Megan McArdle's Case Against National Health Insurance. Sort of.

In my chat today, a reader asked me to respond to Megan McArdle's lengthy case against national health insurance. The problem is that, well, there's not a lot to specifically respond to. In 1,600 words, she doesn't muster a single link to a study or argument, nor a single number that she didn't make up (what numbers do exist come in the form of thought experiments and assumptions). Megan's argument against national health insurance boils down to a visceral hatred of the government. Which is fine. Megan is a libertarian. That's, like, her journey, man. But her attack on national health insurance seems a lot more about libertarianism than it is about national health insurance.

Megan has two primary concerns. The first is that national health insurance would succeed in reducing health-care costs, and that would limit the rewards available for medical innovation (drugs, devices, etc), which would in turn reduce medical innovation and prevent future generations from enjoying wonder drugs. "If you worry about global warming," she writes, "you should worry at least as hard about medical innovation."

Second, national health care gives elites license "to wrap their claws around every aspect of everyone's life." Her primary example is obesity. Megan believes that national health insurance will give the government license to decide that we can never really want a second chocolate eclair. She also believes that the real reason most every epidemiologist in the country is worried about obesity is because they hate, and are disgusted by, poor people.

I bet you think I'm kidding about that last bit. I'm not. Let's take these in turn. Or try to, anyway.

Megan's first argument is properly understood as a simple application of economic theory. If national health insurance reduces the profit reward for medical innovation, medical innovation will decrease.

This is not an argument for or against national health insurance. Medicare, for instance, is undoubtedly America's largest purchaser of new drugs and devices. That's a big part of the reason that it is so expensive. Without Medicare, in fact, there would be a much smaller market for medical innovations, as a substantial portion of the elderly would not be able to afford heath-care insurance -- much less unlimited health-care insurance -- and could not pay for these innovations. National health insurance for the elderly, in other words, is one of the primary drivers of medical innovation.

Nor is there any reason to believe the status quo -- which Megan implicitly favors -- optimized the dollars we devote towards medical innovation. Pharmaceutical companies, for instance, spend less on drug research than on administration and marketing. You could say that administration and marketing increase their profits, which in turn let them spend more money researching drugs. But if research is so important, then maybe the profits being enjoyed by the industry are in fact too small.

In 2002, the pharmaceutical market totaled $200 billion in the United States. Maybe we should be giving them another $50 billion in grants? Or maybe not? Why? Why not? And what about the evidence that drug industry innovation is declining? And what about the defense industry? For all its waste, elevating the U.S. government to sole purchaser seems to ensure a much-higher rate of military technology innovation than if we left it to the private sector. Why wouldn't that apply to health care?

Megan doesn't say. Nor does she say whether the current system works well to maximize innovation. Or what an innovation-oriented system would look like. Or how much of GDP we should spend on innovation. Or what would happen to innovation if Medicare and Medicaid collapsed and the medical industry lost about 80 million purchasers. Or what would happen if universal health insurance brought 50 million new customers into the system. The fact that she is concerned about innovation only insofar as she can shoehorn it into an argument against national health insurance leads me to believe she is not very concerned with innovation at all.

As for Megan's other argument ... I'm sort of at a loss as to the appropriate response. A wealthy white elite, she writes that national health insurance is "a way to extend and expand the cultural hegemony of wealthy white elites." Her argument is that "when you listen to obesity experts, or health wonks, talk, their assertions boil down to the idea that overweight people are either too stupid to understand why they get fat, or have not yet been made sufficiently aware of society's disgust for their condition." I'd be interested to know how many obesity experts Megan has listened to. My guess: very, very few.

I actually do talk to public health experts. Frequently. I know, for instance, that the Rudd Center for Food Policy and Obesity, which is based out of Yale, has policy briefs arguing that weight discrimination is real, it is pervasive, and it is properly understood as a social justice issue. Does Megan? If she does, she's not mentioning it. But it seems like the sort of thing you'd want to address if your argument is that obesity researchers are simply revolted by fat people and want them to face more social stigma.

Indeed, none of my many talks with obesity researchers have touched on the issue of the poor being idiots. Nor do they seem to think that the obese are insufficiently aware of society's aesthetic standards. Megan doesn't have straw men here. She has invented imaginary friends for her argument.

Rather, the obesity researchers I know believe a number of complicated and dispiriting things. One is that the human brain is wired to protect against the dangers of caloric scarcity. As a species, we have evolved to maximize caloric intake, to make the most of periods of abundance.

The problem is, we now live amid constant abundance. Food is not only available, but cheap. It is the center of our social lives and the respite from our workdays. It is the way we spend time with our families and the way we connect with our culture. It is how we meet mates and hang out with friends. Corporations spends hundreds of billions of dollars developing ways to make food taste better and creating advertising campaigns to make us want it more. Restaurants and drive-throughs and frozen foods have reduced the energy required to create a meal. Portion sizes have shot up. And even as our caloric inputs have grown, our expenditures have decreased. We drive rather than walk. We sit rather than stand. We work at desks rather than in fields. This is why obesity experts think Americans are fatter. Megan may, again, be aware of this research. If so, she's not letting us know about it.

Nor does Megan suggest she understands why health wonks or obesity experts spend their days -- rather than write the occasional dismissive blog post -- on this issue. For all her talk of elitism, poor communities are being ravaged by chronic disease. Type II diabetes in particular. These diseases are highly correlated with obesity. The reason people focus on obesity is that, in general, it comes first, and so you can address it earlier, and the things you do to prevent obesity -- better diet, more exercise -- are the things you do to prevent chronic disease.

It's also worth noting the disconnect between Megan's first argument and her second. In her first argument, she is worried that future generations will not have access to the very best medical technology. In her second argument, she is worried that the government will swoop into poor communities and ... give them access to medical technology, and develop programs to reduce the incidence of chronic disease based on the best preventive health-care research. That will interrupt their natural state of being fat and sick, and that's pretty much the definition of imperialism.

I've left out the last part of her essay because, again, I'm not sure what to do with it. Eventually, she stops saying that wealthy whites will simply sneer at poor blacks and decides that national health insurance is one-stop before fascism. We learn, for instance, that a national health insurance program will lead to the government deciding we can't eat a second chocolate eclair. It's like she totally forgot that France existed. And that's only a few sentences after she writes that national health insurance will remind us that "the elderly are also wasting a lot of our hard earned money with their stupid 'last six months' end-of-life care." It's like she totally forgot that Medicare existed.

But I don't believe Megan is unaware of France or Medicare. I don't believe she is incapable of understanding why people care about chronic disease or think obesity is a problem. I haven't seen any evidence that she's interested in medical innovation for its own sake or has thought hard about how to maximize it. As such, I don't really think Megan's post is an argument against national health insurance. It's not even really about national health insurance. It's about the government as it appears to a libertarian, if not to the rest of us.