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Kvetching

Submitted by Jim Aune on October 19, 2006 - 9:21am


I have been in constant pain for 36 hours. I actually used a cane to go to the office yesterday for some meetings. The problem? I have a trapped nerve in my abdomen from a double hernia repair a year ago. I got shot up with steroids about 3 weeks ago, and that worked for about 5 days, but I still can't walk without a ripping sensation (as if my right leg were being separated from my side). I'm about to go see the doctor again today (he's a nice guy, as family practice doctors usually are, as the anesthesiologist at the pain clinic), so I decided to read up on the Internets about this condition. Now, a little learning, especially online, is a dangerous thing, but it appears that entrapped nerves have gone from happening in 1% of hernia repair patients to closer to 40%, and the speculation is that the new use of plastic mesh is a possible cause.

Enter the biggest jackass on television: John Stossel of 20/20, who believes that the market solves all problems, and that any government intervention in that frictionless market creates no end of bad "unintended consequences." From his report:

Suppose you had grocery insurance. With your employer paying 80 percent of the bill, you would fill the cart with lobster and filet mignon. Everything would cost more because supermarkets would stop running sales. Why should they, when their customers barely care about the price? Suppose everyone had transportation insurance. The roads would be crowded with Mercedes. Why buy a Chevy if your employer pays?

See also the admirable skewering of Stossel on DailyKos today.

Now here's the problem, in classic Econ 101 terms: markets are wonderful things, but they only work in cases of "symmetric information." That is,they work efficiently when both parties to an exchange have nearly similar information; for example, if I want a clean, cheap copy of Vol. III of J.G.A. Pocock's Barbarism and Religion, I can compare prices across the world (usually using some website such as Abe Books, which I like very much), and, comparing for condition and mailing costs and exchange rates, I can find the copy I want. (It turned out that in this case, I got the cheapest copy from a bookseller in England; I had to wait maybe a week longer, but that wasn't an issue for me.)Everyone was happy. My transaction, if it goes well, also builds up that more intangible, but valuable, bit of information we rhetoricians call "ethos."

This example is Stossel's world, as it is in more ideologically driven economics courses. Enter Akerlof, Spence, and Stiglitz around 1970, who discover what now seems the obvious truth (they won a Nobel Prise for it in 2001; Stiglitz has gone to become the most accessible and persuasive critic of the international neoliberal economic order)--markets do not work efficiently when information is asymmetric. Even after reading a few medical articles online last night, my information about my entrapped nerve isn't remotely close to those of my doctors. And among doctors, quantity and quality of information will vary along a number of only partly predictable dimensions. This, John Stossel, is why medicine is not like a grocery. My choices seem limited at this point (although I will be offered a choice, as is reasonable): try an oral course of steroids, laparoscopic surgery to snip the nerve (I have no clue as yet about the down side of that--"numb nuts," perhaps?), or going to score some smack in the bad side of town. (There's also an asymmetric information problem with drug dealers, but that's another topic.) One final note: both my family doctor and the anesthesiologist said about my surgeon: "He's not with us any more." Do I ever get to find out why?

Submitted by Unique on March 1, 2007 - 4:06pm.

Hey Jim,
I have the same issues with pain I call it lightning bolts with the tearing, because of a new sedentary lifestyle it has decreased somewhat after 2 years, but I am still in rough shape and I can (and have) hurt myself at any moment because of a misplaced step or slip.
I wish I could find a way to fix it, I think the cutting of a nerve is not acceptable and I have no use for pills they are awful and do nothing for the pain.
If you have any new info please let me know.
Jason.

Submitted by Jim Aune on March 1, 2007 - 4:22pm.

My pain specialist put me on Lyrica, which was originally designed as an anti-seizure med. I've been on it for 3 months, and now have no nerve pain. It doesn't zone me out or anything like regular pain pills. So I really encourage you to ask your doctor about it.

Submitted by Cynthia on March 1, 2007 - 6:50pm.

My doctor prescribed Lyrica for my fibromyalgia. I took it faithfully for months, though I didn't take the full dosage as she suggested (75MG 3 times a day)...I only took 1 75mg tablet. Problem is that it didn't seem to be affecting my muscle pain, so I decided to stop taking it. Within 24 hours I thought I was having a heart attack, but didn't connect the two things. I was having intense and unrelenting heart arrythmias, shortness of breath, insomnia. Then it dawned on me, and I did a search with keywords 'Lyrica withdrawal' and found that it's a HUGE problem. Many people described my symptoms, and worse. Basically I was having anxiety attacks, and this went on for about 6 days....gradually lessening in intensity. SO...if you decide to stop taking it for some reason, consult your doctor about the best way to stop to avoid these side effects.

Submitted by Jordan on October 20, 2006 - 9:47am.

Jim,

I've posted a brief response here.

--Jordan

Submitted by MGL on October 20, 2006 - 11:04am.

I have to bite here. However cordial and carefully reasoned, Jordan’s (and Stossel’s) arguments might be, they commit two missteps: false analogy and the slippery slope. Let’s begin with the former. Comparing the healthcare market to the market for produce or for transportation is troublesome on two levels. The first is the problem of information asymmetry, as Jim points out. In the grocery store, presumably, I can and possibly do know as much about fruit as does the vendor. After all, anyone can learn to thump a melon. In the doctor’s office, however, there is a vast asymmetry of knowledge, making the doctor able to sell me treatments that might not be desirable. Jordan points out that perfectly symmetrical information is an ideal, yet despite its impossibility, markets work pretty well. There is some truth to this, I suppose. Buyers don’t have to have perfect information in order for a market to efficiently allocate resources, though the market might not most efficiently allocate resources in the absense of this symmetry. Once outside of the realm of the ideal, we are not caught in the completely fallen terrestrial realm. There are degrees of fallibility. The greater the information asymmetry, the greater the market’s inability to efficiently allocate resources. In the extreme case of this asymmetry, we have snake-oil salesmen and Lydia Pinkerton’s medicinal compound. I don’t think any free-marketer would advocate returning to the days of unregulated pharmaceuticals because, as free-marketers well know, information symmetry (however unattainable) is an ideal whose approximation determines the capacity of a market to work. And markets don’t work well at all when there is great information asymmetry. The second problem with the analogy between a healthcare market and a grocery store is this: the lack of fungibility. In the event that prices for fruit exceed my willingness to pay, I can easily choose to consume more meat until fruit prices fall. This is to say that fruit is a fungible resource. Fungible resources allow consumer choice, and consumer choice is a necessary component to any functional market—-without it, we have monopoly, coercion, price-fixing...all the stuff that Hayek dislikes. Transportation is likewise a fungible resource. We can choose to buy more fuel-efficient vehicles when gas prices exceed our willingness to pay at the pump. We can even choose to take the bus (even if it’s a non-subsidized system of “public” transportation). Healthcare, however, is not a fungible resource. I cannot choose to forego a coronary bypass, nor can I opt instead to have some gall stones removed. I need the treatment, and so I must pay whatever is asked. I can conceivably choose to go to another doctor, but even this is dubiously labeled a choice. Who, after all, would decide to go with a mediocre physician in the interest of saving a few dollars? I’ll switch from a Cadillac to a Honda to save money, but I won’t penny-pinch my way into a back-alley colectomy. So, healthcare cannot be made analogous to other markets for two reasons: a vast difference in information (so vast as to interrupt any hope for efficient allocation of resources), and an in-fungible resource.

Now we’re into the second misstep in Jordan’s argument: the slippery slope. This, I have to admit, is the most disappointing for me. Jordan assumes that the only option beyond a fully marketized health-care system is full state appropriation, including forced care by state-employed physicians. And just to ensure my good reader that I am _not_ misrepresenting his position, allow me to quote directly:

“Why don’t we just make doctors government employees? Then they can enforce the course of treatment they deem best.”

We do not have to resort to jack-booted doctors imposing cruel and painful medical regimens upon us. There are, as I’m sure Jordan knows, plenty of ways to combine state management with market mechanisms. The single-payer system is one such effort. Everyone buys into the same health-care management organization, while doctors, hospitals, etc. remain private and independent. These independents contract for opportunities to treat patients. They compete with one another, yet they do not compete with single, fragmented patients who know very little about medicine. Instead, they negotiate with an organization that can collectively bargain on the behalf of its consumers and that can insist on the best (and the most efficient) care available. If the public HMO is not for profit, then there will be no incentive to deter patients from treatment (as often happens in our own woefully inadequate for-profit HMO market). Medicare and the VA work exactly like this and to many people’s delight (as Paul Krugman continually points out).

Given that the analogy is (at best) false, and the slippery slope is (at worst) stupid, I’m going to side with Jim here. I’d rather get sick in a more social-democratic state. My daughter isn’t autistic, but I still worry keeping my family in Texas.

Mark G

Submitted by Jordan on October 20, 2006 - 11:18am.

I never said that the only other option is full state appropriation. I was trying to (re)construct what Jim's positive alternative might be given the scant information available from his complaints. And even if that was what I did take the position you attribute me, it would be more properly construed as a false dilemma rather than a slippery slope.

Instead, though, it's more like a syllogism than a false dilemma: If government is the solution to asymmetric information, and doctors are the ones with the superior information, then why not combine the two?

I am, in fact aware that there are "plenty of ways to combine state management with market mechanisms." We in fact are living in the midst of one of those ways right now. Part of Jim's complaint against Stossel seems to be that we have never seen the "libertarian paradise," so there is "no empirical data (other than 'blackboard economics') to base such a decision on."

Submitted by Jim Aune on October 20, 2006 - 9:57am.

Thanks, Jordan! If I weren't a little drug-addled this morning, I 'd draft a more coherent argument, but I appreciate, as always, your careful and reasoned responses. The general question is what role, if any, government might play in cases of market failure. I also recognize, from my classical liberal friends, that there are many cases of government failure, as well. My main beef is with Stossel's analogy to grocery shopping (I've also heard a similar case made for privatizing schooling, using exactly the same analogy). Do you want to go as far some libertarians suggest: eliminate government licensure of physicians and create a completely free market? My problem is that we have no empirical data (other than "blackboard economics") to base such a decision on. So far, from what I can tell, if you're sick and not rich you're probably better off in France than elsewhere. Stossel was really sleazy in his choice of examples, as the Daily Kos writer pointed out. I would love it if private charity would subsidize hospitals and health care generally, but, given my experience with 2 autistic children, it really makes a difference whether you live in a more social-democratic state like Pennsylvania or Minnesota (granted, Bob Casey, Sr., was a consistent pro-life guy, and he made certain that PA had the best system for the developmentally disabled of any state in the US). At some point, I will have to move my family from here, because Texans--despite their profession to love Jesus and the market--really don't care at all about how the retarded, among others, are treated.

Submitted by Jordan on October 20, 2006 - 11:35am.

You are right that we don't have empirical data to support what might be called the pure libertarian position. We do, however, have empirical data to compare the efficiency of France vs. America on this score. You cited some of it, which leads to you think that "if you're sick and not rich you're probably better off in France than elsewhere." I may disagree, but we have an empirical data set with which to argue.

But, even if you are right, it does not follow that the "pure" libertarian position represented by Stossel is therefore worse. It may be that the worst model is a sort of mixed model, represented perhaps by the United States, and that even a purer socialistic model is better, perhaps due to its internal coherence/consistency. In this way, the only real empirical argument against the pure libertarian position is evidence taken from a relevant source of data. Until we have a purely libertarian state with a basis on which to judge, the data is not necessarily conclusive (this holds true for the socialist model as well). Another way of putting it is that the two relatively best positions are at the extremes, and everything in the middle is worse by varying degrees. And perhaps one end of the spectrum is still yet better than the other.

We need to make distinctions about what sort of mixed economy we are talking about as well. A government mandate that insurance be taken out is not the same as the government also being the monopolistic provider of that insurance (car insurance in Michigan is a good example).

I'm not convinced that private groups couldn't perhaps do as good or better a job at medical licensure. As I alluded, there are some market-based solutions that serve the same function.

One of the problems with many libertarians is that they have no role for positive duties...and therefore the necessary role of private charity is overlooked, ignored, or at least de-emphasized. People do have social duties. But from this it does not follow that the state is always the best institution through which to meet these responsibilities.

Submitted by MGL on October 20, 2006 - 12:35pm.

Honestly, I can’t make sense of Jordan’s first response. Whether we categorize his misstep as a slippery slope or as a false dilemma seems irrelevant—the response is still troubled. And the syllogism he presents is not only unreasonable, but it’s also not a syllogism (not categorical, not hypothetical, not disjunctive). So I can’t really respond to that first reply. I’ll do my best to address his second.

The argument against libertarian solutions to the healthcare problem posits that the fre-market model (including its requisite components of fungibility and symmetrical information) _cannot_ in any remote fashion be recreated in the healthcare situation. The model is an ideal. The real circumstances won’t ever gel with its presuppositions. A “pure” libertarian healthcare market, therefore, won’t ever happen. Before we get to any kind of empirical data, we have to at least agree that the model tested is applicable (in some loose fashion) to the situation. No scientist would allow an experiment to see if salmon could internally fertilize their eggs in appropriately warm temperatures because the posited model of internal fertilization doesn’t suit the critter’s jibblies. Despite the lack of correspondence between the model and the material situation, U.S. politicians and corporations alike have pushed free-market policies in healthcare. These efforts to impose the free-market model on U.S. healthcare (however uneven) have disastrous results. At present over 40% of Americans are uninsured, and traditional methods of measuring the efficacy of a country’s healthcare system make the U.S. look pretty bad—little doctor-patient facetime, infant mortality, lifespan (the statistically brief lives of African-American men, even when factoring out violent and unexpected death, is staggering for any industrialized country). Other countries imposing a more socialized model (however impure) score better by these marks. Now, in the social sciences, there is no possibility for creating test situations in which ideal models can be measured empirically. Sadly, in this regard, the social sciences will always be less precise than the natural sciences. The best that we can do is to take ideal models and apply them (unevenly) to real circumstances and then measure the effects. Before that application occurs, though, we should agree about the model’s applicability. Right now, we don’t agree. Despite this disagreement, there have been successful efforts to impose the free-market model on U.S. healthcare. In the case of a (more) marketized system as opposed to a (more) socialized system, the data points to the superiority of the latter.

To respond to Jordan’s closing paragraph: I can only suppose that the retreat into some apparatus of private charity is driven by the market’s ability to leave so many behind and to reap such cruelties. (If that’s true, then not even Jordan believes in the market’s ability to efficiently allocate resources.) I can only suppose that his argument boils down to something like: Yes, the market is imperfect and often cruel, and that’s why we need private individuals (whom the market has blessed) to be merciful and magnanimous towards pitiable and impoverished souls (whom the market has fucked). It’s bad enough that marketized healthcare leaves so many behind in the U.S. Must we also make these people mendicant to Bill Gates? And if we expect a market to function efficiently in any regard because of people’s innate and rational pursuit of personal pleasure and profit, can we then expect these same ruthless people to privately be caring and soft? If public virtue does not come from private vices, why would we expect privately corrupt people to then become publicly virtuous? When AT&T lays off 40,000 people to improve its stock prices, can we then expect the profiting investors to pool their dividends into a fund that will provide healthcare for the families of its newly uninsured ex-employees? I doubt it. Perhaps, instead of plaintively requesting scraps from capitalism’s masters, we should help ourselves to a bounty that we made possible.

Mark G

Submitted by Jordan on October 20, 2006 - 12:56pm.

I think we are in general formal agreement. Simply as a model, neither libertarianism nor socialism is fully realizable.

But it may be that there are some basic, essential premises of an economic model that can all be fully implemented so that in actuality we might say that this is the closest real-world approximation of the model that is possible.

Perhaps the real-world system doesn't have to fully actualize all of the model's premises in all circumstances. In this case, the "pure" system to which I refer would be the maximally-actualizable reflection of model, which may not perfectly correspond in full detail to the model itself.

Submitted by MGL on October 20, 2006 - 3:39pm.

This is as simply as I can state the point.

The market model presupposes at its core that there be symmetrical information and consumer choice (i.e. fungible resources). The health-care industry cannot recreate or even remotely approximate these conditions. Therefore the market model has no potential to realize its promises, even partially, when applied to healthcare. If you scrub information symmetry and consumer choice from the model or from the policy attempting to approximate the model, then you do not have a free market, not even a freer market. This is not about (im)perfect correspondence of representations and realities. It's about representations that have no possible correspondence in reality. That's why the market analogy, when applied to healthcare, is false. The "maxually-actualizable reflection of the model" doesn't even resemble the model. Until Jordan can address this point--and I can only assume that his silence so far indicates an inability--I see no purpose in further deliberating the issue.

I'll also note that he hasn't addressed any of the other claims that I make above, viz:
(1) Empirically, those systems that try to approximate a socialized model of healthcare score better on markers like infant mortality and doctor-patient facetime than does the marketized U.S. system.
(2) It is contradictory (if not naive) to expect ruthlessly possessive and competitive capitalists to care for those they "outcompete" in private charitable endeavors.
(3) Those who shore up a deleterious market system with some idealistic vision of charitable organizations believe in neither the good of human nature nor the efficiency of the market.

Mark G

Submitted by Jordan on October 21, 2006 - 4:52pm.

"Until Jordan can address this point--and I can only assume that his silence so far indicates an inability--I see no purpose in further deliberating the issue."

Contra principia negantem non est disputandum.

Submitted by MGL on October 22, 2006 - 10:55am.

I gather that Jordan’s elliptical and Latinate response indicates that he feels unable to argue with someone (me) who refuses to accept his first principles. I have to wonder, though, what are the first principles here? In order for him to engage my claims, must I accept that markets are, in all cases and in all formations, even those formations lacking dynamics central to the model, the best way to allocate resources? If I accept this as a first principle, where could I then disagree? And there are other points of disagreement as well. Must I accept all of his positions as first principles, not available for disputation? Must I believe that charity and the market are complementary forces? Must I accept that empirically more marketized healthcare systems score better than more socialized healthcare systems? Must I accept that people can simultaneously be cruelly competitive and kindly generous?

Given that Jordan is bowing out of the debate, I’ll direct this last comment to Jim: This exchange has convinced me that there is a kind of “economic correctness” among libertarians, an extensive set of first principles held as dogma. Jordan’s invocation of Aquinas (in the original Latin) to explain that I am an economic infidel conflates religious faith with economic creed. This isn’t about common ground. It’s about fundamentalism.

Mark G

Submitted by rhosa (not verified) on October 21, 2006 - 12:04am.

mgl, would you be willing to extend your analysis -- forgive me if foregiveness is warranted -- to "the media"?

Submitted by MGL on October 22, 2006 - 10:58am.

I think McChesney’s done a much better job of explaining why the information markets created by various media do not sufficiently replicate the assumed conditions of an ideally, “free” exchange. His discussion of the Internet, for instance, in _Rich Media_ shows that consumer choice is compromised by technological devices such as portals and killer apps. That's why we need a publicly funded backbone--there's no hope for anything remotely resembling a free market in online communication.

Mark G

Submitted by rhosa (not verified) on October 22, 2006 - 12:37pm.

ok -- i dig bob's work and have taught it a lot, both at texass and here. further, his work has helped grow local activist groups, like our own centre media values here. i'm a touch surprised, however, that you're sanguine -- forgive the bloody metaphor -- with all of his analysis. still, mcC's a reasonable place to go in extending what you were saying to media. more than anything, dear mark, i wanted to check if i'd missed anything. guess i haven't, at least not according to this.

gawd i can't get over our beloved lyne on youtube. :)

anyone know who posted it?
rx

Submitted by Jordan on October 20, 2006 - 12:48pm.

On the first point, it makes a difference because a false dilemma is a logical fallacy and a slippery slope argument may or may not be fallacious.

You are right in that the way I articulated the argument, it wasn't in syllogistic form...it was in the form of if/then reasoning.

And again, it isn't MY argument...it was my attempt to reconstruct what Jim might have been arguing for.

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