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.