The health care debate has gotten very, very muddled. Most of my reading on the subject is by progressives (writing either for other progressives or for a general audience as an attempt at conversion), or by libertarians for libertarians. There is a pattern I have noticed that I think is worth addressing: progressives tend to see either One Big Healthcare Issue, or lots of issues with the same solution. Libertarians (as personified by me) tend to see hundreds of small issues that are going to need individual solutions. Which is interesting, because it's the reverse of the usual pattern, in which I think everything could be solved by introducing competition and progressives think we need an expert to tailor a solution to the specific problem.

So here are some of the individual problems I see, and short versions of my preferred solutions.

Problem: People can't afford health insurance/health care.

Give them money. To be fair, this is my solution for all problems relating to poverty. It sounds glib, but I'm being sincere. If we want to place a floor on the consumption of adults, we should just do that. If people are not using the money on the things we want them to, we should reevaluate our wishes or their ability to take care of themselves. Alas, this gets considerably more complicated if children are involved.


Problem: Health insurance is too expensive/increasingly expensive.

Insurance profits are reasonable and have not been rising in recent years. What you are seeing is a rise in the price of health care itself.


Problem: Health care is too expensive/increasingly expensive.

This is sometimes called "health care inflation", which is misleading, because much of the increase comes from the introduction of new things to buy. It's like saying we've had smart phone inflation since 2000. You could make the problem go away by not buying new things.

Some of it is that we're consuming more things. I am maybe the only person who liked Obamacare more after she heard about the death panels, because the alternative was everyone deciding for themselves how much of other people's money they wanted to spend on their own health care. Also, it's still not inflation in the technical sense of the word, any more than we experience produce inflation when I double my banana consumption.

However, some of it is genuine inflation , brought on by Baumol's cost disease (short version: if you have two sectors, and one gets more labor efficient, the other one experiences inflation). There are three solutions: pay workers less for the same job (which every politician ever has promised not to do, because health care professionals are sympathetic, have money, and vote), shift work to lower-wage workers (which we are trying, via things like nurse practitioners and physician's assistants. I am in favor of this but think it bears monitoring before we declare it a total success), or invent labor saving devices (which we have actually done some good at, but since in many cases the replacements are themselves expensive, we won't see returns until they go off patent). I am totally in favor of investment, both public and private, in labor saving devices. But we can't do that by wishing really hard, we have to work with the market we have and adjust if it improves later.

Problem: Wait a minute, you skipped over a possible solution. We could just pay less for the new things.

Okay, technically that's true, but it's a one time savings. Profits are what motivate pharmaceutical companies to make new things that let me live longer. I think our patent system actually does an excellent job here, providing some time to make money and then providing the drugs nearly at cost for all eternity (I have no opinion on the proper length of that first period).


Problem: why don't we just cut out the middle man and do it ourselves?

That is a good idea. There are definitely inefficiencies in the current model. But how do we do that? University research isn't directly translatable into usable drugs. There are many possible improvements to this model, and I am fully in favor of government funding for them as pilot projects, but I would like to see them work before we shoot the old model in the back of the head.

Problem: Even if the increase in insurance costs are due to care costs, couldn't we get a one time boost by removing their inefficiencies?

Yeah, maybe. There certainly are inefficiencies introduced by having 40 different billing systems. But considering that the government's systems are the most complicated and time consuming of all, I don't see them fixing it.

Problem: Health insurance is linked to employment.

Yes, this is deeply stupid. There are two causes: one is that the government subsidizes employer-provided insurance by not taxing it as income. This is stupid and they need to stop doing it.

The second is that employment is a way to get around adverse selection and the resulting insurance death spiral. This one is harder to solve. We probably can't fix the information asymmetry, which leaves mandating everyone purchase insurance. There are two problems with this: done by the federal government, it is either unconstitutional or stretches the commerce clause to the point that it can do anything. State governments can do it constitutionally, but still risk what happened in Massachusetts: originally advertised as mandating only catastrophic (i.e. true) insurance, the bill bloated until it mandated all kinds of care (because lobbyists bought the clauses), raising the premiums considerably. (My impression is that the conclusion progressives draw from this is lobbyists and/or money has too much power over politicians. The conclusion I draw is that we should minimize the number of things government can mandate so that there's no point in bribing politicians).

Note that Obamacare introduced mandatory issue (insurers must insure everyone that asks) and community rating (insurers may not charge more for riskier people) years before mandating purchase (everyone *must* purchase insurance). This is the worst possible thing.

So it's a stupid system, but it will be very hard to transition to something else.

Problem: what was that snarking about "true" insurance?

Insurance means insulating you from rare, extremely costly, unpredictable events, like car accidents and cancer. What gets called insurance today is often just 3rd parties paying for routine care, like vaccines and annual check ups.

Kathleen Sbelius, United States Secretary of Health and Human Services, got this exactly backwards .

Problem: but preventative care lowers the costs for the insurance company, so it still makes sense for them to pay for it.

This is just not true. Very little preventative care lowers the total cost of care over someone's life, because we just keep treating you until you die. Everyone dies of something, and the causes get more interesting and expensive the older you get. Even if the cost was exactly the same, you've been alive for longer and sucked up more money for annual care. The only things proven to actually lower costs are vaccines, dental care, and pre-natal care. You can argue about preventative care being a more cost effective way to raise life span or Quality Adjusted Life Years, but that is a different issue. To the extent that it is true, the gains don't accrue to the insurance company. This doesn't mean preventative care isn't an excellent thing, but excellence and money saving are not synonymous

Problem: The same care costs a lot more when you pay out of pocket than when insurance covers it, and with a lot more uncertainty and anxiety too.

This is a big problem. I don't know how to solve it and am interested in hearing ideas.

This is all very hard to argue at cocktail parties. The other side has some very good visuals and easy to explain solutions. I have a lot of graphs and arguments about highly distributed long term consequences.

In a pleasant change of pace, I actually like the positions of the presidential candidate I'm protest voting for.* Usually I kind of grimace at the candidate who claims to be libertarian but is nonetheless pro-forced-pregnancy, pro-drug war, and anti-immigration. The first thing Gary Johnson says about immigration is that it should be easier, he's pro marijuana legalization and favors a harm reduction approach to harder drugs, and... well, he doesn't list his abortion position on his website. The internet tells me he's pro-choice until point of viability, things Roe v. Wade was wrongly decided (which I don't love, but will accept from someone with a consistently limited view of the commerce clause), but is in favor of parental notification and general roadblocks to abortion (unclear what this would mean if abortion was a state issue), and signed the bill against Medical Procedures That Sound Icky** (damnit Johnson, I want to like you).

On attorney general, I swore if there was a non-prosecutor running I'd vote for them, but then the non-prosecutor bragged about his work prosecuting software piracy. I'm probably the most sympathetic to this issue you can possibly be, and even I don't think you can count assisting Microsoft earn marginally more money as helping the downtrodden. But then the prosecutor bragged about an award from Josh Ashcroft. I may never find an AG candidate I like.


*Relax, I've never lived in a state whose presidential vote was in the slightest doubt.

**or as its proponents call it, the partial birth abortion ban.

When libertarians talk about drug policy, they tend to talk about the damage done to people who did nothing wrong. The wrong house raids are especially for this, because everyone can imagine themselves sitting at home not using drugs, but you can also get a lot of mileage out of pretty, well-employed white people who smoke pot, or poor POC suffering for family members' crimes. We use these because it's easier to see the damage done by the drug war without the compounding variables. But that doesn't make it right to use those weapons against mediocre human beings. Petty thieves, deadbeat dads, people who hurt people all deserve to be punished for their specific crimes. It is still morally wrong and damaging to society to execute a no-knock warrants, use flash grenades, and kill pets in search of their drugs.

Similarly, I think when abortion access advocates say "but rape victims", what they mean is "here is the case with the fewest compounding variables. Surely, after stripping out the variable of sex, you can see that forcing someone to undergo a pregnancy and then either raise a child or leave them to be raised by someone else is wrong. And once we've established that, you can see that sex really has nothing to do with it." But what anti-abortion advocates hear is "we're conceding that not carrying a pregnancy is a privilege to be earned through good behavior. Let's debate what you have to do to earn it."

This is what I think about when I read articles like this and this. Pregnancy and childbirth are not just uncomfortable and painful, they are not just risky in some abstract sense of the word. The carry with them the serious chance of permanent damage to a woman's body. And not just "ha ha, women care about being fat" consequences either.* Painful sex for the rest of her life is the least of consequences mentioned in that NYT blog post (read the comments). This is why I was most disturbed not by Todd Akin's ignorance of basic biology, but by the sentence

“But let’s assume that maybe that didn’t work or something. I think there should be some punishment, but the punishment ought to be on the rapist and not attacking the child.”

because it completely ignored the existence of the woman who wanted the abortion. She just wasn't there.

*Although, I think it is 1. legitimate to wrestle with a fundamental change in your body and the lack of control it implies, 2. naive to think that women who become less conventionally hot don't suffer for it, and 3. misogynistic to shame women for noticing that.

Money is not a real thing.

It's okay. Inches and minutes aren't real things either. What they are are ways of measuring things. Inches measure how long something is in one physical dimension, minutes measure time. We use them because it makes comparison easier. But it's easy to see how an inch of vegetable is equal to an inch of desk. Money is tricksy because it has a physical form and what it measures is more abstract, but fundamentally, money is a measure of how much a society wants a thing, relative to how rare it is, modified by how much people want things made by the people who want the thing in question.

It's not a perfect metric of this. Information asymmetric can distort it, different people have different preferences, and humans aren't great at math. But it is pretty fucking useful. Before money, you either made what you wanted, or bartered what you had for what you wanted, which required someone else with, roughly, a valuation of the two things involved that was the inverse of yours (i.e. they want A more than B, you want B more than A). This is tricky to find, and time consuming, and while it's hard to measure without money, value is lost in that friction. So when money comes along and lets you improve your position as long as there is someone who values what you're trying to sell more than you value it, and someone else who values what you want less than you do, it's a great boon for everyone.

So money is an easy way to keep track of who has more and nicer stuff. But if money went away, the amount of stuff would not actually change. England has much tighter restrictions on campaign funding than America does. But money isn't a spell component for conjuring votes, it is used to buy things like time on the TV. Removing money doesn't make time on the TV less important, it just means it's being allocated some other way- like, for example, the whims of the station owner, who will be heavily influenced by their personal politics and the candidate's support of the media. I think this is strictly worse than being determined by money, because, however hard it is to make money when you don't have any (and it is very hard), it is harder to make friends with influence when you don't have any.

Which is not to take campaign reform off the table entirely. It is simply to argue that looking at it as a problem of money is a false trail.

I stopped reading Pandagon when it moved from being a policy blog to a political blog. I like ready about policies I disagree with, those are informative and interesting. Reading Amanda Marcotte call another Republican a dickless wonder? Less so. I gave it another shot yesterday, and have had my decision more than confirmed.

I realize it was SOP in pundit circles to think [Newt Gingrich] ever had a chance against Romney, because it is true that your average Republican voter likes him way more than they like Romney. After all, they believe he pisses off the liberals, since that's what they remember happening last time they tuned in to what liberals were actually thinking in 1995. Pissing off the liberals is the fundamental urge of the wingnut, after all. It's a primal urge that fills in the holes where your sex drive used to be.
...
(Anti-choice nuts are excluded from this, of course. They are like subway masturbators. They know they're inappropriate, and that's what gets them off.)

...because you see, people who disagree with Amanda Marcotte are not merely wrong, they are uninformed children who are deliberately wrong for the sole purpose of annoying her. And they need to be sexually shamed for it. And that is totally an appropriate tactic for an extremely prominent feminist to use.

If I was the sort of person who thought being a victim of a thing made people more sympathetic to that thing, I would be shocked by this. Feminists on the internet are constantly being called so ugly (or hairy legged) or bitter that they can't find a man, and if only someone fucked them straight they'd give up this life of blogging. To turn around and use that tactic against an entire political orientation* is abhorrent.

And I agree with her that there's some weird sexual repression going on in some members of the anti-choice movement. I just also recognize that there are some people who genuinely, sincerely believe that an embryo is a full human being and that, while it is tragic we must violate a woman's rights to honor the embryo's rights, we still have to do it. I think they're wrong, I think they're being manipulated by leaders who genuinely do have "oppress women" as a goal, but I recognize that you can sincerely believe a thing that is different than what I sincerely believe. Hell, there are statistics that prove that evangelicals' sex lives deviate further from the norm than mainstream liberal sects. But in our brave new sex-positive feminist world, that doesn't make them wrong.

And then, when she's called on this in the comments, by someone objecting to the way it portrays asexuals, people actually defender her with "Amanda is clearly a sex positive writer and thinker and her work reflects that." Why didn't they just claim Marcotte has an asexual friend and be done with it?

*and no weaseling out of this with "but some people DO do that." She said average Republican

The tone of a lot of "Why don't poor people favor wealth redistribution/taxes on the rich?" articles bugs me. There's an implicit "Those yokels, too stupid realize this is better for them, or to vote in their own self-interest." Now, some people have been manipulated into voting against their economic interests by identity politics- but some other people have chosen to sacrifice their own self interest in favor of a moral principle. Who is who depends on your own moral principles. The liberals who laud Warren Buffet but decry poor red staters who vote against SNAP seem to me to be condescending to the people they claim to be trying to help.

People sometimes advocate requiring congresscritter's to have family in the military as a method to cut down on aggressive wars, the idea being that when it's your son's neck on the line, you'll think harder before invading. This sounds like a good idea until you remember that we have a volunteer army, and the people who volunteer (and their families) are not random subsets of the population. You will actually end up with more pro-military, pro-military-action congresscritters than before.

Likewise, people advocate preventing regulators of government agencies (most recently financial, but more relevant to my current interests, also medical) from going on to hold or having held positions at companies they regulate. As Overdose points out, that's tantamount to disqualifying everyone who might know something about the topic. You're left with professional regulators or the people too incompetent to get hired elsewhere. Similarly, when you ban university researchers who take government money from doing for-profit work, the chances that you cost the for profit world a researcher are smaller than the chances you cost the public domain world a researcher. But regulators who are in bed with the regulated and researchers diverting public funds to research that benefits them financially are serious problems. Much like with the antibiotics, there doesn't appear to be a solution that doesn't involve judgement calls.

Speaking of antibiotics, why the hell are farmers allowed to give cows continuous prophylactic antibiotics? I can't think of a rational reason that I should be allowed to give my cat the good antibiotics except that I will cut you if you try to stop me, but that's occasional and there's minimal chance his stomach bacteria are going to mix with something infectious to me (although he does his best, what with the throwing up for three nights in a row and all). As opposed to the animals we are going to eat which will then sit in our stomachs and mingle with our stomach bacteria which then go fool around with the more deadly strains of E. coli so they can feel cool and rebellious.

Kevin Drum thinks we should let the dead pay for medicare. In essence, each time you received medical care paid for by medicare, you'd receive a bill, due upon your death. If you die without sufficient money to pay it off, oh well, these things happen. If you die with money, medicare gets first dibs on it, before your kids.

This plan has some face validity to it. Considering the span between dirt poor and upper middle class, it's pretty progressive, especially compared to raising the eligibility age.*

But... like all taxes designed to soak the rich, it's going to hurt the inflexible more than the flexible, and that means that in the span between upper middle class and ultra rich, it's extremely regressive. Rich people can structure their estates, with things like trusts and insurance, to avoid the tax**. Drum handwaves this away by suggesting we pass laws against it, but that's really hard to do, unless you're going to ban old people from sending their grandchildren $10 for their birthday***. What the media calls "loopholes" were often put there for a reason, and you can't argue for closing them without understanding what that was. On the other hand, I don't know how much the ultrarich use medicare: unlike medicaid, it's possible to get good doctors with medicare, but not necessarily the best, and not necessarily on your preferred timetable. And medicare doesn't cover home-care/nursing home care very much if at all, which is a huge expense if you make it to that point in life. And of course there's no cost savings once someone accumulates more bills than they believe their estate will pay off, but there's no cost savings in that situation now either, so we've hardly hurt things.

What if we added a small interest charge? If you're poor and know you'll never pay off the bill, you still ignore it. But if you're middle class and planning on leaving an estate, better to pay it off now****? Or maybe that just incents more estate structuring. I really don't know about this one. But I do have to give Drum a cookie for coming up with a genuinely new proposal, there aren't enough of those in this area.

*I'm pro-raising-eligibility-age for other reasons, but even I have to admit it's horribly regressive, given that poor people die sooner. Actually, with the information at hand we can only prove delta is regressive. Depending on the relative payroll tax contributions, the system as a whole could still deliver the desired about of progressivity. Suppose we had a program that took $5 from the poor and $15 from the rich, and gave them each back $10. Then we change it to give the poor $9 and the rich $11. You've certainly made the system less progressive relative to its starting point, but you could argue it's still a progressive program, given that the poor make $4 off it and the rich lose $4. Or you could argue that the rich get more back so it's automatically regressive. Defining these things is harder than you'd think.

**I know this is true because that's how I define rich: middle class is when you have an estate (or say, an estate over $N, everyone leaves a few things behind), rich level 1 is when you preemptively structure your estate with a lawyer to lessen taxes (which means your estate is over the exemption level, which I think is currently $1 million), rich level 2 is when you start structuring your actual money you have while living to reduce taxes (for example, purchasing municipal bonds because they're tax free). It's not a perfect definition, but on the whole it works for me.

***And as a heartless libertarian, I'd at least consider not allowing people to give money to others when they're not paying for their own medical care. But most people won't.

****For a properly defined interest rate.

For all its faults, Sex at Dawn has made rethink some things. Primarily, libertarianism. One of the reasons sexual and romantic fidelity isn't a big deal in tribal culture is that resources are not really controlled by individuals. Some people are better hunters than others, but no one is so good a hunter that they weren't guaranteed dry spells that could starve them (and their children, if they were the sole providers). So the culture develops an ethic of sharing- not just among adults, but from adults to children. Essentially, there's (at least) two equilibria: everyone strictly invests in their own children, or everyone invests equally in everyone's children. If resources are distributed fairly evenly, the first works out fine, and you save some effort assigning paternity. It's not until you get real differentials in resource holdings that it's worth the effort to control paternity. Add in that most people in the tribe are pretty heavily related to one another, and resource sharing isn't virtuous, it's just good planning.*

I think that a lot of progressives are going by an intuition developed for those earlier times. You don't need a really vicious criminal system when you know everyone and shame can do the job effectively. Ditto for monitoring people for good behavior before giving them welfare.** Notice that a lot of feminists are specifically trying to provide for children and mothers independent of paternity. I keep saying I support libertarianism because I don't think we're on the hook for one another's choices, but that is not a luxury primitive tribes could afford.

Which doesn't mean I'm wrong. First, that kind of shame based control is hard to implement in modern nations. You can do what Japan does, which is have an honest-to-god permanent record for every citizen that includes their relatives misdeeds, so that your uncle's divorce can keep you from getting into college. I'm assuming I don't need to explain why I'm against this.

Second, that kind of control imposed real costs even in primitive societies. Sex at Dawn talks about how jealousy was damaging in these tribes and the methods they used to prevent it, such as group sex rituals and mandatory sex between cross cousins. A society isn't a paradise just because it's a man hiding in a hut trying to avoid the female cousin he is culturally unable to refuse sex. Beyond that, I like that I can choose how much work I do, based on how much I value what the additional money will buy me.


*There's a well know, much repeated psych experiment where people are given a dollar, and told to divvy it up between them and a partner however they choose. The partner can choose to accept the distribution or reject it, in which case neither person gets any money. The game is anonymous and non-repeating, so the optimum thing to do is accept any distribution. But they've gotten amazingly consistent results that show people reject offers of less than ~40%, even when working in very poor countries where the exchange rate enables them to offer an awful lot of money, and that's about what people offer as well. The exception comes from small tribes that are highly related, where they will accept and offer much worse deals, as low as 10/90. Essentially, these people don't develop a sense of fairness because they're always dealing with close relatives, so it simultaneously doesn't matter if one person pulls one over on the other and they're vastly less likely to try. These tribes treat strangers terribly.

**The Mormon church has its own welfare system, and they do go over people's past spending before giving them help.