Category: Health & Nutrition

In Praise of Canned Fish (Some Kinds)
Changing gears for a moment, I want to recommend a food source.
This cheap product sells for $1.60 at Walmart
Before I talk about that, I want to refer you to my long essay about breakfast.
When I embarked on a plan to lose weight in 2008, I rethought my approach to food. I’ve since adopted the philosophy of eating breakfast like a king, lunch like a prince and dinner like a pauper.
Breakfast posed an unusual challenge. I don’t want to spend a lot of time cooking or preparing anything, either because I’m headed off to work or doing some early writing. I’ve tried to avoid processed meats, but I need protein in the morning.
Therefore, I settled upon canned fish for breakfast. It’s cheap, nutritious and convenient. I don’t eat it every day, but usually every other day. Originally I used to eat Crown Prince kippers. Really, I have probably bought over a thousand cans of this product over the last decade. By some bad luck, my supermarket (HEB) stopped carrying this product, and so I had to do some searching to find another place to buy it from. Eventually I found it at certain Walmarts, so everything was fine. Then I learned about the Seasonproducts of sardines which is even better than the Crown Prince kippers in every sense.
Introduction to Canned Fish
Most people have eaten canned fish at some point in their lives. Canned tuna was popular when I grew up (and frankly I didn’t care for it). Sardines have always been always available, but had a bad (and stinky) reputation. In the 1990s I read a book about fish nutrition. It covered absolutely everything you needed to know about fish (fresh and canned).
Here are some things I learned from this great book.
1. The amount of Omega 3s in fish varied wildly across fish. Whitefish like flounder had practically none. Salmon had lots, but so did sardines, kippers (herring) and mackerel.
2. Whether you eat fish fresh, frozen or out of a can, the nutritional content is basically the same (except noted below).
3. Canned fish packed in water offered more nutrients than fish packed in oil. The oil absorbs the omega 3s, and when you drain the oil, you are also losing the nutrients. (Also, oil adds calories).
4. Some types of canned fish add sodium/salt for flavor. (This is often true for water-packed products). Also, smoked fish (which involves curing or pickling) keep the omega 3s and other nutrients, but also have high sodium levels.
5. For both fresh and canned fish, mercury contamination is a concern — for woman of child-bearing age, but if you are not in that demographic, it’s not really something to worry about. According to the National Defense Resource Council, you should avoid a few key species: King mackerel, marlin, orange roughy, shark, swordfish, tilefish, ahi tuna, and bigeye tuna all contain high levels of mercury. Women who are pregnant or nursing or who plan to become pregnant within a year should avoid eating these fish. So should children younger than six. (Read more).
Since that time, I have learned about sustainable fishing and carbon impact of various fishing methods:
- Generally the smaller the fish, the less of a carbon impact it has when eaten. (Smaller fish can have more Omega 3s — horray! and be less in demand — and therefore cheaper).
- Terminology: A Herring, also known as an older and bigger Sardine, is eaten either pickled and fermented or raw. A Kipper, is whole herring that is lightly smoked and split into a butterfly cut. Finally, a Sprat is a Sardine that is smoked for about 3 hours.
- There are varying certifying bodies for seafood. Many types of fish are subject to overfishing. Aquaculture or aquafarming are seen as viable/sustainable alternatives, but standards vary (even though US aquafarming is supposed to be good).
Sardines: A Primer
It’s possible to buy sardines fresh (and actually it’s delicious), but people mostly eat it canned. Here’s a great article I found about sardines (here’s a two part article, the wikipedia page and the Monterey Bay Aquarium watch page for it. Let me summarize.
First, there are different kinds. Their name and taste characteristics may differ slightly according to where they are from. Brisling sardines are from the Norway region, do not have any mercury contamination. Generally they are at the bottom of the aquatic food chain, so they generally don’t accumulate mercury anyway. In Europe, sardines are called pilchards. Two other types are Brazilian Sardinella and Pacific sardines.
The bones are small enough that you can eat them easily. You should also eat the skin! (According to this NY chef — see video!)
Overfishing and sustainability. Generally, the Monterey Bay Aquarium recommends eating only Pacific sardines and urges consumers to avoid Atlantic sardines and Pilchard species because they are overfished:
European pilchard (aka Atlantic sardines) caught in the Mediterranean region are on the “Avoid” list. The status of many populations is unknown, and others are depleted with overfishing still occurring. Also, there are serious concerns about other species that are caught with sardines, and management is highly ineffective. Sardines are an important forage fish (prey for larger predators), and there are concerns about how these fisheries are impacting the food web and ecosystem.
At the same time, Monterey Bay Aquarium might have a kind of bias towards North American fisheries which have applied for its certification. The Season brand has received a Friend of the Sea designation, which is a certification of the World Sustainability Organization (and seems more geared towards Europe and other continents). (Here’s more detail). The FAQ on Season brand says, “With their seal of approval, target stock cannot be overexploited, fishing method cannot impact the seabed and waste management must be in place. All-in-all, it should give you peace of mind in our role as we try to make a difference in the world we live in.”
Generally I have seen very cheap Pilchard sardine cans from Morocco and Mediterranean, and the fish quality is variable — even bad sometimes. Season brand has pretty consistent quality levels. The Pacific sardines are about 50% more expensive, have a firmer consistency and have a so-so flavor. According to Tiana Matson (who loves the Wild Planet Pacific sardines over Crown Prince, King Oscar, Brunswick and Season),
The (Wild Planet brand of sardines) is sourced in California coast which is famous for being a house of sea creatures. The other thing that makes the sardines adorable is that since they are whole, they hold together in the can. This feature is best for those who love seeing what they are eating.
I should note that Wild Planet sardines is also sold at Walmart (hurray Walmart!)
Other Considerations
Here are some other things to think about when consuming canned fish.
1. The Smell. Some kinds smell worse than others and are hard to dispose of inconspicuously. I have gotten used to that fishy smell, so it doesn’t bother me, but a lot of people react negatively, especially at work or in a shared kitchen. When possible, I have even tried to go outside and drain the can over some bushes or the grass so as to minimize the smell in the garbage or sink.
2. Packaging. The old-fashioned tins used to be hard to open by hand. Sometimes they would even break. That was my biggest complaint about the Crown Prince kippers. About 10-20% of the cans would have defective lids, making it a chore to open. I’d use a can opener or a knife, and inevitably it would cause a mess and sometimes even cut my fingers.
3. Taste. Some brands try to add flavoring (usually curry, mustard or tomato flavoring). I used to avoid flavored fish, but occasionally I will buy one of these products, just to try it out. (They’re really not bad — though the cheaper products are not as good). The main problem with these flavored brands is that they often increase the odor for others to complain about. Also, one gets the sense that these flavors are intended to mask the overall fishiness of the product.
4. Price. On my budget I wanted something cheap, cheap, cheap while also being reasonably nutritious and convenient. The Crown Price kipper product costs $1.30 at most stores, but the price can vary wildly. If I were to throw out numbers, the high-end products (tuna, sardines, salmon) cost 2-3$ (although salmon and tuna can get even more expensive). Sardine products can go under $1 — although the quality is not good. Often these products will have oil or flavoring to compensate. Be careful!
5. The basic nutrients. Probably the two things you care most about are the Omega-3s and the amount of protein. The Crown Prince kippers was 92g, 160 calories, 16g of protein, 350mg of sodium and 1.9g of Omega-3s. That’s a really good amount of protein and Omega-3s.
Walmart Alternative: Seasonproducts Sardines
I don’t normally shop at Walmart, but I have started going there specify to buy my Crown Prince kippers. Then I saw a variety of canned fish, some I had never seen before. Then I spotted the generically named Seasonproducts. One can is 85g, 22g of fat, 1.7 g of Omega-3s, No added salt or oil, 170mg of Sodium. Wait, there’s more! The product has a lid which is very easy to peel off and dispose of. It costs $1.55, and had good understandable nutritional information. It even mentions the species and country of origin (Morocco).
I went to its website and found an abundance of products and nutritional information. They had about a dozen products with oil and some packed in water (which is what I wanted).
Look at the stats for this product!
Now for the review!
(Here is the product I reviewed). I have now eaten about 50 cans of this product — and I’ve even tried the oil-based version for comparison.
Generally the can is easy to open and contains about 8 small sardines which have been evenly cut. So you get smaller pieces of fish, but almost all of them are from the entire (miniature-sized) fish. The consistency of the pieces are high, and they are relatively easy to scoop out of the pan. (You can even shake them out if you wish).
There is a higher than average amount of liquid to drain off, but it is easy to do so. The fish has a bland but distinctively fish flavor, and doesn’t smell particularly bad. Although I’m happy eating the product alone, it would be relatively easy to combine this into a recipe without it overwhelming the recipe.
Sometimes the fish has been been a little too moist and soft for my liking, but there will always be variation from can to can. At 22g of protein, it provides just enough protein to make me feel full.
Compare to a MacDonalds Quarter Pounder with cheese which has 30g of protein, 26 g of (saturated)fat, 1080mg sodium and 520 calories and 199g serving size. I know, I know, we’re not comparing apples to apples here, but the point remains you get comparable amount of protein for 1/3 of the calories and 1/4 of the sodium. Even if you look at a plain McDonalds hamburger, you’re talking about 12g of protein, 8g of fat, 240 calories and 510mg of sodium.
I’m not trying to rag on a MacDonalds hamburger here — I love the Big Mac on occasion. I’m merely suggesting that you can get a good protein source from canned sardines –without the risks associated with a “fast food diet.”
Difficulty of no-effort meals
One problem with US life is that often we are preparing food for ourselves under time constraints. As much as we would like to eat healthy, it takes time to prepare meals and sometimes a lot of time.
Probably the best invention against that is the microwave. Suddenly, you can bake a potato or reheat vegetables (or frozen vegetables) with little effort. Frozen dinners have come into being. Perhaps they are not that filling, but they serve a need.
The problem with these kinds of meals is that they involved processed meats or extra sodium.
Extra — How Chefs use Sardines
A Michelin chef offers some ideas to use canned sardines with peppers and paprika for a nice salad. Mark Bittman has a recipe for using canned sardines with pasta.
11/1/2019
Health care in Houston (2018)
A month ago the HHS-commissioned Health of Houston Survey issued its 2018 report. Unfortunately the key information is locked up in a PDF. So I made screenshots of the most interesting charts:
(more…)
10/22/2019
“Perrycare” defined
For better or worse, the Affordable Care Act (the new health care reform law) has been dubbed “Obamacare.”
Here’s another neologism: Perrycare. It is is defined as health care inside a state which has refused Medicaid expansion despite generous financial incentives to do so. It is characterized by skyrocketing health care premiums and overall costs for individuals who fall below 138% of the federal poverty line. Named after Texas Republican governor Rick Perry.
Here are some other characteristics:
- The population between 19-26 have the highest level of poverty. On the other hand, they are still eligible to be on their parents’ plan (that is, if their parents have a plan!). In general, people in this age range are healthy and would require care mainly for emergencies (or giving birth).
- The population between 26 and 30 have high rates of poverty. They are no longer on their parents’ plan; on the other hand, it is assumed that their income will have risen a bit depending on how long they have been in the workforce. Females are particularly at risk here because these are generally the child-bearing years.
- The population between 30-65. More likely to have savings, but on the other hand, more likely to have serious conditions and require several visits.
The Kaiser Foundation has prepared a health care rate calculator. Note that it provides two estimates: the estimate under Obamacare and Perrycare. According to the site’s FAQ, “The federal poverty level varies by family size. In 2013, it is $11,490 for a single adult and $23,550 for a family of 4. The poverty level is estimated for 2014 based on Congressional Budget Office projections of inflation.”
On a positive note, medical underwriting will be prohibited on Jan 1 2014 under Obamacare, so very low-income individuals will be able to purchase a plan without having to go through underwriting; they just won’t be able to afford it!
Update: Here’s a cost estimate from Kaiser about just how much money Texas is not going to spend and not going to receive:
TEXAS (population: 26 million)
Without Medicaid expansion, between 2013-2022, feds would spend 228 billion and TX state would spend 159 billion on Medicaid for Texans.
With Medicaid expansion for 2013-2022, feds would spend 305 billion and TX state would spend 168 billion on Medicaid for Texans.
In other words, spending 9 billion dollars more on Medicaid in Texas will prompt the feds to spend 77 billion more dollars on health care for Texans over the next decade.
New York (population 19 million)
Without Medicaid expansion for 2013-2022, fed pays 468 billion, and NY state pays 451 billion for New Yorkers.
With Medicaid expansion for the same time period, feds pay 553 billion, NY state pays 433 billion for New Yorkers.
In other words, because NY already pays a greater amount into Medicaid, Obamacare will cause New York to spend 18 billion dollars less on Medicaid, while the feds will spend 85 billion dollars more on health care for Medicaid in New York.
A Rand analysis estimates other effects from deciding to opt out of Medicaid expansion.
If 14 states decide not to expand Medicaid under the Affordable Care Act as intended by their governors, those state governments collectively will spend $1 billion more on uncompensated care in 2016 than they would if Medicaid is expanded. … In addition, those 14 state governments would forgo $8.4 billion annually in federal payments and an additional 3.6 million people will be left uninsured… “State policymakers should be aware that if they do not expand Medicaid, fewer people will have health insurance, and that will trigger higher state and local spending for uncompensated medical care,” Price said. “Choosing to not expand Medicaid may turn out to be the more-costly path for state and local governments.”…
…
Researchers also outline how failing to expand Medicaid could have more than financial consequences. Based on earlier research showing that past expansions of Medicaid has led to decreases in deaths, the study estimates that an additional 19,000 deaths could occur annually if the 14 states studied do not expand Medicaid.
My rough ballpark estimate is that Texas accounts for a third of the population of those states opting out of Exchanges and Medicaid expansion. Therefore, applying the Rand’s data to Texas, we could say that Perry’s decision not to expand Medicaid will cost Texans somewhere in the range of $300 million and result in 6000 more deaths.
6/11/2013
Health Insurance Rate Hikes
Ironic Postscript: Hours after I wrote this, I received a note from Aetna informing me of another price increase for health insurance. Until January 2010 my total price for a $5000 deductible health insurance + dental plan was $148. Starting January 2010, it bumped up to $184. Starting April 2010, the price is $207. This seems certainly to be a death spiral.
What happens if you delay passing individual mandates on health insurance?
The prices go up, up up! In a Noam N. Levey piece on health care, he notes:
1. Profits for health insurance co. went up 56% in 2008.
2. The major insurers covered 2.7 million FEWER people than the previous year.
3. Health spending as % of GDP went up to 19.3% (it was 13.7%) in 1993.
The individual health insurance market has gone haywire. My own individual health insurance went up 25%, and in California Anthem’s individual policies had increases up to 39% increases. When I posted an article about it on Facebook, two people chimed in rate increases of 23% and 50%. Robert Reich notes:
WellPoint’s profits rose to $2.7 billion last quarter. Even if you subtract one-time-only financial maneuvers, WellPoint is still fat and happy, which makes Anthem fat and happy. Everyone is fat and happy except Anthem’s policy holders, who are being skewered.
Anthem’s argument is even more questionable when you consider that Anthem has been among the most aggressive opponents of the health-care bills passed by the House and Senate. If Anthem were sincere about why it’s raising its rates, it would be embracing the legislation. The Senate and House bills would add tens of millions of Americans to insurance pools – thereby spreading the costs over more people and avoiding the very problem Anthem says is now forcing it to raise its rates so much.
Even more troubling is the fact that Anthem obviously believes it can raise its rates by as much as 39 percent without losing every one of its remaining customers with average or even somewhat above-average medical needs. The only way it could possibly raise its rates so high and expect to keep its customers would be if Anthem’s customers have no other choice. In other words, Anthem’s strategy makes sense only if Anthem faces little or no competition from other health insurers.
I wouldn’t be surprised if this were the case. Insurers, remember, are exempt from the federal antitrust laws. And WellPoint, Anthem’s parent, is the largest insurer in America.
Caveats are in order. A health insurance spokesman says that the comparisons with when companies were in the middle of recession are not quite fair. Also, average profit margins for the insurance industry are historically low (3% on average). Rick Newman provides more numbers.
The problem I have with health insurers is not that they make money, but they that they claim the right to refuse customers while at the same time benefitting from tax subsidies for employer plans. A private insurer can reject a person without answering to the public. Health insurers don’t need 100% coverage; their goal is simply to maximize profits (even if their business plan to cover only athletic 22 year old billionaires). What happens when there’s too much cherry picking and the public has to pay the tab? "Privatize the profits, socialize the losses" seems to be the strategy for the health care industry. And it gets worse:
Insurance companies last year continued to try to purge their most costly customers, which are often small businesses with older workers, said Richard Kirsch, national campaign manager for Health Care for America Now.
Another reason for the robust profits, Mr. Kirsch said, is that the companies reduced the percentage of their premiums that they spent on actual medical care and devoted more to administrative costs and profits.
A third factor, he said, is that the insurers continued to attract more customers to public programs like Medicare Advantage, in which the federal government pays private insurers 14 percent more than it pays Medicare to cover the same people.
The report said that the insurance industry’s long-term strategy was to shift responsibility for the care of millions of older, sicker and lower-income customers to taxpayer-supported programs, like Medicaid and the state Children’s Health Insurance Program. Those programs in turn are increasingly hiring the big insurance companies — and paying them — to manage the coverage.
(The full PDF report is worth reading; full of good analysis of facts).
In addition there is a power imbalance here. Multibillion dollar companies can refuse coverage secure in the knowledge they have a huge legal department and generally sympathetic regulators to prevent the individual from complaining or suing them.
The justification for the privatized system was that private insurers will step in and provide private insurance for the public. Over the years, this coverage has been declining and becoming massively more expensive. Therefore, the justification for relying on the private system to fulfill a public concern is becoming more suspect.
My preferred solution (if you take the privatized system as a fait accompli) is individual mandates. Generally people on both political sides agree with that, but disagreed with implementation details (subsidies, tax breaks, etc). Also, libertarian obstructionists have used the failures of the private system as a reason to justify even further use of it. (I’ve written about that here).
That private strategy is also costing taxpayers a lot of money. We as taxpayers have a right to demand oversight for an industry that is increasing costs 5-10% per year (or 25% increases in the individual market). It’s easy to say, let the market offer better services. I’m sorry, but that hasn’t been happening; not only are costs increasing, but the number of companies offering services is decreasing.
Update: Kevin Sack reports on the outrage in California.
Medical costs have typically risen by 5 percent to 10 percent during each of the last five years. Mr. Poizner said he was starting to see significant increases for individual policies sold by some of Anthem’s competitors, and double-digit increases have been reported in other states.
Several insurance analysts said it was possible, but not necessarily likely, that such increases would become common, at least while the economic downturn persists. Insurance brokers in Los Angeles said they had never seen jumps of such magnitude.
“It’s more astonishment than irritation,” a Pasadena broker, John W. Barrett, said of the reaction from his customers. “Irritation was last year and the year before. Now they’re astonished.”
2/14/2010
Health care reform and medical bankruptcy: Answering the Libertarian Argument
Nicholas Kristof on how a system based on private health insurance frequently results in spouse impoverishment, sometimes leading to fake divorces. Here are reader comments about the article which turn out to be more interesting than the original article. This argument has not frequently been cited, but it shows how the health care debate has far reaching implications on society. It has already been shown to reduce employer competitiveness, but wrong decisions about health care can also be catastrophic to the financial lives of a person. Health care reform will introduce its own problems to the system, but it will also limit overall risk and provide a system of public accountability for health care providers and insurers. Let me say now that these organizations already use discretion to decide how much charity care and discounting to provide to individuals. The people who run these organizations are not beasts. At the same time, we have no guarantees that these organizations will act compassionately or in the public interest. We just don’t know.
Kristof’s later piece shows that Medicare and VA have generally received passing marks on delivering quality health care. (Comments here). (Update: The point about VA providing superior care seems to have been debunked). By the way, health care reform is a great issue where anecdotes matter (perhaps even more than economic analyses). You really need to read the comment thread on these articles to appreciate the problem. Anecdotes don’t help you to understand the magnitude of the problem, but they help you to understand the nature of it.
Milt Shook relates some anecdotes which reveal the corrupt/inadequate nature of health insurance. He has been one of the most forceful and articulate proponents of health care reform. Here’s one:
A 60-year-old woman is diagnosed with gallstones by her HMO plan doctor. That doctor asks the insurance company to approve a specialist, and the insurance company does so. The specialist wants to use shock-wave therapy to break up the gallstones, because it’s far less invasive and dangerous than surgery. The insurance company refuses to cover the procedure, calling it “experimental,” despite the fact that it’s been in use for almost 20 years, and has become a standard procedure when treating kidney stones. She appeals the decision by the insurance company, but during the appeal, she has a gall bladder attack. She lives nowhere near a hospital, so her husband drives her 40 miles and she undergoes emergency surgery to remove the stones and repair her gall bladder. The surgeon who performed the surgery made a mistake, however, which led to a second surgery to repair the damage from the first surgery.
Two years later, the same woman was diagnosed with cancer. Her physician proceeded to scare the hell out of her, and he told her things about the cancer that were patently untrue. She requested a change of physicians, to someone who actually knew about her cancer, and her insurance company refused. They advised her that she could change her primary care physician during open enrollment, but most of them were full, and that once they assigned a specialist to her case, she was pretty much stuck with that specialist.
He concludes by attacking the freedom argument used by libertarians to justify the private health insurance plan:
How free is a society, when an ever-increasing segment of its people can be ruined, financially and otherwise, by illness or injury? How free is a society when health care is seen as a privilege, reserved for those with the cash on hand to pay a doctor? How free is a society in which those who want to start businesses can’t do so, because they can’t afford to pay for its workers’ health insurance, and therefore can’t afford to hire the best workers? How free is a society in which a worker is forced to stay at his current job to keep his current health plan in force, because a change of jobs puts his coverage at risk? And how free is a society in which a person can pay hundreds of thousands of dollars into the health insurance system over the course of 30 years, lose a job, get sick or injured a month later, and be forced into bankruptcy court? How free is a society in which that same worker can continue working, but be denied coverage, should the insurance company decide they don’t wish to continue coverage?
Shook has correctly identified the problem with the libertarian objection. Even the libertarian has to concede that there is a hierarchy of needs which at some point trumps freedom. Can a completely private system address this? Here’s how we can counter the libertarian argument.
1. present cases where individuals are constrained by the current system, showing that the argument for more freedom does not imply keeping the status quo.
2. present evidence about how bad choices of certain individuals ends up hurting all participants in the overall system. (i.e., emergency room visits, vs. prevention)
3. compare dollars and cents. You can say you oppose higher taxes, but if reform results in lower costs, will the libertarian objection to it disappear? Suppose I presented a plan where health care costs would rise 1% per year rather than the current 10% but with comparable success outcomes. (Comparable, but not superior). If this plan imposed certain limits on freedom (say, limiting the doctors you use), but still had comparable outcomes, I doubt most people would oppose it (never mind the libertarian purists).
4. Compulsion works if it results in minimal intrusion on people’s lives and applies to everybody. Look at two examples. Requiring that people wear seatbelts and requiring that people buy auto insurance. The true libertarian would object to both proposals. But the seatbelt rule just doesn’t intrude on people’s lives that much, and it has an obvious social purpose. The auto insurance is different because you are dealing with finances and also the liability risk for harming someone else. One can argue that society has an interest in making sure that all individuals are prepared for handling liability, so that scofflaws don’t get away with murder. When another person is compelled to buy auto insurance, I benefit because it reduces the possibility that I will have my car damaged without the other driver paying for my harms. Everybody benefits as a result. These are simple cases and health care reform affects many decisions; my point is merely to show that compulsory measures can receive public acceptance if the public regards the intrusion as minimal and beneficial.
5. The religious/values argument. Religion can be a bipartisan phenomenon, and very persuasive to members of the Republican Party. Many religious people don’t care about the nuts and bolts of health care reform; they focus more on moral issues of tangential relevance (like abortion treatments). The Bible teaches compassion and helping your fellow man – a completely different system of values from the freedom-loving individual who wants government off his back. Opposition to health care reform is not inherently Republican (especially to a “Values Republican”). The real opponents are the “free market Republicans” who believe the private system works better than a public system over the long run.
6. The When will you compromise argument? Libertarians often adopt an absolutist position which admits no exceptions. You have to be that way, or else you are not being consistent. (Libertarianism is concerned with methods, while paternalism/utilitarian is concerned with outcomes). The problem is that humans are used to making decisions about individual people where exceptions are frequently made. The libertarian argument says, sure, anyone can freely choose to buy additional care for those who cannot afford it. But is that the way most people think about social issues? Ordinarily we like to look at individual cases and then designate one party to provide a solution. That is paternalism…no doubt about it. Take the case of a homeless man with a life-threatening illness (and receiving no medical care). The libertarian would say that if individuals or groups become aware of this injustice, they are always free to be part of the solution. But there are no guarantees. But we will never have absolute certainty that these individuals will intervene (or more importantly, to intervene soon enough).
7. How can you be sure that sufficient information exists for individuals to make intelligent decisions? In the case of the homeless man with the medical problem, perhaps a charitable person exists….but how will the homeless man locate him? Libertarian solutions depends on the needy individual being able to find assistance during times of need. It also depends on humans finding good information about the consequences of their action and knowing how to make good decisions? This kind of information and cognitive skill may not exist; it may never exist. To use a trivial example: last month, I realized that my health care provider did not cover 100% of my dentist’s services. It shocked me because I thought I read the insurance policy carefully. It turns out that the health care policy claimed to cover 100% of certain costs for out-of-network dentists, but that 100% only applied for certain procedures. This was not obvious information to me; and I am the kind to be careful about insurance. Just think what would happen if 200 million people had to make financial decisions on the basis of their understanding of health insurance. You’d have miscalculations galore, many of them with serious and devastating consequences. For the system to work, each individuals would need to hire an independent agent to counsel the individual about how to make health care decisions. But that is just saying: “I don’t trust a group of bureaucrat to make a bunch of decisions on my behalf; therefore I will hire an individual who can make a bunch of decisions of my behalf.” Those opposed to paternalism may find that individuals will need to rely on advisors to make decisions on their behalf. In my mind that is not much better than paternalism. (I write about this issue in greater depth in my Free Market Can Be a Time Sink essay).
8. The 75,000 deaths argument. I’ve seen statistics quoted estimating that 75,000 additional people die each year as a result of no health care reform. Maybe that figure is an exaggeration, I don’t know. But if a libertarian points to the economic superiority of the private insurance system, all you have to do is to trot out the 20,000 deaths. Most people would say preventing premature deaths is a more persuasive argument than maintaining the efficiency of an economic arrangement.
See also: Health Insurance and Amenable Mortality (which has some further thoughts about libertarianism at the bottom) and the Free Market is a Time-Sink (where I argue that free advocates often underestimate the value of their time).
March 2010 Update. Matt Yglesias points out the amazing fact that libertarian economist Friedrich von Hayek actually supported government intervention in health insurance. Here’s the money quote:
Nor is there any reason why the state should not assist individuals in providing for those common hazards of life against which, because of their uncertainty, few individuals can make adequate provision. Where, as in the case of sickness and accident, neither the desire to avoid such calamities nor the efforts to overcome their consequences are as a rule weakened by the provision of assistance, where, in short, we deal with genuinely insurable risks, the case for the state helping to organise a comprehensive system of social insurance is very strong. There are many points of detail where those wishing to preserve the competitive system and those wishing to supersede it by something different will disagree on the details of such schemes; and it is possible under the name of social insurance to introduce measures which tend to make competition more or less ineffective. But there is no incompatibility in principle between the state providing greater security in this way and the preservation of individual freedom.
Quote #2:
Once it becomes the recognized duty of the public to provide for the extreme needs of old age, unemployment, sickness, etc., irrespective of whether the individuals could and ought to have made provision themselves and particularly once help is assured to such an extent that it is apt to reduce individuals’ efforts, it seems an obvious corollary to compel them to insure (or otherwise provide) against those common hazards of life. The justification in this case is not that people should be coerced to do what is in their individual interest but that, by neglecting to make provision, they would become a charge to the public. Similarly, we require motorists to insure against third-party risks, not in their interest but in the interest of others who might be harmed by their action.
Finally, once the state requires everybody to make provisions of a kind which only some had made before, it seems reasonable enough that the state should also assist in the development of appropriate institutions . . .
Up to this point the justification for the whole apparatus of “social security” can probably be accepted by the most consistent defenders of liberty. Though many may think it unwise to go so far, it cannot be said that this would be in conflict with the principles we have stated . . . It is only when the proponents of “social security” go a step further that the crucial issues arise. Even at the beginning state of “social insurance” in Germany in the 1880’s, individuals were not merely required to make provision against those risks which, if they did not, the state would have to provide for, but were compelled to obtain this protection through a unitary organization run by the government.
9/1/2009