Comments (69)

• USA Today

  "How would truly free-market hospitals handle patients who are now free riders?"

  PAY OR DIE !

  And I have no problems with that !

  Or, instead of insurance, people could be offered financing and pay it up over the years.

  Published: September 24, 2009 7:33 AM

• Zach Bibeault

  Great article Eric. People so often forget that the benefit of helping others (ie letting people into the ER for free or a reduced fee) is ALSO a profit -- a psychic profit. The people who deny this necessarily would have to argue that you always lose out when you, for example, buy a ticket to see a movie, since you are after all not getting a "real good" in return, but a psychic profit.

  And yeah USAToday, the whole "pay or die" thing is how everything works in market societies. What the progressives fail to realize is that food -- something needed DAILY as opposed to healthcare which is usually needed less than monthly for most -- is also "pay or die." They never bother to ask themselves why food costs are low and healthcare costs are high.

  Published: September 24, 2009 8:00 AM

• Christopher

  USA Today,

  It's laughable that the author would suggest that the patient would perform contract labor to pay for services rendered. "Free Riders" still have to pay their bills now and they appear as medical collections on the patients credit report when they chose not to pay. We don't have debtors prisons so there really is no incentive for a "free rider" to pay.

  
  

  Published: September 24, 2009 8:10 AM

• Clayton

  I have a friend who is uninsured and wracked up a $250k bill when she had an allergic reaction to an antibiotic that caused her blood to not clot.

  The hospital worked out a deal with her to take off $1000 from her bill for every bag of blood donated in her name. So we had all of our friends, friends' friends, families, coworkers, etc come out to two blood drives and now she owes nothing.

  So there is one example of alternative payment.

  Published: September 24, 2009 8:32 AM

• Tim Kern

  Well... negotiating a priori for emergency services is, by definition of "emergency," problematic if not impossible.

  The patient would also be negotiating from a position of great weakness (figuratively and literally).

  Thirdly, setting up payment schemes in advance presupposes either a national healthcare database or the requirement that the patient encounters the emergency near the pre-arranged facility.

  I hate the idea of mandated emergency care, also; but I am realistic enough to realize that some problems do not have universal solutions.

  Published: September 24, 2009 8:35 AM

• jl

  Tim, we have roaming for cellular phones, and we have networks of ATMs. Having some kind of coverage that works in most places does not seem like an insurmountable problem. The market tends to find solutions that we have not thought of yet, if only allowed to work.
  

  Published: September 24, 2009 8:39 AM

• KP

  "Without government regulations on their payment collection methods, hospitals would be free to offer more flexible prices and payment options, and to negotiate contracts with individual consumers. Those patients with little financial leverage would be able to form creative payment plans, and those without any savings or insurance could even contract to pay for their services with labor."

  I do not believe it is the hospital choice on how much they charge but the insurance companies that pay them. Situation, if you are out of network with a doctor, the rate they will charge you will be significantly less than if you were in network because of the contract rate hospitals/doctors have with the HMOs. The problem IS with the government but also more IMPORTANTLY with the HMOs that were to provide a capitalist ("free market") solution to health care in the 1970s but are quite the opposite.

  Until we fix the problem with the insurance companies, I do not believe any solution will work.

  Published: September 24, 2009 8:40 AM

• Zach Bibeault

  Christopher, I don't see how contracting labor in exchange for the service is laughable at all. If the person is homeless and has no money, that would likely be the only option. A debtors prison isn't necessary: tasks around the hospital or connected firms in the community could be accomplished to fulfill the labor requirement. And in the event the person still refuses, then it's a matter of breach of contract.

  Published: September 24, 2009 8:58 AM

• James

  It seems like Mises.org has an extremely rosy view of the market's ability to solve health care and other problems. While I agree the health care market should be much less regulated than it is, the idea that you can actually have a free market for emergency room care seems crazy. What about patients who can't communicate? Patients that are traveling and don't have a contract with any local provider? In an emergency people get taken to the nearest hospital, not their preferred hospital. Any hospital would have a de facto monopoly on the surrounding area. You also have to wonder how paramedic and fire services would be paid for. Many poor people use the fire department as their primary care providers. In a free market system, it is hard to image there would be any emergency response in ghettos.

  Published: September 24, 2009 9:02 AM

• Mike C.

  A very good and well articulated article, it is explained in such a way that even an average fifth grader could understand it... it is just too bad that we live in such a forth grade society.

  Published: September 24, 2009 9:03 AM

• Jake

  James (and others)

  You say: "the idea that you can actually have a free market for emergency room care seems crazy. What about patients who can't communicate? Patients that are traveling and don't have a contract with any local provider? In an emergency people get taken to the nearest hospital, not their preferred hospital. Any hospital would have a de facto monopoly on the surrounding area."

  Just to throw out a real world counter-example, based on the concerns you and others express auto repair should require government oversight to function. Afterall, what if people are traveling hundreds of miles away from their local garage? Would not any garage have a "local monopoly" on the surrounding area? Isn't our stranded traveler in a "weak bargaining position"? How are they going to get someone to tow them to a shop? The answers are simple and quite acceptable, just as they would be for healthcare were the market allowed to solve these problems. I see no reason there couldn't be the equivalent of AAA for healthcare, a national or even global network of providers who contract with a large number of potential consumers. There would also still be insurance (REAL insurance) who would also likely provide this sort of function as a service, just as many car insurers provide for road-side assistance.

  You (and others) are looking at the argument unfairly, you look at the problems under the current system and the "solutions" government provides and seem to assume there are no feasible "free market" because the government currently preempts such solutions. Just because you don't know how a problem will be solved doesn't mean it won't. Given that anyone who can solve these problems stands to earn many millions of dollars and in a free market anyone is free to try their solution, it's inexplicably pessimistic to assume there's no way to solve them. Especially when we can see analogous industries where many of the same problems exist, or at least could in theory, were the government performing the same functions of obfuscation and interference.

  Published: September 24, 2009 9:28 AM

• Mike C.

  James,

  Your dark view of man and misplaced faith in government is common but troubling. I truly do not understand your dim view of the nature of people and why you conclude there would be no decent health or fire services in the ghetto.

  There are many charitable institutions that were doing great work long before the state ever stepped into the picture in this country And had the expensive stifling mandates and regulations not been forced on society in the first place there would be far more supply and competition in both medical and fire services and equipment {meaning far cheaper services all around}.

  Visit a veterinarian some time and ask what a comparable service cost for an animal vs. a human being and you will see just how stark the contrast is between the two. No people are not simple animals either but it does show just how much more we pay today simply because crazy liability laws, the inept government run courts, and the inept political responses rashly taken to appease the loudest voices in the masses.

  I could also most certainly envision a tiered system where perhaps the ghetto does not receive the top notch newest equipment too but as the top tier continues to buy ever newer and better equipment I see no reason why good used equipment would not be sold at a deep discount or even given to volunteer organizations to help the poor.

  Also, take a trip to the countryside some time, the volunteer spirit is alive and well and it would be in the city as well if the government wasn’t constantly interfering and meddling and making people more dependent, miserable, and bitter.

  Published: September 24, 2009 9:54 AM

• James

  Jake,

  I take your point, and I think the system would work perfectly for 90% of Americans. However, dealing with the poorest and more irresponsible Americans is always going to be a huge obstacle for libertarian reforms. Yes smart folks have triple A, but a large number of people are either too poor or too irresponsible to maintain roadside assistance coverage, keep their card on them, and carry a cellphone. That is all assuming AAA would even want to service them. When I lived in New Orleans there were large neighborhoods where local businesses would not go. No pizza delivery, no appliance repair, and no car towing. Too dangerous. Even in the nice town where I live now pizza places have stopped delivering to certain neighborhoods. The authorities themselves are reluctant to go into these neighborhoods, but they do because they feel obligated to. However, the best service providers will invariably gravitate toward greener pastures.

  Its similar to the problem in education. The worst schools attract the worst teachers, because the best teachers move on to better schools at the first opportunity.

  I don't see how the market can counter the basic problem here: the people who need the most help are the ones least able to find it, pay for it, and keep it. Libertarian solutions seem ultimately doomed by the simple fact: dumb people exist.

  Published: September 24, 2009 9:56 AM

• nick bradley

  Historically, weren't hospitals charities? Sure, there were parrallel private hospitals for the affluent, but most went to the catholic hospital (or other charity) -- where they were charged based on their ability to pay.

  Published: September 24, 2009 10:19 AM

• USA Today

  Christopher,

  "It's laughable that the author would suggest that the patient would perform contract labor to pay for services rendered."

  The author suggests that hospitals could find an arrangement with the patients which is mutually beneficial. Contract labor is just one of many possibilities.

  Chances are, the entire family of a loved one would agree to work for the hospital in exchange for health care. In the long run, that would prove very beneficial.

  Also, under free market capitalism, prevention would be the key and our current health care system would be more focussed on prevention than curing.

  A ounce of prevention is worth more than a ton of cure but a ton of prevention costs less than a grain of cure.

  Prevention is affordable by everyone.

  Published: September 24, 2009 10:28 AM

• USA Today

  James,

  The market solves NOTHING.

  It's the people who can solve something and it's their responsibility to prevent problems and solve them when prevention failed.

  The market is just the best framework to let you solve your own problems.

  Government intervention always hinders your efforts to solve your problems.

  Published: September 24, 2009 10:34 AM

• USA Today

  Christopher,

  "We don't have debtors prisons so there really is no incentive for a "free rider" to pay."

  Pay or die would at least give smokers and drinkers the incentive to stop their bad habits and give fat people the incentive to shape up.

  How expensive can that be ?

  Published: September 24, 2009 10:41 AM

• pravin

  i speak from my experience in mumbai-india- where i live.govt health services are beyond pathetic here,so the free market came up with 1298 service which is the 911 equivalent .it provides almost 30% people free of charge services (the destitute/poor ones).

  there is aravind eye care in south india which has a 40% profit margin and still manages to provide opthalmology services free for 70% of its patients.
  http://www.icmrindia.org/casestudies/catalogue/Innovation/Healthcare%20Services%20Industry%20-%20Business%20Report%20-%20Excerpts.htm

  the free market provides all kinds of innovative business solutions to those who need it.govt regulations need not strangulate it-thats the only necessity.

  Published: September 24, 2009 10:42 AM

• Michael A. Clem

  However, dealing with the poorest and more irresponsible Americans is always going to be a huge obstacle for libertarian reforms.
  
  You have to take a broader look at society and the incentives involved. Government legislation often provides incentives for people to do bad or irresponsible things, especially when someone else will be forced to pay the cost. But when such incentives don't exist, where society expects people to be responsible for themselves, more people will, in fact, be responsible. Not perfectly, and not everybody, but discouraging irresponsibility through economics and societal pressures will do a lot to help that situation. Don't "enable" stupidity and irresponsibility,and we'll get less of it.
  

  Published: September 24, 2009 10:54 AM

• John Mac

  There is also something that I find completely absurd.

  The FDA refusing diagnostics products on the market.

  I could understand to a certain extent to scrutinize and to refuse or control certain medications because of their dangerousness or serious side effects. Even though I would prefer that the free market handles this.

  But to refuse a diagnostic procedure which constitutes no threat to the wellbeing of the patient ?

  Doctors would evaluate diagnostic procedures and because their reputation would be based on it, they are best placed to decide which diagnostic procedure to offer their patient.

  Even if a diagnostic procedure is flawed or inaccurate, let the patient and doctor decide.

  Those are the kinds of things that makes health care more espensive.

  Published: September 24, 2009 10:58 AM

• Steve

  The uninsured use emergency room (ER) less than everyone else. Those on Medicaid and Medicare use ER the most.

  * * *SOURCE* * *

  Table 6: Emergency Room Services-Median and Mean Expenses per Person With Expense and
  Distribution of Expenses by Source of Payment: United States, 2006

  http://www.meps.ahrq.gov/mepsweb/data_stats/quick_tables_results.jsp?component=1&subcomponent=0&year=-1&tableSeries=1&searchText=&SearchMethod=1&Action=Search
  

  Published: September 24, 2009 11:07 AM

• Ryan

  Eric, This is a really great, well written article. However, i have one concern. In regards to patrons of a hypothetical completely private hospital being able to choose which hospital they choose based on the cost and charitability of the hospital that meets their financal needs and moral needs. I believe that this works in most other fields of business. For example, if a restaurant is relatively cheap and charitable, it may sway me to eat their more often.

  This is because i have the time and options to decide where to eat and for what reasons. In the case of a medical emergency however, it seems to me that most people would simply go to whichever hospital is closest to them regardless of their price or acts of charity.

  Therefore, couldn't a hospital (or all hospitals) that provide reasonable care be relatively expensive and uncharitable and still survive simply because of the location of the hospital?

  Published: September 24, 2009 11:09 AM

• mpolzkill

  Sub-Swiftian proposal combining Michael Clem's and John Mac's posts:

  I'm no legal expert but it seems to me so many great things could be accomplished with waivers. Perhaps both problems here could be solved in one fell swoop. After having signed detailed waivers, "society's" screw-ups could be paid by doctors to try out medical experiments!

  I'm half kidding, but if Obama and crew don't let up on the economic strangulation soon, I'd be about ready to sign up.

  Published: September 24, 2009 11:13 AM

• Ben Ranson

  Mr. Staib's well-written essay gets to the heart of the debate among libertarians about the moral justifications of the free market. Some, such as Mr. Staib, tend to see the greatest good for the greatest number as an adequate justification for the free market. Certainly, in this case, it is persuasive. After all, what better justification could there be for a free market in medicine than improved medical care for the poor, and a reduced burden to the wealthy?

  I do not believe that the poor would necessarily recieve more and better medical care in the free market. Many might recieve little or no care. Nor would the poor own mansions and drive Lamborghinis.

  Interpersonal utility comparisons between lazy, drunken, free-riding bums and Lamborghini-driving yacht owners are a scientific impossibility. My own personal belief is that property rights should be inviolable because of the impossibility of making such interpersonal comparisons in utility. Without the ability to calculate, no interventionist system can ever be proven to be an improvement over the free market. This is true regardless of whether the poor recieve better of worse medical care.

  Published: September 24, 2009 11:13 AM

• Shay

  Zach Bibeault wrote, "People so often forget that the benefit of helping others (ie letting people into the ER for free or a reduced fee) is ALSO a profit -- a psychic profit."

  Since you set a good context, we can notice that being forced by the government to subsidize the exact same help results in a psychic drain, and reduced desire to give to other charities. Some then erroneously conclude that people are selfish and need to be forced to give even more.
  

  Published: September 24, 2009 11:32 AM

• Mr Eko

  Great article Eric. You've addressed the last small reservation I had about free market health care. And I have to admit that you (along with the commenters who have refuted the counterpoints) have smashed it to pieces. What I used to see as a hole in your previous article's argument was simply something that I needed help to think through fully. Thank you.

  Published: September 24, 2009 12:25 PM

• Ribald

  I found this article to be far below the usual quality of writing at Mises.

  Patients with little leverage would have more flexibility in payment options? That's great, provided the provider is willing to negotiate, and less costly if the provider is willing to accept less payment, both of which might occur if the patient had much leverage, which he doesn't.

  People who get emergency care, but can't pay for it, are predatory patients, and should be held accountable....but treating them for free is a highly profitable PR move (as an aside: if you think that people would just take free services with no intent to pay, you're probably very cynical, like those who believe people won't be very charitable without being forced to give). So, should we punish these people or should hospitals pay them for needing emergency care?

  If emergency care and care for the poor are so profitable, why is a mandate for these services detrimental to the industry? Obviously, PR benefit is derived from these services is smaller than the cost of providing them, or else there would be no need to make the case that someone should pay those costs (i.e. the patient).

  The massive assumptions made in order to fabricate a free market that provides free healthcare to those who can't afford it are unfitting the mental aptitude of a seasoned economist, to say the least, relying almost entirely on charity. It'd be necessary to rely on charity so heavily in the free market system, but it is such a surreal utopic vision as to make one recoil in mental anguish. On top of that, it begs the question:

  If the richer among us would be so willing to give freely in the name of healthcare for the poor, why the hell are they so unwilling to do so in the present system?

  Published: September 24, 2009 12:32 PM

• James

  This whole idea seems incompatible with the reality of the modern hospital. It would require much smaller-scale health care. This is probably why Lasik and plastic surgery are often used as examples of the potential of free-market health care, these are very low-capital treatments.

  Most healthcare is delivered through massive bureaucracies with literally billions of capital invested. For example, in my region there is exactly one hospital with a monopoly over hundreds of square miles. This hospital is part of the university, and is absolutely massive. It makes up probably 30% of the entire economy here. This is not an uncommon situation in medium-size towns, many of them have huge hospitals that are a major source of employment for the city.

  I just don't see how you can have a real market for healthcare when you only have 1 giant hospital per 100,000 residents or so, and healthcare is such a locally constrained service. The only real market possible in many places would be a market for different insurance or payment plans, but you are still dealing with the same bureaucracy.

  I think the examples of Catholic medical care for the poor from 100 years ago, or of free-market doctors in India are really out of touch with the reality of the modern US hospital. The costs of a new firm entering the health care market in the US are enormous, and unlike most large-capital firms you can only sell your services to people within a few miles.

  Can anyone here think of a single high-capital investment industry that can only offer services to the local population and yet operates in the free market? Most such industries are exhibit A for market failure and the need for government: roads, sewers, power lines, schools, etc. In fact hospitals and private universities are really the only examples left of large institutions that survive in the free market, and yet most private universities draw their students from far away and do not really have to rely on local demand. And of course as we all know hospitals are financed 50% or more by government sources.

  It seems that the real barrier to free market hospitals may not be government but may in fact be the clunky technology of health care delivery. With more flexible, inexpensive, and small-scale medical technology, perhaps many smaller firms could start up and compete with the giant providers, offering cheaper care and eliminating the political demand for government-run healthcare.

  Published: September 24, 2009 12:58 PM

• Robby

  James,

  A free market would also greatly reduce the existence of ghettos.

  It's not good form to say that a free-market solution is flawed because another government-caused problem exists in the manner of "The market can't fix X because the government has screwed up Y." You can see why Austro-libertarians quickly become "purists" or "radicals" in favor of free markets - the free-market solutions are often sullied by government interference in the free market. In order to make sense, libertarians tend toward no government interference (and thus no government).

  Keep going; you're on to something.

  Published: September 24, 2009 1:01 PM

• Inquisitor

  "It seems like Mises.org has an extremely rosy view of the market's ability to solve health care and other problems. While I agree the health care market should be much less regulated than it is, the idea that you can actually have a free market for emergency room care seems crazy."

  OMG like a free market in food! NUTS I SAY NUTS!

  Published: September 24, 2009 1:02 PM

• Inquisitor

  "Can anyone here think of a single high-capital investment industry that can only offer services to the local population and yet operates in the free market? Most such industries are exhibit A for market failure and the need for government: roads, sewers, power lines, schools, etc."

  They're exhibit A for gov't monopolisation based on claims of "failure" that the gov't itself can't seem to avoid...

  Published: September 24, 2009 1:23 PM

• James

  Robby,

  That's true, but if you let yourself get too "pure" your solutions are impossible to implement and you can start to sound a little crazy. Mises.org seems a bit too extreme for me, I'm more along the lines of Econlog and those guys.

  To respond to Inquisitor's comment, it is true that to actually have a market for something you need to meet a few requirements:

  1. There must be at least 2 firms offering the goods/services. Many areas of the country have only 1 emergency room nearby. Even when there are 2 or 3, only one may be able to provide the type of care you need. There is no comparison to food, in any populated area there will be dozens of places to buy food within a few miles. In health care there is no choice, and thus no free market. I'm not sure that eliminating government intervention would increase the number of emergency rooms very dramatically. In fact from what I understand government subsidies are necessary to keep rural hospitals running at all.

  2. Consumers have to know what they are buying and the price. Many people know very little about healthcare, and even in a free market system where providers tried to advertise prices, the prices would be extremely complex to communicate. How are you going to advertise your prices for 500 different blood tests with meaningless names? With food this is no problem at all because you have reciprocal interaction with the store, and consumers know a great deal about food. In fact food knowledge is one of the few areas in which the general public is not woefully ignorant! In other areas people tend to rely on tradition, reviews, or word-of-mouth, all of which are difficult to imagine working for health care. Some sort of rating agency might work, but would only provide the most general kind of guideline. Of course all this is assuming the patient is even conscious. Tell me, how do people in a vegetative state participate in a free market?

  Healthcare by its very nature puts an extremely large amount of power in the hands of the firm. If I walk in for an operation expecting doctor X and service level A, and I actually get doctor Y and service level B, what's to stop them from charging me even if I get up and leave? The only thing that will make hospitals more consumer-friendly is competition, that's the key. That's what we have to figure out how to get. Anyway, the point is I am not free to refuse to pay and go somewhere else.

  3. Supermarkets aren't morally obligated to give food to the starving, because starving people are unlikely to die on the spot, and not many people starve in America anyway. Not so for hospitals, if they refuse treatment they risk an extremely embarrassing situation. Thus the firm is not really free to refuse services, and would never be free under any system.

  Published: September 24, 2009 1:38 PM

• Seattle

  And hospitals are obligated to provide care to those who can't/won't pay because...?

  Published: September 24, 2009 1:47 PM

• James

  Seattle,

  Because no one who has dedicated themselves to becoming a health care provider is going to sit there and do nothing while someone dies right in front of them. Its just not human nature. Remember you are talking about institutions that will gladly take a baby off your hands, no questions asked.

  ...or did you want to make babies pay for their care too?

  Published: September 24, 2009 2:07 PM

• Robby

  James,

  To preempt Inquistor,

  1.
  You needn't have more than one firm in a field in order to have a market. You need only have no coercive restrictions on the entry of any firm that wishes to compete in order to have a market. There is a real and meaningful difference in the situation where only one firm exists because no one else can compete efficiently enough to gain market share and the situation where only one firm exists because the government will put would-be competitors in jail for trying to enter the marketplace.

  Absent government intervention, the existence of one firm does not indicate "market failure," but rather indicates that the collection of voluntary actors affected by the decision of whether to compete have decided that the one firm in existence can do the job more efficiently than any new firm would be able to do. Otherwise, a new firm would form and give it a go. Increasing the number of emergency rooms is a goal without a logical backing. Reducing legal barriers to anyone who wants to try to open an emergency room makes sense.

  2.
  Here's where this argument heads: Where there is relatively little government interference, knowledge is more accessible and prices are easily established compared to the situation where there is relatively more government interference. Perhaps you've got the cart before the horse?

  You don't do things to get competition. That's planning, and that's what has failed so far. You do things to reduce interference in free decision making and voluntary action. That is the opposite of planning, and that is what leads "crazy sounding" people to believe that if less government is better, no government is best.

  3.
  Supermarkets aren't obligated to provide for starving people, yet very few starve. Charitable actions prevent that in the case of those unable to work to feed themselves. By the same mechanism, it is exceedingly rare to find a person without access to clothing and shelter. If those primary necessities of life are handling in a non-coercive manner by voluntary actions, why do you assume that healthcare will not be handled similarly?

  Published: September 24, 2009 2:14 PM

• mpolzkill

  James,

  How do you feel about "pure" airplane mechanics who learn all the fundamentals and then employ "extreme" caution, learning and skill in the line of their duties? You prefer to fly an airline with mechanics who are a bunch of crooked former lawyers?

  Ha ha, joking around.

  Moderation does not constitute a virtue in and of itself. There is not "moderate rape" and there is not moderate theft and slavery (which is what you propose, whether you know it or not). If you feel that you are a really good egg with really great ideas, rest assured, the State will not give two shits about any of it. The world will continue to be one giant disaster site until enough people figure that out.

  "Tell me, how do people in a vegetative state participate in a free market?"

  Oh shit, you're done for now! LvMI, just close up shop now. That was a good one, James.

  "Healthcare by its very nature puts an extremely large amount of power in the hands of the firm....[yada...yada...monopoly gonna abuse me]"

  (I'm not arguing on any of this, by the way, just making bewildered commentary.) Until my dying day, I will never understand the workings of the millions (apparently) of minds who use variations of this over and over and over. Yes, anything that I believe puts an extremely large amount of power into the hands of a few, well that should be put into the hands of even fewer! Yes, put the State in charge of it, nothing to worry about there! Oh yes, they think they have more choice there because of their "votes". There is no arguing with the religious, especially with the flock of the Church of the Dêmos. Sometimes it's all too sad to bear.

  Published: September 24, 2009 2:36 PM

• James

  Robby,

  1. This is true but it doesn't mean the market is going to be the same in all areas. Currently regulations exist to require a minimum level of care, and that is why there are so few firms, barriers to entry. However, if you remove the barriers it doesn't mean you will suddenly get lots of great emergency rooms springing up everywhere. Areas that have little demand for emergency care will get a few cheap emergency rooms, while areas with high demand will get many nice shiny emergency rooms. Most people find this idea unfair, and they seem to prefer an inefficient but "fair" government solution.

  2. This is just hand waving...yes I'd like to believe "the market finds a way", but it is hard to see how it would be possible to communicate prices to consumers under anything like the current fee-for-service system. The price list would be a phone book, and there would be no reason for one hospital to use the same service and pricing scheme as another, so the prices wouldn't even be comparable even if you did know them. A totally different system would be needed. However I'll grant you that it is likely there is a system that would work (perhaps you just buy a "complete care" insurance package from a hospital chain), but it would be nothing like the system we use for food, which is what Inquisitor was saying.

  3. Because food and shelter are not demanded in a huge emergency chunks. You don't walk into burger king and demand $100,000 worth of burgers or you will die in 30 minutes. You don't suddenly get diagnosed with homelessness and require a $250,000 house within the next year. Also you don't require exponentially more food and shelter as you age.

  I'm sorry but health care is not like any other good. Take for example a poor Mexican farmer. It is entirely possible for him to live his whole life producing less than $100,000 worth of goods, and demanding far less than $100,000 worth of food, shelter, services, etc. Over his entire life! And then that same person could visit Houston, suffer a heart attack, require extensive heart surgery, and cost the local hospital $150,000. In one day this man requires more goods than he will produce in his entire life. What other good behaves this way? The health care cost distribution is so skewed that one day of care can cost years worth of food and shelter. How is the market supposed to deal with that? You know how it would deal with it, the economics of the situation are obvious, but people do not find that solution palatable.

  Published: September 24, 2009 2:48 PM

• gene

  Let's just say this wonderful Libertarian world we propose came to pass.

  And let's just say, the medical industry was actually competitive.

  And let's just say, donors contributed and charity was functioning.

  And let's just say, there was ONE human who was in dire need of life saving care and had absolutely no money and no possibility of earning money and no caring relatives with money and no hope of receiving charity. Nothing!

  Does the rigid ideology say let him die?

  where there is one, there will be many.....

  Published: September 24, 2009 3:03 PM

• John Mac

  gene,

  Where was this ONE human during his whole lifetime ? Didn't he care for himself ? Didn't he worked and save ?

  One day or another, one will have to die. Gene I have some bad news for you, it is certain that sometime in the future you will die. We will all die.

  If it's okay to die at the battlefield for freedom, it's also okay to die for your lack of responsbility in the name of freedom.

  Libertarians hold that forcing someone to provide aid is wrong.

  Either we let that ONE human die or we force many many humans to die on the "waiting" lists.

  What do you prefer ?

  I'd rather let some die freely and forcing us all to die on the waiting-to-die lists.

  That ONE human being could very well be me, but I will die a free man.

  Published: September 24, 2009 3:12 PM

• mpolzkill

  Are you in this hypothetical world, Gene? We'll get your number and give you a ring. Why are you letting him die, Gene?

  I reckon you just may let him die, people generally assume everyone else is pretty much just like themselves.

  Published: September 24, 2009 3:13 PM

• John Mac

  "I'd rather let some die freely and forcing us all to die on the waiting-to-die lists."

  I meant "than" rather than "and".

  Published: September 24, 2009 3:13 PM

• Michael A. Clem

  gene, you're already postulating that nobody is willing to help this person get medical care. In that case, it's hardly an ideology that's letting him die, but everyone else. The question we must ask is why absolutely no one at all is willing to help him (including you)? It's hard to imagine a good reason, unless he's a mass murderer or something.
  
  My point is you can't assume an irresolvable problem and then expect a system, any system, to solve it. If no one is willing to help him in a libertarian world, why would someone help him in any other world?

  Published: September 24, 2009 3:25 PM

• Jake

  Gene seems to think because an ideal libertarian world wouldn't be perfect (by his own personal standard) it's not better than what we have now.

  Let's do that comparison shall we? How many people does the state kill? How many people do state-run medical services let die? Even in the US, how many people die every year waiting for the state to grant them an organ for transplant (as but one example)? Just because the state lies and pretends it's going to solve these problems and bring about utopia by gun does mean that it's likely or even possible to work out that way. You can't argue by comparing the BEST CASE statist solution with a more realistic/worst case freedom based solution... at least not if you want to make a meaningful argument.

  Published: September 24, 2009 3:29 PM

• Michael A. Clem

  Libertarians hold that forcing someone to provide aid is wrong.
  
  Good point. A related point is that if someone is willing to force someone else to help someone in need, why isn't that first person simply willing to help someone himself??

  Published: September 24, 2009 3:31 PM

• John Mac

  Michael,

  "why isn't that first person simply willing to help someone himself??"

  I cannot speak for others but I will speak for myself.

  Why am I not simply willing to help others ?
  Out of resentment at being bullied at school, bullied and taxed by government, mistreated by my parents, having being refused help myself and of being forced to help others myself.

  For the sake of one's own dignity.

  Published: September 24, 2009 3:49 PM

• John Mac

  mpolzkill,

  "Why are you letting him die, Gene?"

  Given that I was poorly treated by others, letting him die is a way to obtain satisfaction and justice.

  I refuse to help a society that refuses to respect me.

  I was routinely abused by my mother as a kid, when she had her back turned, I would sadistically revenge on her cats.

  If I told her all what I did to her cats, she would probably kill me bare handed but then again she brought it on herself.

  Well, having lived a life of miseries and tortures at the hand of others, I don't have any hard feelings but I do refuse to help anyone, it's called justice.

  Published: September 24, 2009 3:52 PM

• John Mac

  I will consider helping a fellow brother in need when society will consider to abolish involuntary psychiatry and to abolish the involuntary census and to abolish involuntary jury duty and to abolish taxes.

  Only then will I gladly defend society and I will be the first one to pledge my life to defend such a society.

  But I refuse to help anyone in such a cruel society.

  Even most of you "libertarians" agree with coercive psychiatry even though it violates human rights and even though it is the most cruel and barbaric practice mankind ever invented.

  I refuse to help people who agree with psychiatry.

  Yes, I would let him die and I would have a sadistical laugh and I would give him the finger while he trepasses. You can thank psychiatry for my attitude.

  I even refuse to give traffic indications or even to give time to people who ask it to me.

  I generally give the finger to those.

  Thank psychiatry for this !

  Published: September 24, 2009 3:57 PM

• Jake

  "Even most of you "libertarians" agree with coercive psychiatry even though it violates human rights and even though it is the most cruel and barbaric practice mankind ever invented."

  I very much suspect you're at the wrong website if you're looking for THAT kind of "libertarian". I don't know what specifically you are referring to, but a few guesses if I may:

  http://mises.org/daily/624

  http://mises.org/daily/2216

  http://mises.org/misesreview_detail.aspx?control=265

  http://mises.org/rothbard/newlibertywhole.asp#p79
  (you'll have to scroll down a little)

  Published: September 24, 2009 4:13 PM

• Rose Ley

  As a person who works in the current health care system, there are a number of issues raised in this article and the solutions proposed may be oversimplified.

  In Australia where I work many people walk through the door in emergency and they fall into two categories those who desperately need care and those who use the free service it provides. Of course, although it is the job of the triage nurse to prioritise care, there are many grey areas that should be addressed in this conversation.

  Having also worked in ICU, a great deal of time and money is used experimenting on patients from ED keeping them alive when there is little prognosis for a good outcome. There are the miracle cases but there are far more sad outcomes. Looking after these patients when they are discharged becomes one of life long devotion, committing many carers to the welfare system because they cannot continue full time work.

  On top of this, more and more health care money is spent on public health (i.e. health promotion). Although many in the health care system see little benefit of such programs this does not prevent government from trying to play God in the belief that somehow if people did the right thing (according to them and the pharmaceutical companies and food companies that sponsor these programs) they would have no health problems. All such programs really achieve is to take funding away from the care of sick people.

  There is no real answer here nor is there any real way that one can balance compassion and true need with ability to pay. Even if workers in the health system were given minimal power in this area, one mistake would be met with someone suing hospitals.

  No doubt this is an age old question and the pendulum has merely swung from one side to the other. When we do obtain some equilibrium, few are prepared to recognize or appreciate this anyway.
  

  Published: September 24, 2009 5:19 PM

• Robby

  James,

  Ok, I think I've got what you're saying now. If I understand your points, you have said this:

  1.
  People in different situations will solve the same problems differently, according to their tastes and means. This is bad, and should be replaced with a standard type of solution to be implemented without regard to local preferences and abilities.

  2.
  Allusions to evidence and logical inferences are to be disregarded and replaced with a hopeless acceptance of the status quo.

  3.
  Katrina and Rita never happened. The San Andreas Fault has never, nor will ever, cause a "humanitarian crisis" via massive, city-demolishing earthquake. Tornadoes do not somewhat routinely destroy wide swathes of the American Midwest.

  The rejoinder:

  1.
  Federal management of local problems (and health care is a local problem, even if it is repeated universally) cannot possibly be done well. The needs of New York City and the needs of west Texas are not the same. The government does not have, and cannot obtain, the necessary information to decide how to allocate health care resources properly among the divers parts of the nation. Even the minimal standards you refer to are problematic. What if the only care potentially available doesn't satisfy the formal requirements of the standard? The government's answer is always clear, whether it is healthcare, education, or anything else. Can't comply with our bureaucracy? Then you get nothing. How is this (by this, I mean forced absence of services) better than any other alternative? Yet this is exactly what must happen when health care is managed without the constraint of the exchange of actual wealth.

  2.
  Your argument is preposterous. All sorts of things are absolutely impossible (in the eyes of statists and planners), yet we use them every day. You cannot fully comprehend the prices of all the parts that go into the computer you use to access this site. But you manage to buy the thing, and make choices you consider informed enough to go with among competing types and suppliers of computers. Same goes for everything around you. Your residence, your ball point pen, your BLT sandwich. All these things are the product of seemingly incomprehensible pricing structures, but life goes on, and does so in an orderly manner. Your argument fails against freedom, but succeeds resoundingly against planning.

  3.
  Obviously food and shelter are demanded in huge emergency chunks. After a disaster, churches, auditoria, and stadia all become places of residence. Just temporarily, but then we don't stay in the ER forever, either. Food that is held in reserve for all kinds of purposes (even undetermined purposes) is moved all over the place very rapidly so people don't get hungry, even in the middle of a catastrophe.

  We're so used to planning that we don't even see it all around us. We're so used to thinking of problems as too big to be left out of federal government control that we don't even remember that the problems were handled quite well--better, often--before the government jumped in to save us. One reason is that a lot of the problems didn't exist before.

  Published: September 24, 2009 5:39 PM

• James

  Robby,

  1. You are right, but the particular kind of mismanagement we have in health care is unique. By and large, we have an artificially inflated supply of care. Usually people throw out government regulation because it makes things worse, but in the case of health care, from the perspective of the individual, the government is making things easier. They require the ER staff to heal you, they subsidize hospitals so there are more in rural areas, they subsidize employer provided health insurance, they pay for the fire department, etc.

  I agree with you that it amounts to a mismanaged mess that productive citizens have to pay too much for, but what I'm saying is that under a free market system there would likely be less services provided in areas with low demand and low ability to pay, at least initially. Perhaps once the market had time to invent creative solutions things would improve, but how long is that going to take? That's the problem politically, people don't want to head down the J curve. People only want the perception of constant improvement.

  2. I had two caveats on my statements here, first that a fee-for-service price list would be incomprehensible, and second that the market would likely invent an entirely different price structure because of this. Health care is nothing like ball point pens or computers. First of all it is a service not a good. It is more like hiring a law firm, cleaning service, or paying for a private university.

  Also, the comprehensibility of prices and the knowledge consumers have of quality is not all or nothing, it is on a sliding scale. My original point was that health care is on the low end of this scale, which means it would be on the low end of market functionality. Out of all the services I can think of health care and education are probably the two most difficult to assess the quality of. Assessing the quality of a pen or computer is trivial by comparison.

  3. Your example shows that food and shelter can be demanded by large groups of people all at once, but it hardly shows that an individual person can consumer $100,000 of food in one day. You also cannot "stock up" on health care services. People have no way of knowing how much they will need in the future and thus no way of preparing for it. If I wanted to spend a million dollars on a nice house I could deliberately go into a high paying career and save for it. But I have no way of knowing if tomorrow I will be diagnosed with a chronic disease, be unable to work, and eventually have to consume a million dollars of health care, so I can't prepare for it. Ordinarily in a market system this would mean I don't get the million dollar service. The basic problem with health care is that society feels obligated to provide the service anyway! This isn't difficult to understand. The problem is that our societal values are no compatible with a free market for health care. It doesn't matter how much more efficient the system would be.

  You also seem to be ignoring the nature of health care and trying to treat it like a commodity. It simply isn't a commodity. Perhaps in the future it will come closer to something easily definable and measurable, but today there is just very little information consumers can go on. For example, if I know I need more RAM for my computer I can find out what kind I need and compare prices on modules of the exact same type. If I need a root canal I can compare prices. But if I have "something vaguely wrong with my foot and need something to fix it" how am I supposed to shop around for that? Call them and ask what the going rate for "foot problem" is? Even if I got a diagnosis and it turns out I have a nice simple problem like a bone spur, I can't compare prices on treatments for that either. If Hospital A wants to do surgery and a month of PT for $5000 and Hospital B wants to try a drug for a year for $1000 how am I supposed to compare those? Either one could be a complete failure or complete success, and I won't know until much later.

  One last point. Remember that the FDA did not always exist. Insurance regulations did not always exist. Laws about physician licensure and such did not always exist. All of these things were created in response to crises and problems with the current system. These crises would not have happened if the free market system was perfect. There are fewer laws and regulations in areas like high tech devices because markets for these products work well in delivering quality, making consumers happy, and not killing anybody. Health care is regulated because bad, cheap health care practice can and does kill people. The argument that bad practitioners will be discovered and driven out of the market is cold comfort for people whose lives have already been ruined. The fact is people would rather have an inefficient regulated market that feels safe than a wild west market where anything goes
  

  Published: September 24, 2009 6:38 PM

• Jake

  James,

  "All of these things were created in response to crises and problems with the current system."

  Please elaborate if you will. What sort of crises prompted the establishment of these various state interferences?

  Published: September 24, 2009 8:28 PM

• mc

  "there's just no arguing with the religious"

  This is especially difficult when you put forth no arguments......

  Published: September 24, 2009 8:58 PM

• Jake

  James,

  And to reply to your post from this morning:

  "When I lived in New Orleans there were large neighborhoods where local businesses would not go. No pizza delivery, no appliance repair, and no car towing. Too dangerous. Even in the nice town where I live now pizza places have stopped delivering to certain neighborhoods. The authorities themselves are reluctant to go into these neighborhoods, but they do because they feel obligated to. However, the best service providers will invariably gravitate toward greener pastures."

  I hardly see how recognizing that the government has done an abysmal job maintaining law and order in poorer areas is justification for why it must provide healthcare too. As for businesses not going into these areas, that's very simple. A pizza delivery shop that charged a 2 dollar premium per delivery to bad parts of town, to pay for the additional insurance perhaps and to compensate the employee for the additional risk, would be berated as racist, and probably face legal trouble based on discrimination as well. I'd also point out that many of the VERY WORST neighborhoods are projects built by the government, and frequently forbid any sort of commercial activity within the project (I'm sure pizza delivery is allowed, but you cant' open a pizza shop on the grounds).

  "Its similar to the problem in education. The worst schools attract the worst teachers, because the best teachers move on to better schools at the first opportunity."

  Why do terrible schools exist at all? Because people are forced to pay for them regardless of how they feel about the service perhaps? Regardless of whether they even make use of the service? Because people are given no choice, or very limited choice, about the schools they may attend?

  I don't think your assessment is accurate that government is involved in these activities, protection, education, healthcare, because these problems make it difficult for the market to provide. Rather I think these problems are difficult for the market to provide PRECISELY because the government is so involved. And has spent decades and even centuries crafting an elaborate system of lies and rationalizations about how only the government can do these things.

  Fortunately I don't have to go strictly on gut feeling about this. There is plenty of evidence that suggests education for example was FAR more effective, FAR cheaper, and even MORE universal PRIOR to the government's involvement. Do you know anything about the literacy in Colonial America? It was astounding, Thomas Paine's "Common Sense" was purchased and read by very nearly EVERY American household of the period, today such would be covered in a college level class (if our colleges had the guts and intellectual vitality to even study it at all, they do not). The best sellers of that day are the literary classics of today, things like Cooper's Last of the Mohicans were the "light reading" of the colonial period, read by Farmers, Tradesmen, laboroers, etc who'd never spent a day in a government school, today your average college graduate would not stand a chance against those people. Nor was this phenomenon relegated to "those who can afford it"... the literacy rate in New England at this time was something like 98 or 99% FAR superior to what we have today even if one ignores just how much the definition of "literate" has been watered down in the time since.

  "I don't see how the market can counter the basic problem here: the people who need the most help are the ones least able to find it, pay for it, and keep it. Libertarian solutions seem ultimately doomed by the simple fact: dumb people exist."

  My first retort is "yes dumb people exist, all the more reason to do away with the states power over our lives. I'm tired of being ruled by dumb people!" But again I'd point out, the government schooled these people, the government decides what they should and should not be taught, the government insulates them from the consequences of their dumbness (ensuring they've no opportunity or motive to smarten up)... and yet you conclude that we must have government involvement in every facet of life because we have dumb people.

  Published: September 24, 2009 9:19 PM

• Gil

  Who's to say all healthcare is expensive? Who went broke buying antiseptic cream or a bottle of aspirin? Indeed comparing 1800s medicine to nowadays is ridiculous. In fact, when did proper medicine even begin? Prior to the 1800s there doesn't seem to be much that we would even recognise as medicinal treatment.

  Comparing healthcare to food is also bunk. Basic foodstuffs are cheap just as many items in a chemist store are cheap. Fancy foods are not found in charities, likewise dire expensive treatments aren't likely to be supplied by charity as charities don't have bottomless pits of money.

  Similarly, comparing doctors to veternarians? Golly, isn't one big difference is euthanasia is available to the vet and the pet owner?

  But when did the U.S. have a free (enough) market in health care? Prior to the 1950's? The 1930's? 1900? When did all the new, fangled equipment for diagnosing and treating cancer, stroke and heart disease, etc.? Gee, after 1950! What a coinkidink!

  Published: September 25, 2009 1:44 AM

• paul stephens

  The problem with your analysis is that healthcare should not be a profit-driven "commodity" or service in the first place. Hospitals used to be considered either charities or public utilities. All who need medical care could get it there, regardless of ability to pay. That's the way it is now in nearly all the rest of the world.
  People who want to run a business and "make money" should be in another line of work. The fact is, everything now is corporate-controlled, and corporations control the government. The outrageous billing and collection policies of even religious or public hospitals and other providers are well-known.
  And "health insurance" is the ultimate protection racket. You're not insuring "health" at all, but only your savings, home, or other assets from being confiscated by the cost-shifting, bill-padding hospitals and clinics who are spending millions lobbying against any sort of consumer protection or patient's rights.
  This is a bad example for a libertarian argument, overall.
  Paul Stephens, Green Party organizer

  Published: September 25, 2009 4:28 AM

• Mushindo

  Thorny issue, with a high emotive kneejerk coefficient.

  Some thinking points:

  1. Modern healthcare can do far more than the healthcare available in the past. Generally, the more cutting-edge the treatment, the more it costs. Somebody's got to pay, and as soon as an expensive treatment is discovered, it is impossible to make it universally available to everyone who could concievably benefir from it, without bankrupting everyone else.

  2. The biggest problem with free healthcare, as with just about any other sphere of government intervention, is that its very availability lowers the cost of high-risk or imprudent lifestyle decisions in the minds of people making their day-to-day decisions. If everyone is to make reasonable risk-seeking or risk-averse choices according to their own optimal balance, it is essential that the potential cost of healthcare is brought to account. If its not, the effect is to drive a wedge between choice and consequence.

  3. As regards those whose need for medical care emerges despite a prudent approach to their life choices, the charitable impulse is quite sufficient to cover those cases at the margin, if it was not crowded out to the extent the State has this last century or so. what follows probably applies to any sort of charity, but I offer it here in the healthcare context:

  there is a huge wellspring of people who devote their time, money and effort towards dealing with those 'social problems' that they feel strongly about, and medical trageties are no exception. Witness the innumerable voluntary foundations and support groups for innumerable diseases, invariably staffed, funded and advocated for by people who are passionate about them. Given a free market in charity, any dollar raised and deployed by passionate volunteers will buy far more bang than the equivalent dollar spent through any government-run agency.

  Bear in mind too that a free market in medic al charity entails donors giving to those causes that they feel most strongly about. It follows that the most dire need on any concievable compassion or pity index will generate the widest response, so the scale of the problem will be matched by the size of public response - which provides a natural fit between the scale of the problem and the charitable effort devoted to its solution.

  Published: September 25, 2009 7:27 AM

• Ron

  Interesting points. I don't think every possibility situation would work without adjustments and support to morality but the basic precept that individuals pay there own way and a system that supports that through service with bartered trade if necessary is going back to how it worked before.

  If the government hadn't competed with the private sector and used coerced finances to inflate worth to substantiate health care costs over the past systems that were in place included the churches, private hospitals, family Doctors and many more avenues that provided care and kept the cost within societies ability to pay, perhaps costs would be more inline with what people could afford.

  Something has gone dreadfully wrong in our entire system where we trust a government solution that is supposed to make things more affordable or improved and the mere cost of the bureaucratic waste becomes its Achilles heal, and its proven track record shows it can't manage costs or quality.

  Even with the advent of insurance, cost have steadily risen, become more inflated, support more retirements and specialized careers for people just to handle those who have refused to pay for treatment or get treatment because it can be had for free.

  Many people develop into despotism because the system allows them the opportunity to be that way by confiscating moneys from people not involved in the actual immediate care of said individual. Health care gets complicate when a certain amount of people trust decency with no evidence or encouraged commitment to it or financial responsibility, especially when they have created a system that supports or encourages neither.

  The first step in any government or community based system is to insure a responsibility toward value..........Governments don't seem to do that well and impose wasteful, politically motivated solutions that adhere to no morality in there business model but a huge morality assumption in their sales pitch.

  Even though a large amount of people sincerely believe affordable health care can be reached by spreading more burden to more people, the simple lack of morality of economics will create an atmosphere that promotes financial failure and burden to ever increase until care becomes the sacrificial lamb and life becomes cheapened to support the thesis.

  The simple question is; is it moral to invite people to carry the burden of others, leveraged by bureaucrats, another cost layer without a real financial responsibility to anyone, and condemn them to bureaucratic induce decisions based on no morality but political expedience?

  As soon as you, as an individual give up your responsibilities for your future moral commitments, you have accepted the changing morays of bureaucratic desires. Instead of supporting responsibility it will migrate to the government model that we see in medicare, medicaid, the VA and welfare; huge cost over runs, paperwork up the cuzzoo and wasteful spending with fraud at a ration 2-3 times normal activity. the bonus will be great retirements and careers for doing very little good at the cost of all, with the most unscrupulous gaining the upper hand.

  What America is confused in, is the moral dilemma of how to enforce responsibility with finances and peoples worth and how do you take care of those with little worth.

  Some trust the government to remove the moral commitment from society and let the cost be dictated by a surrogate, a bureaucrat..... while others know that if you remove human achieved value for the sake of no human commitment to worth, then you automatically detach individual respect and control to invite a state of decay where all become less morally bound to their worth. The resulting devaluation of not supporting others worth lends society to develops an attitude of presumptive value that no system can financially maintain......and gives the power and value to the government bureaucrat over peoples choices.

  Free exchange of service with a leveraging of value that has the individual as its keeper is the only leverage point that has its source based on human morality.

  Why we are choosing to condemn every one in this country to a systematic raping of individual rights, power and economic value by continuing inviting in a system of bureaucrats to leverage value and service for political needs, disguised as a morality blanket for civilizations lack of commitment to human value, will do exactly the opposite of its intentions as usual, is anybodies guess.

  Published: September 25, 2009 7:43 AM

• Robby

  Mushindo,

  Spot on with your second point. The biggest improvement my driving ever made happened the day I lost free (to me) major medical coverage from my parents. Paying for my own much less comprehensive coverage reminds me that there are real costs associated with reckless behavior and encourages me to avoid that behavior in order to reduce the odds of the consequences occurring. Government-mandated and -controlled "insurance" will only insulate people from that signal.

  Published: September 25, 2009 11:31 AM

• Paul Stephens

  From the libertarian point of view, the whole "welfare state" and political/bureaucratic control over its agencies is a bad thing in itself. I agree with that. Any humane social order is based on "values" (morality) rather than profit-maximization or coercion.
  But viable, humane, free, and democratic welfare institutions are certainly possible and desirable. Food Stamps or education vouchers are good examples of how the State (or local city-states, rural counties, etc.) can maximize social welfare at the least cost to taxpayers (those who have acquired surplus wealth from whatever source).
  I was trained in both Austrian and Chicago School economics, and they differ somewhat on some of these philosophical issues. But I think they agree that there is nothing wrong with assuring that all members of the community should have some sort of guaranteed income and access to all the necessities of life. Only Social Darwinists (and maybe anarcho-capitalists) really maintain that the community has no responsibilities to those whose survival and well-being depends on outside help.
  Self-help communities of such people, subsidized wisely, are probably the best answer to this problem, but they must be open, transparent, self-governing, and democratic.
  We're all opposed to Authoritarianism, aren't we?

  Published: September 25, 2009 1:59 PM

• James

  Jake,

  There are so many differences between modern america and colonial america that I think any attempt to draw educational lessons from that time period is pretty much a wash. Even defining what "literacy" means is difficult. Do you realize that historians define literacy rates during that period as the percentage of people who could sign their name on a document? And even then they come up with a wide range of figures, from 70-100%, for white males only. I can assure you that in the period for which we actually DO have data, the literacy rate has been increasing ever since WWII until leveling off recently.

  Regardless, none of this addresses the point I was making. I agree that education should be free-market, but my point was that in a market the best teachers will go to the highest bidder. They aren't going to hang around the ghetto. The same would go for health care. That is the basic point I've been making in this whole thread, and I haven't heard any response to it other than the faith that charity will supplement demand for health care for the poor. I also don't believe we can educate our way out of the situation. No matter how wonderful the education system is, there will always be a good 10-20% of the population that are just genetically low-IQ and/or irresponsible. What's more, as technology progresses and more low-end jobs are automated, there will be an increasing proportion of the population with nothing productive to do.

  Paul,

  That is an interesting idea, that hospitals should all be run as charities. I'm not sure it would work given the high cost of medicines and equipment today, but it certainly sounds like a viable solution. Those on the left would probably argue there should be a market system for those who can pay, and a tax on them to subsidize the charity hospitals for the poor. This seems like a realistic outcome of a push toward a more free market health care system.

  Mushindo,

  You make a good case for the ability of charity to pay for health care for the poor, but how would the system actually work? Would the poor have any incentive to worry about costs and quality if they knew their costs would all be reimbursed by charity? Wouldn't the charity hospital be more concerned about donors than patients? It seems like the system could develop some of the same problems we have under the current system and people might still call for government intervention.

  
  

  Published: September 25, 2009 2:19 PM

• Justin

  Clearly hospitals should withhold life saving care until it can be confirmed that the patient is able to pay. Regardless of whether or not the patient is conscious.

  Published: September 25, 2009 8:41 PM

• James Fogal

  I am a part-time paramedic in Georgia and Alabama. I currently work for a private EMS service and have worked for government EMS services. I can tell you that from my perspective, patient care is better with the private services because they care to serve the needs of the patient. Not so with government services, they are government employees so they can treat patients badly and can (and often do) try to not transport many of their calls to hospitals.
  Private EMS is possible and would make our world a better place. Governments need to quit involving themselves in crowding-out private industry in this much-needed field.

  Published: September 28, 2009 12:45 PM

• chads

  Here's my perspective as an ER doc, and MPH student studying health systems: Interesting, idealistic, Utopian (for libertarians, of course) view written by someone who seems to have no real grounding in the history of emergency care in our country, the challenges that would face a market in emergency care, the systemic nature of emergency care, and no realistic plan for implementing his plan.

  Bottom line: private charities have failed rather miserably both here in the US and globally at providing universal emergency health care for the most destitute. And the crucial question is: Is that OK? Would it be OK with you, with voters, with politicians, with the media for occasional deaths and long-term disability because of all of the inconsistencies that would accompany a plan suggested by the writer? That's where we were about 20 years ago, and it wasn't OK (for society, at least). Would it be OK now? It may be the case that, with time, charities would step up to fill in the gaps, but would the bad outcomes be acceptable during the transition period?

  The question at hand, of course, is: Given the current political, legal, and cultural climate, what is the best long-term plan? Few are truly willing to answer that question from any political ideology, it seems to me. And that is a thought that is much more concerning than even the government take-over of health care (which is terrifying). Because the alternative to all current proposals is the status quo, which is government-run health care that is incredibly inefficient, and is unacceptable.

  Where are the libertarians that are willing to take a long, hard look at this issue and propose a realistic plan? The little I've seen comes across the same way: idealistic and superficial, appealing to emotions and "the good old days when I used to practice" without a realistic, thoughtful plan.

  I would LOVE to read a thoughtful, realistic, libertarian (or even just conservative) plan that reasonably addresses the emergency care quandary, and the implications for the rest of health care. This isn't it.
  

  Published: October 4, 2009 5:19 AM

• newson

  to chads,
  what about getting rid of the ama for starters? getting rid of licensing, and opening the market up to competition, or is that part of the utopia you don't care to think about?
  

  Published: October 4, 2009 6:44 AM

• chads

  Newson,

  If abandoning licensing for emergency physicians and other providers and opening emergency care to the market is a strategy that you think will be best given the current cultural, legal, and medical environment, then pursue it. Fight for it. Advocate for it.

  I think that it would be a disaster. And I hope others that trust the market and fear the government can come up with a better proposal. If not, we're in for a tough road ahead.

  Published: October 4, 2009 6:25 PM

• Orion

  chads,

  What's wrong with private licensing similar to Underwriter Labs or the BBB?

  Published: October 4, 2009 7:10 PM

• newson

  to chads:
  i suggest you've got a conflict of interest as big as a house. as an opening gambit, what's wrong with freeing up competition in the professions?

  as orion points out, professional reviewers will provide paid ranking services. costs come down, and service improves.

  Published: October 4, 2009 7:34 PM

• chads

  newson: Are you really making assumptions about my political motivations when you know nothing about me?

  orion: Interesting. I don't know much about the private licensing practices of those organizations. Could you elaborate?

  Published: October 5, 2009 11:58 AM