A Pox on Both Your Houses

Full disclosure: I used to work for John Goodman. I respect his intellect. I agree with him on many, many things. Nevertheless, he recently posted a comment on his blog that I think was pretty … hmm, what do you get when you combine ill‐​considered and substantively incorrect? 


Since people without health insurance routinely get medical care financed through some other mechanism, Goodman impishly suggested that the president could solve the problem of the uninsured by ordering the Census Bureau to stop counting people as “uninsured” and instead label them according to who pays for the care they do receive. “Voila!” Goodman blogged. “Problem solved.”


Predictably, every Church of Universal Coverage congregant and his mother pounced on Goodman for appearing callous. (He’s a witch! Burn him!) Even the McCain presidential campaign distanced themselves from Goodman. I can’t say that I’m overly concerned with appearances; I did launch the Anti‐​Universal Coverage Club, after all. But this is not just an issue of appearances.


Goodman’s comment was substantively problematic because there is a very real difference between having health insurance and not having it. When you don’t have health insurance, it’s generally more difficult to get medical care, especially high‐​end care. If you choose not to purchase health insurance, fine. It’s your life. But many Americans who would like to purchase health insurance cannot, for no other reason than their government has made it prohibitively expensive. Those people are uninsured by government, not by choice. That’s a very important category of people. (Are you listening, Census Bureau?) Government also makes being uninsured, and providing charitable care to those in need, much costlier than necessary. Those factors constitute “the problem of the uninsured.” Best not to whitewash it.


Goodman is correct that his “solution would put the United States on a par, say, with Britain and Canada,” whose governments “insist that all of their citizens are ‘insured,’ whether or not they get needed medical care.” Yes, the Church of Universal Coverage is goofy for thinking that having coverage is the same thing as having access to care. Yes, they should drop their obsession with universal coverage and instead obsess over, say, continuously making medical care better, cheaper, and safer. 


But let me put this question to all those (Reggie?) who gave Goodman a laurel and hearty handshake in the comments section of that post:

If free‐​market advocates pretend that lacking health insurance has zero effect on access to medical care, or describe ex‐​post subsidies as insurance, how can we accuse the Church of Universal Coverage of being muddle‐​headed? 

That said, the Church of Universal Coverage really should have stuck to what was substantively wrong with Goodman’s comment. 


Ezra Klein sees in this episode proof that everyone who disagrees with him (Klein) is basically a Death Eater. I can’t complain too much, though; Klein did plug the Anti‐​Universal Coverage Club. (Thanks, pal.) 


Jonathan Cohn agrees with Klein, and doesn’t see any connection between the large number of uninsured Americans and the fact that even more Americans are over-insured. (Jonathan Cohn, meet Alan Garber and Jonathan Skinner.) 


Worse, Cohn is guilty of the exact same thing as Goodman — only Cohn whitewashes access problems stemming from waiting lists in other countries, rather than a lack of insurance here at home. In his book, Cohn writes that in France, “Waiting lists and lines, the supposed drawbacks of universal health care, appear to be nonexistent,” and then implies that concerns about rationing in government‐​run systems are often “imagined” (p. 227–8). In a post on TNR’s The Plank, he explains why waiting lists appear to be nonexistent in France and Germany (TNR took down Cohn’s post, but Arnold Kling blogs the relevant Cohn quote):

some countries with universal coverage don’t seem to have waiting lists at all, even for elective procedures. It’s hard to be 100 percent certain about this: France and Germany, for example, don’t actually keep official statistics on waiting times. But that’s because nobody in those countries seems to consider queuing a problem.

The French and Germans don’t consider queuing a problem, eh? At the time, I responded to Cohn with polling data from those countries:

the French and Germans who were dissatisfied with their health care system’s waiting times outnumbered those who were satisfied (50 percent and 55 percent dissatisfied, respectively). So there may be a problem [with waiting lists] in those countries, even if the authorities do not measure it. (Perhaps we could approach the uninsured the way that France and Germany approach waiting times, and just stop counting them.)

Of course, I was just kidding about not counting the uninsured. Who knew that Goodman would take me seriously? But Goodman can always claim that he was just following Cohn’s lead.


Where’s the outrage from the Church of Universal Coverage over Cohn’s whitewash? Oh, that’s right: a lack of access doesn’t bother them as much as a lack of coverage.