Lady Justice Is Swinging
This proposal for reforming our healthcare system was linked by The Browser, of all places. I suppose I should give the latter credit for giving exposure to other ways of thinking, but I worry in this case that they are giving some intellectual credence to something that is, at its core, horrific.
Wherein There is a Plan
The author, one Karl Denniger (who seems to work in finance) starts off rather sanely, with things like no hidden costs and requiring that people agree to the costs beforehand. Fair enough.
But then things go off into libertarian dystopialand.
Amoral provision 1: no insurance company should be required to cover the costs of “lifestyle” choices. The example he cites is people who have type-2 diabetes who refuse to modify their diet.
This is one of those things that seems reasonable in the United States of Thought Experiment, but actual reality is far less clean. Who can say when the lifestyle changes make a difference? With the type-2 diabetes example he uses, sometimes it matters for people and sometimes it doesn’t. You can have two diabetics that eat crap, and one will have blood sugars around 150, and other will have them in the 300s.
The next problem is who can decide that someone isn’t doing enough. If we’re relying on doctors, 99% of the time they won’t say their patients are making inappropriate lifestyle choices even if they are, since they know what the consequences will be (both for the patient and their own bottom line). If we’re relying on, God forbid, insurance companies, we’ll have the opposite problem: they’ll deny cases constantly. At that point, either people have no recourse whatsoever and are simply fucked, or we’ll have to get the government involved (which will take so long to adjudicate cases that the end result will be similar —just look at how backed up the disability system is, for example).
He also doesn’t explain how this would apply to more attenuated causes. If someone smokes for 30 years, quits when they’re 50, and then has a heart attack at 65, would we refuse to pay for it since the smoking raised their heart attack risk? At the same time, how would we know whether they would’ve had that heart attack anyway?
But regardless of who becomes the final arbiter of whose lifestyle choices meet the Holy Standard, what you’re really doing is in essence passing a law that says people have to lie to their doctors. This is incredibly dangerous to healthcare outcomes, and is one of the reasons we enforce confidentiality between doctors and their patients (just as we do with lawyers and clients, priest-penitent, etc.): these professionals cannot properly advise those who come to them if they are given incorrect information or not enough.
It’s not hard to imagine how this would play out. Let’s take the case of our theoretical type-2 diabetic. He or she decides not to tell their doctor that they’re still eating lots of carbs (because they know they won’t be able to get their basic medicine paid for). Meanwhile, their blood A1c just isn’t coming down. What does the doctor do? Prescribe more aggressive treatment. Now, maybe this is fine, because increasing their metformin will help. But maybe it doesn’t, or maybe it makes things worse. Metformin is contraindicated in people with liver disease, but our theoretical patient doesn’t tell his or her doctor about how much they drink, so the liver disease isn’t picked up. The point is, there are any number of scenarios where encouraging people to lie to their doctors (whether by omission or otherwise) is really, really, dangerous.
Amoral provision 2: emergency care is only available to people here legally. Making being an illegal alien a capital offense is one way to do it.
Amoral provision 3: Pre-existing conditions aren’t required to be covered. Mr. Denniger explains his thinking in a comment: He says that it is theft for someone with a pre-existing condition to get a job with a group health policy to cover that condition (I promise I’m not making this up). His answer to the pre-existing condition thing is that people with those conditions should get together and cure them, saying that technological progress is the only answer.
His response to criticism on this point is to ban the poster:
Yes, there’s a public policy debate to be had on this but it needs to be HONEST and FORTHRIGHT: Do you have the right to demand tens of millions of dollars from other people because you had a misfortune of genetics?
THAT is the debate you raised and it’s NOT one of health care and its delivery.
(Emphasis and capitalization in original.)
Most of this proposal is a manifestation of how good it feels to crow about “justice” and “fairness,” while actually being sociopathic and horrible. One could say that Mr. Denniger’s proposal is just an outlier, but that’s the problem: it is not.
We in the United States have a specific and very ingrained idea of justice, and it makes us bad people.
It’s an irony of humanity that, the more we believe that the world is a just place, the less moral we become. We blame people for the ills that befall them. If we think people get what they deserve, then clearly a poor person deserves to be poor, or a sick person deserves to be sick. This is the same reason that those teachings of Christ that are most routinely ignored by Christians are the ones about doing good for people who may not “deserve” it.
So when our Mr. Denniger talks about it not being part of the “social contract,” in his words, to pay to keep someone alive in the face of “an accident of genetics,” he’s coming from this very idea of justice and fairness. Why should I have to pay to keep someone else’s child alive? It didn’t happen to me, and since I didn’t agree to take care of someone else, I shouldn’t be made to. It’s an incredibly childish idea of “freedom.” It’s an idea that says we should be free to be lousy to each other. But this freedom only matters if you first want to be lousy to people. I’ve never heard anyone complain that they’re not free to murder, because they don’t want to commit murder.
One of the great propaganda victories of the last century was when the aristocracy began to couch everything related to public policy in terms of numbers. Initially, it was a way to demonize leftists as being too “touchy-feely,” and they basically said that the mature, grown-up thing to do was accept facts. It’s a beautiful sleight-of-hand: suddenly we’re no longer talking about leaving millions out in the proverbial cold, we’re talking about making markets more efficient. We will thus make everyone better off, even if it kills us (or, preferably, them). Just look at Mr. Denniger’s reply above: he has completely separated and compartmentalized the issues of the policy itself and that policy’s moral consequences.
This is what happens when people are reduced to numbers. It’s why someone can argue persuasively that we should bring coal back, since that means jobs and then the magical capitalism fairies will make the world a better place. And if you’re a business owner or investment banker or whatever, it probably will be good for you (at least for another generation or two, until the effects of Global Warming kick off in earnest). But it ignores the reality of those jobs, what it does to the environment, and the like.
In other words, if we can’t quantify it, it doesn’t exist.
Education policy is a prime example of this. The public fight is always and exclusively about funding and where it should go. But as Frederik deBoer explains,
What people who are stuck in test-scores-and-neoliberalism mindset are saying is that only a very narrow perspective on education matters and that the basic distribution of economic advantage in this country will never change.
He goes on:
But if we recognize that schools perform a set of vastly important social functions that have nothing to do with standardized tests or even with learning as traditionally defined — including housing, and often feeding, children in a safe environment for half their waking day, providing them with socialization and the ability to form meaningful peer-group relationships, and providing the only support for those with developmental and cognitive disabilities that many families will ever be able to take advantage of.
One of the most terrifying things for human beings is to be vulnerable. It’s one of the most fundamental questions of survival, and everyone alive today is descended from those who were the best at surviving long enough to have kids.
There is a famous quote from C.S. Lewis, where he refers to us living in a Managerial Age:
I live in the Managerial Age, in a world of “Admin.” The greatest evil is not now done in those sordid “dens of crime” that Dickens loved to paint. It is not done even in concentration camps and labour camps. In those we see its final result. But it is conceived and ordered (moved, seconded, carried, and minuted) in clean, carpeted, warmed and well-lighted offices, by quiet men with white collars and cut fingernails and smooth-shaven cheeks who do not need to raise their voices.
We’ve gotten very good at combining the two. It seems like every time we think of “progress,” we think of ways life is made easier. This isn’t always bad — I’m all for progress on social issues, medicine, you name it. But in the meantime, we’ve also become a low-trust society. We don’t trust people not to game the system, not to take advantage. We don’t trust teachers to teach their students or their students to learn. Public policy has become nothing more than attaching a number to everything while glorifying this idea of “accountability.” If we want the government to do something, we start out on the back foot: we have to overcome this by now entrenched idea that it will automatically be less efficient, accountable, or effective.
This paint-by-numbers approach to policy and governance isn’t really a new thing. It’s best thought of as a new technology. Technology’s purpose is to shrink things down, or what Huxley calls “the reduction of multiplicity to unity.” Technology’s purpose is to make things simpler and, more significantly here, easier. But this becomes poisonous to us; there’s a reason rates of mental illness go up as a country becomes more industrialized.
Acting morally is hard. It’s far more difficult to give back to someone who doesn’t live up to our standards. It’s much harder to forgive. But most of us know on some level that we’re supposed to, so we don’t feel good when we avoid doing what we know to be right. People being clever, we come up with increasingly elaborate ways to avoid both doing the right thing and subsequently feeling bad about it. Think about the last time you walked or drove by a homeless person on the street and did nothing. I would wager that every person reading this has done that at some point. I’m certainly no different.
If you think back to that event (which is probably happened more than once), I ask you to be honest enough with yourself to realize how quickly your mind came up with an excuse not to give them some cash, buy them some food, or whatever. We’ve all heard them: Oh, they’ll just spend it on drugs. Or oh, I don’t have any cash right now (one of the little-thought-of consequences to money becoming increasingly bank-controlled in the form of credit cards). I don’t want to encourage them. He/she should get a job. Of course, this is assuming you allow yourself to think about the person at all.
That same skill allows us to shrug our shoulders when we vote for laws that will get rid of people’s health insurance, or after-school care, or whatever. When we try to keep a halfway house from opening on our block.
It’s easy because that’s how we’ve chosen to make progress.