ACCUMULATING PERIPHERALS

McArdle vs. National Health Care — Crooked Timber.

John Holbo has a more charitable reaction to Megan’s “Slapping the Camel’s Nose” post than I did:

McArdle’s opposition to national healthcare is based entirely on slippery slope arguments, arguments from unintended consequences, and suspicions that those who are proposing national health care really want different things than they say they do. Now, this is reasonable. But only up to a point. Because at some point we need something more, but McArdle is quite strident in her insistence that what she has said is enough.

But I still disagree with Holbo’s contention that Megan’s all-slippery-slope approach is reasonable, even “up to a point”. It might be reasonable in some other form in some other argument, but in this one, it just isn’t. Every one of Megan’s arguments is predicated on the contention that reform will lead to the effective disappearance of private health care, and complete government dominance of both the health insurance and health care markets. That’s what she means by the “camel’s nose”. The problem is this: countries that have the Bismarck model of universal coverage through regulated private health insurance do not move to single-payer government-controlled systems. Germany started the first Bismarck-style system 126 years ago. It still has it. France, the Netherlands, Switzerland—they all started with regulated private insurance backed by a public plan for the needy, and they all still have regulated private insurance backed by a public plan for the needy. Except for the Netherlands. They used to have a public plan for the needy, but in 2006 they scrapped it and moved to an all-private health insurance system, with subsidies for those who can’t afford private coverage. What they have, roughly and leaving some bits out for simplicity’s sake, is what the US would have if it passed the current House bill, then eliminated Medicare and Medicaid, and funded the system by handing out subsidies or vouchers so everyone can afford coverage. The direction that Megan envisions things “naturally” going is precisely the opposite of the way they actually went in the Netherlands over the past 20+ years.

The evidence shows that in the real world, there ain’t no slippery slope. There is, if anything, a sticky plane. And there ain’t no camel behind the camel’s nose. Ain’t even a nose, actually—that metaphor can’t even be tweaked to make it work. I mean, we already know that the health insurance systems in every other advanced economy work better than the US’s. But within the subset of those better systems that rely on private insurance, the evidence of a century-plus of experience is that they don’t eliminate private insurance. Let alone private health care providers. In the face of such overwhelming evidence, it is not “reasonable” for Megan to abstractly theorize that a Dutch or French system is really a stalking horse for a British system. If it were, the Dutch and the French would have the British system. They don’t. End of story. Refusing to talk about the real world and preferring to stick with discussions of theories that do not fit the real world is not “reasonable”, and it seems to me that this has to be the point of first engagement with what Megan is saying.