(some notes toward a manifesto of sorts)
I've generally found myself in agreement with Thoreau:
"I heartily accept the motto, -- 'That government is best which governs least'; and I should like to see it acted up to more rapidly and systematically. Carried out, it finally amounts to this, which also I believe, -- 'That government is best which governs not at all'; and when men are prepared for it, that will be the kind of government which they will have."
and with Kerry Thornley's "Zenarchy":
"As a doctrine, it holds Universal Enlightenment a prerequisite to abolition of the State, after which the State will inevitably vanish. Or - that failing - nobody will give a damn."
Over the years, some of you have heard me rail against many things the government has done: war, drug policy, domestic surveillance, censorship, and so on. For example, way back in 1993, in a USENET discussion about drug policy I spoke of the feds as
"...the government that gave us the Dredd Scott decision, Prohibition, McCarthyism, MK-ULTRA mind-control experiments with LSD, the Bay of Pigs, the Vietnam police action, Watergate, Iran-Contra, the House banking and Post Office scandals, the Waco [assault], and 20-page MILSPECS for brownies..."
and a decade and a half later, I find nothing to disagree with in that statement.
(I Am Not Making This Up: the 2003 version of the military specification for brownies actually runs to 26 pages.)
So, how is it that I now find myself arguing in favor of that same government taking up a greater role in health care?
It is because, under current and foreseeable circumstances, the alternative is health care from the same sorts of massive corporations that brought us the Bhopal disaster, the Exxon Valdez debacle, the Merck fake medical journals, the Enron and Halliburton and KBR and Blackwater and Madoff and Goldman Sachs scandals.
A large corporation is an animal dedicated to its own preservation and growth; if actual goods and services are produced, that's just a fortunate by-product of its metabolic processes. And that's fine when we're dealing with ordinary consumer goods. But a health care system in which some people might occasionally receive care, if it doesn't affect the bottom line too much? Stacked against that, a government-regulated system (however subject to inefficiency and corruption and mistakes) that claims as its prime directive to provide care, starts to sound attractive.
Now, I can imagine -- and hope for, and work for -- a time when men and women are prepared for Thoreau's government that governs not at all, when Universal Enlightenment holds sway. Perhaps it's an asymptotic process, to be approached but never fully realized. Still, in a world with social justice, where economic resources were broadly distributed and people were educated enough to understood that their neighbor's health impacted their own, that health is as communicable as disease, there would be little need for some central bureaucracy to see that everyone had good access to medical care. Communities could and would handle it locally through voluntary co-operation.
But that is not the world in which we live. We live in a society of gross inequality, where income and wealth are distributed in an "L curve" -- where a handful of billionaires and multi-millionaires form an aristocracy that controls most of the wealth. And this is, to significant degree, a hereditary aristocracy -- the U.S has lower inter-generational economic mobility than most other developed nations.
The day of Universal Enlightenment appears to be a way off yet. So the question for the practical Zenarchist is, what sort of government shall we try to have while we wait around for it?
Again to quote Thoreau, "I ask for, not at once no government, but at once a better government. Let every man make known what kind of government would command his respect, and that will be one step toward obtaining it."
I say that, if we can't have a government that creates social and economic justice -- for it is true that "Law never made men a whit more just" -- we ought to at least have one that does not push it further away; one that provides the infrastructure necessary for ordinary people to live in security and build that justice on their own.
But instead we have a system where the government gives birth, through the issuance of corporate charters, to organizations dedicated solely to allowing the investment class to accumulate wealth. And rather then placing limits on these state-created entities to them to prevent them from harming the interests of the people, it gives them all of the rights of a citizen and lets them grow into immortal psychopaths -- artificial persons that can live forever, untroubled by the inconveniences of conscience or real responsibility. (Recommended viewing: The Corporation.)
This, by the way, is the ultimate answer to those who still yell that hoary Reagan-era slogan, "Government is the problem, not the solution!" Never mind that it was a government program that put men on the moon, arguably the greatest accomplishment in human history; never mind that it was a government project that laid the foundations for the Internet, or that D-day and the defeat of Hitler was a government project. Never mind those public schools, public libraries, public roads, public fire departments and police forces -- and the government-run military. There are always some who will hold firm to their ideology and claim that the private sector would have done it better (even though the reason the government got involved was usually because the private sector was doing a lousy job).
But as it turns out, that very fundamental tool of modern capitalism, the corporation, is a government-created entity; and so anyone who believes that government is always the problem, and wishes to be intellectually consistent, must tear up any corporate shares they own.
(And also any government-issued copyrights, trademarks, or patents. And any government-issued land deeds. Trace any claim of real property back and you'll find that it's not just recorded with and enforced by the government, but descends from a land grant by a king or a conquest of one nation by another: no government, no land ownership. And then there's government-issued money: as that great Jewish philosopher Yeshua ben Yoseph once told some tax protesters, "Render on to Caesar what is Caesar's". I can imagine a Thoreau-ean anarchy without any of these things, but it looks nothing like the "anarcho-capitalism" sometimes described by my right-libertarian friends.)
We need to be clear about the nature of the large corporation. While it may use the same legal structure, a mega-corporation is qualitatively different than a mom-and-pop business incorporating for tax purposes and to protect the owners personal assets from creditors if the business goes bankrupt. When the ownership of a corporation gets separated from the workers, to the point where ownership is traded as casually as baseball cards and the management becomes separated from the owners; when a corporation starts to own other corporations, a fiction owning fictions; when a legal fiction in one state starts to impact lives on the other side of the country, what we have is not a healthy business doing well by doing good, but a beast that must be leashed.
The mega-corporation gains its mass not by winning the competition of the market, not by providing a superior product, but by mergers and acquisitions and accounting, by wheeling and dealing. In theory a corporation that misbehaves or grows too powerful can be dissolved, its charter revoked by the issuing state. But as a political reality this is only used against small companies, never against the giants. The politics are unworkable.
The existence of a corporation should be seen as a privilege subject to the common good, not a right. But the bizarre idea of corporate personhood -- that a corporation has all the rights of a citizen -- has become too deeply entrenched for us to expect it to change any time soon. And as for regulation, the mega-corps are simply too large to expect the state governments that birthed them to effectively leash them.
Just how big can these beasts get?
To look at a relevant example, UnitedHealth Group reports revenues of $41.66 billion dollars for the six months ending June 2009. Assuming the next six hold steady, that's annual revenue of over $83 billion dollars. For comparison, Bangladesh, a developing nation of 162 million people, has a total GDP of about $82 billion. Closer to home, there are 15 U.S. states with a Gross State Product less than this.
The company projects a profit of $5 billion dollars in 2009. There are 39 countries whose entire GDP is less than this, and four states whose total budget is less than this.
When William McGuire stepped down as the company's CEO in 2006, he left with $1.6 billion in stock options.
When companies are this large, they do not merely compete in markets: they control them. As James K. Galbraith puts it, "Corporations exist to control markets, and often to replace them. Business leaders reduce uncertainty not through clairvoyance (or 'perfect foresight,' as the economics textbooks call it), nor by confident exploitation of probability ('portfolio diversification'). They do it by forming organizations large enough to forge the future for themselves. In politics these are countries and parties; in economics, big corporations."
The expectation that consumers can get an organization with the economic power of a midsize country to behave by the mechanisms of the market is nothing but a fairy tale. And we can't hope that they will choose to do right on their own: any display of conscience or morality, any behavior other than relentless profit-seeking for the short term, is seen as a flaw and results in a shareholder lawsuit for failing to maximize returns. It is the nature of the beast to be amoral, even immoral if that improves the bottom line.
Not even a state government can reign in a behemoth like this. In the case of the multinationals, even a national government may not be strong enough -- for example, ExxonMobil reported 2008 revenues of nearly $373 billion and a profit of almost $41 billion. For comparison, the EPA's 2010 budget is $10.5 billion, meaning that if the EPA devoted itself entirely to policing this one oil company, ExxonMobil could outspend it three to one -- and still turn a profit!
But let's stick with the topic of health insurance. Right now, people are dying because insurance companies, incapable by their nature of doing anything except maximizing profit, are denying coverage to millions of people. Sometimes they refuse outright to sell them a plan, or offer plans only at unaffordable rates, but that at least is somewhat honest and up-front behavior. The sick thing, the stories that twist my stomach, are the ones where a company sells someone a plan and collects premiums for years -- and then denies coverage when it's needed. If the patient manages to pay out of pocket, they often fall into bankruptcy (the majority of personal bankruptcies are related to medical expenses); if they can't, they may be left to die.
Well, say some, so what? It seems that Social Darwinism is alive and well (curiously enough, often among the same demographic that rejects actual Darwinism), and some would say, let people who can't pay for their health care sicken and die. They fail to realize one of the great truths about health care: it is a public good. The access, or lack thereof, that our neighbors have affects us, because health is communicable.
It is directly communicable because one of its enemies, disease, is communicable. When my neighbor starts showing swine flu symptoms, it is in my interest that he can see a doctor ASAP, before he coughs on me as we wait in line at the supermarket. When my girlfriend's ex-boyfriend notices a funny rash in a personal area, it's really in my interest that he can get it checked out.
This is even more true in an age of bioterror threats. Easy access to basic health care is the best early warning system; access to basic health care is essential to the national defense.
And health is communicable in more subtle ways. When people get to have meaningful consultations with their doctors and other health professionals -- not the quarter-hour quickies that managed care gives us, but real dialogue -- they learn how to make healthier lifestyle choices. The more that people make these choices, the more demand there is; the more demand there is, the more supply will arise, and thus the easier it becomes for everyone to lead healthier lives.
When all my neighbors know the benefits of eating fresh fruits and vegetables, my local supermarket is likely to expand its produce offerings. When everyone is exercising, community planning will more likely include running and biking paths and pedestrian-friendly roads. Suddenly, health is breaking out all over, as everyone finds it easier to eat right and exercise. Just as disease can lead to a vicious circle where those sickened are unable to perform the tasks that treat and contain illness, so supporting health leads to a virtuous circle, a positive feedback loop.
And so a system where all have access to affordable health care, where no one is discouraged from seeking treatment or advice because of expense, is to the ultimate benefit of everyone.
Everyone, that is, except for the insurance giants, whose profit model depends on discouraging or preventing people from getting care. And so they are fighting change tool and nail.
If market mechanisms can't reign these monsters in, and if they're too large for individual states to control, the only remaining option is for the federal government to step in.
But as a proponent of limited government -- as someone who has an "I'm A Constitution Voter" sticker on my car -- I have to ask, is it Constitutional for the feds to do so?
Since these mega-corporations are doing business across state lines, it is within the fed's Constitutional power to regulate them under its power by Article I, Section 8 to "regulate Commerce...among the several States".
And more, health care is at least as important to the national defense as the interstate highway system. Not only is there the bioterrorism aspect discussed above, but in case of an emergency or foreign invasion, a sickly populace cannot defend itself.
So if the private sector cannot provide the services necessary to keep Americans sufficiently healthy that they can readily be in fighting shape, then the federal government should use its authority "To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States": impose the necessary taxes (for example, rolling back the Bush tax cuts for the richest Americans, restoring the top marginal rate to the 39.6% it was during the Clinton years, or even the 50% it was during most of the Reagan years -- or the 91% of the Eisenhower administration) and do what's needed to keep the nation healthy and strong.
Rabbit (not verified)
Wed, 08/19/2009 - 02:23
Well written and well argued points. I agree that health is a public good, and that we are all better off when we are all healthier. It seems silly to think otherwise. I also agree on all points on your assessment of corporate power structures. Not only are they bigger, better funded, and more aggressively self-serving than the government attempting to audit their activities, in many ways it is difficult to separate the mega-corporate superpowers from the government. When the Fed and the banking industry are swapping executives back and forth from appointed positions to corporate boards to numerous variations of "consultant"... why is anyone surprised that the rules are rewritten to remove the diseconomies of scale that are the only natural market force keeping corporations in reasonable growth patterns?
However, I do not believe that government managed health care will improve the health of Americans as these programs would be implemented.
First off, I mistrust handing the federal government a project of this size without the transparency to assess the costs of services provided. We need to measure an undertaking of this scope in order to keep the bureaucracy on track, or the Iraq war could end up looking like a rounding error in comparison. National spending on health care under the current system accounts for something like 15-20% of our GDP now. We need transparency in order to rate the efficiency of the solution, for example forcing government agencies to adhere to generally accepted accounting principles to provide the same documentation required of publicly traded corporations (who still manage to cheat, but have to break the law in order to do so).
Secondly, it could very well end up that the same private interests remain in control of a federally managed health care system. This system will not be run solely by civil servants, because the government does not possess the resources to "get 'er done". No, private companies will be hired to provide a myriad of services to this enterprise. What then? Think 'Halliburton'. Serious thought needs to be given to the management of contractors hired to provide these goods and services, or the institutional waste will eat up a hero's portion of our GDP and spit it out in some robber baron's pocket.
I do not believe that the conciliatory Obama administration has the right stuff for this task. Watch the drama unfold; I would bet a great deal that the government run health care leadership will be plucked right out of the boardrooms of the managed care industry that is already raping us for every pill and bandage.
I do not see a balanced solution in front of us, but I agree that the nation as a whole should recognize the cost of healthy citizens. Thanks for the thoughtful article!