The post in which I continue to attack the damn libertarians

Also pissing me off this week is the continuing nonsense from Cato’s anti-universal health care club which is suggesting that increasing health care coverage will lead to an increased number of deaths because of increasing medical errors.

Sack notes that “at least twice as many Americans are estimated to die each year from medical errors as from lack of access to care.” He quotes economists Helen Levy and David Meltzer’s conclusion that there is “no evidence” that expanding coverage would be the best way to improve health and save lives.

If there is no evidence that expanding coverage would deliver the biggest improvement in health for the money, then expanding coverage could actually increase death and disability compared to a superior policy. I’ll be debating Nichols tomorrow at a meeting of the National Association of Business Economists. Should be a good time.

Now, if you want to be a libertarian and think of no one but yourself all the time, that’s just freaking great, but it’s totally different if you’re going to start spreading around this crank nonsense about medical errors being a big bad killer. Inherent is this suggestion is that medical care is of net negative benefit, which is totally absurd. And the Institute of Medicine reports on medical errors are poorly understood as people fail to understand two critical aspects of the studies. For one, much of the medical errors resulting in injury have to do with inpatient care and an inpatient population is a really different beast from the types of medicine we’re talking about with universal coverage. People under universal healthcare won’t go into a hospital, lay in a bed for a few days and get a decubitus ulcer because they suddenly have free medical care. Much of the medical “mistakes” described in these reports aren’t really mistakes by doctors but represent fundamental problems with keeping people healthy in hospitals. Much of it has to do with nursing and support care, spread of nosocomial infection, and clerical errors (the last of which we’re improving on with increased digitization) and affecting a population which tends to be very fragile to start with. This stuff simply isn’t relevant to the type of outpatient care universal coverage seeks to provide.

The second idiocy here is that the type of medicine under a universal health system will hopefully be fundamentally different than what we have now. Currently, doctors are essentially penalized for providing more care, and rewarded by insurance companies for providing less care. There is also completely inadequate support for preventative medicine. Despite these measures to reduce cost we still manage to spend more per capita on healthcare than any other nation, are ranked almost dead last among industrialized nations for provision of care (mostly due to access problems), and have over 40 million uninsured. These facts make a prima facie case for the need to reform our medical delivery system. The current system is unjustifiably stupid economically, and the restructuring of healthcare delivery has the potential to gear medicine more towards better disease prevention, screening, and overall increased quality of care as people are less fearful of being dinged by their insurance company for the crime of getting sick or being diagnosed with a disease.

The third idiocy is to say the reason for universal healthcare is just improving patient outcomes. We’re also trying to prevent people from being bankrupted, whether they’re insured or not, because of medical problems. Even with insurance illness frequently leads to financial distress and even bankruptcy.

I want universal health care because I think it is the right thing to do medically, morally, and economically. Our current system is too expensive, poorly designed for delivery of good medical care, and ultimately is biased against people getting the care they need. If you can fix the system under a free-market approach that will prevent people from being financially ruined by health issues, will cover everybody, encourage the widespread adoption of preventative care and not cost five times as much per capita as any other country’s care, I’m all for it. As it stands what we have is too little care for too much money. The best Cato can do is make the absurd argument that more care = more mistakes. By this logic we should just stop all medical care from being provided if mistakes are such a net negative. If that’s the best the defenders of the free market can do, the free market is in trouble.


  1. natural cynic

    …and not cost five times as much per capita as any other country’s care.

    Where do you get this number. The numbers I have seen are more like the British spend ~45% as much and the Germans and French spend ~60% as much as we Americans do.

  2. It is my observation that anyone who does not want universal health care is either rich or employed by a company that provides health insurance. Thus I take Cato’s opposition to stem not from legitimate philosophical differences but from an attitude of “I got mine.”

    Another thing about universal health care: it can provide for long-term assisted living for aged people who cannot otherwise afford it. The alternative is to condemn some old men and women to lie in their shit and piss for the rest of their lives. But, hey, they’re old, they’re useless, and I’m not old yet.

  3. It should be noted that many libertarians are also opposed to state run schools like UVA.

  4. Casmall

    It should also be noted that most libertarians would not have had an education without state run schools. Clear evidence of the failure of public education.

  5. It should also be noted that the libertarians opposed the creation of public schools, one of the most important innovations for the improvement of our country, and absolutely necessary for serving their fetish for wealth.

  6. When arguing against anti-universal health care people like that, always have at the ready examples of countries in the here and now where such a system actually is working and working well, as in France, Cuba, Scandinavian countries, etc. The libertarian/Republican types are always saying that universal health care is too unrealistic, too utopian, so refute them by throwing real world examples in their face. Plus, Americans often have no awareness that other systems but their own even exist.

  7. Maybe he’s thinking of something else when people say universal health care. Like how some conservative types think that all prisons are luxurious country clubs, you know? Maybe this guy thinks that hospitals are all exactly like Club Med and that the “universal” part of universal health care means that everyone is going to move out of their homes and into these new paradise-hospitals for treatment even if they aren’t sick.

  8. Euripedes

    Would it be possible to raise consciousness about what Libertarianism actually is, and what it’s roots are, or is it a lost cause?

    These people who profess to be libertarians despite what they think, do not seem to actually be libertarians at all. At best I think they could be described as Anarcho-Capitalists, although they do not meet the philosophical standards of any form of Anarchism either. Anti-state Capitalists perhaps?

    Libertarianism has a longer history than those on the right would like you to believe and is more aligned with Anarchism than with Capitalism.

    Are these self proclaimed ‘Libertarians’ actually denialists in this regard?

  9. My suspicion is that the vast majority of “medical errors” occur in situations that are already mostly past hope of recovery. An important benefit of single-payer universal health care is that, by incorporating ongoing effective primary care for everyone, a lot of really bad, expensive, error-inducing specialist-requiring shit gets prevented from happening in the first place.

  10. Natural cynic,

    I was referring to the cost of creating a functional health system based on the free market. Yes currently we’re running at about 2-3 times the cost of other countries with universal coverage, and we’re failing. We don’t cover 40 million + people, we provide dismal preventative care etc. While do we have excellent facilities and doctors but poor access, unequal access, and the potential for bankruptcy for anyone south of millionaire in the case of serious medical illness. How much more do we have to spend to fix the current broken system? 2-3x more than we currently spend? Maybe, using the retarded system we currently use where we pay insurance companies not to deliver care while taking home a hefty profit. That was the nature of my suggestion that it will cost such an excess.

    Euripides. It is hopeless to argue that real libertarianism is something else and more noble. This is what libertarianism is today. I realize many people are similarly shocked when, like Bill Maher, they describe themselves as libertarian and then find out twits like these exist. You are screwed. Make up a new name for what you’re going for, hold a meeting and start over.

    Physioprof. You are correct. The majority of mistakes in the IOM report are “mistakes”. Preventable medical errors in a population that was probably doomed from the start. If you read what the majority of mistakes were that caused significant morbidity and mortality you’re looking at nosocomial infections, decubitus ulcers, and failure to rescue. While perfectly “preventable” in theory they are not preventable in practice and represent expected complications and outcomes of the very sick in the hospital setting. Healthy people going to see a doctor in their office aren’t leaving with c. diff enterocolitis and decubitus ulcers.

    That does not stop cranks from waving around the IOM report to call doctors worse than Hitler however. They scream “you kill 100k people a year, you’re monsters” – no joke, it’s happened here on this blog quite a bit. However they make it sound like we’re going out on the street and killing healthy people with ball-peen hammers rather than just failing to maintain life in people who outside the hospital would be dead in days.

  11. It is hard to take this seriously, when there are such obvious misunderstandings about the current healthcare system and basic economics.

    You state: doctors are essentially penalized for providing more care, and rewarded by insurance companies for providing less care. In fact, the vast majority of providers are paid more for doing more. Yes providers have to fight with insurance companies to get stuff approved, but providers incentives are almost always to do more. Currently we pay way to much money for way to little value- Doctors do more to make more, patients (with insurance) demand more because it is ‘free’. The solution is to pay doctors for value (v. volume) and to help patients be consumers. This can happen with or without universal coverage. It is naive to think that universal coverage would automatically solve this problem. In fact, if we implement it through a political process, it is most likely to make matters worse given the feel good, pandering solutions politicians like to follow.

    You also mention that uninsured will get ‘free’ healthcare. There is no free healthcare, it has to be paid for by someone. Payments will never really come from the government or companies, it will ultimately be paid for by patients/consumers via direct payments, taxes or reduced wages. Yes, we can spread the cost across everyone (the purpose of insurance), but individuals will pay for your ‘free’ care. Unfortunately, the more ‘free’ the care appears the more it aggravates the problem above.

    Imagine how your perspective may change after you have practiced medicine in the community for a few years and seen how real patients behave and how your colleagues game the system to get paid. Denialism is easy to find at both extremes, make sure you don’t run to far to one edge.

  12. Pay based on capitation of health care encourages doctors to give more care yes, if you define “more” as seeing more people and doing less for each of them. So while they see more patients they tend to get penalized for doing right by those patients. From the point of view of the doctor-patient interaction I define this as “less care”. Explain to me how capitation encourages doctors to provide more care based on a definition that matters to patients, and I’ll listen.

    Currently the uninsured still get medical care. They show up at ERs and the state eats the cost if they can’t mortgage their house to pay for it. It has been pointed out multiple times that this is a shitty way of running a health care system because what you’re seeing in the ER for 5k is often a cheap medical problem that could have been taken care of in the PCP’s office for $5.

    Either way we’re paying for this crap. Either we’re paying for prevention, PCP visits, and quality care, or we’re letting people fall through the cracks, go bankrupt, and show up in the ER with preventable problems that are ideally solved by good community prevention and primary care.

  13. The economic incentives are currently structured to encourage more relatively ineffectual expensive specialist procedures and less highly effectual basic primary care.

  14. I take Cato’s opposition to stem not from legitimate philosophical differences but from an attitude of “I got mine.”

    Ah but that’s the genius of libertarianism: it convinces people that acting selfishly is philosophically the best position. Garden variety libertarians imagine their selfishness benefits others; Randians think wanting to benefit others is itself moral weakness.

  15. This is a great one for argument fallacies and argument study in general. Look, if they’re right, then they should give up their own health care coverage, NOT to maintain consistency, but they should REALLY want to. They should see it not as a sacrifice, but as a true benefit to them. And of course not only should they give up their coverage, they should refuse medical treatment altogether because of the number of errors makes it worse for them!

    So many of the cases where inconsistency is charged, such as the one leveled at Al Gore for (allegedly, and I’m not questioning this) wasting lots of energy personally, are cases where the person’s not following what they are instructing others to do doesn’t affect the case for their claims. Gore could be absolutely right in his arguments, and just a hypocrite. IThis is, if I remember correctly, the tu quoque fallacy.)

    But the charge here directly affects the truth of the libertarian’s claim!

    Libertarians, or at least all the ones I’ve read and met, are idiots, albeit ones with (as someone pointed out) good typically state-sponsored educations. That’s not an argument (if it was it would be a fallacy), just an observation.


  16. “at least twice as many Americans are estimated to die each year from medical errors as from lack of access to care.”

    Man, if we just get rid of you doctors, we’ll all live forever.

  17. ” … help patients be consumers …”

    Every time I hear this absurd kind of argument I can’t decide when to stop laughing insanely. I’m sorry to have to point this out, but it’s stupid. Patients are consumers in the sense that they pay for services for themselves, but it is idiocy to argue that patients should buy their health care the way they buy toasters; it’s just doesn’t work that way. When I fell off a ladder a year ago, I needed to see a doctor and then have surgery to repair a torn rotator cuff. Should I have solicited bids for the work, evaluated the cost, assessed their proposals for medical competency, then solicited bids from outpatient surgery centers, and their staff, and the anesthesiologist? I guess I should have hired a medical consultant to help me evaluate the proposals since I’m not a doctor and I couldn’t possibly know how to evaluate the medical aspects of the proposal. I would probably be having the surgery right about now, I guess, unless I didn’t get any bids. I suppose I could have widened my search to surrounding states, or possibly countries. Or maybe a different planet.

    I don’t know you, Jeff, but this is not the way to make a good impression.

  18. Mark P:
    When my wife went to the ER with abdominal pain that was a text book case of appendicitis, the doctor did treat us as consumers. He laid out several diagnosis options (just based on pain of a particular quadrant or other tests) and several treatment options (traditional surgery or surgery that would minimize scarring). In each case, the doctor discussed the costs involved. Based on this information, my wife made a decision that took into account both costs and outcomes.

    It seems to me from the outside looking in, that there is plenty of room for costs to be reduced by patients acting as consumers and make decisions about how much to spend on health care.

  19. Inherent is this suggestion is that medical care is of net negative benefit, which is totally absurd.

    Relative to what? Extending the lives of self-absorbed and self-indulgent Americans does very little for the general good of the planet in relation to consumption of resources and negative outputs (energy consumption, contribution to CO2, etc). More people, living longer require more resources, and the general answer seems to be that we should secure those resources through the barrel of a gun or exploitation.

    Medical care is good. Extending life for profit, not so good. Our system happens to be primarily concerned with profit because that’s what fuels capitalism and both parties support the general view.

    But yeah, despite the badness inherent, I support universal healthcare similar to the Canadian or British models. Just to spite the libertarian/closet republican d*ckheads.

    (I don’t really know why “libertarians” need a separate designation. Just call them even more extreme and rabid republicans.)

  20. Mike, your experience is not an example of consumer-driven health care, it is an example of good health care practice. A physician should always present treatment alternatives, if they exist. You didn’t go to another ER, did you? You didn’t solicit treatment and cost estimates from other physicians and health care facilities, did you? You did just what everyone in the US does: you went to a health care facility and took the treatment you got there. If you were looking for a primary care physician, you might actually be able to do at least a little consumer-like things, but that’s really about the only time you can. In some cases, you might get a second opinion, but in that case, you have already consumed health care from one provider and are consuming even more from another provider. That’s not the way people generally buy toasters.

  21. Mark P:
    My wife did not go to the closest ER, instead she chose one that was further away due to quality considerations. This is very much a consumer decision. Unfortunately, no information about price was available before hand, so cost could not factor into the decision.
    I do not think that comparing to toasters is the best analogy. I would posit that a better comparison would be with something like design plans for a house. Some people might pay multiple architects to design a house or a room and then go with the plan that seems the best. But this would only be for non emergencies.

    Emergency care is different, particularly when time is of the essence. In such cases, it is only natural for a monopoly to develop as people need to be taken to the closest ER. This situation makes increased government regulation reasonable.

  22. I’m always astounded when I hear that wealthy countries like the US don’t have universal health care. We’ve had it in Australia since 1972. Several conservative governments have whittled it away a little (we now pay some money to doctors – we used to pay nothing, those on welfare payments still pay nothing. We don’t pay for public hospital care). It’s not a Utopian dream and Australia has not fallen to pieces. Very few people argue against it. It would be considered very mean to let the poor go without health care.

  23. Mark H, I agree that capitation can lead to bad incentives that lead to less care in today’s shortsighted/short term approach to business/healthcare. BUT, if you are going to talk about the US healthcare system in general, then it is a huge mistake to assume that care is capitated. Very little care is paid for on a capitated basis nationally. As I said in earlier post, the vast majority of care is paid for/produces incentives for providers to get paid more money for doing more services (including the many cases where more care is not better care).

    re: ER visists, yes very true. Just confirms that there is no “free” care. It will be paid for by consumers/taxpayers in the end. Please keep in mind, insurance is best served to cover expenses that the average (or a particular) person can’t afford. You insure your house for fire, not for fixing a broken heater. You insure your car for being totaled, not for an oil change. Why do we assume everyone needs insurance to cover the $5 PCP visit? We trust people to feed, shelter and cloth themselves, but think they won’t get preventative care unless it is “free”. I can assure you from my own professional experience that the larger obstacle is a person’s motivation. While running a health program for children we had some who couldn’t afford the fees so we offered free scholarships, the result was: we couldn’t give away all the scholarships we had to offer. I agree that a good system would provide financial assistance to those that can’t afford a $5 PCP visit, but it would also NOT COVER the $5 PCP visit for for the 80+% of those that can afford it. One problem is a PCP visit isn’t $5….

    Which gets to Mark P’s issue: Of course we can have price transparency in healthcare and of course it is a good idea, and if we did, then of course patients who had to pay for their care would behave like the consumers that they are.
    Once again, picking out an emergency condition is a great example of when patients can’t price shop, BUT once again the vast majority of care is not emergency related. We all hear that health care is different, but I don’t really think so. In the parts of healthcare that aren’t covered by insurance (lasik, cosmetic, etc.), doctors provide set prices for specific things that patients can understand. We don’t get cpt terminology and 35 different prices for one thing. How is this different from a knee replacement surgery? It is easy to say it wouldn’t work, but I don’t think so. It worked fine before the current system, and would likely do as well or better than what we have now.

  24. Jeff, you and others always argue about areas that are irrelevant to the issue of universal health care. We don’t need universal health care to make sure people can afford cosmetic surgery. We need it to take care of real health issues. It is patently absurd to say that all we need is transparency in health care costs. I go back to my rotator cuff surgery. What am I supposed to do if I have no insurance and tear my rotator cuff? Shop at Wal-Mart for an orthopedic surgeon? Where do I go for the surgery when there are only two places in town that provide surgical facilities? A typical carpenter who works for himself or for a contractor without health insurance might well not be able to afford insurance. Without it, he would almost certainly not be able to afford rotator cuff surgery (and a fall and injury are high probabilities in that trade). Without rotator cuff surgery for the kind of injury I sustained, a carpenter would not be able to work again. But I suppose all he has to do is be a good consumer and all of his problems will go away.

    What nonsense.

  25. Oh, by the way, the total cost for my rotator cuff injury repair was nearly $40,000, including $25,000 for the outpatient surgical center at our local public hospital.

  26. Mark P- I agree we don’t need universal care for cosmetic surgery, I certainly didn’t suggest that, rather we need a healthcare marketplace similar to that segment. I also agree that today you can’t shop for your RTC surgery, and that IS the problem. If we had price transparency and fair pricing, then you would be able to learn that your RTC surgery typically costs insurance companies $6,000 (1700 for MD and 4300 for facility). It is only the messed up current system that tolerates providers charging those without insurance $40k for $6k worth of services. And based on your income you could buy insurance to cover the $6k risk or not, your choice. Current universal care proposals want everyone in the US to get coverage similar to the federal employee program (Cadillac benefits at twice the price v. value). The point once again is Universal coverage or private insurance should ONLY cover higher cost situations and we have to fix pricing of services to make it fair and upfront and worth the money we spend.

  27. Jeff – the point of universal health care is the many people cannot even afford the cost of basic care. According to the govt., per capita disposable income is $33k a year. That’s less than $3000 a month, from which you’re paying for housing, food and all the other nickel-and-dime items required to stay alive in America. If my doctor’s visit costs $50 and the medication I need costs $100, that’s a huge hit to the monthly budget of the 150 million people living below this level. That’s what you’d pay for health insurance a month, and less than the retail cost of many meds when they’re not provided to you at an insurer-negotiated discount.
    So even in a world where healthcare pricing was perfectly transparent, you’d still have people who cannot afford it. So unless you don’t care that government policy leads to sick people not being treated and without access to basic preventative care, you require universal health care.

  28. Since the subject of universal healthcare in the US has come up, its worth noting the comments of the Republican congressman Todd Tiahrt, of Kansas. According to the Guardian he has protested against the awarding of the USAF tanker contract to EADS/Northrop Grumman, because he see’s that the ‘UK’s nationalised healthcare system as an unfair advantage to EADS. “We give advantages to the UK, to France, to Germany that we don’t have in America,” Tiahrt said.’

    So a Republican has said it loud and clear – universal state-run healthcare makes you more competitive – which means that logically, if the US had a universal system of healthcare, it would be better for the economy as well (something that us pesky Europeans realised some time ago).

    I wonder if the Congressman realised what he said?

    Jeff – Owen is absolutely right – you can only act like a consumer if you can afford to in the first place – if you have insufficient funds, your choice is basically zero. We don’t choose healthcare like we choose a toaster; instead ill-health unfortunately tends to choose us.

  29. I hear the position and agree that some people can’t afford healthcare. We don’t want people to starve, so we have soup kitchens (private/philanthropy) and we have food stamps (government). In fact, for those that can’t afford healthcare, we created Medicaid.

    I think it would be a poor decision to try to grant universal access to our current system with over priced, over mandated benefits, over bloated administrative costs, etc. The current system would be too expensive and would not provide value for the high price it would cost. We can’t pretend it is ‘free’ because it is funded via the government- the funds will come from the tax payers or, even worse, left as a debt to our children.

    Universal access to healthcare via a government program or a private program with subsidies for the poor could certainly make sense if it was based on a rational set of benefits and on a rational pricing structure. And while I could personally support that approach, any honest conversation has to recognize that even systems with universal access have their own problems (benefit limitations, 2 tiered access standards for those that can afford to go outside the system, etc). Unfortunately, I don’t see any evidence our current political system (partisan demogogs, corporate interest driven, short term orientation, pork and financially irresponsible…) can exercise the discipline required to achieve a thoughtful universal system.

    It sounds like we will just have to agree to disagree on whether a Universal Plan produced by our current government will cause more problems than it solves.

  30. any honest conversation has to recognize that even systems with universal access have their own problems (benefit limitations, 2 tiered access standards for those that can afford to go outside the system, etc)

    These two “arguments” are complete hogwash. The first argument fails in that piratized health care has far greater restrictions on access: You have to be able to pay for it. Universal health care can, does and should use the income of the CEO to pay for the health care for the hobo.*

    The second limitation is not a problem either – pirate hospitals simply shouldn’t exist. Period. The existence of such pirate hospitals serves primarily to decouple the health care of the CEO from the health care of the hobo. The problem with that is that this removes any incentive that the rentier class has to ensure that the public system works.

    Now, if CEOs were generally ethical and upstanding members of the human species, that would not be so much of a problem. Unfortunately, in the real world, such decoupling uniformly induces the rentier class to screw the public system over. We see this everywhere in the USA and other banana republics: The rich gather in walled enclaves guarded by pirate gendarmes (another instance of the rentiers being decoupled from a vital public service), with pirate emergency services for such things as floodings, storms, outbreaks of fire, etc.**

    And since physicians are trained by the government anyway (education being another one of those basic, government-guaranteed rights that all civilised people acknowledge), a pirate health sector would at any rate be ruinously expensive if it had to properly account for the implicit government subsidies granted it through the public medical schools.

    Finally, it is no great surprise that Americans don’t trust the government to provide high-quality services. For the better part of half a century, the conservative movement in the USA has deliberately and maliciously sabotaged the ability of the US government to do anything worthwhile. But the fact that the US has a dysfunctional government largely run by lobbyists and sociopaths, and for the benefit of industry insiders rather than the general public, does not by any stretch of the imagination mean that governments can never do right by the people.

    – JS

    *And before you launch into any screeds centred around the na�ve assumption that the CEO actually earned his income, let me assure you that such arguments leave me entirely cold. Nobody earns € 1 million a year from honestly compensated real work, and I have yet to hear of a board of directors that made anything of real value anyway. The top 1-5 % of the income distribution – the rentier class, if you will – are pure parasites on the backs of working people. So their whining leaves me completely unmoved.

    Incidentally, the rentier class is also the only group of people in any reasonably civilised industrial society that pay significantly more in taxes than they recieve in services from the government, so the notion that “tax-payers” – as if they were a homogeneous group – are paying for universal health care is a red herring.

    **The iconic example is the New Orleans flooding; the rich got out of the town virtually unscathed. The poor, who did not have the means to afford transportation, were left to drown in their own feces as the public system (which had been systematically screwed over by the rich because they knew they wouldn’t need it in the event of an emergency) failed.

    Compare and contrast this to the Netherlands, where there is nowhere to flee, and thus the rich are stuck in the same polder as the poor in the event of a levee breach. The dikes in the Netherlands are rather stronger than they dikes around New Orleans were. And government maintained, of course.

  31. Jeff, how do you account for the fact that most European countries have universal health care without it causing more problems than it solves? Germany has had it since the 1800s.

    The United States is the only wealthy, industrialized nation in the world that does not have a universal health care system. It’s probably the thing that most astounds people about the US. (Besides the gun laws).

  32. JS- I just came across a website that promotes free market solutions to healthcare access. It may be too much for you but, if not, you might want to watch the videos that clearly document some of the downside to a government run health system with no ability for individuals to seek private care if they need or want it. Regardless of how we solve the issue of the uninsured in the U.S., I imagine (and hope) we will always have a private option (like England has).

    Another interesting article you may want to read highlights that the government can’t automatically give people access just by saying they will pay for your care. We provide care to our senior citizens and yet ask many of them and they can’t find doctors who will treat them because the government pay is below what it costs to provide the care. See:

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