A Small Reason Why I Don’t Want Big Government

Santa Cruz, California is really Silicon Valley Beach. It’s the closest; the next one is quite far. That’s in addition to drawing visitors from deep into the Central Valley of California, and a surprising number of European visitors.

One attractive beach close to its municipal wharf has only two (2) toilets. On Labor Day weekend Sunday, one of the two toilets was out of order. I estimate there were between 500 and a thousand people on that particular beach.

The day before, Labor Day weekend Saturday, the same toilet was already out of order. It was still out of order on Monday, Labor Day itself.

It was only a few months ago that the City of Santa Cruz joined a class action suit by a number of government entities against major oil companies for causing climate change. The first judge to look at the suit send the plaintiffs packing, of course.

So, this city of 60,000 wants to stop global warming but it does not have the ability to place two working toilets at the disposal of hundred of visitors who leave thousands of dollars in its coffers. The city cannot afford to hire a competent plumber on an emergency basis to fix the problem immediately. It does not have the timeX2 that would be required. Make it timeX3 on the outside. The total would come to $500 tops. Make it $1,000. It does not change anything.

The same happened last year or the year before. Surprise!

This is pathetic. We are governed by morons. Their gross incompetence is not natural, I am guessing. It’s learned stupidity. Our fault. We vote them in – with big help from UC Santa Cruz undergraduates who don’t care one way or the other, just want to feel good by electing “progressives.”

No one told our City Manager that Labor Day weekend, and its crowds, were coming. How was he supposed to know?

Nightcap

  1. White saviors abroad – social doctors at home? Tine Hanrieder, Duck of Minerva
  2. The case against Woodrow Wilson Philip Conway, et al, Disorder of Things
  3. Tragedy, statecraft, and world order Neville Morley, War on the Rocks
  4. “All leaders are constrained by their underlings” Rick Weber, NOL 

Nightcap

  1. The promise of liberalism in a world of groups Mark Koyama, Areo
  2. Becoming a man William Buckner, Quillette
  3. Choosing your own family Nora Caplan-Bricker, New Republic
  4. Home sweet home (California) Kerry Jackson, City Journal

Nightcap

  1. After Federalist No. 10 Greg Weiner, National Affairs
  2. Photos of the Paris “Yellow Vest” Riots Alan Taylor, the Atlantic
  3. A century of HIV Thomas McDow, Origins
  4. The long, entwined history of America First and the American dream Kevin Kruse, the Nation

Nightcap

  1. A libertarian case for postmodernism Candice Holdsworth, Spiked
  2. South Sudan and wealthy LA enclaves have same vaccination rate Olga Khazan, the Atlantic
  3. The rise of Turkey’s new ultranationalism Burak Kadercan, War on the Rocks
  4. Past Masters of the Postmodern Simon Blackburn, Inference

The Real Cost of National Health Care

Around early August 2018, a research paper from the Mercatus Center at George Mason University by Charles Blahous made both the Wall Street Journal and Fox News within two days. It also attracted attention widely in other media. Later, I thought I heard sighs of satisfaction from conservative callers on talk show radio whenever the paper came up.

One figure from the study came and stayed at the surface and was quoted correctly many times (rare occurrence) in the electronic media. The cost of what Senator Sanders proposed with respect to national health care was:

30 trillion US dollars over ten years (actually, 32.6 over thirteen years).

This enormous number elicited pleasure among conservatives because it seemed to underscore the folly of Senator Bernie Sanders’ call for universal healthcare. It meant implicitly, federal, single-payer, government-organized health care. It might be achieved simply by enrolling everyone in Medicare. I thought I could hear snickers of relief among my conservative friends because of the seeming absurdity of the gigantic figure. I believe that’s premature. Large numbers aren’t always all they appear to be.

Let’s divide equally the total estimate over ten years. That’s three trillion dollars per year. It’s also a little more than $10,000 per American man, woman, child, and others, etc.

For the first year of the plan, Sanders’ universal health care amounts to 17.5% of GDP per capita. GDP per capita is a poor but not so bad, really, measure of production. It’s also used to express average gross income. (I think that those who criticize this use of GDP per capita don’t have a substitute to propose that normal human beings understand, or wish to understand.) So it’s 17.5% of GDP/capita. The person who is exactly in the middle of the distribution of American income would have to spend 17.5% of her income on health care, income before taxes and such. That’s a lot of money.

Or, is it?

Let’s imagine economic growth (GDP growth) of 3% per years. It’s optimistic but it’s what conservatives like me think is a realistic target for sustained performance. From 1950 to 1990, GDP per capita growth reached or exceeded 3% for almost all years. It greatly exceeded 3% for several years. I am too lazy to do the arithmetic but I would be bet that the mean annual GDP growth for that forty-year period was well above 3%. So, it’s realistic and probably even modest.

At this 3% growth rate, in the tenth year, the US GDP per capita will be $76.600. At that point, federal universal health care will cost – unless it improves and thus becomes more costly – 13% of GDP per capita. This sounds downright reasonable, especially in view of the rapid aging of the American population.

Now, American conservative enemies of nationalized health care are quick to find instances of dysfunctions of such healthcare delivery systems in other countries. The UK system was the original example and as such, it accumulated mistakes. More recently, we have delighted in Canadian citizens crossing the border for an urgent heart operation their nationalized system could not produce for months: Arrive on Friday evening in a pleasant American resort. Have a good but reasonable dinner. Check in Sat morning. Get the new valve on Monday; back to Canada on Wednesday. At work on the next Monday morning!

The subtext is that many Canadians die because of a shortage of that great free health care: It nice if you can get it, we think. Of course, ragging on the Canadians is both fair and endlessly pleasant. Their unfailing smugness in such matters is like a hunting permit for mental cruelty!

In fact, though, my fellow conservatives don’t seem to make much of an effort to find national health systems that actually work. Sweden has one, Denmark has one; I think Finland has one; I suspect Germany has one. Closer to home, for me, at least, France has one. Now, those who read my blogging know that I am not especially pro-French or pro-France. But I can testify to a fair extent that the French National Healthcare works well. I have used it several times across the past fifty years. I have observed it closely on the occasion of my mother’s slow death.

The French national health system is friendly, almost leisurely, and prompt in giving you appointments including to specialists. It tends to be very thorough to the point of excessive generosity, perhaps. Yes, but you get what you pay for, I can hear you thinking – just like a chronically pessimistic liberal would. Well, actually, Frenchmen live at least three years longer on the average than do American men. And French women live even longer. (About the same as Canadians, incidentally.)

Now, the underlying reasoning is a bit tricky here. I am not stating that French people live longer than Americans because the French national healthcare delivery system is so superior. I am telling you that whatever may be wrong with the French system that escaped my attention is not so bad that it prevents the French from enjoying superior longevity. I don’t want to get here into esoteric considerations of the French lifestyle. And, no, I don’t believe it’s the red wine. The link between drinking red wine daily and cardiac good health is in the same category as Sasquatch: I dearly hope it exists but I am pretty sure it does not. So, I just wish to let you know that I am not crediting French health care out of turn.

The weak side of the French system is that it remunerates doctors rather poorly, from what I hear. I doubt French pediatricians earn $222,000 on the average. (Figure for American pediatricians according to the Wall Street Journal 8/17/18.) But I believe in market processes. France the country has zero trouble finding qualified candidates for its medical schools. (I sure hope none of my current doctors, whom I like without exception, will read this. The wrong pill can so easily happen!)

By the way, I almost forgot to tell you. Total French health care expenditure per person is only about half as high as the American. Rule of thumb: Everything is cheaper in the US than in other developed countries, except health care.

And then, closer to home, there is a government health program that covers (incompletely) about 55 million Americans. It’s not really “universal” even for the age group it targets because one must have contributed to benefit. (Same in France, by the way, at least in principle.) It’s universal in the sense that everyone over 65 who has contributed qualifies. It’s not a charity endeavor. Medicare often slips the minds of critical American conservatives, I suspect, I am guessing, because there are few complaints about it.

That’s unlike the case for another federal health program, for example the Veterans’, which is scandal-ridden and badly run. It’s also unlike Medicaid, which has the reputation of being rife with financial abuse. It’s unlike the federally run Indian Health Service that is on the verge of being closed for systemic incompetence.

I suspect Medicare works well because of a large number of watchful beneficiaries who belong to the age group in which people vote a great deal. My wife and I are both on Medicare. We wish it would cover us 100%, although we are both conservatives, of course! Other than that, we have no complaints at all.

Sorry for the seeming betrayal, fellow conservatives! Is this a call for universal federal health care in America? It’s not, for two reasons. First, every country with a good national health system also has an excellent national civil service, France, in particular. I have no confidence, less than ever in 2018, that the US can achieve the level of civil service quality required. (Less in 2018 because of impressive evidence of corruption in the FBI and in the Justice Department, after the Internal Revenue Service).

Secondly, when small government conservatives (a redundancy, I know) attempt to promote their ideas for good government primarily on the basis of practical considerations, they almost always fail. Ours is a political and a moral posture. We must first present our preferences accordingly rather than appeal to practicality. We should not adopt a system of health delivery that will, in ten years, attribute the management of 13% of our national income to the federal government because it’s not infinitely trustworthy. We cannot encourage the creation of a huge category of new federal serfs (especially of well-paid serfs) who are likely forever to constitute a pro-government party. We cannot, however indirectly, give the government most removed from us, a right of life and death without due process.

That simple. Arguing this position looks like heavy lifting, I know, but look at the alternative.

PS I like George Mason University, a high ranking institution of higher learning that gives a rare home to conservative American scholars, and I like its Mercatus Center that keeps producing high-level research that is also practical.

Midweek Reader: The Drug War, the Opioid Crisis, and the Moral Hazard of Overdose Treatment

Today, I’m reviving an old series I attempted to start last year that never came to fruition: The midweek reader. A micro-blogging series in which I try to link to stories that are related to each other to provide deeper insight into an issue. This week, we’re looking at the relationship between the Opioid Crisis and the drug war, and the academic debate around a controversial paper finding moral hazard in policies that try to increase access to Naloxone.

  • At Harpers Magazine, Brian Gladstone has a fantastic long-form piece looking into how attempts to crack down on opioid addiction by targeting the prescription pain meds have left many patients behind and questioning the mainstream narrative that the rise of opioids was driven primarily by pain prescriptions. A slice:

    Yet even the most basic elements of this disaster remain unclear. For while it’s true that the past three decades saw a staggering upsurge in the prescribing of opioid medication, this trend peaked in 2010 and has been declining since: high-dose prescriptions fell by 41 percent between 2010 and 2015. The question, then, is why overdose deaths continue to skyrocket, rising 37 percent over the same period — and whether restricting access to regulated drugs is actually pushing people toward more lethal, unregulated ones, such as fentanyl, heroin, and carfentanil, a synthetic opioid 10,000 times stronger than morphine.

  • Similarly, at the Cato Institute, Jeffery A. Singer has a good piece exploring the relationship between America’s War on Drugs and the rise of opioid addictions. He concludes:

    Meanwhile, President Trump and most state and local policymakers remain stuck on the misguided notion that the way to stem the overdose rate is to clamp down on the number and dose of opioids that doctors can prescribe to their patients in pain, and to curtail opioid production by the nation’s pharmaceutical manufacturers. And while patients are made to suffer needlessly as doctors, fearing a visit from a DEA agent, are cutting them off from relief, the overdose rate continues to climb.

  • At Voxphilosopher Brendan de Kenessey of Harvard has a piece exploring the philosophy of the self and of rational choice to argue that it’s wrong to treat drug addiction as a moral failure. A slice:

    We tend to view addiction as a moral failure because we are in the grip of a simple but misleading answer to one of the oldest questions of philosophy: Do people always do what they think is best? In other words, do our actions always reflect our beliefs and values? When someone with addiction chooses to take drugs, does this show us what she truly cares about — or might something more complicated be going on?

  • An econometrics working paper by Jennifer L. Doleac of University of Virginia and Anita Mukherjee of the University of Wisconsin released earlier this month, which sparked spirited discussion, investigated the link between opioids and laws increasing access to Naloxone. They found the laws increased measurements of opioid use but did reduce mortality, which they theorize is because Naloxone increases moral hazard for addicts by reducing potential costs of an overdose. However, they conclude:

    Our findings do not necessarily imply that we should stop making Naloxone available to individuals suffering from opioid addiction, or those who are at risk of overdose. They do imply that the public health community should acknowledge and prepare for the behavioral effects we find here. Our results show that broad Naloxone access may be limited in its ability to reduce the epidemic’s death toll because not only does it not address the root causes of addiction, but it may exacerbate them. Looking forward, our results suggest that Naloxone’s effects may depend on the availability of local drug treatment: when treatment is available to people who need help overcoming their addiction, broad Naloxone access results in more beneficial effects. Increasing access to drug treatment, then, might be a necessary complement to Naloxone access in curbing the opioid overdose epidemic.

  •  Alex Gertner, a PhD candidate at UNC-Chaple Hill, published a criticism of Doleac Murkhejee at Vox pointing out that their data linking Naloxone and opioid-related hospital visits are not necessarily due to a casual story involving moral hazard:

    The authors find that naloxone access laws lead to more opioid-related emergency department visits, the premise being that naloxone access laws increase opioid overdoses. But there’s a far more likely explanation: People are generally instructed to seek medical care for overdose after receiving naloxone.

    Overdose is a general term to describe experiencing the toxic effects of drugs. People can overdose, and often do, without either dying or seeking medical attention. If people who would otherwise overdose without medical attention are instead using naloxone and going to emergency rooms, that’s a good thing.

  • The widest-ranging and most thorough critique of Doleac-Murkhejee comes from Frank, Pollack, and Humphries at the Journal of Health Affairs. They argue that the original authors (1) assume too much immediacy in effect of changes in Naloxone laws than is probably warranted (2) ignore a variety of exogenous variables like Medicare expansion. They conclude:

    We believe the best interpretation of Doleac and Mukherjee’s findings is that their main treatment variable—naloxone laws—thus far have had little impact on naloxone use or nonmedical opioid use during the period studied. This disappointing pattern commands attention and follow-up from both public health practitioners and public health researchers.