Atlas Shrugged: The Mocking

Wednesday, July 29, 2009

Pay My Bills, Sucker

I just don't understand. We know Megan McArdle believes that people should pay their own way. She's a libertarian. She believes in personal responsibility. She's stated that being without health care made her more against national health, not less. She doesn't believe the young should have to pay for older people's care. And yet, when she went to Vietnam and Cambodia on business, she refused to pay for her own health care, going to a free clinic instead.
I just made an appointment with one of those free-for-all clinics where you can get into see a doctor immediately, so long as you aren't picky about which doctor. This is all part of my frantic attempt to ready myself for Vietnam: antimalarial meds, ho!

I am solemnly informed that this is not the right way to get medical care; I should have a primary care physician who really knows my case well. But this does not actually describe any primary care physician I have ever had, who was reading off the chart just like a perfect stranger would have. Not only did my physicians clearly recall nothing about me; in many cases, I had to remind them of the details of my chart. So can any of my readers tell me what actual good having a single primary care physician, rather than just any old doctor at a walk-in clinic, makes?

Yes, that certainly sounds like she went to a free clinic to me. It's not a pay-per-visit clinic; McArdle states it's free. She could have paid--she was going on business, not on vacation. She planned to spend money having clothing especially made for her. She went shopping. She was being paid to travel and had enough money to pay for a doctor, but she didn't.

What does McArdle think about other people who do what she does?

To wit: should we expect families to sell assets in order to qualify for benefits? On the one hand, Medicaid's ludicrous rules keep disabled people in crippling poverty. On the other hand many people, including me, don't want to pay for the health care of someone so that they can stay in their Park Avenue mansion. At some point, it is reasonable to expect people to liquidate assets in order to pay for expenses, rather than expecting society to pick up the tab. But I'm not sure what point is reasonable.

I don't think this is particularly interesting as it applies to S-Chip; frankly, I doubt there are enough low-income families with children and sizeable assets to make it even worth debating the issue. But it is a very important question regarding Medicaid, because of all the elderly people who shelter significant assets in order to get Medicaid to pay for their nursing home care.

In the case of a spouse, this seems (usually) legitimate, again with the Park Avenue mansion exception: I don't care how long you've lived there, if you're squatting on five or ten million worth of real estate, you should sell it and pay for your spouse's nursing home, rather than asking the payroll clerks and bank tellers of the world to lend a helping hand. But normally, I don't think it's reasonable to demand that anyone make themselves homeless in order to qualify their spouse for a nursing home.

But that isn't the only reason people shelter assets; often they're doing it so that they can leave something to their children. This doesn't strike me as at all reasonable. You have a right to have society pay for your nursing home care if you are destitute and will otherwise suffer and die. You do not have a right to have society pay for your nursing home care so that you can leave the house and some financial assets to the kids. Aside from its rather repulsive moral logic, it's regressive; the people who benefit are upper-middle-class kids who have already benefitted quite a lot from their fortuitous choice of parents.

The taxpayer paid for McArdle's vaccinations, saving her a couple hundred dollars, which go a very long way in Vietnam and Cambodia. Think of all the silk dresses you can buy for that money. McArdle did.

Bleg:A number of people have recommended getting tailored clothes while in Vietnam. Does anyone have a recommendation for a specific tailor in Hanoi?
Hmm, that's kind of contradictory. And hypocritical. Am I sure McArdle is against paying for others' health care?

Now, healthcare is a special case, because unlike most of the other "basic goods" we think everyone should have, the costs can vary widely from person to person. But there are ways to deal with this--alter the income transfer for different diseases, and then let people decide how to spend the money. Maybe some of them will spend their healthcare money on a fabulous car and let their diabetes fester. This violates a lot of intuitions: the intuition that we only want to help people have medical care, not fabulous cars; the intuition that we have to protect people from themselves by ensuring that they spend the money on what they need, not what they want.

As a radical anti-paternalist, you can imagine I don't have much patience with the latter argument. Who am I to say that your life is not better with a sports car and five years to live? And to the former argument, I point out that in fact, you'll probably end up giving the wastrels less money if they do fritter it away. Because once you've actually provided people a minimum income that is adequate to take care of their basic needs, there's no moral reason not to turn away those who decline insurance from the emergency rooms. Giving people more choices also means allowing them to live with the consequences of those choices.
McArdle didn't live with the consequences of her choices, however. That's for the little people. She chose to spend her money on clothes or eating out or something else, not on health care, and left the tax-payer to pick up the bill.

A commenter responds to my last post thus:
People don't have a right to money from society simply because they have gotten sick.

I disagree. Now what?
Well, obviously, at some level we're just going to have to agree to disagree. But it raises some interesting questions. Why do you disagree? If we should give money to sick people regardless of need, is it because being sick sucks and we're giving people bonus payments for having sucky things happen to them? If that's the case, why don't we give people bonus payments for, say, being really ugly, or being severely socially awkward, both of which seem at least arguably worse than, say, having chronic asthma.

Also, if they deserve money just for being sick, why give them the money in the form of healthcare? Wouldn't a cash transfer be even better? Then the people who wanted to be treated could spend the money on healthcare, and other people could spend the money on something they valued even more than healthcare. It seems like a Pareto improvement in net happiness over a simple single-payer system. Finally, if they deserve money just for being sick, why don't we peg the money to the suffering the disease causes, rather than the cost of treating the disease? Inquiring minds want to know.

So McArdle took the money and the free health care. Rules are for the little people. In the interest of fairness, I have to contemplate the possibility that I misinterpreted due to a lack of full knowledge of McArdle's circumstances. It's possible she did have health insurance and paid for her health care (or her employer did), or paid cash. McArdle might just be the world's crappiest writer instead of a hypocrite. (But then why would she call it a free clinic instead of just a clinic?) I will be happy to post a full correction if necessary.


clever pseudonym said...

"why don't we peg the money to the suffering the disease causes, rather than the cost of treating the disease?"

I've read that four times now and I still have no frigging idea what in the world she's trying to say. Help me out here?

Mr. Wonderful said...

Society (which MM seems to regard as a bunch of people she doesn't really want to hang with) has a stake in a person getting treatment for diabetes rather than driving around in a nice car. If the diabetic suffers a blood sugar plunge and drives her nice car into someone (a Megan McArdle, say), when treating the disease and doing without the car would have prevented it, which is preferable?

If the diabetic can afford to ignore her symptoms and spend her own money on a car, then she can do that. If society is asked to subsidize or pay for one or the other, the choice is obvious--to everyone except MM and her fellow Imagitarians.

Mr. Wonderful said...

And as for that idiotic question re the benefits of a primary care physician: if nothing else, the primary has in his or her office your medical history, including your history with that office. The clinic or "urgent (sic) care" doesn't. Feel like waiting a day or a week while you get your primary to fax (or email) the info to the clinic? Be my guest.

God, she really is a nitwit, isn't she. Educated, intelligent, and a nitwit.

Susan of Texas said...

I'm not sure the clinic thing is worth a post, but the quotes are interesting. She doesn't want the poor to go without but she wants the middle class to pay through the nose for healthcare? Wants corporations to pay for health care? She's ideologically confused, to say the least. It's government=bad, nothing else.

To me the funniest part about all this (if true) is that the only people that care will be McArdle's commenters.

Kathy said...

"I was even more militant..."

I'll bet you any amount her parents or someone else paid for her life-or-death medications and doctor visits.

I expect the parents or 'other' also subsidized her gas and rent and clothing.

And all the time she was whining about... everything. And blaming the Poor. She really is a sickening person, and a really really CRAPPY writer.

"...antimalarial meds Ho!" is exactly correct.

BillCinSD said...

McArdle might just be the world's crappiest writer instead of a hypocrite.

Is there a reason she can't be both?

Dylboz said...

If a service is provided for free, that is the price of the service. Using that service doesn't make a hypocrite out of her anymore than taking a free sample of salami while shopping at the Costco does. If the clinic is state supported, that's different, because it's subsidized with the extorted earnings of other taxpayers, but she didn't say that it was. Until that bit of information is resolved, you've written a whole lot about nothing.

Dylboz said...

WOW, it's clear that you misunderstood the term "free-for-all," referring to the unorganized and haphazard way that patients are triaged without appointment as a statement about how much the clinic costs in order to paint her in the worst possible light. You're a very confused woman, Susan.

I loved your comment about people being free to do whatever they want, except, apparently, things like selling their organs, or offering money to entice donors to save their lives, because it offends your personal aesthetic sensibilities and seems unseemly or "exploitative."

I could not possibly imagine a more textbook example of doublethink and self-imposed cognitive dissonance. Nice job.

Dillon said...

Dylboz is boring me to tears. I demand trolls that are worthy of my attention.

(where is Mousey when you need her?)

CaptBackslap said...

Two things about Medicaid and assets:

1) If someone has divested assets in the previous five years, Medicaid will not pay for long-term care until the assets are returned.

2) Medicaid recovers costs it incurs from beneficiaries who shelter assets (in Medicaid Trusts and the like) before inheritance can be taken. The advantage there is that Medicaid pays significantly less for services than private parties do, so the total bill is lower. Of course, that knowledge would only make Megan more adamant that people be made to liquidate assets first, rather than getting a GOVERNMENT DISCOUNT.

Mr. Wonderful said...

"one of those free-for-all clinics where you can get in to see a doctor immediately..."

The meaning of "free-for-all" is ambiguous, but if you can get in to see a doctor immediately, then it sounds like it's NOT a "free-for-all" in which there is anarchic triage. It sounds like there's no one waiting and doctors to spare, however second-rate by MM's standards.

In fact I doubt where there is any clinic in the US where you can get in "immediately," since whether they're "free" or conducted as a "free-for-all" they're always over-booked and have people in the waiting room. You can't get through if there's anarchy, and you can't get through immediately if they're at-no-cost.

Either way you cut it, it's bad writing. And writing is all she does. In her effort to be breezy and amusing she's obscure. Defend that.

Susan of Texas said...

It's a pretty important point, although hypocrisy from McArdle wouldn't exactly be a novel event. I've done the city's walk-up immunizations, which were given in a drug store.

Susan of Texas said...

Wow, doctors hand out freebies? THe little sign by my docotr's window say differently. Mostly it says "Pay Before You Leave."

It's funny, I can think of better criticisms of the post than I read here.

Kathy said...

"I could not possibly imagine a more textbook example of doublethink and self-imposed cognitive dissonance..."'re soaking in it!

jp said...

How is it that a rich spoiled brat like MMcA has gone to such crappy primary care doctors? I am way below her class/economic markers, and I go to a practice where I am shuffled among 3-4 different docs, but they know who I am and my basic history (guess they take a moment to read my chart before walking in). I smell foul, as in McA is just making shit up to make it seem as though she has a point.

Anonymous said...

A "free-for-all" clinic may not be the same as a free clinic. Maybe she went to a "docs in a box" place. The paragraph is unclear.

Susan of Texas said...

Yes, anon, it's ambiguous. And maybe unimportant. It's not like McArdle has ever been unclear before, and she's so very wrong on so many matters that hypocricy is the least of her problems.

It's kind of funny if true, though. Although we have ample evidence she thinks the rules don't apply to her anyway.

Dylboz said...

Dillion, I am not your dancing monkey, if you're so bored, go entertain yourself.

Kathy... Uh, how, exactly? I am consistently applying my principles, not twisting logic backward upon itself into a pretzel of confusion like Susan here. In the same breath, she says she supports freedom, yet endorses a coercive prohibition on organ markets, because they offend her very subjective values and emotions. She thinks everyone should be free to do exactly what she thinks, to conform to her moral standards, and if they don't like, they can go to jail, just like that New Jersey Rabbi will.

It's an ugly solipsism backed up by state force. She repeatedly denies the validity of any other choices besides the ones she'd make, even if they are voluntary and mutually beneficial. Then, for good measure, she disingenuously redefines "coercion" to include just the kind of remunerative exchange she finds objectionable, even though it's freely, even eagerly agreed to by both parties. Can't have that, can we?

According to Susan, people are just too stupid to make their own decisions, especially those moronic po' folks, whose lack of financial resources renders them unable to calculate risk versus reward, so wise old Susan better step in and make their decisions for them, at government gunpoint, no less. That's compassion! But then, that's always how you "liberals" roll, isn't it? We're free to be just like thee!

Dylboz said...
This comment has been removed by the author.
Dylboz said...

Oh, and glad to see you begrudgingly admit that you misconstrued Megan's writing in the worst possible light, even though it was pretty clear what she meant. Free-for-all clearly refers to a walk-in, first come, first served clinic with no appointments, multiple doctors and triage like an ER. They're commonly referred to as "Doc-in-a-box" clinics, which was also THE TITLE of her post. "Anarchic?" I guess.

Finally, only on the loony left can providing an opportunity by ENDING its forcible prohibition and REMOVING the threat of punishment from those who choose to do it be considered "coercion." Yet that is what Susan thinks providing an opportunity for organ markets is, literally "forcing" the poor to choose which body parts to sell. As if. Apparently, she's more comfortable "forcing" them to stay poor, by depriving them of this opportunity to make money and help those in need, but at least they retain their "dignity" in her eyes, and they wont be moving into her neighborhood with their newly earned wealth, either.

Dillon, sorry to misspell your name, people do that to me all the time, but maybe it was a little entertaining, no?

Cheerio, chaps, I'm done here, no minds are a-changing, just glad to see that cleared up. You wont soon catch me on your blog again. Good day.

Anonymous said...

You honestly think it's some kind of contradiction to say you believe in personal freedom, yet still believe in the rule of law? Do you think it's unreasonable to say people should be free to do as they choose, within limits? That's like contending that believing in freedom means you'd be a hypocrite if you didn't think it was okay for a person to murder if they so wished.

Dylboz said...

No, I believe that the standard is, if there is no victim, there is no crime. This is often paraphrased from Oliver Wendell Holmes as, "your right to swing your fist ends where my nose begins." If two people wish to make a mutually beneficial exchange, then no one else has any business interfering with it. Murder is obviously not voluntary for the person being killed, who is thus a victim, and therefore murder is obviously a crime. The "rule of law" is just a means by which men in power make criminals of us all, by writing down arbitrary rules backed by threat of force, even where there are NO victims, like these cases:

Organ markets are a means to facilitate the kinds of completely voluntary exchanges I was defending, and forcibly interposing yourself and threatening these people with violence or imprisonment because you don't like what they're doing makes THEM the victims, their rights are being violated, you're swinging your fist right at their nose when they've done nothing to harm you, except in Susan's case, making a decision she finds morally questionable and incompatible with her personal, subjective values.

That's common among lefty liberals, they promote diversity, so long as it deviates no more than one tenth of one percent from their narrow, politically correct ideology. Their peans to tolerance are just lip service paid to a very small, superficial range of ideas and behaviors.

Truth be told, lockstep obedience in thought and deed is what they really want, and they have no compunction about using the guns of the state to make that happen. Not that they're any different than conservatives in that respect, it's just the conservatives are more honest about that fact.

Anyway, I only responded because I was asked a question. I'll not comment again unless it is in response to another direct question, as I'm not really a regular reader of this blog and only came here via the comment section of an article Radley Balko had linked on his site.

Andrew said...

If two people wish to make a mutually beneficial exchange, then no one else has any business interfering with it.

Exactly, I never understood why they banned slavery. Just liberal lefties and their intolerance, really. Their personal, subjective values.

Batocchio said...

Until this past week, I had no idea that not being able to sell one's organs was such a great injustice and huge problem. Gosh.

Thanks, Susan, for a very thorough rundown. I had read her the-old-and-sick-are-lucky crap years back dissected at Sadly, No, but I went back to read her posts. Holy crap. As Jesse Taylor put it, "she’s wrong in ways that require a 10:1 energy-to-stupid ratio to correct." She generally argues from a theoretical perspective and ignores reality, but even then, it's rarely solid or thorough theoretically. It's more glibertarian free association, working from Randian conclusions backwards, and using really wacky (and sometimes convoluted) arguments along the way. When she's called on it, she loves the 'you guys, what I meant to say was...' I guess it's a bit better than Jonah Goldberg claiming every refutation and debunk proves his point. We all have our starting points, but McArdle will wade into issues without doing even basic research or thinking things through – and sometimes cops the attitude that she's a bold, independent (and intelligent) thinker, unlike her critics. I found that particularly annoying when she tried that in response to Hilzoy, of all people (when Hilzoy was politely smacking McArdle down repeatedly over the course of a few weeks earlier this year).

For instance, she's contemplating some very complex system to "peg the money to the suffering the disease causes, rather than the cost of treating the disease," whatever the hell that means (as clever pseudonym noted upthread). Why bother? Why not just move to single payer, or one of the other effective systems used in other countries? Why not pool the risk to lower costs - and because a purely free market health care system means anyone who's not wealthy who get certain diseases will die otherwise? In terms of fair "cost" according to ability to pay, a government health program funded in part through a progressive tax system does that without resorting to Megan's "classes" and with much more accuracy and ease. Why not look at any of a number of systems that work fairly well, and look at why they do so? Oh, wait, empirical analysis and libertarianism often don't mix that well.

There are many ways to dissect and rebut McArdle, but I think Ezra Klein was right when he essentially said she's simply not interested in solving problems in any serious way. If your goal actually is to provide health care to people better and cheaper, for instance, you're simply not going to go the routes she does. Like Richard Cohen, McArdle really just is a set of attitudes who often can't form a coherent argument and has little connection to the reality-based community. I don't like to ascribe everything to demographics, but I've never seen much from her that wasn't the usual privileged, self-interested glibertarian pap.

It's a travesty anyone's paying her for such an unrelenting flow of crap, but I really have been enjoying this round of smackdowns. So thanks again!