Upturned Earth

“… to think clearly is a necessary first step toward political regeneration.” – George Orwell

(Still) Against the Medical Cartel

Via Jesse Walker, Kevin Carson has a great piece up at the P2P Foundation’s blog on government regulation and “radical monopoly”, with a particular focus on cartelization and the medical industry. Here’s Kevin’s comparison between the sort of deregulated, “open-source” system he favors and the mess we’ve presently got:

In an open-source healthcare system, someone might go to vocational school for accreditation as the equivalent of a Chinese “barefoot doctor.” He could set fractures and deal with other basic traumas, and diagnose the more obvious infectious diseases. He might listen to your cough, do a sputum culture and maybe a chest x-ray, and give you a round of zithro for your pneumonia. But you can’t purchase such services by themselves without paying the full cost of a college and med school education plus residency.

The government having made some aspects of treatment artificially lucrative with its patent system and licensing cartel, the standards of practice naturally gravitate toward where the money is. The newly patented “me too” drugs crowd out drugs that are almost (if not entirely) as good, so that the cost of medicine is many times higher than necessary. The licensing cartel requires diagnosis and treatment by someone with an MD’s level of training, when something much less might be all that’s needed.

Result: radical monopoly. The state-sponsored crowding-out makes other, cheaper (and often more appropriate) forms of treatment less usable, and renders cheaper (but adequate) treatments artificially scarce.

Now that’s a libertarian, my friends. As with most of what Kevin writes, you ought to read the whole thing.

Earlier: I talked up a paper by Shirley Svorny on the economics of state-sponsored medical licensure, and Kevin left some “baby step” proposals for reform in the comments.

Elsewhere: Mike Riggs in Reason on the nefarious ADA; Kevin’s “Free Market Agenda for Healthcare Reform”; Roderick Long on false dichotomies in the health policy debate; and here is Kevin’s blog.

Filed under: government/law, health care, libertarianism

When Theory and Reality Collide, Family Style

by Nathan P. Origer

My ninety-four-and-and-two-thirds-year-old grandfather has spent the great bulk of his nine-plus decades on the same farm, born and raised in the older of the farm’s two Sears houses, built in 1913, and residing since he married my grandmother, in 1940, in the other. For most of my life, the man has been an extraordinary example of remaining healthy and living well in old age; however, in the last few months, his health has become less reliable, and he’s made a few overnight stays in the hospital. After his last visit, my aunt, who happened to have planned to come home from Texas for a week, filed the emergency paperwork necessary to have him admitted immediately to a local nursing home. He remains there presently, ostensibly only for as long as he must to finish his rehabilitation program.

Studying some seven hundred miles away, I don’t have a particularly clear, complete understanding of all that’s going on, but what I do know is that, even though it’s a nice facility (My dad has had nothing but good things to say about the accommodations and the staff, and my grandpa, who seems to have found himself a “girlfriend” across the hall, grudgingly agrees.), Grandpa, quite understandably, isn’t all too thrilled, because it’s not home. He actually lamented to my father, “I was born and lived my whole life on the farm; why can’t I just die there?” (not that, as far as any of us have reason to expect, he’s anywhere near passing on from this temporal existence!). But, fear not, this is just a necessary temporary arrangement, until he’s feeling better regularly and has regained strength.

Right?

Enter this weekend, when, for the first time in a few years, my dad’s brother (and one of my cousins) and two sisters descended on North Judson, IN, simultaneously. They all spent time catching up in person, visiting their father, and, presumably, saying hello to an old friend or two in town; inevitably, they also talked about my grandfather’s situation. My father, I think, was rather blindsided when his three siblings concluded that Grandpa probably ought to spend the rest of his days, however numerous — and, even, healthy — they be, in a nursing home — however nice and well staffed it is — twenty long miles away from his birthplace, where his parents raised eight (I think) children; his home, where he and my grandmother raised four kids; his farm, where he milked cows twice daily, seven days a week, for decades, and grew numerous crops; and his cats, which, until his present exile, he dotingly fed every morning and every evening.

My aunts and uncle, my dad tells me, proffered plenty of cogent reasons for this, and presented this alternative as the easiest for my father — the only child still nearby, who already has been making daily trips to the farm on which he grew up, which he worked for two decades, to tend to Grandpa’s needs and to offer company —, on whom Grandpa’s returning to the farm in greater need will prove to be even more burdensome. However, being Origers, they obstinately refused to accede to my father’s assertions that a) he’s willing to put in even more effort to keep their dad at the only home he’s ever known and b) they have an obligation to their dad to exhaust every possible option (e.g., hiring live-in help) before they, in Grandpa’s own words, dump him in a home. (My father, a wonderful man, is clearly more compassionate than Homer Simpson.) Moreover, recalling that bringing my grandmother back to the farm for thirty minutes, on a trip out of the nursing home where she spent her finals months, nearly killed her, they essentially averred, in response to my father’s query, that he could never, when checking Grandpa out for an afternoon, take him back to his farm, lest it should have a similar — likely worse — effect on him. Ninety-four years on the farm, and then no more. Not even a drive by the property.

Here’s where the two conflicts between what I profess and what I wish, in the real world, to see happen. First, the carefree, easy-living nursing home lifestyle ain’t cheap; after a couple of months of Medicare (and AARP) coverage, the patient foots the bill, approximately two hundred dollars per diem — and that’s in low-cost-of-living rural Indiana. My grandfather, though far from impoverished, is not wealthy; in no more than a year, if that, of his living in the home, his liquid assets would be a thing of the past (and, thus, so too would be my aunts’ and uncle’s inheritances; I’m not particularly concerned with matters of inheritance though, save my father’s . . . ). Once that happens, they (whoever, exactly, undertake what I hope is an unpleasant task) either seize the farm, in the hands of the Origer family for more than a century, or compel us to sell. This being so, my father, on my aunt’s suggestion — and my insistence, too, I must admit — will be calling the attorney to determine whether transferring the property to my parents, the designated inheritors of the farm upon my grandfather’s passing, early, to avoid our having to lose the land, is possible.

If (The gummint folks ain’t always stupid, ya know!) this works, the land remains with the family (giving my parents a nice additional bit of rental income — Thank you, moronic ethanol-encouraging policies! — and allowing us to do our small part to maintain continuity and to live out, indirectly (We no longer farm the land ourselves, but rent it to a local farm.), some sort of conservative, Distributist, agrarian way), and Medicaid foots the bill. Great for my family in practice; gut-wrenchingly hypocritical for me to support. And yet not only have I emphatically encouraged my father to try to make this transaction, but have further suggested that he transfer any of Grandpa’s liquid assets possible into a savings account solely in my dad’s name, one left untouched so that Grandpa still can access the money, should he return home someday, or so that my dad can take care of any bills due in Grandpa’s name, further denying the nursing home my grandfather’s money and, of course, increasing the taxpayer burden for caring for him. So much for my purportedly principled opposition to the welfare state and reliance upon taxpayers, rather than ourselves, eh?

A friend to whom I spilled my guts about all of this, whose own grandmother was in something of a similar position (though she’s much younger, and in at least moderately better health), asked if the alternative ultimately settled upon for her grandmother might work for my family’s situation. To wit, she inquired whether moving Grandpa into my parents’ home might be a sufficient compromise. This I should support wholeheartedly; just as I find the welfarism that I now find myself encouraging (assuming that my father’s siblings prevail) to be fundamentally wrong, the mere thought of taking a reasonably healthy family member out of his home (In my grandmother’s case, I don’t believe that anything other than a nursing home was a viable option, sad enough.) and dumping (again, Grandpa’s dolorously chosen term) him in even a really nice nursing home, rather than welcoming him into his child’s house, is anathema to me.

But there’s no way that I could realistically suggest this to my dad. As I said, three other siblings live one hundred-plus, hundreds of, and a thousand-plus miles away, so moving him into their homes is out of the picture; their moving back to the farm is an equally preposterous proposal. (Well, in theory any of them, particularly my two aunts, could do it, but that involves self-re-deracination in order to replant roots at home.) Thus, my parent’s home remains the only option here; we have three finished bedrooms in the house (parents’, mine, and my brother’s, the latter two of which are only intermittently occupied, other than by feline family members), four if you count the office — but all of those are upstairs. A small room off of the dining room served as my great-grandmother’s room (My family’s house has been in the family, through my paternal grandmother, for more than a century, too: We got roots, I tells ya!) in her later years, but it would spell claustrophobia for just about anyone, especially someone who’s spent his entire life on a farm. Furthermore, my parents both work full-time (another thing about which I probably shouldn’t be thrilled, but I’m more than cognizant of the fact that the sort of sacrifices required for a family to rely on one income just have never been something that my parents could afford; small-scale farming just offers too little, too often, for too much input, to try to rely solely on that income when raising two children; the bills, it seems, didn’t stop after we became independent of them, especially because of health problems that have plagued my father in recent years). They could not provide the sort of support necessary here any more than they could if Grandpa were to stay on the farm, where at least having daily nursing visits or live-in help would be more practical than at my parents’ home.

So now I find myself attempting to reconcile fundamental beliefs about how families, society, and government ought to function with a reality that tests my ability to maintain these beliefs to my limits. I want to see my grandfather remain on the farm, as he wishes, as my father would prefer, but I recognize that this entails sacrificing the attentive care provided at the nursing home, and likely will cost him, if not as much as remaining in the home will, a fair amount of money. If this turns out, either by necessity or my aunts’ and uncle’s loving obstinacy, to be an impossibility, I seek to place the financial burden for caring for him not on us, where it should belong, but on a government — that is, on taxpayers — that at least ostensibly can better afford it. I don’t like it, but I realize that my parents simply could not handle having Grandpa in the house (whereas Dad is more than willing, if not always possessed of sufficient energy to be wholly able, to do everything within his power to keep his progenitor on the family farm), and for reasons personal (selfish?) and philosophical simply cannot fathom the thought of the farm passing out of the Origer family. Does an appropriate compromise — both practically and philosophically, for me — exist? If so, where?

Filed under: conservatism, family, health care, personal

blogrollin’

The job application that’s been taking up all my time of late finally goes in the mail tomorrow morning, which means that blogging should pick up after then. In the meantime, why not content yourself with the three terrific reads I recently added to the UE sidebar in my latest bout of blogroll maintenance?

You should also check out Mark’s two posts on health care policy. Oh, and watch this space for some forthcoming announcements about the immediate future of this blog.

Filed under: health care, miscellany, personal

Against the medical cartel

Via Jesse Walker comes a terrific paper (pdf) by Cato’s Shirley Svorny, explaining how state-sponsored medical licensure drives health care costs up and accessibility down, while doing very little on its own to protect patients from incompetent physicians. Money quote:

Groups representing mid-level professionals are currently threatening to erode what little workforce flexibility exists. Like physicians in the early part of the 20th century, lobbying groups of mid-level clinicians are working to secure legislation that would allow them to stake a claim to specific areas of practice, excluding all others from providing services in those areas. In addition, many clinician groups are lobbying to increase education requirements for new entrants to their field. When government issues licenses to medical professionals, it creates a regulatory apparatus that organized clinicians can manipulate to increase their incomes.

And again:

According to Dr. Derek van Amerongen,Chief Medical Officer of Humana Health Plans of Ohio and Indiana: “People and the legislatures read way too much into licenses. They are extremely poor proxies for quality and knowledge.” Oversight of medical professionals by state medical boards is at best redundant to those quality protections provided by courts and market processes. Because licensing reduces access to care and may give consumers a false sense of security, it may in fact do more harm than good.If there were no state licensing of medical professionals, consumers would search more and demand more information, as they do with other goods.

Importance of this issue? Pretty damn huge, as Kevin Carson and Roderick Long have argued in considerable detail over at AOTP. Chances of anything serious being done about it? Pretty much zero, though Svorny does suggest some compromise strategies:

If eliminating licensing is politically infeasible, some preliminary steps might be generally acceptable. States could immediately increase workforce mobility by recognizing clinician licenses issued by other states, or Congress could require states to do so. For midlevel clinicians, such as physician assistants, physical therapists, and audiologists, eliminating education requirements beyond an initial degree (say a bachelors’ degree) would let employers and consumers select the appropriate level of expertise. At the very least, state legislators should be alert to the self-interest of medical professional organizations that may lie behind the licensing proposals brought to the legislature for approval. When physician groups insist that changes in scope of practice be contingent upon evidence of improved outcomes, politicians should remember that, at present, there is no basis for the claim that patient safety is assured under the current system (an artificial construct of past legislative action) or the claim that patients are at greater risk when state regulation is relaxed.

I for one am very much looking forward to having Kevin weigh in …

Filed under: education, government/law, health care

Getting Journalism Right

Like Rod, I highly recommend Conor Friedersdorf’s C11 piece on conservative journalism, which was originally published at Doublethink Online a few months ago. In the first place, Conor is an extraordinarily talented writer, and this piece displays a lot of those gifts. Secondly, though, the argument he makes – that what conservatives need is not more “echo chamber” polemics, but rather a responsible attempt to show the ways in which liberal pieties are contradicted by the world’s “stubborn facts” – is really quite important, and it suggests the possibility of a kind of conservative or libertarian journalism that is of a higher quality than much of what American conservatives are presently in the business of churning out.

That said (and Conor is explicitly aware of this), the real world is one whose stubbornness contradicts conservative pieties, too, and a responsible journalist will be able to take note of these as well. Moreover, there’s the fact that narrative journalism, with its essential focus on particulars, has a tendency to overplay the power of singular anecdotes: and so while Conor rightly notes that the sadness of one family being thrown out of a home does not do much to mitigate the demonstrable stupidity of rent control, one of the further examples he goes on to suggest as a model for Right-leaning journalism – he’d like to dispatch a fleet of Tom Wolfe clones to every country whose health care system Ezra Klein hopes to draw on – raises concerns of its own: the mere presence of (even lots of) people who are frustrated with or underserved by their country’s health care system doesn’t show that that system is no good, or otherwise no system would be any good. It’s ultimately the bigger picture – the one that’s borne out, however imperfectly, by opinion surveys and expert analysis – that matters most, and a war of anecdotes (For every displaced renter you find, I’ll turn up a frustrated landlord who can’t make ends meet! — Oh yeah? Well, I’ll see your impoverished cancer patient and raise him one uninsured two-year-old!) is not going to get us to where we need to be.

But Conor knows all of this, and ultimately the critical point is that compellingly-reported anecdotes are needed to illustrate the facts that the best theory and expert analysis bear out. (I’ve tried to do this myself, of course.) And Conor is also open, I’m sure, to recognizing that in certain cases those facts aren’t all that “conservative”, after all. And so his essay is an important one, and well worth the read. That Conor is one of the guiding minds behind Culture11 is a very hopeful sign for the magazine’s future.

Filed under: conservatism, health care, libertarianism, media/culture

Sin Taxes And Federally-Funded Abortions For All!

Every now and then, as I find myself disowning movement conservatism over torture and foreign policy, or admitting vague sympathies with the possibility of government-run health care, I begin to wonder whether I am, after all, nothing but a fake conservative on a laughably transparent pinko-commie rebranding trip. But then Ezra Klein’s guest-bloggers step up to remind me that you cannot be a “progressive” unless you hurl terms like “anti-choice” at those who believe that abortion might be a less good thing than ice cream, claim that a woman does not, in fact, have “reproductive rights” unless she is able to pay for her ice cream abortion without financial strain (Does this mean that I presently don’t have the right to a new car and a steak dinner? The possibilities are intriguing …), and insist that taxing cigarettes is the sine qua non of a good “public health” policy. And so I conclude that I must be a crazed, Christianist right-winger indeed.

Have no fear, though: the cigarette taxes will be used to fund the cost of health care for the poor folks who do most of the smoking, and unlimited ice cream abortions will no doubt be included as part of the package. What government will do with itself once income has been successfully redistributed and all of our designated public vices negative externalities taxed out of existence remains a question for another day.

[UPDATE: Apparently our work will not be done until we've slapped some hearty sin taxes on drinking, too.]

Filed under: abortion, conservatism, government/law, health care, taxation

Hurrah!

Matt Yglesias gets fired up about a cause I can share.

Filed under: family, government/law, health care

Can’t get no satisfaction

Jonathan Cohn’s take on why 43% of French citizens say that “fundamental changes are needed” to their country’s health care system – they “want to sustain what they have”, he writes, “and are worried that, given medical care’s escalating costs, they will have trouble doing so in the future” – seems overly complacent, given that, e.g., seventy-four percent (.doc file – see p. 3) of those same citizens report that the standards of care and treatment in their health care system are declining, a number that is ten percent higher than that in the U.S. Perhaps they would like to regain what they used to have.

But let’s be honest with ourselves about who’s got it worse. The report in question – which illustrates the extent to which Americans are far less satisfied with our nation’s health care systems than the French, British, Spanish, Germans, and Italians are – is indeed very revealing, and Ezra Klein is right to say that anyone who looks at them and insists glibly that we have “the best health care system in the world” needs to posit an incredibly high degree of false consciousness. (Though we should note that there is of course, and to say the very least, no guarantee that Americans will be happy with the same sort of system as the French.) The possibility that modern, industrialized, highly technological health care is the sort of thing that can only be successfully delivered through a (*swallowing hard*) state-run system is one which, I think, needs to be taken seriously and debated on its (empirical) merits. I for one would be much happier to work toward a compromise position which included measures – substantial co-pays and deductibles, for example, and stringent distinctions between necessary and optional forms of treatment – to encourage people to turn to medical intervention less often and rely more on preventative measures, an all-around healthy lifestyle, and their bodies’ natural capacities to cope with pain and heal themselves. (The differences between the prevalent approaches to childbirth in Holland and the United States may provide a helpful illustration of what I’m trying to gesture at.) But the people have spoken: there is no getting around the fact that our present system is broken, and that the voting populace is clamoring for something to be done.

(Photo via Flickr user otherthings.)

Filed under: government/law, health care, politics

More on “national projects”

Fellow grad student blogger Peter Boumgarden responds to my rant against National Purpose Progressivism, which he helpfully relates to the excellent Jim Manzi post on subsidiarity and self-governance that I discussed at some length earlier:

Specifically, I think societies [sic] oppressed need some type of financial or systemic support, people deserve to be cared for medically even if they don’t have enough money, and older people deserve attention medically (I think this one will become more important to me as I get older). In these types of situations, the government can initiate projects that cover for the lack of support by the ‘free market’ and ‘localized control’ …

Fair enough, though I think it’s an open question which levels of government are best equipped to deal with the kinds of social problems that Baumgarden lists – and part of Manzi’s point was that it seems to be wise, given “our ignorance of human society”, to let different communities experiment with various sorts of projects designed to address these problems, rather than settling on a single overriding “solution” that may or may not be the best one.

More importantly, though, it’s worth emphasizing that the kinds of problems that Baumgarden is arguing are in need of federal solutions – he specifically mentions care for society’s oppressed, the creation of a (single?) universal health care system, and the need for nurses in elder care – are exactly the boring issues that call for the sorts of “narrowly targeted government programs” that Chris Bowers was complaining about in the post that got all of this started. Hence when Ross Douthat differentiates between directing our political urgency against “real and pressing problems” (which is good) and using the government to “provid[e] ‘purpose’ to American life” (which is silly and irresponsible), he is speaking in favor of the kinds of technocratic wonkery that takes care of genuine social ills like poverty and inadequate health care, and against the use of “national purpose” politics to give meaning to the lives of the disaffected. The kinds of federal “projects” that Boumgarden favors are, in other words, very much the sorts of “transactional” policies that Bowers was arguing are insufficient to “complete the progressive realignment”, and so not the sorts of “transformative proposals” – Great Society, New Deal, man on the moon, globalizing freedom, and so on – that really get my goat. Explaining what’s wrong with nationalized health care is a project for another day.

Filed under: conservatism, government/law, health care, libertarianism, politics

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