between various insurers and doctors’ groups) of medical practitioners and force us to choose between them, even sometimes dismissing local options if the market calculations weren’t quite right. Case in point: when during her yearly check-up, our oldest daughter was told that she was developing a curve in her spine, which meant possible scoliosis, we were financially obliged to ignore perfectly adequate Wichita back doctors and seek the help of a medical practice in Salina, a morning’s drive away (tally up the cost of the gasoline to take us there and back), because no one local was part of our particular plan. So much for empowering medical options close to home!

(Moreover, note that the single-payer option–or other similarly subsidized or state-supported plans, that set basic foundational requirements for health providers (which will, of course, include some rationing and redistribution, but no more than the gatekeeping which private insurers and hospitals already put in place) so as to make certain no one is excluded from the essentials of care–can be administered in a highly localized fashion. An old friend of mine, James Meloche, whose comments I quoted in one of my earlier posts, helps direct a Local Health Integration Network in Ontario, Canada. The LHINs were set up a few years ago to formalize the efforts on the Ministry of Health and Long-Term Care in Ontario to respond to the diverse needs and desires of the different socio-economic and cultural populations that had health needs throughout the province. By all accounts, they take their devotion to interacting with, make decisions in line with, and trying to strike balances in what is available (and where) amongst the local communities within their boundaries pretty seriously.)

Of course, we’re not going to get single-payer (though thankfully, the delightfully goofball Congressman from Cleveland, Dennis Kucinich, has managed–thus far successfully–to keep in the proposed bill an amendment which would allow the different states to pursue single-payer plans on their own, which might be an ideal arrangement for our federal system). What we’re looking at most likely at the current moment is a proposal that will keep private insurance companies, with their constant negotiations with hospitals and doctors’ groups and other providers over what is available and where and at what premiums and under what conditions, very much in the game. However, the federal government will claim some oversight over (and some subsidizing of) those insurers, making the rescinding of coverage and the excluding of people due to preexisting conditions mostly a thing of the past, which will enable millions of more people to keep their insurance, which means fewer people crowding into emergency rooms and defaulting on the costs, which means fewer pressures to increase premiums, all of which will be good for working families and the local communities trying to hold on to them. The bill may also include a public option, namely a fully-funded government-run insurance plan (or, in other words, Medicare available for someone else besides retirees), which Karl Rove tells us will destroy the country, but which others claim, should the provision survive the House and Senate, wouldn’t put private insurers out of business so much as open the door to the sort of public-private supplemental insurance arrangements such as exist in France (which has, incontestably, the best overall health care in the world, and delivers it mostly on a region-by-region basis).

It should be noted, if it isn’t obvious, that a more egalitarian provision of health insurance doesn’t preclude the choices and innovations that really matter (specifically, who your doctor is, and where you have to go–or he has to go–for health care transactions to take place). E.D. Kain, over at The League of Ordinary Gentleman, made a strong argument against government health care monopolies a little while ago, but while much of what he said was true in principle, overall he was arguing against strawmen. The egalitarian frustration with profit-hungry insurers is not about running the market entirely out of health care; it is about making the availability of health care more populist, more just. Single-payer systems like Canada’s are not socialized; all those who are actually meeting with patients and providing surgeries are private actors. All the government does is work with different localities to find out where hospitals need to be build and resources need to be invested…which seems to me to be far more potentially respectful of the communities people live in than our present system, in which (assuming we are not enormously wealthy) we’re often simply tossed a book and told to look up and go find one of the eight doctors listed on page 238, wherever they may be, assuming they’re accepting patients at the moment. The same things could be said for state-supported insurance systems like France’s–yes, they are somewhat socialized, yet private transactions still flourish (and, in fact, are able to reach out to distant or poor communities, leaving them more empowered to protect their own members, than was the case before their system emerged). E.D. even praises the Dutch system, which is famously a combined state-private “third way” arrangement–exactly the sort of social democratic policy-making which, as I and others have argued before, is essentially “conservative” in how it views peoples’ lives and their families and homes…certainly more conservative than the not-quite-regulated-but-nonetheless-crudely-centralized patchwork we have today.

Can health care be local? Probably never entirely, not unless we happen to put down roots in a locality that is lucky or wealthy or both–or not unless we become even more willing than the Amish to reject the medicines and technologies and therapies that the modern concentrations of resources have made possible. (I’m not defending, by the way, any particular medicine or technology or therapy here; I’m an old fan on Ivan Illich, and I don’t particularly trust in the “medicalization” of modern life…but I’m not going to pretend that there aren’t times and places–when our children are desperately ill, for example–when we’re glad it’s there.) So it comes back to delivery–can the provision of health care be local? In the best of cases, it should be: you ought to know your family doctor, and come to trust her as she comes to remember your children as they grow older. But to make that localist ideal more possible–and especially to make it more possible for all people, in all their respecive places–we need a little more fairness in coverage, we need a little more populist justice in distribution. No plan that emerges from the federal government is going to be without bureaucratic annoyances and consequences. But such a broader, more coherent plan would be, I think, an important aid for communities to build themselves upon.

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  1. Check out these two websites for some interesting information on healthcare comparisons :-



    I decided just out of curiosity to take the country healthcare comparison figures in Table One in the first website PDF and just allocate simple rankings to the first six columns and then add up the rankings for each country with lowest total ranking being the winner. To my surprise Japan won easily and with a healthcare system very similar to the American one but with critical exceptions which you can discover in the article on the second website. OK this was a crude analysis and maybe somebody will blog and give chapter and verse why the Japanese way is crap but why is there so little comparative information available in main stream media and so many people rushing to take up positions of vigorously defending either market or state? Why does everything automatically have to be a jousting tournament in this country? Surely there’s room for nuanced solutions instead of sledgehammer ones!

  2. Among the “the various blessings of specialized and concentrated technological advances,” I’d include only two of the three you mention: “penicillin, sterilization, [and] artificial limbs.” The middle one is a family-, community-, nation-, and ultimately soul-destroying curse.

  3. Why does everything automatically have to be a jousting tournament in this country? Surely there’s room for nuanced solutions instead of sledgehammer ones!

    I agree, Bruce. I can’t speak to the comparisons you develop; I’d have to look into the data a little bit more. But as for your condemnation of that all-or-nothing approach which puts all proposed reforms and all defenders of the status quo in the same boxes, you won’t find any disagreement here. There are lots of ways to understand and approach the problem of protecting and making more just the delivery of health care–paying for doctors, providing coverage for the sick and injured, etc.–that, as far as I can tell at least, do not fit into the stylized boxes by which the mass media categorize things. Like I said in the post above, public-private partnerships of different sorts are very common around the world; it does no one in America any good to assume that any such proposed arrangements are just Trojan horses to sneak in some “sledgehammer” solution.

  4. Western Confucian, maybe I chose my words poorly, but please don’t jump to eugenics conclusions far from my intent. By “sterilization,” I mean the sterilizing of equipment, hospital rooms, and the like…something which wasn’t seen as necessary before the advent of scientific tools which made clear the role of germs in the spreading of infectious diseases.

  5. Arben, dude, you’re a favorite but I was trying to watch Pete Seeger’s birthday party on PBS (dude, Joanie got old!) and read this post but it’s too long! So I re-read this morning. You know short and powerful is good!
    My response is: Gummint caused the health care problem and it ain’t gonna fix it…it can’t fix it!
    So, we go back to a pay for service, either with private insurance or cash, and poor folk (and God bless ’em) receive private charity (church, private institutions such as Elks, Kiwanis, Masons, Sons-of-Italy, ect, ect,) Let the churches do their job, do Christ’s work!

    So my question is: Arben, as a practicing liberal, what do you think of He Who Speaks God’s Wisdom’s ‘health care’ proposal and what do you think of the Democrat response to the ‘greetings’ their congressional representatives are getting back home when they try to defend His Holiness’s plan?

    Arben, I always look forward to your stuff; you’re an honest, straight forward tree hugger who isn’t ashamed to admit it, and I do admire that.

  6. Enjoyed the post. This is a very complex issue and I will not be one of those critics who pretend to make it seem more simple than it is. However, I would suggest that, as Localists, centralization of health care should be approached with some hesistation and carefully examined. This is not happening today. Beltway politicians are trying to rush it through legislation. That is problem number 1. The idea might (I emphasize MIGHT) be good, but how is it implemented? My job is analyzing business processes and I can tell you that 9 times out of 10, problems experienced in business are results of poor (or no) strategy. Without strategy, you cannot come up with tactics, without tactics, you cannot execute, if you don’t execute, things turn into a cluster____. Tell me, exactly what type of strategizing is ocurring at our highest levels on this extremely important issue? Are they trying to understand the problem and strategize a solution that works in the long-term, or are they playing politics and simply trying to look like they are doing something important? Planning for election day and all that. The fact is this, without strategy and processes in place for a national health care contingency, things will get ugly. What’s more, are we prepared to hand over to government yet another service that was once in the domain of the private sector? We The People seem to have relegated our role at holding both accountable (not to mention ourselves for our actions). This remains Ground Zero for a myriad of current issues – not just of health care – and is where, I believe, the battle should be waged.

  7. Bob,

    You know short and powerful is good!

    I know it is. Sometimes I achieve that, but usually I fail. I can’t be succinct to save my life, I fear.

    we go back to a pay for service, either with private insurance or cash, and poor folk (and God bless ‘em) receive private charity (church, private institutions such as Elks, Kiwanis, Masons, Sons-of-Italy, etc., etc.,)

    But Bob, a strict “pay for service” arrangement would mean that a great many forms of care–anything beyond the most basic of surgeries, cancer treatments, medicines for blood disorders, etc.–would not only going to be out of the reach of the poor, but out of the reach of the great majority of God’s children, you and I included. That’s why insurance programs developed in the first place, and that’s why hospitals and doctors’ groups starting dealing with insurers–because when the suffering ended up on the doorstep for the most part they didn’t (as you say, God bless them!) turn folks like you and me away, but instead kept us alive (mostly), and hence wanted to find some way to arrange the burden of the costs. And then of course there were the demands of the wealthy, who kept pushing for more research and more trials of newer and better drugs and technologies, which also kept up the costs. So pay for service will only work as a panacea if we simultaneously are willing to forgo many of even the most minimally complex health care responses disappearing for the majority of us. The issue of moving from “pay for service” to “pay for performance” or some other such approach is a complicated one, but it’s been ongoing for years in the U.S. and elsewhere around the world, and I think it would be foolish (not to mention unjust) for localists to play resistance fighters against such an evolution.

    I’m all for voluntary charity, but middle-class people like you and me what our kids, in times of emergency, to have care more expensive than even we can afford, and yet it would be unreasonable to tap the limited funds of my local church to pay for my child’s complicated and expensive gastro-intestinal disorder: hence, we set up insurance schemes that we pay into, to provide collective support for us all. If charitable giving seems to be in competition against complex public or private insurance exchanges, the fault isn’t the government’s alone so much as it is 1) our own, for wanting us and our children to be healthy (more healthy that we should reasonably expect, perhaps?), and 2) the patchwork, repetitive, costly system that has evolved from all our and our employers’ and our government’s efforts to respond to 1). Assuming 1) isn’t going to change (and speaking as a selfish parent, I don’t want it to!), then a little more effeciency and flexibility and universality in the delivery of 2) seems worth exploring.

    what do you think of He Who Speaks God’s Wisdom’s ‘health care’ proposal and what do you think of the Democrat response to the ‘greetings’ their congressional representatives are getting back home when they try to defend His Holiness’s plan?

    Assuming you’re talking about President Obama, I think the current House plan is costly and threatens to be unnecessarily bureaucratic, but so long as some sort of public insurance option is preserved and the possibility of states moving in a single-payer direction remains in the bill, then it’s better than the status quo. The bipartisan Wyden-Bennett bill is also a good one, but I’m not sure the political calculus for it to garner wide support is out there. As for the popular response to the bill, it depends on where you’re looking. I see a committed, distrustful group of people talking about how the current House bill will force euthanasia on people over 65 (false) and other nonsense, and then I see millions of older folks who like the system they have and don’t want any change. You breakdown all the polls, and what you see in the long run is that most people under 50 want health reform to go forward, and most people over 50 don’t want it too. It’ll be a hard row to hoe, getting anything pass the House and Senate in September, that’s for certain.

  8. Western Confucian, thanks for the article. I often like what Dean Baker has to say, but I think he’s wrong there. You’re right to note that our arguments could be understood to complement each other: if some broad, egalitarian centralization can work to empower local responsibilities, why can’t the same logic be extended globally? I won’t go that far because I think the bonds that legitimately hold people together in communities weaken and change as the scale and distance increase. This means that some things that people can pull together and establish generally (thanks to a shared culture, history, language, sense of place, etc.) for a local community won’t work as well if they try to do it at a higher level (this is the principle of subsidiarity, in other words). I happen to think that health care, certain elements of it anyway, could use some rethinking and reform on the national level; I see that, at the present time, as being plausible. Beyond the national level I just don’t see it.

    Justin, thanks for your comment about process and implementation. The proof is in the pudding, as always.

    What’s more, are we prepared to hand over to government yet another service that was once in the domain of the private sector?

    This can be a good argument, but then again, it can be a red herring. Are hospitals, doctors, and all the rest right now “in the doman of the private sector”? They are their own employees, surely; that’s something I note in the post above (the same thing is true in Canada, France, Holland, and many other nations). But are their payment and reimbursement schemes entirely in the private sector? Despite Medicare, despite the Veteran’s Administration? And, of course, which private sector? Is the near-monopolistic power wielded by the giant private insurers, Blue Cross/Blue Shield and the like, really “private”? I see no reason to assume that the virtues of choice and personal responsibility will be more threatened by occasional government rationing than by the rationing already being imposed by profit-hungry, nation-wide, corporate insurance monoliths.

  9. Bob. Viz your healthcare post. The nineteenth century private charity thing on healthcare didn’t work too well for my ancestors nor for most other folk’s ancestors which is why governments got involved in the provision. I wouldn’t dream of asking you to directly fund the healthcare insurance of somebody who can’t afford it. I would though like you, me and others, to give up small contributions to those who can’t afford it and with a method that minimizes free-loaders. Tell me how the Church prevents free-loaders and you’ll understand why the “gummint” got involved!

  10. Smitty,

    Good idea, let me know when you have the particulars worked out. So far gummint has failed, but maybe you won’t! And, I do want to read your comments on the other issue!

  11. Health care costs are under the control of monopolies and oligopolies. The economic signature of a monopoly is that costs rise even as services remain stagnant or deteriorate. This is what has happened in the United States, as the cost of medical care went from 8% of GDP to 17% in 20 years, even as the percentage of people covered declined. And these costs continue to rise. Patents create government guaranteed monopolies; licenses limit the supply of doctors; and the consolidation in the insurance industry means that it is controlled by five giant firms. In the face of monopoly and oligopoly, it is misleading to pose the argument in terms of “free-market” vs. “socialism.” The reality is that we have a privatized socialism; that is, the worst of both worlds.

    There is simply no way to control costs in the face of monopolies. If you have monopolistic systems, then you must have price controls of one sort or another. This is why single payer systems work; they function as price controls. It is no accident that the rest of the world spends far less than we do to cover all of their citizens. The irony is that we already spend more tax dollars then these systems do without getting the universal care that they have.

    To make it a free market system, you would have to do away with patents and licenses, and break up the insurance oligopoly. The patent problem is easy enough to handle; simply replace patents with manufacturing licenses that would allow anybody to manufacture a given medicine or produce a given machine for the payment of a license fee. This would open up competition in medical technology, which is just what happens when medicines lose their patents and become “generics.”

    Licenses are a tougher problem because no one wants to go back to the days of unlicensed doctors. Or at least I don’t. However, the supply of medical personal could easily be increased by increasing the kinds of licenses available, and allowing independent or semi-independent practices for a variety of license levels: midwives, nurse practitioners, medical practitioners, medical doctors, medical specialists.

    Finally, the delivery of services has to be addressed. I believe there is a role for medical cooperatives and guilds in this. For a more complete discussion, see http://distributism.blogspot.com/2009/04/chapter-xvii-distributism-and-health.html

  12. Russell, in order for your question to be answerable you must make a distinction between health care and medical care. In all the debate about medical insurance, the sloppy interchange of these terms has clouded the debate to the point that it has become a tragic parody.

    (I am going to borrow heavily from the Ivan Illich bucket here, but his discussion is most relevant, and like all of Illich’s essays you have read the definitions first.) Medical care is a part of health care, and medical insurance is only a part of medical care.

    In my opinion, health care must be local. Local to the point of an individual, or even perhaps to level of an individual’s thoughts. Health care in its most basic form is taking care of your health: Getting enough sleep. Eating right. Getting enough exercise. Brushing your teeth. Etc. On the family level it is: Teaching you kids how to take care of themselves. Telling you wife that her pie Kung Fu is better than her sister’s, but I am really full. And of course giving and receiving hugs are important. On the community level health care is about having safe places to recreate, walkable communities, access to clean water, pure air, and healthy food. These circles continue to expand to the regional, national and global scale. For good or bad, the arrow of causality is (mostly) pointed from the individual out to the larger segments of society. Having a global authority telling people to brush their teeth is insanity embodied.

    Medical care is different. Telling someone that should have brushed their teeth when have a broken arm is nonsense. Having trained doctors and nurses and adequate facilities is a necessity. However, it cannot replace health care at the its most basic and most inclusive form. Telling a 350 pounder that can cure her diabetes with a syringe is equally nonsensical. The causality arrow is much more balanced here.

    Medical insurance is a subset of medical care. Medical insurance can never supplant either medical care nor health care. You can insure against medical costs, but you can never insure health. Perhaps our failure is semantic. We want to “ensure” our health, but all we talk about is “insuring” our medicine.

  13. Rex, that was a wonderful, important, and very wise comment; I wish I could have read before I wrote this post! You’re absolutely correct–what this post is really asking is, “Can Medical Insurance Be Local?” Now, one could argue that since doctors must be paid, and the costs of developing medical technologies much be recovered, and since we are (thankfully, as John Medaille notes above) generally unwilling to challenge too many of benefits of licensing and centralization that have come along in the past century (and which perpetuate the spiraling costs of the above), perhaps one could argue that in talking about enabling medical insurance to operate both justly and locally, we really are talking about “medical care” itself being made local. But certainly “health” is much broader, and much more fundamental, concept than that. So thank you for you semantic correction; it’s much appreciated.

  14. TY Russell,

    Mr. Médaille often gets some wood on the ball, almost Pujols like. Being a confirmed agnostic, I often find myself just short of fully buying in to his thoughts, but I always listen. Contrary to Mr. Cheeks view, you cannot blame the gummint, industry is the real tyrannical force in this dog fight, gummint is just a consort.

    My style is more Vlad Guerrero, (chin music to shoe laces), and I am glad that you could wade through my Palinesque word salad to find a few nuggets. (Proof reading my own writing has been a pox.)

  15. Medicare and Medicaid are “working”? Not what the NYTimes says today:

    With the aging of huge Boomer populations in the West, we are just witnessing the first signs of unsustainability. This from today’s London Times:

    Also, to present the Canadian system as a friendly ghost that facilitates contact with private doctors is not quite telling the whole story. They play an immense role in operations they will pay for and drugs they will include on the State Formulary. I hate to get anecdotal on you, but a good friend of mine, Tony, who lives outside contracted kidney cancer several years ago. His battle to get drugs and treatments – available in the US – offered in Canada led him to create a lobbying organization for other cancer sufferers, Kidney Cancer Canada: http://www.kidneycancercanada.org/main.php

    Of course, insurance companies have formularies as well, but they’re not nearly as restrictive as Government formularies. We may say there’s no competition in the American system, but what bigger monopoly is there than a single payer system, which doesn’t cover your treatment? There will be no “American” system to go to then…

  16. Rex, an excellent distinction. I knew a doctor who said he was prescribing antibiotics for things that could be cured with chicken soup. He even prescribed them when there was no bacterial problem; people just wanted a prescription.

    Speaking of causality, it is not straightforward. Somebody (it may have been Illich) pointed out that doctors believe that strep throat is caused by streptococcus. But it isn’t, because most people have this bacteria at any given moment. You might as well say that strep throat causes the multiplication of streptococcus as the other way round. Illich argued that doctors and hospitals made us sick. “Iatrogenic” disease he called it; disease caused by doctors. He may well have been right.

  17. Arben,

    Thanks for your reply and forgive me my snarkiness re: the current resident of 1600 Penna. Ave., my meds haven’t worn off.

    One query in all seriousness re: “pay for service.” If the gummint was out of the picture and there was a condition of “true” competition among those nasty, blood sucking, insurance companies, do you think that they could deliver a price for health care insurance that “most” of the more than 300 million Americans could afford?

  18. Mr. Cheeks at the risk of being a putz, I am going to offer an answer, even though your question was not directed to me. Competition won’t make medical insurance affordable, because the medical insurance companies have no interest in your health or the cost of medicine, and as long as medical insurance is perceived as necessity the cost is not relevant to the insurance company.

    It is like asking whether competition among auto insurance companies will control the cost of cars or improve highway safety. As long as they have accurate information for underwriting, they simply don’t care what car you drive, or how many wrecks you get into. Car insurance companies are only competing with other car insurance companies and as a result, they only care about the probability of you getting into a wreck and the associated cost as compared to other drivers. The market is actually much more lucrative for poor drivers in expensive cars on dangerous roads.

  19. Pete, don’t feel a need to apologize for getting anecdotal; I did in my original post, with my references to my friend working with the Local Health Integration Network in Ontario. I don’t want to throw up my hands and simply say “well, different people have different perspectives,” but to an extent that’s true. There is reams of polling data that suggest levels of satisfaction with Canada’s health care system amongst residents that equal or exceed the reported levels of satisfaction in the U.S.; for every example like your friend Tony–and good for him for organizing for the purposes of making his voice heard!–there are comparable examples in the U.S. Are you so certain that, when all is said and done, the restrictive formulas employed in Canada are quantitatively worse than those employed by our own patchwork of employer-tied monopolies? (I notice, in poking around your friends site, that one of the primary complaints seems to be that Canada’s system isn’t universal enough!)

    Bob, Rex essentially gave the answer I would give. I suppose there are marginal ways in which greater competition between insurance companies results in certain savings, but it seems to me that by and large what insurance companies compete over has little or nothing to do with extent and cost of medical care itself. I don’t see how, absent government regulations/subsidies or pressure from a public option, insurance companies could see it as to their profit-maximizing advantage to strive to insure the very poor or extend the availability of expensive procedures to more people, much less reduce costs. Insurance companies make their money from offering as much high-premium security as possible to people who are as healthy as possible; none of that points towards a competitive desire to reach out to undesirable populations or to make cancer treatments cheaper.

  20. I am a believer in the right of the any human being to get medical care. Period. Money should even be discussed when it comes to taking care of one’s heath.
    But is insurance needed to pay for the poor like Russel said? Then why are they for profit organizations? Making their executives filthy rich? I have not seen charity as being a value for insurance companies and I have worked for a big one. They are mostly concerned with their own profit and the “shareholder profit”. I think this is preposterous for organizations that pretend to “bring value” to people health need and help “pay for the poor”.

    Insurance is costing the nation an arm and a leg, it’s a huge bureaucracy that we pay for to come between us and the doctors. We all lose from their existence. Patient and doctor alike. All that money that goes to these huge bureaucraties should be spend on assuring that everyone gets medical attention to whatever level it is needed.

    Charity however is a value and a reality for not-for profit hospital and medical foundations organizations.
    They could do so much better in taking care of everyone if they did not have to run (themselves) huge bureaucracies to keep up with regulations and insurance.
    Like some some in this dialogue I do not think insurance and more insurance will help the poor, or will bring down the cost of heath care.
    It is a paradigm that needs to be broken.
    Let’s open our minds to how to get rid of non-value adding organizations and activities and moving our attention to things that really matter to ensure “health care” to all not “health insurance”. That is where I would like to see this nations creative minds working and not on how to come up with yet another bigger bureaucracy.

  21. Rex, at the risk of being fair to health insurance companies, the situation in car and home insurance is different from the one in health insurance. In the former, the insurance companies can rely on the free market to hold down repair costs. But if all the repair shops where taken over by a few companies, and the licensing requirements for mechanics raised so high that few could afford the training or pass the examine, the car insurance business would face the same problems as Health care insurance.

    Car insurance companies do have an interest in overall safety, since bad roads and bad drivers cause claims even for good drivers.

    Oddly enough, one advantage of an oligopolic health insurance structure is that they should be strong enough to negotiate with drug companies and the like to hold down costs. I suspect they don’t do so because the drug companies are too strong politically, and would start causing problems for the insurance companies.

  22. Bruce, compare Stiglitz with Benedict in the recent encyclical: On the part of rich countries there is excessive zeal for protecting knowledge through an unduly rigid assertion of the right to intellectual property, especially in the field of health care.

  23. Here is a website that relates to Stilglitz’s idea and it doesn’t take a great deal of imagination to see it extended outwards towards his idea:-


    I think Benedict’s encyclical acts as a great counter-message to the very self-centered American Rugged Individualist one which largely seems to be a message of work as hard as you can to make enough money so that you don’t have to work. A lot of the time to do this, of course, individuals rip the surplus value off other people’s backs. I’ve always thought though even if I do it morally “what then.” I guess the life history of John Harrison (he invented the first accurate chronometer and saved many seafarers lives)indicates that it never has been just money that drives us. Harrison was 80 years old when he received less than half the government prize money on offer for inventing the first accurate chronometer. He kept going all those years to perfect his device and it clearly was a matter more of pride than money. Here is the website:-


  24. John, I agree that the markets are different, however, the corporate models are not. My point was that the insurance companies don’t care what the costs are. As long as insurance is perceived as a necessity, the number of policy holders is more or less stable. And if the risk to the corporation is calculable, the risk to an individual is not important. Similarly the cost of corrective action is just a number without a connotation of good or bad, as long as that cost is standard across the industry.

    If public policy was that auto mechanics had to have ten years of schooling and only use $500 wrenches to save your car at all costs, the auto insurance companies would not give a hoot. I believe that the only reason that the medical insurance industry has allowed congress to consider this question is that they see a way to force everyone to buy their product further ensuring a radical monopoly.

    In another thread you pointed out Lloyd’s of London as a different model. Excellent! In my opinion the co-op is the only model that holds any hope of controlling costs. However, the charter of the co-op must be strictly written to avoid playing both sides of the coin or cost will spiral upward.

    (I am going to sound pedantic, but please don’t call it health insurance, it is medical insurance.)

  25. Rex, I don’t disagree, but what I am trying to point out is why the “free market” can provide near universal car and home insurance, but not medical insurance. The former can depend on the free market in repairs to control costs, the latter is subject to monopoly markets whose costs are not controlled. Therefore, a significant number must be priced out of the market. It’s not quite correct to say that the insurance companies don’t care about end costs, because rising costs price some out of the market.

    I am for coops, but coops will be equally powerless in the face of monopoly suppliers.

    Monopoly markets have another characteristic: the more money you supply, the more costs rise. So far from controlling costs, any plan that doesn’t address the monopoly problem will merely drive costs up. There is no fix without either ending the monopolies or imposing price controls. If you don’t do this, no plan can work; if you do, nearly any plan will work.

  26. Coming late to the party I know…

    I guess one of the problems I have with health care reform is the concept of “providing equality and fairness.” Before we even get into the question of which way is the best way to ensure good health care to Americans, I feel we’ve already lost because we’ve bought into a bargain that requires massive government to provide, which to me, and I say this as a Federal bureaucrat, is a guarantee of failure. Such a venture would be too large and too much money involved, believe me the time from establishment to corruption and transformation to a self-licking ice cream cone is very short. And this quite besides the fact that these “who, whom” questions are poisoned by the seething class, race and sex divisions and tensions in this country which will only make things worse. This may be one of the problems that has no good solution, under our current form of government. You just can’t get there from here, no matter how you try, and trying may make things even worse.

    In any case, to the particularities of our place and time, I also do not trust, in any way, the current government, Executive and Legislative branches together, to do this without ruining the country and increasing misery and resentment. Given this and our dire financial situation which robs the government of the means to really do this without it coming at the expense of our future, makes me an automatic and incorrigible opponent of any government health care initiatives. At least until 2012 (and probably after then even if the other side wins, I hold them in scarcely higher regard).

  27. Sorry you feel so sick about it all Steve but at least you have the option of affordable psycho-therapy with your Government heath insurance!

  28. Steve, I don’t think Bruce was calling you insane; I think he was making a joke. If he was saying that your doubts require you to have therapy to regain your mental health, than I’d agree he was over the line, but I don’t think that’s the case.

    I guess one of the problems I have with health care reform is the concept of “providing equality and fairness.” Before we even get into the question of which way is the best way to ensure good health care to Americans, I feel we’ve already lost because we’ve bought into a bargain that requires massive government to provide, which to me, and I say this as a Federal bureaucrat, is a guarantee of failure.

    I’m curious about this statement of yours, Steve. Do you say that “I feel we’ve already lost” because of your belief that the concept of “equality” in opportunities for health and medical care will inevitably require a “massive government” to deliver it, or because of your problem with the concept itself? I don’t see this as a pedantic point; I think it’s a crucially important one. It’s one thing to disagree with my claim that local and populist provision of medical insurance and care could be better sustained when undergirded with broad, egalitarian actions, because you see such actions as creating bureaucratic monstrosities. But if that is your disagreement, then we only have a disagreement about means, not ends. However, it’s a very different thing to disagree with my claim because you think that any talk of “equality” in health and medical is itself flawed. Which is it? I’m not trying to be harsh here; I’m honestly curious. If it’s the former, then there is room for argument and critique over various plans and ways of overseeing the distributing and delivering medical care. But if it’s the latter, then we have much more fundamental disagreement, as one of us (me) believes that access to medical care is something of a universal Christian principle (or a human right, if you prefer), and you may believe otherwise.

  29. Arben, I don’t know about Bruce. He called me “Cheeky-Butts” and that hurt my feelings; I’m just now recovering.
    Steve K., dude, you’re speaking truth to socialists here, so go gentle. Arben, Steve’s a Fed. Bureaucrat so we might want to read his ‘comments’ rather carefully.
    D.W. surely you have a comment about this?

  30. Anyone who is still attempting to divine any real distance between Big Business and the Government of the Lapsed-Republic is a Romantic. Today, despite all the rhetoric about the Free Market or protecting the little guy from the evil machinations of big bad business, the entire system is a mangy mutt, neither fully public nor private but wholly and extravagantly bureaucratic as well as logic-averse. This is the role of the modern technocratic state, to bury us all in a silken load of paperwork. Rest assured, whatever is finally produced by the current regime, no better nor worse than the last regimes and likely just as bad as the future regimes…but whatever these Public-Private Bag Men produce will be broken right out the gate. At least in horse racing, they shoot the lame horse…in government and “business”, they elevate the lame to stud status. Needless to say, this is why they refer to horse racing as “gambling”…there is still the off chance to actually win.

    I do like the cheekiness though, calling this debate a discussion of “health care”. Obviously, health has little to do with it.

  31. How, I ask myself, can a man of D.W.’s obvious acuity write such prose, “Rest assured, whatever is finally produced by the current regime, no better nor worse than the last regimes and likely just as bad as the future regimes…”
    Pleazzzzzzzzzzzzzze, we are talking here about LBJ on steroids, we are talking about the FED gummint taking over YOUR health care. My goodness George might have gotten us into two wars (which BO continues) but he didn’t try this crap!!!!!!!!!!!!!!! This is Stalin city, dude!

    Thank you, D.W., I needed that. All’s better, ready for the wars! RE-Cheeked!

  32. I’m sorry Steve that you didn’t get the point of my black humor but whilst you are enjoying government provided insurance you were announcing in a fairly fatalistic way that the idea of getting health care reform through the only feasible route, government initiative, was crap. At least that’s how you came over to me. I was hoping to get you to see the contradiction in your position. I clearly failed. But please tell us how you would do it without government involvement and urgently because it is a priority for many people.

  33. Come now Cheeks, you insult Stalin here. These current Junior Chamber Of Commerce Bolsheviks may be planning on turning the befuddled lapsed-republic into a kind of Club Med Debt Gulag but this is hardly the Siberian Gulag of Uncle Joe. After all, there are “green shoots ” popping up everywhere.

    Soon enough, there will be the kind of inflation and currency chaos that normally requires everyone to cash out and sleep the auto-beating off. At that juncture, an Uncle Joe or two generally arises and then, Cheeks, we’ll really have a problem or two on our hands.

    Welcome to the lapsed republic, where a few political consultants decided that there was money to be made in the gutting of the Separation of Powers under cover of factional identity politics. This Factionalalapalooza has been building for some time and is about to unfold its crowning achievement: The Screw-Up of a One Car Funeral Procession.

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