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phonypapercut comments on Politics Discussion Thread August 2012 - Less Wrong Discussion
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Why is a government more likely to cover preventative care? If the argument is it's cheaper, a private insurer or individual paying out of pocket has just as much, if not more, incentive to pay for it.
If the benefits of preventative care are realized over the rest of the patient's life, then an insurance company is only incentivized to pay for it if they are obligated to insure you for the rest of your life. Which is true for gov't insurance, but not for any private insurance I am aware of. Even requiring any insurance company to insure any person in the group at any time they ask for it is not enough to change the insurance company's incentive: they would still be wise to "free ride" on any other preventative care payer than to pay for it themselves.
I think part of the problem here is that we do not, in fact, have health insurance in the US, but rather have healthcare plans.
Health insurance would be an insurance policy on your health - if your health declines, they pay out based on that. So if you come down with tuberculosis while on their policy, they pay you for the expenses of that (or possibly just pay out the average cost of tuberculosis treatment), even if you immediately drop your insurance after coming down with it.
What we have are healthcare plans we -call- insurance. And I agree that the incentives are screwed up with healthcare plans, but disagree that government is necessarily the solution. I'd prefer genuine health insurance, which would have much better incentives.
I have auto insurance. My car is worth much less now than when I originally insured it, 7 years ago. My auto insurance does not cover that change.
I have home insurance. The value of my home declined by many 100s of thousands of dollars in 2008. My home insurance did not cover that change.
Isn't there some relevant Eliezer sequence I should be citing on how defining things to mean things different from what they mean to virtually everyone else who might be in the discussion is suboptimal?
Well here is an Eliezer post arguing that using misleading labels is suboptimal even if everyone else is using them.
I meant what I wrote, exactly how I wrote it.
Car insurance doesn't cover the monetary value of your car; home insurance doesn't cover the monetary value of your home. If they did, they'd have covered those things. They cover the thing itself in both cases, provided you have full coverage auto insurance or live in a no-fault state. (If you have liability insurance, of course, something else entirely is being insured.)
You could be leading into something about old age, but unless there's a specific health concern related to old age that you don't think should be covered, I don't think there will be anything to discuss. If I had health insurance and my heart started to go out and they declared that the value of my heart has depreciated so it's not worth the cost of replacement... well, then they haven't insured anything at all. I think I'd have some strong words for my insurance agent.
Insurance isn't there to protect the value of your home, it's there to -replace- your home if it gets destroyed. Which means if your house got destroyed in 2008, odds are (although it varies by insurance policy and possibly jurisdiction), you'd get less from your insurance company than if it had been destroyed in 2007.
Similarly, insurance isn't there to protect the value of my health, but to provide me the ability to restore it in the event that it gets damaged.
By your definitions, EVERY country has healthcare plans and NO country has health insurance.
So why do you say that is the problem "here... in the US"?
Why would you choose to use language differently from everybody else, especially in a way that reduces the application of a phrase from 100s of millions of people to zero? I personally think this is a WAY sub-optimum way to use language.
Are you attempting to persuade me that we can't have rational arguments about politics here?
Because this is the second attempt you've made to attack the same comment on the basis of its semantics. The first I could get, because I saw a line of argument that might arise depending upon my clarification. In this case, you seem to be asking me to make broad generalizations.
An excellent question. I don't know if "we," meaning you and I in particular, can have a rational argument based on what you say in your this response. Maybe I should try harder.
I don't know, maybe I can't do it. The evidence is not strong that I can, that's for sure :)
It seems to me that your response proposes a form of private contract which does not exist at all in real life, and that you state a preference for this theoretical solution over any of the real systems that actually do exist.
So I guess if I were rationally arguing politically with you, I would say something like this:
Perhaps in some very long run, we might find health care arrangements would move in the direction that you like, that contracts such as the ones you say you would like will be offered, and will be purchased at the offered prices. But in the meantime, we have hundreds of millions of people in the systems that do exist. Does it make sense to take existence as evidence of possibility and plausibility, and emphasize in our arguments what we might do in the near term, primarily in terms of choosing among proven possibilities, to improve the health care system in the U.S.? In any case, that is what I prefer to argue or discuss politically.
Well, let me ask a rather pointed question: Do you consider any existing successful healthcare systems undesirable?
Or, from the converse, is there any healthcare system which conflicts with your political beliefs that you regard as having been successful? Did you arrive at a healthcare system after formulating criteria by which you would judge a healthcare system acceptable, or did you formulate criteria which excluded healthcare systems you don't approve of?
(These are distinct questions; I'm not attempting to trick you with the second one.)
For your reference, my criteria for a successful healthcare system, in order of importance as I judge it:
Doesn't constrain individual choice
Encourages innovation and research
Provides affordable/accessible healthcare
A healthcare system which forces people to be vaccinated is undesirable to me. I don't argue with the efficacy of vaccinations, nor do I contest the safety of the common vaccinations; I simply believe that the volition of rational beings is more important than their physical well-being. This is probably a point we are going to disagree on, and hard.
Innovation is the delta of healthcare. In a choice between wider availability and improvement, I'll take improvement. You can't make nonexistent treatments more widely available. However, innovation cannot take place at the expense of somebody's volition; they cannot be forced to participate in a trial, for example, even if would be the only way a drug or treatment could be tested (say, there's a rare condition, and there aren't enough willing participants for the trial to be statistically meaningful).
And finally, affordability/accessibility. That this comes last doesn't mean it isn't still important; it remains one of my conditions of a successful system. However, it comes after volition and innovation. I will accept trade-offs favoring volition, and I will accept trade-offs favoring innovation. If something can only be made affordable by forcing people to engage in particular actions, it is acceptable to me that it won't be affordable. If something can only be made accessible by discouraging innovation, it is acceptable to me that it won't be widely available.
If it is "successful" how could it be "undesirable?" The answer is that you are using one set of value judging criteria to judge success and a different set of criteria for judging desirability.
So a slightly subtle answer to your question is, I use the same set of value judging criteria to rate something successful as I do to rate it desirable, at least in health care systems. And let me state what they might be:
provides the maximum effect for the resources used
maximum effect includes:maximizing average quality-weighted lifespan of the the population covered by the system.
lifespan metric is weighted by degree of full functionality, that is various deficits like unable to run, unable to walk, unable to talk, blindness, deaf, missing limbs, confined to nursing home, confined to hospital, would all and each reduce the weighting of years of life in the metric. So procedures which reduce functional deficit increase the success metric. Procedures which extend your lifespan increase the metric, but they don't increase it much if the lifespan added is spent confined to a hospital.
physical coercion or the threat of its use 1) provides a large quality hit when actually used, and 2) is only used when the quality of the lives improved are other lives than the person being coerced. So my system would allow for the requirement of vaccinations to reduce diseases that spread through the population, as a precondition for being allowed to associate with the population. My system would not attempt physical coercion to get the obese to lose weight, the smoker to quit smoking, or the racecar driver to slow down.
the general coercion of taxation is not part of the medical system but rather is orthogonal. If a society which is in some broad sense "democratic" is willing to vote itself in the taxes to try a particular medical system, and that medical system works brilliantly according to the metrics above, then I consider it a success and desirable. I'm not too concerned about some medically coercive dictatorship, so I'll concede all points that relate only to them to you right up front.
Note my success criterion doesn't include whether the system is national health or free market or individual choice. It primarily includes that it ACTUALLY results in better outcomes. So a brilliant system of exercise and vegan diet would only rate highly on this metric if it ACTUALLY resulted in people living longer higher quality lives. If it fails for any reason, it is not a success, whether it is because people refuse to eat vegan or because eating vegan doesn't have the health benefits originally thought.
I think it is remarkable that none of your criteria involve a metric of success in producing or promoting health. The closest you come is access to healthcare, which I am concerned means I can easily get procedures that may or may not actually help me, but whether they actually help me is irrelevant to whether the system is succeeding, as long as I can get them.
So are our values so far apart as to explain any difficulty we have even discussing this?
I don't have an objective mechanism of evaluating whether or not a system actually promotes health. The issue is exemplified in comparing Japan's health system to the US; do you compare averages of everybody, or just the averages of, say, Japanese-descended people living in the US?
Somebody whose lineage traces back to Japan does as well in the US as in Japan, is the issue. Comparing the two health systems of the basis of population health ignores that the healthcare system may represent only a minority contribution to the health of the population. It's not that I don't think it's an important criteria, it's that I don't believe I have any mechanism of reliably measuring it; to the extent that it can be measured, I judge it being measured in the "Innovation" column, which produces in successes a better healthcare system. (That is, I believe the metric of success in promoting health is better measured at the rate of change in the system's ability to promote health.)
I do agree that taxation is orthogonal to healthcare, which is why I'd prefer a national healthcare system with private options to the healthcare bill we got, which directly violated my #1 criteria.
It seems to me that this sort of procedure has some problematic consequences in how it ranks possible futures. Consider these two possible futures:
A. Alice, an able-bodied person, lives for another year as such.
B. Alice lives for another year but loses the use of her legs this afternoon.
This procedure (correctly, in my view) prefers A over B. However:
C. Alice, who is able-bodied, lives for another year; while Bob, who has no legs, dies this afternoon.
D. Alice dies this afternoon; while Bob lives for another year.
The procedure prefers C over D as well. It is not clear to me that this is obviously the right answer. The procedure is asserting that saving Alice's life is more worthwhile than saving Bob's, by dint of Alice having legs.
Moreover, for any degree of "weighting by full functionality", the procedure prefers to save the lives of a smaller population of able-bodied people rather than a larger population of disabled people. If the "weighting" for loss of legs is, say, 0.9, then the procedure prefers to save the lives of 901 able-bodied people rather than save the lives of 1000 legless people.
It seems to me that such a procedure will — given constrained resources — prefer to maintain the health of the healthy rather than ameliorate the condition of the sick and disabled. While obviously we do not want a medical decision procedure that goes around allowing people to become disabled when it could be avoided (as in A and B), I don't think that we want one that considers someone's life less worthwhile because that person has already become disabled.
A stronger signal comes from the age/life-expectancy of Alice and Bob. But all other things being equal, and in the highly artificial situation that only one of Bob and Alice would be saved, it seems more reasoanble to pick the more functional than the less functional. Your intuition is the cases are equal, what would you propose as a way to allocate one life-saving in the case you have two equally valuable lives to save? If this is the worst criticism of my proposal, then it is way better than I expected it to be!
What if you thought of it in terms of being able to afford to keep 1,000,000 people healthy for the same cost as ameliorating the miserable lives of 100,000 compromised individuals, and we don't have enough resources to do both. I have heard of people having babies whos quality of life sucks, which kids will die at young ages, and spending 1,000,000 of public money a year on medical care for these poor creatures. It may not seem fair, but when resources are finite, choices will be made. How would you propose to make those choices if every life is equal in worth?
Just to be clear... you are not saying only that for all rational beings H, H's volition is more important than H's physical well-being.
You are also saying that for any rational beings H1 and H2, H1's volition is more important than H2's physical well-being (and vice-versa).
Yes?
(Not planning to argue the point, just want to make sure I've understood you.)
With certain necessary limitations on the valid domain of volition (as otherwise volition becomes contradictory), yes. (Negative rights as a concept encapsulate these limitations pretty well for purposes of political discussion, although I'm not sure of their value in a broader philosophical sense; I consider legality a subdomain of morality, which is to say, law should be moral, but morality shouldn't necessarily be law. Negative rights address only the legal considerations of the domain of volition.)