Tyler Cowen is right.

Inequality of all kinds takes years off the lives of those on the bottom. So the argument for equality of access to health care – “you shouldn’t die of being poor” – actually supports a much broader program of redistribution.

Since inequality shortens the lives of people on the bottom, the idea that health care should be equalized, leaving the rest of the distribution of income, wealth, and status unchanged, lacks a coherent basis.

But doesn’t that suggest reduced inequality as a policy goal?

Footnote Actually, it’s reasonable to think that health care is less positionally consumed than other goods. There are strong reasons for me to want my suit to be nicer than yours, my car flashier, and my house bigger and fancier. But I don’t want my visit to the dentist to hurt less than yours: I just want it to hurt as little as possible. So in medical care – unlike housing – it’s possible to accomplish a genuine Pareto improvement: to make someone better off without making anyone else worse off. That constitutes an efficiency argument for allocating resources toward health care and away from more competitively consumed goods.

But Cowen’s other point remains: since relative income and status influence life expectancy, the same argument that supports equality of access to health care – that you shouldn’t die of being poor – actually supports equality across the board.

And of course that’s the source of the basic dishonesty of the entire debate over ACA. The difference between the Heritage plan and Obamacare is about $200 billion a year worth of downward income redistribution. But neither side wants to make that point: progressives because white middle- and even working-class voters have been taught to regard “redistribution” as meaning taking from them to give to those below them and darker than they are, and conservatives because they’d rather argue about “liberty” than admit that they’re waging class warfare from above.

Author: Mark Kleiman

Professor of Public Policy at the NYU Marron Institute for Urban Management and editor of the Journal of Drug Policy Analysis. Teaches about the methods of policy analysis about drug abuse control and crime control policy, working out the implications of two principles: that swift and certain sanctions don't have to be severe to be effective, and that well-designed threats usually don't have to be carried out. Books: Drugs and Drug Policy: What Everyone Needs to Know (with Jonathan Caulkins and Angela Hawken) When Brute Force Fails: How to Have Less Crime and Less Punishment (Princeton, 2009; named one of the "books of the year" by The Economist Against Excess: Drug Policy for Results (Basic, 1993) Marijuana: Costs of Abuse, Costs of Control (Greenwood, 1989) UCLA Homepage Curriculum Vitae Contact: Markarkleiman-at-gmail.com

13 thoughts on “Tyler Cowen is right.”

  1. “There are strong reasons for me to want my suit to be nicer than yours, my car flashier, and my house bigger and fancier.”

    Strong reasons? Really?

    I know a lot of people think like that. But I have no objection at all to anyone else acquiring goods comparable to mine. Why should I? It doesn’t hurt me.

    1. … as long as you’re not competing with those people for jobs or mates or other social positional goods. But you are. We’re all graded on the curve.

      And that’s taking your hypothesis: that other people acquire goods comparable to yours. What if they stuff they acquire is sufficiently better that you’re marked as one of life’s losers?

  2. “because white middle- and even working-class voters have been taught to regard “redistribution” as meaning taking from them to give to those below them and darker than they are”

    Do you ever get tired of viewing the world through a racial prism? I seriously can’t seem to go a day without reading crap like this somewhere. Wouldn’t your argument have been just fine without it?

    Conversely, are you arguing that the darker people favor redistribution because they want the white man’s money?

    What if the government offered people money in lieu of expensive medical procedures. Some people would take it. Maybe they would be happier that way. Not everyone would want to spend their accumulated fortunes in the last year of their life on healthcare, some people would rather help their kids buy a house or pay for college for the grandkids.

    As for me, I just want to cut off all those dark people.

    1. Right. Because the southern strategy wasn’t real and didn’t work, and white people of below-average means suddenly stopped favoring redistributive policies once the civil rights movement began to succeed for some other reason that you apparently don’t feel the need to specify.

    2. As a wise man once said, “Any sufficiently advanced obtuseness is indistinguishable from racism.”

  3. Health care not a positional good? Mark, you’ve been in Southern California too long. Come to NYC. “My doctor got his MD from Oxbridge and is the chairman of the lobotomy department at Crankheit University Hospital! What about yours?”

  4. Wha? Forgive me, but I thought that there are such things as common goods that come not out of individual transactions, but are based rather on larger ideas of human decency, social egalitarianism and brotherhood of man that transcend reductionist appeals to capital transaction. There is a reason we guarantee access to roads, parks, libraries, schools and police – and it ain’t because individuals earned it.

    Maybe the most stomach-turning legacy of conservatism has been the way in which its craven notion of individualist social-contract-keeping has infected the body politic. I am my brother’s keeper regardless of any rudely calculated ledger.

  5. “Since inequality shortens the lives of people on the bottom, the idea that health care should be equalized, leaving the rest of the distribution of income, wealth, and status unchanged, lacks a coherent basis.”
    It’s a start. Most good deeds and good policies are incoherent in this way. Shouldn’t Brigitte Bardot be more worried about Africans with HIV than about cruelty to animals? Probably; but she does something abut the animals. People like Tyler Cohen can achieve ethical coherency by systematic selfishness. They are welcome to it.

  6. For the past several years, I have been asking my policy class to think about five “essential” goods and services – food, shelter, clothing, education and health care – and to do the mental experiment of asking what the median person in the society expects and how far below that median someone can fall before the society is unjust. Asking about the median gets away from judging distributions at the low end by the opportunities of the most well to do. In the language used in the health care debates, it’s a chevy, not a cadillac.

    Consistently the acceptable distance from the median is smallest for health care and then education, two of Amartya Sen’s enabling services. I think this is one of the reasons the efforts to construct acceptable minimum service sets for health insurance for low cost plans consistently fall short, and instead we simply have the risk shifting of high deductible plans (“consumer driven” plans in the euphemistic parlance of the right). Identifying services the middle class should expect that the poor should not proves very hard.

    In another post, “Fear of Falling,” Harold Pollack talks about meeting or failing to meet the educational needs of the non-meritocrats, and some of the same tensions my class sees in health care can be seen in that post as well.

    Food, clothing, shelter are different. From a social perspective, there are low cost, boring diets that will provide the calories & nutrients needed to survive, Good Will and hand-me-downs can provide plenty of wearable clothes, and living with fewer square feet, more crowding, needed repairs, and a few rodents or bugs proves to be not unacceptable. The gap between median and minimally acceptable really is much larger.

    There is often a tendency to argue that if you can’t do everything, you shouldn’t bother doing anything. That’s Tyler Cowen’s invitation. The response should be some inequalities are more troubling than others for a community, both in the moment and for their long-term impacts, and social efforts to achieve more equality, to keep the bottom from being too far from median, and the median from falling as total wealth grows, are justified.

  7. The problem, or at least a problem, is that healthcare and education pretty much need to be consumed in reverse-positional quantities for a society to be really just.

    Well-off parents will (generally) see that their kids get decently educated even if their school is underfunded; poor parents don’t have any of the resources needed to do the same. And poor kids have to cope with a whole raft of issues that better-off ones don’t. But of course spending per district goes the other way.

    Or consider my acquaintance Dave, who died last year after a 30-plus-year career working in granite quarries. Even before he contracted lung cancer, he was a wizened, white-haired, creaky old man. He was 53. (And yes, every time I hear some Very Serious Person talking about what a reasonable thing it would be to increase the social-security retirement age to 69 or 72 or whatever, I think of Dave.)

    1. There is a fair amount of truth in this. When we lived in the Boston area, we lived in Newton, with strong schools. But when my kids had a weak teacher, they had two college educated parents at home to backstop, and whether their teachers were weak or strong, my kids had tutoring, editing, and academic advice all available at home, indeed sometimes pushed on them. Talented kids in the Boston schools may have had none of these advantages at home, and needed stronger schools and after school programs to level the playing field.

      1. In some ways, public schools in the US have taken on the same kind of role that state enterprises often did in the former east bloc. There, faced with a failure of the general civil society and social infrastructure, state enterprises became responsible for childcare, sometimes food distribution and housing, medical care and so forth for their employees. Here, we make schools responsible for ensuring that kids get adequate nutrition, have access to physical and mental health services, occupational therapy and so forth. Which is all quite dauntingly wonderful in some ways, but also highlights the many ways that the larger society falls short.

  8. I don’t want my dental appointment to hurt less than yours (I want both of them to hurt not at all), but I am glad mine takes place in a safe, pleasant neighborhood with a dentist who wasn’t in the bottom half of her dental school class and didn’t finish school just last year. I’d like yours to fit all these criteria too, but I know that’s not realistic in a capitalist society. My dentist, BTW, LOVES the American health care system and seems to think she’s in mortal peril whenever she ventures more than six blocks from UCSF, Cedars-Sinai, or Columbia Presbyterian. Knowing her as I do, I think that thinking might be somewhat positional.

Comments are closed.