Ezra Klein has a couple posts up today where he explains why he doesn’t see the disconnect between two of his posts yesterday that I and others observed. They’re good posts, and definitely worth reading if you want insight into why liberals and progressives are so exasperated at conservative and libertarian opposition to Obamacare.
After reading these, I think the reasons Klein saw Mark Steyn as ignorant, insane, or arguing in bad faith is due to a fundmental disconnect in world view. A defining feature of the outlook of libertarians and small-government conservatives is a strong general suspicion of the coercive power of the state, believing it to be a necessary evil at best that should be kept to a minimum, especially in economic matters, and considering the coercive power of the state to be overused already. Mark Steyn and I, although we disagree on a great many matters, agree on this.
Progressives, on the other hand, see government authority as a powerful tool that can do great evil if used improperly, but which can also do great good if deployed carefully to correct the natural injustices and inefficiencies that arise in an uncontrolled environment where everyone’s looking out for their private interests but nobody is looking out for the public interest.
I’ve observed in the past that Klein seems to have a bit of a blind spot as to this philosophical difference. For all that he has a solid understanding of conservative and libertarian policy proposals and makes an admirable effort to debate them on their merits, he doesn’t seem to really get the underlying philosophy. For instance, in his examinations of Paul Ryan’s alternative health care reform proposals, he expresses bewilderment that Ryan is staunchly opposed to Obamacare, but Ryan’s own proposal contains the health insurance exchanges that are superficially very similar to the centerpiece of House and Senate bills (government-defined minimums, community ratings, guaranteed issue, etc). The difference is that Ryan’s exchanges are voluntary — insurers can offer policies in lightly-regulated markets off the exchange, and individuals can buy insurance off the exchange or forego health insurance entirely – while the House and Senate bills would forbid insurers to offer new policies outside the exchanges and would fine individuals for failing to buy policies on the exchange unless they already hold an exchange-compatible plan through their employer or a grandfathered pre-Obamacare individual-market plan. To Klein, this is a minor and superficial difference. To Ryan and to me, it makes all the difference in the world, the difference between offering to sell someone a candy bar versus forcing the exchange of money for candy at gunpoint.
With the fundamental difference in attitudes about government coercion in mind, the disconnect makes perfect sense. To someone who views government coercion as an necessary evil at best that is already overused in the economic sphere, there is plenty to hate in Obamacare. It may preserve the appearance of a private market, but it erodes a large piece of the substance, and Klein’s pep talk for progressives called attention to just how much it does so. Viewed from the right, the difference between the Senate bill and a full nationalization of the health care sector is one of degree, not of kind. And when Steyn criticized Obamacare using terms that were better suited to a discussion of single-payer or an NHS-style full nationalization, it seems to be understandable hyperbole. But viewed from the left, particularly by someone who doesn’t fully understand the nature of the conservative/libertarian philosophical antipathy to government coersion, the intensity of Steyn’s reaction is mystifying. Steyn, Ryan, and I see Obamacare as breaking the free market (what little free market there is in health care), while Klein sees it as fixing it.
I wish Klein had written today’s more thoughtful posts yesterday rather than snarking at Steyn, and I wish I’d done the same thing with respect to Klein’s posts. At best, snark invites explanation, and at worst it crowds out productive discussion. Generally better to skip directly to explanations and productive discussion.
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Generally, lefties think that if democracy is good, a powerful democratic government that is set up to do wonderful things has to be even better. You’ll find that lefties don’t like to admit that the government even exists as an entity with its own objectives and interests apart from “the people” – this would be questioning the very basis of democracy as they see it.
The idea that government is fundamentally an instrument of coercion is something they reject, since it’s “democratic”. If you’re libertarian-minded or a non-statist conservative, you accept the equation that bigger government equals more coercion equals less freedom, no matter what boons the government doles out. Whether the top officials are elected or not doesn’t really affect this fact.
A little test I like to use is whether someone uses “we” and “us” to refer to the government. You’ll rarely hear a non-statist (who isn’t actually working for the government) use the first person to refer to the government as an entity.
It’s been frequently observed on both sides that one of the big differences between lefties and righties is that lefties are more distrustful of big business and righties are more distrustful of big government. I’ve tried to explain several times that I’m more distrustful of big business because I’m not forced to deal with any particular buisness, but I am forced to deal with the government. I think you’ve hit the nail on the head for the other side of the argument, that government is “us” because it’s elected by the people as a whole, while businesses are “them” because they’re not.
For my part, it’s the consequences of failure. I don’t much like big _anything_, since the consequences of failure of individuals or bureaucracies in big business or big government tend to be more sheltered.
I don’t trust you unless you are personally and professionally exposed to the consequences of your screwups, particularly willful screwups. Few large bureaucracies are so exposed and work hard to avoid mechanisms by which bureaucratic failure can be exposed and dealt with. Also, government unions work feverishly to make sure that it’s nearly impossible to fire poorly performing employees at all levels of government.
Big business, especially if it’s big enough to manipulate government to entrench itself, is similarly unexposed to the consequences of failure, although big biz hits the wall a bit faster than big government, since at the end of the day, business has to produce something useful to maintain revenue streams. Government just has to make sure tax payers exist and don’t move away in large numbers.
I absolutely agree with you.
The Constitution was explicilty and plainly written to protect individuals from the government. In the wake of people being overriden & trampled by big-business.
Health care insurance & the whole medical industry is one of (if not the) most heavily regualted sectors of the economy; if the government can’t regulate-it right now, what gives one the confidence it will do better tomorrow?
> Whether the top officials are elected or not doesn’t really affect this fact.
As a thought experiment I propose a Constitutional amendment which would require all bureaucrats not confirmed by the Senate in charge of more than 1000 people to be elected by the natural constituency of their function.
I suspect that having lots of elected bureaucrats would do wonders for the responsiveness of the bureaucracy.
As a conservative with libertarian leanings, less rules would be better, but I think we could get liberals / progressives / Democrats behind this idea, simply because it is democratic.
Oooo! Here’s another thought: In order to be on the ballot every four years bureaucrat candidates must be approved as qualified by a jury of their peers.
Frank Herbert said we need to use juries for more than just trials. I think he had something there.
> Health care insurance & the whole medical industry is one of (if not the) most heavily regualted sectors of the economy; if the government can’t regulate-it right now, what gives one the confidence it will do better tomorrow?
My health care is neither interstate nor commerce. I think it is unconstitutional for the Federal government to regulate it.
Yours,
Tom
The thing that needs to be understood is the individual health insurance market is simply not a viable market. Individual health (or family health) is not an insurable risk. The US health insurance system is mostly employer based. Employers form groups that are large enough to be insurable.
The individual insurance market is now in deep trouble. Rate are rising very rapidly because healthy people in this market are dropping insurance. This could easily turn into a death spiral that will lead to the collapse of the individual insurance market. Only large groups are insurable.
A key part of health reform is that the government will create large groups for those people not covered by employer groups. These groups will be large enough to be insurable and help to keep rates down in this market.
Current individual health policies all have the pre-existing conditions clause, which makes if very difficult to change coverage if you have serious pre-existing conditions. To eliminate the pre-existing condition clause you need to get everyone or almost everyone covered by health insurance. This is the reason for the dreaded health insurance mandate.
You can argue that individuals should be allowed to be stupid and go without health insurance, basically chancing it that they will not be in a serious accident or become seriously ill. I would be ok with that, if they people were just tossed out of hospitals and allowed to die from their stupidity when they do need serious medical treatment they cannot pay for. But that is not going to happen. Those people will get some life saving medical treatment at huge expenses paid for by tax payers like me and people who have health insurance like me. I don’t want to be stuck paying for my own health insurance and the medical care of stupid people who decided to go without it.
I would be happy to allow stupid people like that to opt out of health insurance, provided that hospitals required cash on the barrel head (or credit cards) for their medical treatment and just threw them out on the street if they could not pay. Since that is not going to happen, I think we need the government to form health insurance groups for people not covered by employer groups and to mandate everyone to get coverage.
Why isn’t individual health an insurable risk? The “death spiral” only shows up when you force insurers to “insure” against events which have already happened, equivilent to buying homeowners insurance for a house that is already on fire.
Outside of states which mandate community ratings and guaranteed issue, large group insurance rates are rising just as quickly as individual rates. And the rate increases are driven by the cost of care, and there are a number of contributing factors to the rising cost of care:
1. Technological advances. Medicine can do more than it could a few years ago, so we’re paying through the nose for new techniques and treatments (which were expensive to develop and even more expensive to qualify to FDA standards), many of which treat problems that would have went untreated (for free!) otherwise.
2. A broken price mechanism. Doctors don’t know what the procedure they recommend cost, patients don’t care because they aren’t paying (directly), and regulation limits the ability of insurance companies to deny coverage. So nobody has any incentives to economize by foregoing marginal care, seeking out more efficient care providers, or finding more efficient ways to provide care.
3. The regulatory structure intended to ensure high-quality from medical providers is written and run largely by those same providers, and has the effect of artificially restricting the supply of health care providers beyond the degree necessary to ensure an acceptable quality of care.
4. The government provides open-ended subsidies for medical care for large segments of the population, driving up demand, and coupled with 3 this causes a price spiral as the government bids against itself for an artificially limited supply of medical services
5. Malpractice lawsuits have a small but significant direct impact on medical costs as doctors pass their malpractice premiums on to their patients, and there’s a larger indirect impact as fear of lawsuits drives doctors to over-test and over-treat their patients.
Obamacare as currently proposed would make 2 and 4 considerably worse, and would do nothing to address 3 and 5. The excise tax on medical device manufacturers could go a little ways towards “fixing” item 1 by creating disincentives for medical research, but it’s hard to argue that that’s a desirable outcome.
As I was falling asleep last night, I had a thought about how I see the liberal perspective:
Government by representative democracy is supposed to be the “will of the people.” It inherently addresses what is good for the people as a whole, which is patently not necessarily good for an individual. The Constitution recognized and tried to protect individuals from this conflict. (I haven’t heard the term “tryanny of the mahority” in press in decades, not sure why.)
Liberals in general do not see the conflict – unless someone they disagree with is in office; then they see the ruling party as an abberation, not an inevitable event. Liberals see corporate rights (i.e., for the country as a whole) as the ultimate (or maybe only) invidual rights. Liberals do not recognize limited resources for the country as a whole. Aggregation of resources with an individual reduces availability to the country as a whole, and is therefore robbing the country as a whole — immoral and nearly criminal.
P Mike, what you are describing is the liberal fascination with Collectivism which is the fundamental belief that the collective is more important than the individual.
It is from this fundamental core belief in the supremacy of the group that all socialist and communist dogma descends. It is why liberals view those who promote the individual as supreme over the collective as being evil. It is why liberals can promote policies that are in direct violation of the fundamental concepts of human liberty and see no harm.
This is the fundamental difference between liberals and conservatives. Conservatives see individual liberty as the goal, liberals see the “public good” as the goal. The two are in direct conflict in virtually every field of human endeavor.
This is why mikeca up above can indignantly demand that individuals be forced to pay into a scheme that is a blatant redistribution of their wealth because it supports their definition of “the public good”. This is why they write books like “What’s Wrong with Kansas?” which have as their basis the fundamental belief that conservatives are too ignorant to understand how to vote in their own interest. Because they view everything in larger or smaller collectivist blocs.
I’m afraid that this fundamental ideological conflict is getting worse as the liberal side of things has gained dominance over the past 50 years, and those who see the supremacy of the collective as the enemy of the liberty of the individual have just about had enough.
The next few decades might be very unpleasant ones.
Don’t forget supply, Eric. The supply is capped. When that occurs and there aren’t any other mechanisms to prevent cost increases, if you throw more money at it, the cost just rises.
I didn’t forget. That was what I was driving at with point #3 and the bit in point #4 about the government bidding against itself.
With regard to the origins of political differences, Thomas Sowell has dedicated a lot of his lifes work to exploring this topic (though not so much lately).
I would highly recommend his book “A Conflict of Visions” as it delves into this via well known historical political philosophers.
mikeca’s did not complain about tort reform, which drives about 2% of medical costs. Instead he complained about people who don’t pay their medical bills, which drives about 2% of medical costs. I’m almost as dubious about tort reform as I am about manditory insurance. They both sound like human rights violations.
What we need instead of tort reform is medical process improvement reform. Doctors need strong incentives to find and then implement the simple procedural changes which save lives, rather than being bashed in court by silky tongued, silky haired, pseudo scientific spouters of specious speeches.
As regards medical deadbeats we need something like we have for child support deadbeats and unlike what we have for parental access deadbeats. You can’t get rid of the debts via bankruptcy and your wages will be garnished according to your ability to pay till you are all paid up or you die.
We also could use cheap catastrophic coverage via voluntary cross-state insurance pools.
As regards the supply problem, neither party has been talking about medical staff accreditation reform. That’s a shame.
Oh, and all regulation of medicine should be by the states. Medical care is almost never interstate and it is not commerce. It’s medicine. Medical insurance should be interstate, but it’s not commerce either. It’s either actuarial or medicine. (Many insurance plans were created by medical professionals.) If you would naturally use the word merchant to describe the people who drive the economic sector, it’s commerce. If the natural word is doctor or lawyer or engineer or miner or carpenter, etc., it’s not commerce and none of Congress’s business.
Yours,
Tom
Whoops. Cato points out: “It turns out the consumer price index for health insurance premiums fell by 3.2% in 2009.”
See http://www.cato-at-liberty.org/2010/03/04/health-cost-projections-to-2019-the-doc-fix-trick-again/.
My guess is that mikeca is looking at places like Massachusetts, where regulation is driving up cost, rather than the whole country.
Yours,
Tom
I call poopie on the idea that liberalism is “the fundamental belief that the collective is more important than the individual.” That’s just Ayn Rand’s pernicious influence, which has done so much to pollute thinking and rhetoric the last generation or so. And in a weird way too, because, like Marx, much of what she actually believed is nowadays forgotten by people who still tout a lot of her philosophy. (Which, granted, is also true for many other philosophers, including Karl Marx and Adam Smith.)
In point of fact, modern conservatives as a rule absolutely love collective action and back it with gusto. They are the absolute bedrock of support for collective action on military matters–with a bullet, and no sane person can deny it. Without conservative support, we wouldn’t even BE in places like Afghanistan and Iraq trying to build democracies there. And anyone who thinks that isn’t collective action, being taken with the belief that Americans collectively (and the world at large) will benefit, is simply not paying attention.
With the exception of the libertarian-oriented, conservatives also tend to love collective action on things like drug interdiction, and social conservatives also want to see massive collective action against things like pornography and other sexual activities.
Modern day conservatives–wildly unlike conservatives of a half-century or more ago I might add–tend to have an enormous blind spot about those massive collectivist enterprises known as publicly-traded corporations, about which I’ve written many times and will again. These large enterprises–which can only exist in the form they do because the state says they do, and which only have any rights because the state says they do–are purely, and nothing but, massive collectivist enterprises. Yet conservatives routinely use language describing them as if they are individuals. So, you know, being mean to Comcast Corporation is the same thing as being mean to Bob who works at Comcast.
No, I’m sorry, the truth is that with the exception of a few wild extremes (extreme libertarians, extreme Marxists, etc.) the truth is that modern-day conservatives and modern-day liberals both think they’re looking out for the individual, and both are deeply suspicious of some KINDS of collective action but highly supportive of OTHER kinds of collective action.
Liberals are deeply suspicious of corporations and view them as an enemy to individuals and to small enterprises. They seek a high degree of personal autonomy on non-economic matters, but are less inclined to care that much about autonomy on what they see as “social justice” matters, including things like health care and decent housing and decent wages. Conservatives seek a high degree of economic autonomy, up to and including the freedom to completely fail without help from anyone.
The truth is, the fight isn’t between those who seek more power for the individual vs. the collective, because both liberals and conservatives believe it is the individual they are putting first. It’s where they put the emphasis, where they put the importance, the emphasis, of individual autonomy vs. the need for group action.
The estimates I have seen suggest that cost of treating the uninsured drives up the cost of health care by 8-10%, while tort reform is maybe 2%.
There are many issues related to health care cost and some of them have been pointed out in this thread. Tort reform is an issue, but the usual reform, caps on non-economic damages, is the least effective. Only a small percentage of malpractice cases result in large non-economic damage awards. Most nuisance cases are settled out of court for small amounts and capping damages does nothing to discourage them. As I said before California capped non-economic damages from malpractice suites in the 1970s, and it has not done much of anything for health care costs in California.
It is not just licensing and regulatory issues that limit the number of doctors, doctors have long lobbied states to keep the number of students in medical schools limited. Limited supply of doctors is one factor in high costs.
Probably one of the biggest issues is there simply is almost no medical research on cost effective treatment. More than half of all medical research is funded by drug and medical device companies. This research is focused on verifying that the latest drug or device (ie. expensive) is “effective” at treating something so they can get FDA approval. These studies rarely compare the effectiveness with other treatments. Doctors just don’t know if the $100 a month drug is more or less effective than the $10 a month drug.
On insurance rates, the prices in employer based plans, which cover most Americans under 65, have only been going up like they always do. It is prices in the individual market that have been raising very rapidly this year. One large California company just raised individual rates by 25% average and as much as 39% for some people this year. The reason is that more younger, healthier people are dropping individual insurance leaving the companies with an older, sicker pool of customers. This is forcing more people to drop individual health insurance policies, causing premiums to go up even faster.
> The estimates I have seen suggest that cost of treating the uninsured drives up the cost of health care by 8-10%, while tort reform is maybe 2%.
Haven’t seen that estimate. Everything I’ve seen is much lower.
> It is not just licensing and regulatory issues that limit the number of doctors, doctors have long lobbied states to keep the number of students in medical schools limited.
Thanks for noticing that letting the government control the budget via politics rather than letting people control their budgets by mutual agreememt is another reason for less government interference in health care.
> Probably one of the biggest issues is there simply is almost no medical research on cost effective treatment.
The biggest issue is that there is no incentive for the individual patient or doctor or insurance company to lower costs because of moronic never mention cost christmas club health care plans rather than actual catastrophic insurance and revealed costs. The patient is always trying to maximize received care. The doctor wants to provide the best care regardless of cost, ’cause that’s principled and noble and heroic (see every hospital show pitting the noble doctor against the nasty corporate cost cutting hospital bureaucrat). It aso slims down the school debt like a tapeworm. And the highly regulated insurance company makes a percentage, so mo’ cost = mo’ profit just like every regulated utility.
Virginia Postrel talks about this. She bought two wigs when she had breat cancer because they were covered in accordance with California state law, even though she wore them only three times.
> One large California company just raised individual rates by 25% average and as much as 39% for some people this year. The reason is that more younger, healthier people are dropping individual insurance leaving the companies with an older, sicker pool of customers. This is forcing more people to drop individual health insurance policies, causing premiums to go up even faster.
A local problem caused by local regulations – typically community rating. Community rating was created by Satan, or Freddy Krueger, or at least that unpleasant family in the Toyota minivan commercials.
Yours,
Tom
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