On American Healthcare – Another Response to Chris Sacchim

This article is a response to this piece by Chris Sacchim, which is a response to this article by me, which was in response to his original piece found here.

I suppose I should start off by joining my new intelectual adversary in recognising our shared value in (mostly) polite public discourse. Admittedly, this is why debates such as this are far better conducted over lengthy blogs rather than on Twitter. I also recognise that I may have been a little rude in my original response, which was admittedly my intention. Whilst no overt hostility or offense was meant, attempts to be overwhelmingly polite tend to make such discourse rather boring.

With formalities out of the way, a good starting point would be to point out that, in his response to my response, the author failed to address a number of critiques on the issues of job losses, market competition and Obamacare being responsible for higher healthcare costs. I should therefore assume that, for now, he has conceded on those points.

Moving on, I suppose we must discuss morals, freedom and libertarianism. The author acknowledges the fact that he did not engage with the moral side of the healthcare argument in his original article, although his explanation strikes me as rather curious. I’ll cite the first half of the paragraph here as we will be dealing with it in some length.

“I’d like to start by addressing the idea that I did not engage with the moral side of this argument; this is 100% true. This didn’t come up in my article because I was starting with the knowledge that nothing is free, and that it is immoral to tax the citizenry for non-essential functions of the federal government.”

Let’s start with the apparent knowledge that “It is immoral to tax the citizenry for non-essential functions of the federal government.” First, I certainly appreciate that the author admits there are certain state functions which do warrant taxation, meaning we aren’t dealing with an “All taxation is theft” style of argument (although Mr Sacchim is hardly consistent on this). However, most Americans and everyone in favour of universal healthcare would contend that making sure people don’t die due to being poor is indeed an essential function of the federal government. I would certainly like to know what other state departments and services the author thinks constitute essential functions.

Presumably the military and police are two. Probably also the fire service. So where do we draw the line? I hope Mr Sacchim does not think that people should have to dish out their credit cards in the event of a home invasion, or if their living room catches fire. Moreover, if protecting people from bodily harm via the police is an essential function, then why is achieving that exact same goal by providing them with healthcare not?

A bit later in his article, the author does indeed explain why he doesn’t see the point that “the industry should not be run as a business” as “a valid part of the discussion”. This is because America does not have a history of nationalised industries like “Socialist” countries. He backs this up by stating that the US Constitution says nothing about universal healthcare and rather a lot about freedom.

I do not want to seem rude, as Mr Sacchim is so keen on polite discourse, but that is a tremendously weak argument. Of course the Constitution has nothing in it about universal healthcare because, in 1788, universal healthcare wasn’t really a thing. I honestly do not understand why so many Americans insist on invoking a 230 year old document in contemporary debates.

After all, the constitution has been amended before to comply with new developments. Once upon a time, the 13th amendment was passed, which abolished slavery. Some time later, the 18th amendment prohibited the sale of alcohol. Some time after that, the 21st amendment repealed the 18th amendment after everyone and their grandmother realised that prohibition is ridiculous. Furthermore, America also has a history of not really giving much of a toss about its sacred Constitution whenever it becomes too inconvenient, even with regards to its most cherished values such as freedom of speech. I would highly encourage everyone to look up the Espionage Act of 1917.

Ultimately, “this is the way it has always been and so it must therefore remain” is not terribly convincing. Britain, Norway and other “““Socialist””” countries did not always have their current healthcare or economic model, and it would sure sound weird if someone tried to defend feudalism on the basis that that is what the wealthy lords once agreed must be. I would think that someone as compelled by the battle of ideas as the author clearly is would not so easily dismiss ideas purely on the basis of historical precedent.

Anyway, let’s return to the debate above regarding freedom and what government should and should not do. Again, I’ll just cite the appropriate section of Mr Sacchim’s piece.

Personal property rights and individual freedom are the magnetic north pole to which my moral compass points. “Free healthcare for all” or “Medicare for all” are both infringements on those personal freedoms, as “free” truly means having the program paid for by other people who may or may not want to pay for it.

The first thing to be said about “individual freedom” or “property rights” is that they don’t really exist, and this isn’t some weird totalitarian idea. Freedom is, after all, a social fiction, just like property rights or human rights or, indeed, The United States of America. As such, there is hardly a single commonly accepted political or philosophical interpretation of what freedom actually means.

Regardless, we can certainly identify the two most popular ways of looking at the issue. First, the libertarian or classical liberal idea that freedom or liberty means the freedom from government interference (commonly referred to as negative liberty). This is the version to which the author clearly subscribes. However, a socialist or social democrat will argue that freedom can also be “positive”. To this effect, a person is not truly free whilst they are confined by social structures which inhibit their agency. Therefore, the state has a role to play in liberating the individual and giving him or her the opportunity to achieve their full potential.

This positive view of freedom is an essential foundation to modern left-wing principles such as universal healthcare or social safety nets. Essentially, a person who struggles to feed their family and constantly has to worry about the financial consequences of falling ill is not really free, even if he is free from taxation and other government meddling. On the contrary, it is quite liberating to know that a sudden medical emergency will not force you to sell your house, or your business, and trap you in a mountain of debt which you can never hope to repay.

The author later talks disparagingly about “equality of outcomes” and that too fails to recognise what his opponents on the left are actually calling for. Literally no one except those on the most extreme fringe advocate for wealth and property to be equally redistributed. What they do want is for everyone to have a fair chance. Obviously, this has its own problems given that nobody is able to choose their parents (few would surely contend that Donald Trump would have done quite so well for himself were it not for that “small loan of a million dollars”) but the principle still stands.

Are the two views of freedom mutually exclusive? No, of course not, and most socialists tend to have rather strong views about what the government should keep out of. However, as a segway into my next point, the problem with only debating principles is that they often happen to conflict.

When the author states that his “Personal property rights and individual freedom are the magnetic north pole” to which his “moral compass points”, we have to recognise that the two cannot reasonably coexist in their absolutes. A strong state is needed to enforce property rights, both in terms of social constructs such as legal documents (e.g. A conveyance agreement) and in a more straightforward physical sense, such as paying a police force to defend your property from violent intrusion. However, such as state will inevitably have to encroach on individual freedom, since bureaucrats and cops don’t tend to work for free.

My point here is that the moral argument presented by the author appears somewhat inconsistent. He claims to be wedded to the principles of property rights and individual freedom yet the two inevitably conflict. Meanwhile, he concedes that there are certain functions which the federal government should perform (without naming them), however fails to adequately explain why providing people with healthcare does not constitute such an “essential” function (aside from a lacklustre appeal to tradition, of course).

This has already gone on longer than my entire previous piece, so I will deal with the next few points relatively briefly. Yes, we do both agree that America is the richest country in the world, since (if you calculate based on nominal GDP) that’s merely an objective fact. What I will certainly contest is the assertion that America’s wealth means it should not shift “to the more socialist and less successful models”.

While it may be the richest, it is also the most unequal. Now, given what I said earlier about equality of outcome, wealth inequality is not in itself a problem. What is a problem is that 40 million Americans live under the poverty line and a similar number of them lack access to basic healthcare.

So is a nation’s total wealth really a great indicator of how “successful” it is, and whether we should follow its economic and political model? By that logic, the author should soon be calling for America to model itself on China, given that the latter is widely projected to overtake the US in terms of GDP over the next four decades. Obviously that would be ridiculous because calling a country “successful” purely based on how much capital it has managed to amass, irrespective of total population or what share of which can afford to get by, is simply that.

How do we measure national success then? We could do so based on the World Happiness Report, which ranks America at 18 and the social democracies of Finland, Norway and Denmark as its top three. Or we could just not since there are clearly better things to worry about, which in America’s case includes people not being able to afford their ambulance ride. I should of course point out that, with regards to health insurance, the author has failed to properly address the argument in my previous piece regarding the lack of actual market competition. Furthermore, were Mr Sacchim to be right about

America’s free market approach, the two following things should also be true:

  1. American healthcare is much better than in “socialist” European countries.
  2. America is a much better place to do business than those countries.

On the contrary, however, the United States consistently ranks below a number of European social democracies, such as Norway, Denmark and the United Kingdom, on both those points. I also can’t help but point out that there is no such thing as a “free market”, as much as the author might fervently disagree. A true free market requires government intervention to restrict monopolies and protect intellectual as well as physical property rights, which means it is no longer a free market.

I suppose we must again examine the charity argument, which I previously said was not a credible substitute for universal healthcare. In his response, Mr Sacchim writes the following;

“Without the tax burden of Medicare and Medicaid, there’s no telling what amount of that $1.2 trillion (spent on both programmes) would be given to those same charities, or would be used to cover personal medical expenses and private health insurance. All we know is that it would be the right amount, since it would properly reflect the disposable income those Americans are able to part with and the individual priorities of the taxpayer.”

It is true that we cannot say with certainty what share of that money would be given to medical charities, but it definitely will not be enough. Based on 2010 figures, individual Americans would need to donate over $1000 every year to cover those dependant on Medicaid alone. This would require more than doubling current charitable contributions (not to mention people voluntarily giving away practically all of the money they receive through said tax cuts). I’m not sure which world the author thinks he’s living in, but that is simply not going to happen. Frankly, I do wish libertarians would just admit that they would rather more people die due to lack of access to healthcare than have to pay a little more in taxes, because these kind of semantics are just embarrassing.

Meanwhile, given that medicare for all has been shown to be cheaper than America’s current private system (individual Americans spend more than the citizens of any other country on healthcare), adopting it will allow us to cover everyone whilst at the same time giving people more money to spend on charity (or whatever else they’d like). As far as healthcare is concerned, I’ll just quote Orwell in saying that “Socialism is such elementary common sense that I am sometimes amazed that it has not established itself already”.

Then there is the case of Alfie Evans, which has little to actually do with the NHS and rather a lot with how the British state sees its role in protecting children from cruel and negligent parents. Just to be clear, I am not suggesting that the parents of Alfie Evans or Charlie Gard are such, but the relevant doctors in these cases concluded that further treatment was likely futile and would only prolong the children’s suffering. Both were complex situations and the way the Evans case in particular was exploited by people like Ted Cruz to further their own domestic agenda is rather appaling. My point is, whatever you may feel was right to do, you can have a national health service without implementing the kind of child protections that exist in Britain (which effectively sees the state as a co-guardian). But to use this as a point against universal healthcare in general, as opposed to local UK child protections, is certainly disingenuous (Italy, where the parents of Alfie Evans wanted to seek treatment, after all, has a national health service).

With regards to my comments on people using GoFundMe to finance healthcare costs being a “sick joke”, I suppose the author has somewhat misinterpreted me. The “sick joke” I was referring to is the fact that so many  Americans feel the need to resort to crowdfunding in the first place, and how the vast majority of them don’t receive the required funds. This is quite different from “compelled charity”, which is how the author describes a national healthcare system.

The next seven paragraphs have the author explain at length as to why medicare is expensive and inefficient. My only retort here is that he’s right, and that certainly says a lot about America’s private healthcare system given that it’s even more wasteful and expensive. As for the idea that we face an ageing population which will make healthcare more costly in the long run, well, that’s also true, and I’m under no illusions that governments might have to increase healthcare spending in the future in order to deal with that. However, this is not a problem exclusive to government provided care. I hope the author is not suggesting that, as medicare costs increase, the state just pulls out altogether and leaves its elderly to fend for themselves.

On a related side note, this should definitely serve as an argument in favour of immigration. As the native population in Britain, the US and other developed countries gets older, we are increasingly dependent on young, entrepreneurial, people from other parts of the world to assist with our tax burden.

Two final points. First, the assertion that “If people weren’t so heavily taxed by the government, maybe they wouldn’t even need to rely on charity (voluntary or compelled) and could afford their own medical expenses”. This is another instance where the author could have really helped himself with a bit of Googling. An American earning $20,000 will pay approximately $3,000 in federal income tax. The average annual cost of healthcare is way higher than that. Therefore, even if we were to eliminate federal income tax for low earners entirely (which, as the author may be surprised to hear, I’m actually in favour of), that would not even get close to covering their healthcare costs. The only way many people in lower income brackets currently manage to afford care is either through their employer or, surprise surprise, the Affordable Care Act (thanks Obama).

Finally, there’s this;

“I’d be more than happy if an individual municipality decided to vote for socializing the healthcare in their specific town or city, which is why the concept of federalism is essential. At that point, I would still have the option to not live in that municipality if I didn’t want to participate in that redistributive program. It is immoral to force citizens to partake in something they may not believe in or may not directly benefit from.”

Right, so, according to the author, socialized healthcare is fine on a local level, which certainly sounds nice on paper until you consider the practicalities. Such an approach would certainly benefit wealthy areas but would leave struggling communities in the dust. This is, after all, why the federal government redistributes a certain amount of wealth between states, forcing Texas, New York and California to pay extra so that South Carolina, Montana and Oregon can afford infrastructure and social security.

And how far should we be expected to take this logic? Should this apply to other “essential” government services? Would it be fine for a whole state to socialize its healthcare, such as was proposed in Michigan, even if many of these states have populations greater than entire European countries? Surely, at that point, someone with strong moral objections such as the author could still move across state lines? One thing is certain. If America as a whole adopted such a system, he would have few options to flee from this alleged socialist dystopia. After all, the entire developed world has long since realised that access to healthcare needs to be a human right.


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