Out of Control Policy Blog

Libertarians Do Care About Patients

Friday night, at a 4th of July-eve BBQ, I got mixed up in a health care debate as can tend to happen at social events in the greater Washington DC area. At one point a truly undecided individual stopped and asked me point blank, "Assuming you're right about the ineffectiveness of universal health care, are libertarians just comfortable with people being uninsured and dying in America?"

It's a valid question, particularly because classical liberals tend to fall into the Party of No on this issue. But, like my reasoning for getting rid of minimum wage laws and decriminalizing prostitution, I'm opposed to a single payer system for health care (and anything that resembles it) because I think people are better off with out it. I don't want to see life or the quality of life rationed by Uncle Sam because I actually do care about people, American and otherwise.

Minimum wage suppresses wages in some areas and increases unemployment elsewhere, laws against prostitution push the age old practice into the shadows and black market, putting women in serious danger without legal recourse to fight violence and pimps, universal health care forces the government to ration treatment and pick winners and losers in terms of who gets what medical treatments.

The Wall Street Journal makes my case better than I did at the BBQ last week. The British National Institute for Health and Clinical Excellence (NICE) was established in the 1990s to "ensure that every treatment, operation, or medicine used is the proven best. It will root out under-performing doctors and useless treatments, spreading best practices everywhere." If that sounds a lot like Comparative Effectiveness Research—you're right. But as the Journal puts it:

What NICE has become in practice is a rationing board. As health costs have exploded in Britain as in most developed countries, NICE has become the heavy that reduces spending by limiting the treatments that 61 million citizens are allowed to receive.

Rationing is expected, given that even government has limited (at some point) resources and can't provide treatment to everyone for everything all the time. Like the case of Debby Smith, even the president can't promise the Public Option insurance company will have the funds to cover everyone's liver cancer. Could we really expect the government to pay for the removal of everyone's brain tumors, all the appendectomies, and each wisdom tooth extraction? That's not how it works in the "successful" systems of Canada and Britain; that's not how it would work here.

Instead, the government winds up picking winners and losers, and we've seen how well that works out in the economy. How does it do this? The Journal runs down a nice list of examples, but two stand out:

  • In 2008, NICE ruled that certain drugs like Sutent that help terminally ill kidney-cancer patients are too expensive, running around $50,000 After the ruling, Peter Littlejohns, NICE's clinical and public health director, noted that "there is a limited pot of money," that the drugs were of "marginal benefit at quite often an extreme cost," and the money might be better spent elsewhere. Is this a decision government bureaucrats in Washington should decide?
  • In 2007, NICE restricted access to two drugs for macular degeneration, which leads to blindness. The drug Macugen was completely banned, while the other drug, Lucentis, was limited to about one in five sufferers. "Even then, the drug was only approved for use in one eye, meaning those lucky enough to get it would still go blind in the other." NICE director Andrew Dillon explained at the time, "When treatments are very expensive, we have to use them where they give the most benefit to patients." Perfectly logical reasoning, but again, who should have the power to make this choice?

There are others, including the rejection of a drug for rheumatoid arthritis, limiting use of Alzheimer's drugs, and banning medicines for myeloma and sclerosis. Ultimately, it comes down to what the value of life is. How much does it cost to extend the quality or actuality of one's life? Who decides whether person A should get the last treatment of a medicine or person B? The number the British health care system has come up with is $22,000 per six months:

NICE currently holds that, except in unusual cases, Britain cannot afford to spend more than about $22,000 to extend a life by six months. Why $22,000? It seems to be arbitrary, calculated mainly based on how much the government wants to spend on health care. That figure has remained fairly constant since NICE was established and doesn't adjust for either overall or medical inflation.

Is a year of your life worth more than the monthly mortgage payment on a high rise midtown Manhattan apartment? I favor choice in the medical field because I believe that if rationing need be done, it shouldn't be arbitrarily decided by those who don't know what they are doing in Washington. It is not the politician's fault, they can't know better. No one can fully know what the best rationing of care should be, who should be saved and who shouldn't.

Again, I don't want to see life or the quality of life rationed by Uncle Sam because I do care about people.

Anthony Randazzo is Director of Economic Research

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Comments to "Libertarians Do Care About Patients ":

Sam | July 7, 2009, 3:19pm | #

"Again, I don't want to see life or the quality of life rationed by Uncle Sam because I do care about people...with money."

Fixed it for you. You're arguing for a system in which treatment of all kinds will be necessarily unavailable to many as an improvement over a system in which most treatments of all kinds are available to most people. The deciding factor will be money, which some people have and other people don't, a condition that isn't going away anytime soon.

Oddly, you're claiming to care about people by advocating for a system that does a worse job of insuring people than the models like the one in Canada. You should make a point of being clear that you care about people with the means to afford treatment though, not all people absolutely.

David | July 7, 2009, 3:45pm | #

Sam is falling prey to a classic mistake (not the one about getting involved in a land war in Asia, though). He makes the assumption that having insurance is the same as actually having health care, which is by no means a given.

He points to the Canadian national health system, and in one respect, he is correct - 100% of Canadians are covered. The problem comes in trying to actually get in to see a doctor. The Wait Time Alliance recently did a study and found that a majority of patients in Canada had to wait in excess of 18 WEEKS to see a doctor, and the average wait to see a doctor in an emergency room was 23 HOURS.

So, yes, national health care does cover more people. Doesn't mean it will provide them with actual treatment, though.

Badtux | July 7, 2009, 4:04pm | #

Thankfully nobody proposes the British system (where all hospitals are government owned, all doctors are government employees, and private insurance is illegal) for America. Luckily we have better models just across the channel -- the French and Swiss systems. France looks like Medicare + MediGap, Swiss is regulated private insurers with mandates somewhat like ObamaCare, both work very well with more doctors/hospital beds per 1000 than USA has, much lower costs per capita than US, and 100% coverage.

It's funny how, in the healthcare universe, so many people seem to believe that only the US, Canada, and Great Britain exist. There's a whole world out there, people, with lots of working healthcare systems to pluck for their best ideas!

Sean | July 7, 2009, 4:04pm | #

@Sam -- So let me get this straight. Very expensive treatments -- such those Mr. Randazzo mentioned -- are currently unavailable to the poorest U.S. citizens because of their cost. Yet by taking them away from people who CAN afford them (due to their own hard work to earn a living) that makes the system 'better.'

Of course, the very VERY rich can afford anything, so even a nationalized health care won't affect their treatment. So if the poor get something for nothing, and the very rich are uneffected, who loses? Oh, yes, the middle class! The ones who have to pay extra taxes, yet still can't get the best treatment.

Okay, thanks, just wanted to clear that up.

Badtux | July 7, 2009, 4:09pm | #

Oh, regarding Canada: There IS no "Canadian health care system". It is provincial. Each province has its own system, and they vary in quality. For example, here are the current wait times for BC, which are much better than, say, Alberta:


People who say "Canadian system" are either operating upon incomplete information, or are being deliberately dishonest.

Henry Bowman | July 7, 2009, 4:34pm | #

Perhaps coincidentally, today's New York Times has an article explaining just how the Canadian system works! It seems informative despite the source.

Fay | July 7, 2009, 6:45pm | #

Never mind that we already HAVE rationing in the US, and it is done by insurance companies, practically on an arbitrary basis. Try getting insurance if you have diabetes. Try getting insurance if your old policy booted you because you had the audacity to get leukemia. Hell, try getting insurance if you have a yeast infection once a year, and then you lose your employer-provided "benefits."

Sam is right. You care about patients... with money. Nowhere in this article do you propose any regulation of insurers, any recourse for families of patients who die by spreadsheet after being denied treatment... nothing. Middle class families are losing everything they have, every day, because someone breaks a leg, or gets breast cancer, or is in a car accident. That is not okay, and its wrongness has nothing to do with political philosophy and everything to do with corporate greed and power. The American "system" is barbaric for far more of the population than just the poorest of the poor.

And yes... there are middle grounds between the US and the UK. My suggestion is Australia. Articles like this peddle ignorance.

Sigh | July 7, 2009, 7:32pm | #

Thankfully, everyone who has insurance now under our current system is able to see a doctor immediately upon being presented at an ER, and all treatments are available to all patients who have insurance, because the current system works so well. *sarcasm*

I'm fine with people who don't want a single-payor system. I'd just like to see an actual idea that works better than the current one.

And that still only addresses people who have health insurance when those people go to the ER and use the scarce resources there without paying. Right now, those of us with insurance STILL pay for those without, only it's a hidden cost.

Sam | July 7, 2009, 10:56pm | #

Look, I don't care what mechanism you propose, but claiming to care about all people when proposing a system that does nothing for a significant minority of those people is absurd at best. Just be clear that you want a system that benefits only some people, not all of them, and that if the system is biased, you'd prefer it be biased against the poor.

Logic | July 10, 2009, 9:12pm | #

@ sigh

you obviously missed the point. the point is, what is the difference between insurance companies rationing health care, and government rationing health care?

think with your head, not your heart. you'll go farther and do greater things.

Steve | July 10, 2009, 11:42pm | #

@ Logic

The difference is that, if my health care company is rationing my care in a way I don't like, I can (or should be able to) find a new company. If we got rid of the tax incentives for employer-controlled health care, and let people shop around they way they do with auto insurance, the competition would force these companies to give more care then they do now.

With the government option, you can't down to the neighborhood Competing Government for a better way. You can vote with your feet when it's a private company doing the rationing. People may also vote with their feet under single payer, but not in the way we would like.

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