Topic: Political Philosophy

Full-Spectrum Lindsey

Cato vice president for research Brink Lindsey tries to be a uniter, not a divider. In his much-discussed “Liberaltarians” article for the New Republic, Brink held out an olive branch to liberals. TNR’s Jonathan Chait was, well, less than enthusiastic.

In his “A Farewell to the Culture Wars,” recently published in National Review, Brink does much the same for conservatives, advising them to seek to conserve the “great American heritage of limited government, individual liberty, and free markets,” instead of, say, exclusively heterosexual marriage and a not-so-Mexican America. Perhaps unsurprisingly, NR’s Ramesh Ponnuru has declined the advice. Brink’s rejoinder, published online this Tuesday, is smart and effective:

Ramesh Ponnuru concedes the main point I was trying to make. Specifically, he admits that “[i]t really is pointless to pine for the social order that existed prior to the late 1960s,” and that “most conservatives would not want to go back if they could.”
 
Ramesh makes this concession almost casually, as if it were no big deal. But I’m sorry, it’s a very big deal indeed. After all, a great deal of intellectual and emotional energy on the right has been expended over the years in precisely the kind of pining Ramesh now regards as pointless. Conservatives have defended, with great conviction and moral passion, positions on race relations, the role of women in society, and sexual morality that most conservatives today would disown as ludicrous or offensive. I don’t think it suffices to dismiss these glaring errors of judgment with an Emily Litella-like “Never mind.”

While commentators left and right may be hesitant to pick up what Lindsey’s laying down, that doesn’t mean he’s about to stop trying to transcend the stale terms of yesterday’s political dialectic.

Tune into Cato Unbound on Monday, where Brink will kick off a fresh round of discussion on “The Politics of Abundance” with a panel of blogosphere luminaries. On the left, we’ll have The Atlantic’s Matthew Yglesias. On the right, National Review’s Jonah Goldberg. And in the … middle? … Reason contributing editor Julian Sanchez.  

Does Cost-Sharing for Rx Reduce Health?

Unknown, say Dana Goldman, Geoffrey Joyce, and Yuhui Zheng of the RAND Corporation. 

In this week’s Journal of the American Medical Association, the team presents a meta-analysis of “132 articles examining the associations between prescription drug plan cost-containment measures, including co-payments, tiering, or coinsurance[;] pharmacy benefit caps or monthly prescription limits[;] formulary restrictions[;] and reference pricing[;] and salient outcomes, including pharmacy utilization and spending, medical care utilization and spending, and health outcomes.”

Here are their principal findings and conclusions, from the abstract:

Increased cost sharing is associated with lower rates of drug treatment, worse adherence among existing users, and more frequent discontinuation of therapy. For each 10% increase in cost sharing, prescription drug spending decreases by 2% to 6%, depending on class of drug and condition of the patient. The reduction in use associated with a benefit cap, which limits either the coverage amount or the number of covered prescriptions, is consistent with other cost-sharing features. For some chronic conditions, higher cost sharing is associated with increased use of medical services, at least for patients with congestive heart failure, lipid disorders, diabetes, and schizophrenia. While low-income groups may be more sensitive to increased cost sharing, there is little evidence to support this contention.

That last sentence was certainly interesting. But here comes the kicker.

While increased cost sharing is highly correlated with reductions in pharmacy use, the long-term consequences of benefit changes on health are still uncertain.

That echoes points I’ve made previously in this blog:

  • The mere fact that cost-sharing causes people to reduce their consumption of prescription drugs (or other medical care) does not mean that their health suffers. 
  • Even if cost-sharing does cause some people’s health to suffer, that does not mean that the overall health effects of cost-sharing are harmful. 

Indeed, as Goldman et al. conclude that these studies leave open the question of long-term health effects, the best evidence on this point remains the RAND Health Insurance Experiment, which showed that the overall health effects of cost-sharing are nil.

But as Tom Firey has argued in this blog, even if it could be shown that cost-sharing does reduce overall health outcomes, that is not a public policy problem.  It means that people prefer to spend their money on things other than medical care.  That is their right.  We might try to persuade them to spend their money differently.  But we are not justified in taking their money away from them to spend it according to our preferences – or more likely, those of the health care industry – rather than their preferences.  Whose life is it, anyway?

Unequal Justice?

There it was, emblazoned across the front page of the Washington Post, a headline made especially disturbing by its publication on July 4:

Justice Is Unequal for Parents Who Host Teen Drinking Parties

What did it mean, I wondered. Poor parents go to jail, rich parents walk? The law is enforced in black neighborhoods, winked at in white suburbs?

Not exactly. In fact, the Post reported,

In Virginia and the District, parents who host such parties can be charged with contributing to the delinquency of a minor, a misdemeanor that can carry jail time. In Maryland, hosting an underage drinking party is punished with a civil penalty, payable with a fine, even for multiple offenses.

So it’s not a story about unequal justice, just about different jurisdictions with different laws. But the Post sees it differently:

The stark contrast in punishments is just one inconsistency in a patchwork of conflicting legal practices and public attitudes about underage drinking parties.

“Inconsistency.” “Patchwork.” “Conflicting legal practices.” This is ridiculous. Move along, folks, nothing to see here. On the Fourth of July, let’s pause to remember: The United States is a federal republic, not a unitary centralized state. Different states and even different cities and counties have different laws.

One of the benefits of a decentralized republic is that laws can reflect people’s different values and attitudes. Decentralism also allows states and counties to be “laboratories of democracy.” If voters in Maryland and the District of Columbia read about how Virginia sentences parents to 27 months in jail for serving alcohol to teenagers after taking away their car keys — and they think that sounds like a good idea — then they can change their own laws. Or if Virginia voters notice that Maryland has a slightly lower highway fatality rate, then they might decide to change their laws.

States in our federal republic have different laws about lots of things, certainly including alcohol since the repeal of national Prohibition. I grew up in a dry county in Kentucky — no legal sales of alcohol of any kind — but neighboring counties were wet. The old joke was that Bourbon County was dry while Christian County was wet, but that seems not to be true any more. First cousins can marry in some states but not in others. The rules used to vary on interracial marriage until the Supreme Court stepped in and banned laws against it. In the past couple of years we have begun to experience different state laws on same-sex marriage.

Some people seem to want all laws to be uniform across this vast nation, from California to the New York Island, from the redwood forest to the Gulf stream waters, from sea to shining sea. They use their power in Congress to impose national speed limits, national environmental rules, national school testing laws, national marijuana bans, and so on. But the beauty of America is that we have resisted many of those pressures, and there are still real differences in the laws of San Francisco and San Antonio; Manhattan, New York, and Manhattan, Kansas; Wyoming and Wyomissing, Pennsylvania.

The laws are even different in Virginia and nearby Maryland. That does not mean that justice is unequal.

Happy Birthday, America—and Thanks for Having Me

This will be my first July 4th holiday in Washington, DC. Last year I was in New York City with my family, celebrating my 30th birthday (yes, I’m a bicentennial baby). So I am looking forward to seeing how the nation’s capital celebrates Independence Day.

As a recent arrival, I know that my experience of Independence Day is necessarily limited. But the ideals upon which America was based and which we celebrate tomorrow are common to many around the world, no matter where they call home. The American dream–to make a better life for yourself and to pursue whatever brand of happiness to which you aspire–is the human dream. As David Boaz notes in his podcast (mp3) today, the line of people at the immigration centers of American embassies is larger than the line of picketers outside, no matter how harsh the criticisms of the rest of the world can seem.

The government and the country are not the same thing. So for all those who have taken offense at a foreigner criticising U.S. farm and trade policy over the last year, please know that I will be celebrating a wonderful country tomorrow, along with all of you.

Cato@Liberty: Safe For Children

Libertarians are often associated with such out-of-the-mainstream activities as drugs, gambling, prostitution, etc., because out-of-the-mainstream activities are the very things that intolerant mainstream types try to stamp out via coercion.

But according to the web site mingle2.com, the Cato@Liberty blog you’re reading right now would be rated PG by the motion picture industry.  Evidently, the words “drugs” and “torture” kept us from getting that coveted G-rating. 

Good god, have we gone mainstream?

Heritage — Unhealthy

In his post on the differences over energy policy between the (conservative) Heritage Foundation and the (libertarian) Cato Institute, Jerry Taylor mentions that the two Washington think tanks also have differences regarding health care. For those who are curious, here’s where I see the biggest differences between Cato scholars and Heritage scholars on health policy:

The Heritage Foundation’s health policy team generally supports having the government force people to buy health insurance. Cato scholars generally do not. A couple of weeks ago, Heritage’s director of health policy studies Bob Moffit wrote in the San Diego Union-Tribune:

[M]y Heritage Foundation colleagues and I support the “personal responsibility principle.” It’s a simple idea: All adults have a responsibility to buy their own health insurance, pay their own health care bills, and not shift those costs to others….

People who can reasonably afford it have a responsibility to buy health insurance to protect themselves and their families against the financial devastation of catastrophic illness….

People who do not wish to buy health insurance for whatever reason should be free to do so. But, in exchange, they must demonstrate in some tangible way that they are really going to pay their own hospital bills. 

My Cato colleagues and I generally differ, for a number of reasons: such “individual mandates” are impractical, ineffective, and expand government power beyond its legitimate scope. Government should and does require people to pay their debts, meaning that patients already are legally responsible for their medical bills. The Heritage “personal responsibility principle,” on the other hand, would hold a Christian Scientist responsible for debts that he will never incur.

In addition, Heritage scholars embrace the idea that government should pursue “universal coverage.” Meanwhile, I do things like start the Anti-Universal Coverage Club (whose membership is growing).

There are many areas where Cato and Heritage scholars agree. I personally respect every member of their health policy team. Why, just yesterday Cato hosted Heritage’s Ed Haislmaier at a forum where we released a study critical of the Heritage-backed Massachusetts health plan. 

Where we disagree, we criticize. But I consider such criticism a form of praise. The only reason we bother to criticize is because what Heritage scholars say matters.  A lot.

This Cato-Heritage disagreement over health care goes back more than a decade. It contributes to the free-market movement’s lack of direction on health care reform. The movement cannot move on in a unified manner until that disagreement is resolved.

Announcing the Anti-Universal Coverage Club

Inspired by National Review’s recent editorial and Andrew Sullivan’s embrace of same (as well as by Greg Mankiw), I have decided it would be fun and educational to keep tally of those who reject the idea that federal or state governments should strive to provide every American with health insurance.  Call it the Anti-Universal Coverage Club.

Here are the guiding principles of the Anti-Universal Coverage Club:

  1. Health policy should focus on making health care of ever-increasing quality available to an ever-increasing number of people.
  2. To achieve “universal coverage” would require either having the government provide health insurance to everyone or forcing everyone to buy it.  Government provision is undesirable, because government does a poor job of improving quality or efficiency.  Forcing people to get insurance would lead to a worse health-care system for everyone, because it would necessitate so much more government intervention.
  3. In a free country, people should have the right to refuse health insurance.
  4. If governments must subsidize those who cannot afford medical care, they should be free to experiment with different types of subsidies (cash, vouchers, insurance, public clinics & hospitals, uncompensated care payments, etc.) and tax exemptions, rather than be forced by a policy of “universal coverage” to subsidize people via “insurance.”

If you’d like to join the Anti-Universal Coverage Club, let me know by posting something to your own blog, or by emailing me mcannon [at] cato [dot] org (here).  Feel free to forward items from other like-minded individuals.

I predict that neither the American Medical Association, nor the Federation of American Hospitals, nor America’s Health Insurance Plans will join the Anti-Universal Coverage Club.