Tuesday, September 18, 2007

HillaryCare and an offense taken without being given

John Trenchard and Thomas Gordon

Idiots and lunatics indeed, who cannot take care of themselves, must be taken care of by others; but while men have their five senses, I cannot see what the Magistrate has to do with actions by which the society cannot be affected; and where he meddles with such, he meddles impertinently or tyranically. Must the magistrate tie up every man's legs, because some men fall into ditches? Or, must he put out their eyes, because with them they see lying vanities? Or, would it2 become the wisdom and care of Governors to establish a traveling society, to prevent people, by a proper confinement, from throwing themselves into wells, or over precipices; or to endow a fraternity of physicians and surgeons all over the nation, to take care of their subjects' health, without their being consulted; and to vomit, bleed, purge, and scarify them at pleasure, whether they would or no, just as these established judges of health should think fit? If this were the case, what a stir and hubbub should we soon see kept about the established potions and lancets? Every man, woman, or child, though ever so healthy, must be a patient, or woe be to them! The best diet and medicines would soon grow pernicious from any other hand; and their pills alone, however ridiculous, insufficient, or distasteful, would be attended with a blessing.

Let people alone, and they will take care of themselves, and do it best; and if they do not, a sufficient punishment will follow their neglect, without the Magistrate's interposition and penalties. It is plain, that such busy care and officious intrusion into the personal affairs, or private actions, thoughts, and imaginations of men, has in it more craft than kindness; and is only a device to mislead people, and pick their pockets, under the false pretense of the public and their private good. To quarrel with any man for his opinions, humors, or the fashion of his clothes, is an offense taken without being given. What is it to a Magistrate how I wash my hands, or cut my corns; what fashion or colors I wear, or what notions I entertain, or what gestures I use, or what words I pronounce, when they please me, and do him and my neighbor no hurt? As well may he determine the color of my hair, and control my shape and features.

     John Trenchard and Thomas Gordon (1721)
     Cato Letter Number 62

In October 1993, I wrote,
Pacifists who strive to avoid the use of force in their day-to-day affairs ought not be coerced into coverage by force. Likewise constitutional libertarians, who advocate non-aggression and who accede to the use of civil government in the equal defense of natural rights, ought not be coerced into what they see as coverage through aggression. There are some who do not want to be covered if it will involve any or certain uses of force by government....

Ours is a government rooted in the awareness of that peace-minded sphere called society. Thomas Paine began his pamphlet Common Sense, which sparked the American Revolution, with a clarification of the difference between "society" and "government." We may preserve the health of our society (and government) by the respect we have this difference....

The American Declaration of 1776 was a call to Independence. "Universal coverage" is a call to Dependence. What ought our country's touchstone be? "Universal coverage" is nothing but "universal control" to be enforced by that long train of abuses that so characteristically goes with unlimited government and limited society. Let's leave alone those who, in their peaceful pursuit of happiness, wish not to be corrupted by power, however minimal or monstrous, so that each generation may understand the compatibility of limited government and unlimited society.

     Back to First Principles in Health Care
     Minnesota Libertarian 24(2) - April 1994, p. 7

What roused me?
In December [1993], a member of the Clinton Health Care Task Force, Dr. Steven Miles, came to present the Clinton Plan at a Sunday forum hosted by First Universalist Church in Minneapolis. Apart from his overall effort to convince his audience that the plan did not ential socialism, he made the shocking statement that "no one has a constitutional right to be a cardiologist." This statement has stuck in my mind. Contrary to his intention, he convinced me then that we do indeed have a crisis now—a crisis in government. This is why I for one am beginning to become active in the libertarian effort to elect to office persons dedicated to the Declaration of Independence and the Constitution in deed, not simply in creed. Government officials and quasi-officials are now attacking our rights, not securing them as their office demands. [Five and a half years later Miles would make a run for the U.S. Senate.]

Have we not learned from the experiences of the rest of the world how precious our American principles are? In his Inaugural Address, Clinton said, "We must provide for our nation the way a family provides for its children." One famous Czech dissident Milan Kundera, the author of The Unbearable Lightness of Being, described another presidential address made by Gustav Husak, the president of Czechoslovakia in 1969, just after the Soviet invasion:
The ghosts of statues long torn down wandered around the podium where the president of forgetting was standing with a red scarf around his neck. The children clapped and called out his name.

Eight years have gone by since then, but I can still hear his words sailing through the blossoming apple trees.

"Children, you are the future," he said, and today I realize he did not mean it the way it sounded. The reason children are the future is not that they will one day be grownups. No, the reason is that mankind is moving more and more in the direction of infancy, and childhood is the image of the future.(The Book of Laughter and Forgetting)
In an interview with Philip Roth, Kundera is more specific: "The basic event of the book is the story of totalitarianism, which deprives people of memory and thus retools them into a nation of children. All totalitarian regimes do this." Eight days after Clinton's Inaugural Address, I reread these words.

On February 22, I along with other Minnesota LP members, attended the Minnesota Summit on Health Care Reform, featuring Governor Pete du Pont, Senator Paul Wellstone, Congressman Tim Penny, Dr. John Goodman, and many other prominent speakers. Dr. Steven Miles was there, too, again presenting the Clinton Health Care Plan. In a question and answer period, I reminded Dr. Miles of his statement at First Universalist Church, outlined what I have written above, and asked him one question: "Do we have a constitutional right to be an adult?" In a confused manner, he responded and actually answered "to the latter question... no." Given his befuddledness, I am not sure whether he really meant to answer no to my rhetorical question, but he did.


If we are to go back to first principles in this debate, we must re-amplify the spirit of 1776, and the wisdom of 1787. As Kundera wrote: "The struggle of man against power is the struggle of memory against forgetting."

Back to First Principles in Health Care
Minnesota Libertarian 24(2) - April 1994, pp. 3, 7

I was not alone in my skepticism.
On April 8 [1994], KSTP hosted a town hall meeting in the Twin Cities at which President Clinton presented his plan and answered questions from the audience. If the first two questions are indicative of how the debate is changing, even here in Minnesota, then we libertarians should find hope that people are indeed coming around, however slowly, to see what we see.

The first questioner asked: "Is your plan really a health plan or is it a power grab?"

The second remarked: "I'm wondering if your program is about controlling rather than better service."

President Clinton became extremely flustered and was unable to give a coherent response to either person.
Minnesota Libertarian - June 1994, p. 4

Hillary Clinton has come around full circle. In the day, MinnesotaCare, a Clintonesque program at the state level, bestowed upon health maintenance organizations a privileged position of dominance over indemnity insurers. (See In Bed with the Devil by Brigid McMenamin, Forbes, Sep. 12, 1994) Insurers were in government disfavor. Now she is putting into place the requisites for an insurance cartel dominated by the whims of government officials. She extends them a qualified favoritism now.

In February 1995, as a Director for Citizens for Choice in Health Care, I wrote,
Health care ought to be controlled by individual choice and individual responsibility with equity towards all, including insurers.
To be clear, by equity I mean equal, full, inalienable natural rights. Let's get off this yo-yo of privilege and disfavor, and return to America.

What are we to do when politicians display, showing how tough they are by breaking the law, by breaking the Constitution, by breaking the Declaration, running through the forest breaking branches?

Let us rebuild liberalism.

For now, let's support Ron Paul 2008. His position on getting us out of the health-care mess (see video below) is largely on target.

Please reread the 1721 quote from Cato's Letters. This struggle has been going on for centuries from continent to continent. Cato's wisdom is timeless.

Liberda, da, da...

In Europe, charters of liberty have been granted by power. America has set the example ... of charters of power granted by liberty.
James Madison
"Charters", The National Gazette, January 19, 1792

Update (Sep 19, 2007): Check out this video, the last part of a Bill Moyers Special on impeachment with Bruce Fein and John Nichols. At the end (7:40), Nichols makes the point about the dangers of treating citizens as children, though in a different context. Liberty and adulthood can bring us together.

Update (Sep 19, 2007):
I don't support Fred Thompson 2008, but I do think this video commentary of his on HillaryCare is spot on.

Version 1.2

Update (Oct 5, 2007): Dr. Steven Miles has commented thoughtfully on this article. I verified his comments by emailing him directly. Today I ordered a book he published last year Oath Betrayed: Torture, Medical Complicity, and the War on Terror, on an issue about which my guess is we're in strong agreement.

Update (Oct 6, 2007): In short, government has been granted neither the power to coin doctors nor the power to coin health insurance. By right can it never have such powers to the exclusion of competing, freely-formed professional associations. Government power must be distinguished from social power.

As David Boaz of the Cato Institute wrote,
The right term for the advocates of civil society and free markets is arguably socialist. Thomas Paine distinguished between society and government, and the libertarian writer Albert Jay Nock summed up all the things that people do voluntarily--for love or charity or profit--as "social power," which is always being threatened by the encroachment of State power. So we might say that those who advocate social power are socialists, while those who support State power are statists. But alas, the word socialist, like the word liberal, has been claimed by those who advocate neither civil society nor liberty.

Update (Oct 7, 2007): On the various types of dictates government office-holders have strewn across our path to happiness, John Seiler has written an excellent article, Mandated Health-Care Socialism, which I just received in the mail, cataloguing these beasts.

First there are those at the state level who dare mandate that free citizens buy health insurance. Such is mandated coverage. Seiler writes, "So far only Hawaii and Massachusetts have mandated coverage supposedly for every state resident," Hawaii since 1974, Massachusetts since 2006. Where is the 14th Amendment when you need it?

Next Seiler writes, "A less obvious path to socialized medicine is mandatory benefits, which require insurance providers to cover everything from athletic trainers in Arkansas to breast reduction in Maine."

Third, there are provider mandates, mandating the inclusion of various types of providers, from marriage therapists (13 states) to massage therapists (5 states).

Finally, there are covered-person mandates, such as the requirement that noncustodial children be covered (10 states).

If we are to make progress in making health more affordable, it must not be beyond criticism. Each of us must be able to shout out that something is absurd, and with effect. What good is it to exclaim, when we cannot claim. We have the right to make our own choices based on our own judgment as adults, as parents, facing real consequences, natural consequences. Learning what's best takes time, takes generations even, and it takes choice and diversity. What we have is dying "the death of a thousand scalpel cuts" thanks to the advocates of socialized medicine, who, like economical predators of the wild, wound first and feast later. Let's not punish health care apostasy. We have a right to say no, just plain no.


Steven Miles said...

Thanks for spelling my name right. My statement that "no one has a constitutional right to be a cardiologist" was in response to a question about government funding of specialist training. I do not believe that the government has a duty to subsidize the education of everyone who wants to be a cardiologists. Do libertarians disagree? Steven Miles

Casey Bowman said...

Sorry for not having responded earlier. I just noticed your comment this evening!

Thank you for responding to my concern, Steven. I am delighted to see your comment. I appreciate any clarification on what you meant. There are areas where I suspect we are in agreement, such as those found in your book of last year, Oath Betrayed.

I agree with you that government does not have a duty to subsidize the education of someone who wishes to be a cardiologist. So we do agree on that.

What I would like to clarify is if you agree that everyone has a right to be a cardiologist. That is, is there free entry, as an economist would put it? Are there to be no artificial barriers to entry into the profession?

Of course, there would still be the natural cost of educating oneself, establishing one's reputation, and earning the accreditation of a free professional association, all of which natural forces would drive any aspiring cardiologist to do.

Where there are government barriers, there are cartels or monopolies to one degree or another, artificially keeping the price high by locking out competition. This is an essential point, which any well-trained economist would look at first. Why aren't government office-holders and office-seekers focussing on that (with one exception)?

Speaking of well-trained, let me underline that just because one may claim to be a cardiologist and put up a sign doesn't mean that I would put my heart in his or her hands. Associations would set standards of excellence. There would also be freedom of entry in establishing such associations. The key is to loosen up the rigidities of the market where they exist.

Government would then play its plain role of enforcing laws against fraud, leaving the complexities of medical care and risk management to associations and individuals.

There are many concerns I have about government control, of government establishing its dominance in principle, in businesses it has no business in, namely health care and health insurance. I will only mention two here.

1) Government simply has no business in health care, per se, apart from the military. The Ninth and Fourteenth Amendments recognize our right to pursue health care freely, both from federal and state law. Government may not dictate. Sovereignty is limited by rights.

2) After having read The Road to Serfdom by Hayek, I am concerned that the centralization of power by those who ignore our rights will lead to unintentional consequences akin to those you warn against in your book Oath Betrayed, judging from my reading of your book's description on Amazon. (My apologies, by the way, but I have only bought Alfred McCoy's excellent book A Question of Torture). I think we can both agree that we do not want to travel further down the road of pre-war Germany. Where we may disagree is in my fear of both the neocons and the neosocs.

As a former Democrat, from a family of Democrats, I fear the Democrats do not see how their own actions build the groundwork for the horrors we are beginning to see.

Our only hope is in decentralizing power and establishing plain rule of law. Beauty is not to be found in government.

Returning to point at hand, free entry into the provision of health care and the free pursuit of health care are essential.

So are the issues of intellectual property, risk management freedom, and tax equity, but these are for another day.

Do you agree with the principle of free entry for medical professionals?

Steven Miles said...

Steven Miles replies: sure I agree with the principle of free entry into the medical professions. One should however recognize that all cardiology training, almost all cardiology clinical programs, and all clinical services are government subsidized either through Medicare, Medicaid, VA.
Second, it is also clear that the more cardiologists one puts into a health system, the more cardiology services (partly government subsidized) will be provided.
Thus, I do not think that the free market/government market can be as neatly divided as you suggest it can be.
A couple of final throughs: 1. it is ironic that the entry of government into paying for so much cardiological care has made if possible to create the very high reimbursements that draw people to become cardiologists. On a non-government subsidized fee structure--cardiologists salaries would probably fall by about two thirds.
2. Lastly, the volumne of some services, such as valve replacements surgery or heart transplantation is kept high by the government money coming into the health care system. It is clear that practice makes a better surgeon. Far fewer persons would be able to pursue current careers in cardiology if the volume of those procedures dropped given that the quality standards that you correctly praise often include some requiement for minimum volumes or service.

Casey Bowman said...

I'm glad to hear that you do agree in principle.

Your points are very interesting, and I've learned from them. If people were able to disentangle the economic consequences enough to realize what effect this flow of money has on the income of medical professionals, many would prefer a more natural equilibrium price and shrink from supporting such favoritism to this profession, however worthy. The 200% increase in salary you claim to be the effect of subsidies is staggering. I hope to write a longer comment when I have a moment away from work. In a natural economy, there are countless tradeoffs, but they are made freely.

For now, let me ask you a question focussed squarely on my original concern, now that we understand one other's meaning, I hope.

If you agree with free entry, free competition--say, for the sake of this argument, the new competition demands no subsidy--, you don't support a government dictate limiting the number of doctors, do you?

To my mind, such dictates are dictates. They are beyond the powers ever to be granted to government, disallowed by our rights.

And for those who don't believe in rights, think cartel. We need competition among medical associations that establish and experiment with standards and best practices under the watchful eyes of consumer groups and ethicists.

After our revolution, "[b]etween 1830 and 1850, many of the medical licensing laws left over from the colonial period were repealed." [John Goodman and Gerald Musgrave, Patient Power Cato Institute, 1992 (excerpt)]

Let us continue the revolution.