March 31, 2012
Cancer v. the Constitution « Dr. Jen Gunter

The patient in the emergency department smelled of advanced cancer. It is the smell of rotting flesh, but even more pungent. You only ever have to smell it once.

[…]

She hadn’t gone to the doctor because she had no health insurance. The only kind of work she could get in a struggling rural community was without benefits. Her coat and shoes beside the gurney were worn and her purse from another decade. She could never afford to buy it on her own. She didn’t qualify for Medicaid, the local doctor only took insurance, and there was no Planned Parenthood or County Clinic nearby.

So nothing was done about the bleeding until she passed out at work and someone called an ambulance. She required a couple of units of blood at the local hospital before they sent her by ambulance to our emergency department.

[…]

She needed a biopsy to confirm the type of cancer and a CT scan to see if the tumor had spread beyond the cervix. If she were lucky, she would have a some combination of a hysterectomy, chemotherapy, and radiation with a 50-65% chance of survival. If the cancer had spread, she would have radiation and chemotherapy with about a 25% chance of surviving.

But the cancer surgeons were not allowed to offer an uninsured woman a hysterectomy. Every now and then they snuck someone in, claiming to the administrators that the patient was more emergent than they really were. But one surgery doesn’t cure stage 2 or 3 cervical cancer, or even stave it off for long. It takes multiple admissions and week after week of expensive chemotherapy and/or radiation.

The radiation doctors were also not allowed to see uninsured patients. They could not even give a dying women a few weeks of radiation to ease her tumor’s stench while it caused her to bleed to death or killed her another way. They could give her one dose today. A very temporary measure for the bleeding, but only if her blood count was low enough. It wasn’t because she’s had the blood transfusion to get her here.

There was a charity program that paid providers and hospitals pennies on the dollar for cancer care. One hospital had signed up, resigned to the fact that they were seeing those patients anyway so better to get something for the cost of the care than nothing. Our hospital administrators had declined to participate. Better to get no money and keep seeing these uninsured patients over and over in the emergency room, each time providing the same stop-gap care that has no hope of cure or even palliation like a purgatory version of Groundhog Day, than to be inadequately reimbursed for the right care.

I had never encountered this clinical scenario during my training in Canada. I had never seen a woman suffer because she couldn’t afford something as simple as a Pap smear, never mind deal with the indignities of shopping around her sorrow and hard luck to try to patch together what would inevitably be inadequate medical therapy. It is this reality of medical care in America for which I was wholly unprepared. Many times I found the residents comforting me.

I gathered my thoughts before explaining the situation. To get her care through the charity program there was a catch. A set of hoops to jump through and we could jeopardize her eligibility with specific tests. I explained the ins and outs of accessing care through the program, where she needed to go, and what specifically she must say. The Intern printed out the sheet of community resources and advocacy groups that might also be able to help her patch together some kind of treatment.

It’s not health care, not by any stretch. But as long as the Supreme Court finds it constitutional I guess they’ll sleep better than I do.

LTMC: Oh look; another person who avoids seeking healthcare due to short-term cash flow incentives until her condition has deteriorated to the point where she can no longer feasibly avoid seeking treatment, at which point, her financial position runs into the conflict-of-interest generated by a for-profit insurance model.

Nobody could’ve seen this one coming.

(Source: sarahlee310)

11:18pm  |   URL: http://tmblr.co/ZMMjnxItx_ge
(Notes: 31)
  
Filed under: politics healthcare healthcare reform universal healthcare 
March 27, 2012
The Case For A Single Payer Healthcare System

In a 2009 interview, Jon Cohn sat down with Dr. Michael Chen, Vice President and CFO of Taiwan’s National Health Insurance Bureau, the government office in charge of managing Taiwan’s government-run health insurance program.  Some excerpts from the transcript, via PNHP:

Jonathan Cohn (JC): You have what most people refer to as single payer health insurance - the government is the main insurer for everybody.

Dr. Michael Chen (MC): Yes.

***

JC: How did you decide on that model - the single payer? Why did you go in that direction?

MC: Well, we sent our people around the world to learn their programs, including the United States. Actually, the program is modeled after Medicare. And there are so many similarities - other than that our program covers all of the population, and Medicare covers only the elderly. It seems the way to go to have social insurance…

JC: Now, one issue that comes up in the United States when people talk about a single payer system, or even any kind of a system where the government is defining the benefits, there’s a big concern that there’s not enough choice. People in America… we want to know that you can choose the kind of insurance you want - how much coverage, what services. Is that an issue you dealt with in Taiwan? Was that a concern?

MC: Not at all, because in Taiwan the benefit package is rather comprehensive… We maintain a very long list for prescription drugs - more than twenty thousand items. And the benefit package includes inpatient, outpatient, and dental service which is usually not covered in this country.

JC: Now the flip side is that if you are offering such a generous package, that’s very expensive, is it not? I mean, how do you pay for it?

MC: Not the case.

JC: Not the case. What percentage ofGDP?

MC: Six percent of GDP,so that’s very affordable. The premium on average that the family pays is about two percent of the household income because the premium is shared by your employer.

JC: … In this country we spend far more than that, and even looking at Europe - Switzerland, France - they spend a lot more than that also. Are there waiting times for services in Taiwan? Is there something that people are going without? I mean that’s a lot of services for such a little amount of money. I’m trying to figure out what it is that you’re not getting.

MC: No waiting lines.

JC: No waiting lines? I can see a doctor any day I want…

MC: If you are not too particular.. you can visit even a specialist in a matter of minutes…

***

JC: … If I were to be sitting here with a doctor in private practice in Taiwan - I know in this country doctors worry a lot that Medicare doesn’t pay enough money and that it’s very bureaucratic - what kind of complaints would I hear from them?

MC: Of course, doctors would complain in public, but appreciate it in private - because, you know, especially in this economic downturn, how can you find an industry with assured growth rate annually? Right now they enjoy somewhere between four percent to five percent increased rate, and this is a sure thing.

Much like any institution or business, a single-payer system can be poorly run or competently run.  When they are competently run, most of the systemic horrors that people like to attach to “socialized” healthcare delivery systems become apocryphal phantasms.  That doesn’t mean people are never going to have trouble, or that tragedies won’t happen.  No system will ever be perfect.  But the question is which system is “least worst” among those that are available.  Taiwan’s system is both viable and effective without sacrificing outcomes or access.

Ezra Klein notes that if the Individual Mandate in Obamacare is ruled unconstitutional, then Progressives will be left with no way to achieve universal health insurance coverage without pressing for a single payer program.  Interestingly enough, I’m sure conservatives would very much prefer Obamacare (or perhaps Romneycare) over a single payer system.  But in the absence of these programs, all we are left with, it seems, is a giant tax credit, which does nothing to solve the problem of pre-existing conditions.  Private insurers will continue to deny coverage to people with pre-existing conditions who are not profitable unless they have a mandate that forces everybody to pay in to the risk pool, which allows them to use the premiums of healthy (i.e. profitable) people to pay for the care of sick (i.e. unprofitable) people.

If the rest of the civilized world is any indication, market-driven delivery systems for health insurance are a beast of antiquity.  That’s because no amount of deregulation or tax credits can resolve the anti-patient incentives that health insurance companies must reconcile.  It remains the only industry in America where, the more you need their product, the less they want to give it to you.  That’s an impossible dichotomy to reconcile without regularly screwing people over.  As one J.C. might put it, you cannot serve two masters.

We know that other approaches work.  We know that ours doesn’t.  Taiwan’s system has an 80% approval rating.  In America, it’s closer to 50% on a good day.    So if the mandate is found unconstitutional, Conservatives may find themselves in a difficult position, because the only route to universal healthcare at that point is through a single-payer system.  Indeed, if the mandate is struck down, that may be the political capital that progressives need to get single-payer on the national agenda.  Winning the battle, for Conservatives in this case, may mean losing the war.

5:07pm  |   URL: http://tmblr.co/ZMMjnxIfXH0u
(Notes: 38)
  
Filed under: politics healthcare healthcare reform individual mandate taiwan universal healthcare 
March 19, 2012
Some Daylight On The Right With Healthcare Reform

Matt Sheffield, founder of the Right-leaning website Newsbusters, has written a relatively sane piece about healthcare reform in which he approvingly quotes Avik S.A. Roy, who discusses Switzerland and Singapore’s universal healthcare system:

One of the most frequently-made arguments in favor of socialized medicine is that it saves money, relative to the American system. And it is true that Europeans et al. spend less per-capita, and as a percentage of GDP, than we do. But the pro-socialism argument has a glaring weakness: it ignores the two most significant examples of market-oriented universal coverage in the developed world, Switzerland and Singapore, where state health spending is far lower than it is in other industrialized nations. Neither Switzerland nor Singapore could be described as libertarian utopias—both systems contain aspects that conservatives wouldn’t like—but they provide powerful examples of how market-oriented health care systems are more cost-efficient than socialized ones.

Sheffield then refreshingly admits that the Right has never put forth an honest, coherent alternative to Obamacare:

The reason we have Obamacare is that the Right, once it stopped supporting the individual mandate, has not aggressively put forward a market-based solution to the problems that plagued the American health care system.

Ideas have been thrown out there in the past, but simply throwing them out there isn’t enough, especially now that Obamacarehas been put into law. Policy abhors a vacuum. We had a healthcare policy before Obamacare, and we will have one after Obamacare. Conservatives owe it to America to propose free-market policies to replace Obamacare.

It’s nice to see some introspection on this topic from the same folks who were for a mandate before they were against it.  But putting that aside for a moment, I find this entry from Roy intriguing:

The Swiss and Singaporean models wouldn’t be perfect models for America; we would want to replace the Swiss individual mandate, for example, with a more market-oriented approach like allowing people to opt out of buying health insurance if they also agree to forego subsidized care. But both Switzerland and Singapore embody the most important principle of all: shifting control of health dollars from governments to individuals.

This is where advocates of a market-oriented approach to healthcare reform continually fall down.  The only reason that this opt-out would be necessary is if the person opting out wanted to stay uninsured voluntarily.  In which case, they’ll certainly opt out of subsidized care…up until the time they have a catastrophic injury or illness that requires medical intervention.  Which once again, takes us to the crux of the healthcare debate: when someone shows up at a hospital looking for medical care that they can’t pay for, you have two choices: 1) give them the care they need, and make someone else pay for it, or 2) deny them care.  Option #1 is the definition of subsidizing the individual’s care. Option #2 is morally untenable for the vast majority of people.  And the notion that private charity would pick up the slack is counterfactual, to say the least.

Removing the mandate also makes it impossible for insurance companies to cover people with pre-existing illnesses whose coverage would result in a net loss for the company.  You can’t get universal coverage with a market-based approach without a mandate.  You need everyone paying into the risk pool so the unused premiums of healthy people subsidize the care of people with chronic and/or serious health issues.  

In other words, Roy and Sheffield want to imitate everything about Switzerland and Singapore’s healthcare systems that make it successful, except the parts of the system that make it successful.

As Fareed Zakaria noted this evening, just 5% of Americans account for 50% of America’s healthcare spending.  That’s an enormous disparity.  And given the fact that we all consume more healthcare as we get older, it’s a safe bet that most of us will end up in that 5% at some point in our lives.  So this isn’t an issue of subsidizing irresponsible people.  It’s about subsidizing the care of people who the private sector won’t cover because it’s not profitable.  Either that, or we start letting hospitals shut down Grandma’s/Uncle Joe’s/Little Timmy’s respirator once their family’s estate is bled dry.  Or, alternatively, to stop treating you or a loved one’s cancer in the same event.  Call that scaremongering if you wish, but this sort of thing already happens to people on a regular basis.  So this isn’t hyperbolic bluster.  It’s the status quo.

I’d be happy to hear a policy proposal from Sheffield et al. where this doesn’t happen.  I want to hear the market-oriented solution to healthcare where people with pre-existing conditions can get access to affordable health insurance without a mandate or a gov’t-subsidized program of some sort.  Sheffield himself admits that this solution has yet to be forthcoming.  I suspect they haven’t found it yet because it doesn’t actually exist, which explains why Right-leaning thinkers supported mandates in years past as the market-oriented solution to healthcare reform.  We are now at a point where that solution is apparently no longer tenable.  And all we are left with is tax credits.  An example of Epistemic closure at its finest.

12:34am  |   URL: http://tmblr.co/ZMMjnxIDsnfL
(Notes: 22)
  
Filed under: politics healthcare healthcare reform universal healthcare 
March 16, 2012
"

Twenty years ago, Switzerland had a system very similar to America’s - private insurers, private providers - with very similar problems. People didn’t buy insurance but ended up in emergency rooms, insurers screened out people with pre-existing conditions, and costs were rising fast. The country came to the conclusion that to make health care work, everyone had to buy insurance. So the Swiss passed an individual mandate and reformed their system along lines very similar to Obamacare. The reform law passed by referendum, narrowly.

The result two decades later: quality of care remains very high, everyone has access, and costs have moderated. Switzerland spends 11% of its GDP on health care, compared with 17% in the U.S. Its 8 million people have health care that is not tied to their employers, they can choose among many plans, and they can switch plans every year. Overall satisfaction with the system is high.

"

—

Fareed Zakaria

Like I said, universal health care has worked in many countries for decades. The evidence is overwhelming.  

(via prettayprettaygood)

LTMC: whatever do you mean?  Socialism has ravaged Scandinavian welfare countries.  Just look at this hellhole:

what a wretched monument to tyranny.

(Source: prettayprettaygood)

9:16pm  |   URL: http://tmblr.co/ZMMjnxI5uDan
(Notes: 61)
  
Filed under: politics universal healthcare switzerland 
March 4, 2012
Why An MRI Costs $1,080 In America And $280 In France

On Friday, the International Federation of Health Plans — a global insurance trade association that includes more than 100 insurers in 25 countries — released more direct evidence. It surveyed its members on the prices paid for 23 medical services and products in different countries, asking after everything from a routine doctor’s visit to a dose of Lipitor to coronary bypass surgery. And in 22 of 23 cases, Americans are paying higher prices than residents of other developed countries. Usually, we’re paying quite a bit more. The exception is cataract surgery, which appears to be costlier in Switzerland, though cheaper everywhere else.

And why is this the case?  The government negotiates with private companies on behalf of the largest risk-pool possible; the nation as a whole:

Other countries negotiate very aggressively with the providers and set rates that are much lower than we do,” Anderson says. They do this in one of two ways. In countries such as Canada and Britain, prices are set by the government. In others, such as Germany and Japan, they’re set by providers and insurers sitting in a room and coming to an agreement, with the government stepping in to set prices if they fail.

Something which America, of course, doesn’t do:  

In America, Medicare and Medicaid negotiate prices on behalf of their tens of millions of members and, not coincidentally, purchase care at a substantial markdown from the commercial average. But outside that, it’s a free-for-all. Providers largely charge what they can get away with, often offering different prices to different insurers, and an even higher price to the uninsured.

And the money quote:

Health care is an unusual product in that it is difficult, and sometimes impossible, for the customer to say “no.” In certain cases, the customer is passed out, or otherwise incapable of making decisions about her care, and the decisions are made by providers whose mandate is, correctly, to save lives rather than money.

In other cases, there is more time for loved ones to consider costs, but little emotional space to do so — no one wants to think there was something more they could have done to save their parent or child. It is not like buying a television, where you can easily comparison shop and walk out of the store, and even forgo the purchase if it’s too expensive. And imagine what you would pay for a television if the salesmen at Best Buy knew that you couldn’t leave without making a purchase.

Precisely.

3:28pm  |   URL: http://tmblr.co/ZMMjnxHTJhDz
(Notes: 167)
  
Filed under: politics healthcare healthcare reform universal healthcare 
February 28, 2012
In Defense Of Britain’s NHS

From a 2010 LA Times article, preceding the implementation of Britain’s austerity package:

Britain is about to undergo an extreme makeover. And Festus Grant is worried.

The 71-year-old was crippled by a stroke early this year, and he doesn’t know how he would have coped without the “angel of mercy” who knocked on his door a few days after he came home to his modest flat after three months in the hospital.

The care worker from the Stroke Assn. helped him piece his life back together.  She arranged follow-up trips to the doctor and signed him up for a shuttle service that takes him shopping once a week.

But her visits are set to end in a month. Funding for her program is being axed, a victim of budget cuts by the local authority.

“She has been there for me…. I wouldn’t know where to go, what to do,” said Grant, who walks with difficulty and whose right arm is nearly useless. “Her work is very important, not just for me now, but others who will follow me.”

The cutback is part of the most stinging national austerity plan in decades, one that will shrink the British state to a degree not even former Prime Minister Margaret Thatcher, with her passion for small government, was able to accomplish 30 years ago.

Of all the universal healthcare systems in the western world, Britain’s is probably the most problematic.  Still, stories like this are a reminder of why the NHS maintains the support of staggeringly large majorities of the British population.  People tolerate its flaws knowing that what they get in return is often precious and priceless.  People in Britain are more scared of not being able to afford healthcare than they are of having to wait for it.  That’s a lesson, in my view, that America still desperately needs to learn.

10:32pm  |   URL: http://tmblr.co/ZMMjnxHDKFt2
(Notes: 9)
  
Filed under: politics healthcare britain nhs healthcare reform universal healthcare 
January 16, 2012
European Socialists Are Better At Capitalism Than America

I wrote a post recently in which I explained the idea that civil liberties and universal healthcare are not only compatible, but in many ways co-necessary to preserve and maximize personal liberty within a practical framework.  You can see this exemplified in countries like Norway, where police officers don’t even carry firearms, prisons are more like Rehab centers than dungeons, and their response to terrorism was more democracy.  All this while government spending accounts for roughly 45% of Norway’s GDP.

With this being said, let me ask you a question: how much do you pay for your smart-phone plan?  ArsTechnica has reported on cell-phone plan pricing in France, where a company is offering unlimited talk, text, and 3G web access for 20€/month:

Remember when AT&T tried to buy T-Mobile last year for $39 billion, and how it kept insisting that reducing the number of national wireless carriers from 4 to 3 wasn’t a problem because the market was just so competitive? If you want to see what real competition looks like, turn to (gasp) France, where the hugely popular Free.fr broadband provider just blew the doors off the mobile marketplace with its €20month unlimited use plan.

This was a story too important to bury beneath the deluge of gadget news pouring forth from CES. Free has long been one of France’s most popular Internet providers. When we profiled them back in 2009, the company was offering 20-30Mbps Internet, free landline phone call to 100 nations, and TV service along with an HD DVR for €30 (US$45) a month.

…This last week, Free dropped a nuke on the wireless business, too. For €19.99, subscribers can get unlimited calls to mobile and fixed line phones in France (and to fixed line phones in 40 other countries). They get unlimited text messages. They get unlimited 3G data (with a “fair use” policy). They get net neutrality. And they get it all without a contract.

It gets better. If you subscriber to Free broadband, the wireless phone service costs only €15.99 a month.

Finally, light users can have 60 minutes and 60 texts for €2 a month—and Free broadband subscribers get it free.

This story also comes on the heels of the Heritage Foundation’s 2012 Index of Economic Freedom, in which 9 countries ahead of the United States all have some form of universal healthcare, most of which are accompanied by a robust safety net.

These anecdotes and the Heritage rankings demonstrate an important point: the inefficiencies inherent in any system of public redistribution are netted out by productivity gains which inure from distributing healthcare costs across society as a whole, rather than placing them solely on the individual.  In an era where access to healthcare can easily become a six-figure venture, we can’t reasonably expect individuals to bear the burden of their treatment alone.  62% of Americans who filed for bankruptcy in 2007 were linked to medical expenses, and 80% of people who filed in the same year had health insurance.  I challenge you to find a statistic that is more damaging to the credibility of America’s healthcare system, or that demonstrate so profoundly how economically inefficient our system is.

This inefficiency is part of the reason why virtually every other 1st-world nation has come to the conclusion that publicly-funded, and yes, socialized healthcare schemes are superior to the private-centric alternative.  People don’t consume healthcare the same way they consume other goods.  Public health functions as a floor for all other economic activity.  The fact that you can get an amazing cell phone plan in France for nearly half what it would cost from America’s corporate giants exemplifies the trend: countries with universal healthcare and robust safety nets tend to be more practically free than countries without.  A shibboleth-like fetishism of perfected individual liberty in economic matters tends in practice to lead to the exact opposite, as it has in America.

12:52pm  |   URL: http://tmblr.co/ZMMjnxEs_UAN
(Notes: 87)
  
Filed under: politics economics economy european socialism europe france cell phones universal healthcare healthcare healthcare reform 
January 13, 2012
Heritage Foundation Study: Canada Is Freedomier Than the United States

ilyagerner:

The interesting thing, besides the discovery that Heritage analysts are actually Canadian infiltrators (admitting that other people are better than you was the giveaway), is that many policy interventions that are controversial in the United States come standard in the high-ranking countries.

Hong Kong’s public healthcare system is still modeled on the Beveridge Plan that created the British NHS. Canada is well regarded for its single-payer insurance scheme known as Death to Grandma Medicare. Switzerland joined the universal healthcare club in 1994. The Danes contribute 49% of the nation’s GDP to taxes. Every country in the top 10 has a higher union density than does the United States.

It’s almost as if systems of subsidized heath-care, egalitarian tax and spending schemes and pro-labor policy can be a part of “freedom.” 

LTMC: It’s almost as if civil liberties and universal healthcare are not only compatible, but one tends to follow the other.

Hmmm…

2:39pm  |   URL: http://tmblr.co/ZMMjnxEitVoK
(Notes: 54)
  
Filed under: politics healthcare universal healthcare canada heritage foundation healthcare reform 
January 5, 2012

individualgait asked: I just read your article on Civil Libertarianism And Universal Healthcare, and I just want to say what a pleasure it was to read. I am a strong advocate of civil liberties, but I am also a believer in the importance of universal healthcare and education in particular. I believe that without education and healthcare, people cannot be actually free. A lot of libertarians seem to believe that money = freedom, but without education and health, how can you earn money?

Well said.  Public Education and healthcare essentially spread the cost of two expensive but necessary aspects of any technologically and socially advanced society among all of its citizens.  The end result is that the cost of medical services are lower in countries with robust public education and healthcare programs because medical professionals don’t need to take out over $200,000 in loans in order to become educated, so they can live comfortably off much lower salaries.

12:25pm  |   URL: http://tmblr.co/ZMMjnxEI_8-r
(Notes: 7)
  
Filed under: politics healthcare universal healthcare public education 
January 5, 2012
Civil Libertarianism And Universal Healthcare

basedgodtrilla asks me the following question:

[H]ow do ‘civil libertarian’ and ‘proponent of universal healthcare’ go together[?]


Short(ish) Answer:

Civil Libertarianism is not Economic Libertarianism.  It’s the difference between how much of your paycheck gets taken in taxes, and what you’re allowed to actually do with the money you keep.  It’s the difference between being allowed to earn money, and being allowed to spend it on whatever you like, and to use the proceeds in whatever manner you like.

An absurd example demonstrates the distinction: if you were allowed to keep 100% of your paycheck, but 100% of possible purchases were banned by force of law or by virtue of circumstance, your ability to keep your entire paycheck is of little use to you.  Now apply that logic to health insurance.  being taxed less doesn’t help you when you have cancer, and your private insurance company is desperately trying to find any excuse to drop your coverage.  It is little comfort to tell someone with a pre-existing condition that they are “free” to choose any health insurance they like, when those insurers are also “free” to turn them down; at which point, in the absence of EMTALA-style laws, you will then be “free” to die.  And I think we can all agree that dying sort of defeats the purpose of having freedom in the first place.


Long Answer:

First, let’s start with negative v. positive liberty.  Negative liberties are those liberties which exist in the absence of any external influence.  Every liberty you have in the state of nature is the full scope of your negative liberties (state of nature = absence of civic and/or governing institutions).  Positive liberty, on the other hand, is liberty which exists only by virtue of an external influence.  In 99% of cases, that external influence will be a law.  

What is important to understand is that in the state of nature, every person is free in every way imaginable.  The problem with the state of nature is that freedom without limits extends to your freedom to trespass upon the life, liberty and property of others.  Some libertarians try to make a “theoretically nice” distinction here by saying you don’t actually have this liberty, but this is a misunderstanding of what “natural liberty” is.  You can’t just declare by ideological fiat that natural liberty doesn’t extend to your liberty to “tread” upon others.  The lion has the natural liberty to hunt the gazelle.  The squirrel has natural liberty to steal eggs from a robin’s nest.  Neither of these animals seem too awfully concerned with libertarian theories about the moral limitations of natural liberty.  To say that humans can do less in the state of nature than the lion and the gazelle is to do violence to the very definition of natural liberty.  

Under these circumstances, the diversity of humanity’s experience will create adversarial relationships by virtue of competition for scarce resources.  Even if we were to assume that people are basically good, that they tend to cooperate rather than compete, and that they will form large societies without seeking to form a government, it remains the case that humanity is diverse enough that individuals will act on their biases.  In doing so they might collectively create a society in which a particular group of people is systematically denied access to resources they need to thrive.  When this situation occurs, and the natural process of “market” selection does not seem to be solving the problem, the creation of positive liberties through force of law generally becomes necessary to alleviate this condition.

Examples of laws which create positive liberty are the Civil Rights Act(s), the Voting Rights Act, and the Americans with Disabilities Act.  Also, government programs such as Medicare, Medicaid and Social Security ostensibly increase positive liberty as well, which I’ll return to in a moment.

In order to explain why Universal Healthcare is compatible with (and in my eyes, a function of) Civil Libertarianism, you need to ask yourself what freedom actually means.  If you think hard enough, you will discover that absolute “freedom” can fail to be useful when all individuals within a society exercise that freedom so as to deny you access to resources you need.  When an employer refuses to hire you because you’re a woman, or a business owner refuses to serve you because you’re Black, you are, in a very real sense, being denied personal liberty.  And it’s a direct result of them exercising their personal liberty to choose whether they want anything to do with you.  Your inability to access certain spaces in society constitutes a very real restriction on your freedom.  When this happens, the only way to preserve your actual freedom to create it positively through external influence.

When one pre-supposes civil society, it is often the case that the only way to preserve liberty in these situations is to apply the force of law.  Consider the fact that the 6th Amendment guarantees you the right to legal counsel in all criminal cases.  However, legal counsel costs money.  So what happens if you’re too poor to afford a lawyer?  Under a paradigm of negative liberty, you’re shit out of luck; negative liberties include only those to which you have access in the absence of any external influence.  So negative liberty isn’t going to save you in this situation.  

In the situation above, you have two options: you’re either shit out of luck, or society must create a mechanism by which the poor can have access to legal representation.  That mechanism necessarily involves an exercise of State power.  The freedom of poor individuals to be protected from criminal charges is thus preserved by virtue of a redistributive act: people contribute taxes to the government, which then uses those tax dollars to hire Public Defenders for poor people.  

This is a textbook example of positive liberty: the government literally redistributes wealth through taxation of those with resources, and distributes it to those without, so that the freedom of the latter group can be preserved when they face criminal charges.  By redistributing such wealth, it preserves the life and liberty of the indigent, who would otherwise be marginalized by virtue of their indigency.

What does all of this have to do with Universal healthcare?  If you are sick or injured and can’t afford medical treatment, your position is not that different from a poor person facing criminal charges.  You are in need of a service to preserve your life and liberty, but lack the resources to provide it.  Other people in society, however, do have those resources.  And private health insurance companies aren’t exactly giving away free MRI’s and chemo treatments during the holidays.  That denial can result in an empirical loss of liberty.  Let’s briefly examine the form of private insurance to explore this further.

There are generally two ways to organize a private insurance system: the first is through an employment-based system where your access to health insurance will generally depend on maintaining gainful employment.  The other way to organize private health insurance is to have it be entirely the purview of the individual.  Under the latter system, employers would ideally just pay their employees the difference of what it costs to provide them with health insurance, and allow them to seek coverage on their own.

But the problem with individual health insurance markets is that some people won’t qualify for coverage due to pre-existing conditions.  Coverage will also be more expensive because they have no real bargaining power as a single consumer.  The advantage of employer-based health insurance is that the entire company constitutes a risk pool.  That pool becomes a bargaining chip through which employers can convince insurers to lower their per capita premiums, and also to cover individuals who might otherwise not be able to attain health insurance on their own.  

The problem with employer-based coverage is that it often traps people in their jobs that might otherwise leave to pursue other vocations.  Let say you want to leave your current job and start a business.  But you also have a family with young children, and your spouse is covered through your employer.  If you leave that job, your entire family will become uninsured.  All of a sudden, that great entrepreneurial idea you had can’t be translated into useful economic activity, because you feel bound by the circumstances of your job.

Are you “free” in this situation?

With a universal healthcare program, you wouldn’t have to worry about your family.  You could switch jobs anytime you like, and your kids would still be covered.  This is part of the reason why countries  like Norway can have extremely high tax rates (~45% of GDP) and universal healthcare, and yet they have a Purchasing Power Parity (PPP) that is roughly $5,000 higher than the U.S.  Norway also spends less on healthcare than we do for better outcomes.

Now put this in the context of society at large with respect to civil liberties: Norway’s police officers don’t even carry weapons, and there response to terrorism was more democracy.  Meanwhile, in America, the NYPD spies on American citizens, violates the constitutional rights of peaceful protesters, and brags about being able to shoot down military aircraft.  The President thinks he has a right to kill me without access to the courts, the federal government deports children without even cursory investigation, the police have tanks and aerial drones, and if they fuck up, chances are they’ll be immune from liability.  And if the police initiate force against me without cause, I have a legal duty to let them kill me.

In Norway, not only do the cops not have missiles, but I am free to walk into a hospital and receive medical treatment no matter who I am or how much money I have.  I always have that freedom, regardless of where I work, or how much money I make.  In America, that’s not the case.  A lack of resources can essentially deny me that freedom.  Losing my job could deny me that freedom. That doesn’t happen in a nation with universal healthcare.

That is how universal healthcare is compatible (and for practical purposes, necessary) to a functional civil libertarianism.  Freedom which is “literally” maximized does me no good if I cannot practically access the resources or services I require to thrive.  Even in a completely pure free market, some people are going to fall through the cracks.  And the lesson of modern economies is that it doesn’t have to be this way.  Creating mechanisms of redistribution, such as universal healthcare, that create a functional guarantee to certain resources, e.g. healthcare, ensures that my freedom to access them is preserved from misfortune by happenstance, or by the collective acts of other people in society, whose consequences materialize to my detriment in unforeseeable ways.

Orthodox Libertarians call this slavery.  But I have yet to meet a doctor or nurse who feels their legal obligation to treat a patient regardless of ability to pay is equivalent to the yoke of a hebrew tribeseman or a plantation slave from the Antebellum South.  I feel freer in a country like Norway than I ever would in America, for all the reasons stated above.  And it’s due in no small part to the existence of a universal healthcare program.

UPDATE: logicallypositive has written a libertarian-oriented response to this post, which you may read at your leisure.

12:16am  |   URL: http://tmblr.co/ZMMjnxEHvnHN
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Filed under: politics universal healthcare civil liberties libertarianism healthcare healthcare reform 
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