Dear Julian,

Interesting. Polemics aside, it looks like once again, we are substantially in agreement, even though I am presumably coming from a socialist perspective, and you from a Libertarian. Major points of agreement:

• Leaving people to bleed to death when they can’t pay for services is unacceptable.
• Significant government involvement in health care is required.
• Coverage needs to NOT be tied to employment.
• Coverage needs to NOT recognize “pre-existing conditions.”
• Coverage needs to be universal, and paid for by everyone.
• Covered costs need to be contained in some fashion.
• Covered care will probably need to be regulated/rationed in some fashion.

The simplest and most obvious solution is a national single-payer system, paid through mandatory (progressive) taxation. Medicare For All. I wouldn’t be utterly opposed to seeing it at the state level, but because the entire national pool splits into fifty pools that vary dramatically in size and overall health, there will be states where it sucks, and states where it’s great. Wyoming, which has no state income tax and a very small population (and therefore a very small pool), will suck. Louisiana will suck. Colorado might suck. On the other hand, state taxes everywhere will have to go up, so Wyoming might turn out to be a great place: they’ll impose in a 5% tax and cover everyone. California will try to raise their taxes another 2%, legislators will get death threats, and they’ll end up with an underfunded and completely broken system.

I acknowledge your instinct to turn to the market first, though I disagree with it — I am far less sanguine about the market than you are, as you are less sanguine about the government, probably for the same reasons (bitter experience), but we both seem to agree that neither health care nor insurance are governed by theoretical market principles.

So I don’t understand why you continue to push for market-based solutions. Market theory does not apply, and 50 years of supposed “free market experimentation” has led us directly to the current unacceptable dead-end. No marketplace can find efficiencies that aren’t there. Costs and prices never stabilize in a system driven by positive feedback. There seems to me no reason to continue looking in the private sector for solutions.

The “fines” approach you mention is a desperate attempt to retain private sector solutions no matter what, and it is deeply misguided: it misses the basic point that health insurance is unaffordable. You can’t fine people into paying for something they can’t afford in the first place. Are you seriously suggesting fining a household over $11,000 a year for failure to participate in a private health insurance plan? Because that’s what my insurance plan is costing me right now. Fine us $4,000 (as proposed in Washington), and I’ll pay the bloody fine and go uninsured, having no other realistic choice. The $7,000 I’ll save each year on the difference will pay for all ordinary medical expenses, and either way, I’m uninsured for larger expenses: that $11,000 coverage goes away completely the first time I miss a premium payment, which will happen the moment I get sick enough to need the coverage. It’s called bait and switch: sell me “insurance” and actually give me “oops, let’s just be friends.”

Paying the bloody fine, I will also, of course, curse the government from the depths of my soul and start seriously listening to talk about tax revolt. I’m sure someone will start one, and it won’t be a quaint little tea-party in funny hats on the steps of the capitol.

On the other hand, I’d happily pay $4,000 in new taxes for Medicare-level benefits. It’s a damn sight better than what is available to me through private carriers right now.

Yes, I understand the theory that by adding healthy people to the pool of the privately-insured, the cost of insurance will come down. What will actually happen is that insurers will split the difference, and pocket the excess. So if $4,000 (the amount of the fine) actually covers my large-pool averaged costs, and $11,000 is what they are gouging me now, I’d see a reduction to maybe $8,000. The insurance company will pocket the $4,000 profit over the actual cost of insuring me. If I drop out, the government will confiscate $4,000 through a fine, and I have no doubt this will make its way back to the insurance companies, even though they now provide me with absolutely nothing. So they are suddenly guaranteed $4,000 pure profit per citizen. Not per voluntary customer. Per citizen. And if I actually become seriously ill, I won’t be able to pay the $8,000 premium any more than I can pay the $11,000 premium, so they either get to drop me completely (and collect the $4,000 fine in return for nothing), or they get the government to pay my $8,000 through subsidies after I drop into official poverty. Clever bastards.

Because the positive feedback has not been addressed, costs will continue to rise. All the cozy relationships among big pharma, big health-care, big insurers, and big government remain completely intact, unreformed, unchanged. Clever bastards.

This is a tidy way for the insurance companies to get in on the Wall Street-style bailout business and start living off the government teat instead of the fickle marketplace. Very clever bastards.

Yes, of course any sensible government solution is going to destroy the health insurance industry completely. The only way to keep insurance companies luxuriously profitable in the style to which they have become accustomed is to subsidize them with tax money. All of these public/private hybrids being discussed are merely convoluted ways of subsidizing the insurance industry without admitting it. Surely that is clear?

So why are we still talking about private insurers? What possible advantage do they offer?

I’m also sensing an odd contradiction in what you’ve written. Is Medicare paying care providers too much or too little? Are they not meeting the “real costs” of health care, or do they need to cut back even further? I don’t get a clear read from what you’ve written.

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I don’t know what causes the familial disruptions. I’m not even completely sure it’s a bad thing. It’s an observation.

There appears to be a generational lag in the effect. New immigrants tend to have stronger family ties than those who are more acculturated. There was a huge wave of immigrants around 1900, and the next generation would have reached adulthood around 1920-1925. The third generation would have reached adulthood in the 1940’s or 1950’s.

We just got back from San Antonio, where we met the new in-laws. Suzy is second-generation in a large, typical Mexican extended family — delightful people and a delightful family. Mom is the quintessential immigrant: hard-working (seven days a week, two jobs), debt-free, honest, big heart, a single-parent matriarch who has created a home in which sons, daughters, cousins, uncles, aunts, friends, and everyone else cycles in and out comfortably. She’s put every one of her kids through college, and her children sport a couple of master’s degrees and one PhD among them.

Suzy’s generation is still very close-knit. But I can see breaks: one son (the PhD) is working near Louisiana, one daughter (a Master’s) is working in Houston. The separation from family seems to cause them pain. The daughter talked openly about it, wanting to move back home.

The oldest in the next generation is four years old. When that generation reaches adulthood, Mom will be quite elderly, and when she passes, the family may well lose its center. It’s impossible to draw from a single experience like this, but I’m wondering if this next generation will have acculturated so thoroughly that they will lose their extended family. The four-year-old already refuses to speak or listen to Spanish — he’ll stick his fingers in his ears and start talking.

My own father’s generation broke up in the second generation, rather than the third, possibly driven by the Depression. His parents were European immigrants; Dad was born in 1913, and his father died in the late 1920’s, which threw the family into hard times right about when the whole world collapsed. Dad quit school and joined the CCC. By the time I came along, his family had become Christmas-card relatives, spread out on both coasts and us stuck in Wyoming. No one stayed in Manhattan.

My mother’s generation broke away from the family, too. Born in 1920, she left the farm in the early 1940’s for Wyoming: two siblings left for California, two stayed near home, one went to Chicago. Grandpa was not an immigrant, per se, but he was an “Okie,” one of the settlers in the Oklahoma territory right around its statehood in 1907. His generation was tight with relatives, and my mother’s was, too, though less so: she had dozens of cousins that I’ve never been able to keep track of. Their children all (I think) drifted away from each other.

If we go back to the post-Civil War period, the late 1800’s, the United States was a completely different place, and the American Dream was a different beast.

Hmm. Interesting: apparently the phrase “the American Dream” was coined in 1931 by James Trueslow Adams. Here’s an excerpt from Wikipedia:

The American Dream is a national ethos of the United States of America in which democratic ideals are perceived as a promise of prosperity for its people. In the American Dream, first expressed by James Truslow Adams in 1931, citizens of every rank feel that they can achieve a “better, richer, and happier life.”[1] The idea of the American Dream is rooted in the second sentence of the Declaration of Independence[2] which states that “all men are created equal”[3] and that they have “certain inalienable Rights”[3] including “Life, Liberty and the pursuit of Happiness.”[3]The “American Dream” has been credited with helping to build a cohesive American experience but has also been blamed for overinflated expectations.[4] The presence of the American Dream has not historically helped the majority of minority race and lower class American citizens to gain a greater degree of social equality and influence.[5] Instead, the American wealth structure has often been observed to sustain class differences in which well-positioned groups continue to be advantaged.[5] In common parlance, the term American Dream is often used as a synonym for home ownership since homes have historically been seen as status symbols separating the middle classes and the poor.[6] This usage, though, while common, is generally considered a very specific use of a more general term.

It’s possible that what we take for granted as the “American Dream” was simply not part of the general culture at all prior to 1900. Combined with the fact that the United States was agrarian in the 1800’s, that may be sufficient to explain why American families were stronger in the past than they are now.

However, what I wanted to point out was that all of the potential causes for familial disintegration that you list are simply the American Dream dressed in different clothing. The modern women’s liberation movement is simply women saying that their social potential is unbounded, too. When you say “modern transportation,” you aren’t talking about Eurorail or the Chunnel — you clearly mean the automobile, which is an expression of personal freedom to go wherever you wish, whenever you wish, for any reason or no reason at all. The wealth destruction of the Fed began in 1913 when the Fed was founded, and is based upon putting debt and interest at the center of the banking system: this only makes sense when the economy is assumed to expand geometrically without limits. These are all expressions of the American Dream of endless opportunity. So you’re actually kind of reinforcing my hypothesis….

I also have to take issue with your wording: “Americans are entitled to the fruits of their own production.” Where on earth is this written?

Have you ever read an IP rights waiver that a salaried engineer or scientist is typically forced to sign as a condition of employment? Employees have an entitlement to the fruits of their labor? I don’t think so. Employees are serfs. They’re entitled to an exit interview, IF the company wants one.

The only way you can even dream of this is to own your own business. Running a successful business isn’t accessible to everyone, however. It requires a fairly narrow set of skills and talents which I have discovered the hard way that I do not have. I’m hardly alone in this. It also requires a big helping of luck. Most businesses fail. If I were entitled to the fruits of my own production, I’d be quite wealthy by now. But entitlement is not something you get in business. Your inventions get stolen, your business gets slandered by a competitor, you get bounced by “business cycles.” You get sued. A bank calls in a debt.

I don’t think this entitlement is anything but a dream, largely disconnected from reality.

Thank you again for thought-provocation.

— Themon