There is something of a spat developing between NHS Blog Doctor and the Taxpayer's Alliance. Last week, the TPA published
their Town Hall Rich List
, and the good Dr Crippen took exception to this
; the TPA have now responded
. The TPA are big boys and more than capable of defending their ethos and working practices, but I must take exception to one of Crippen's lines.
That is it. No exemptions. No explanation. No penumbra. No analysis other than that in which the conclusions have been pre-defined. Tax is a bad thing. Surprising they have not joined up with the Libertarian Party amongst whose avowed aims is the abolition of income tax. Come to think of it, maybe they have.
No, Crippen, they haven't; and believe me, much of the rest of the post seems to be based on a similar lack of evidence. For the record, employees of the TPA are specifically forbidden from being members of political parties and, as such, there is absolutely no affiliation with the Libertarian Party at all.
It may come as a surprise to Dr Crippen, but there are, believe it or not, people outside of the TPA who also think that taxes are too high and who are more than capable of coming up with their own policies.
For the good Doctor to link LPUK in with the TPA and then go on to say that the TPA "only attract fascist hyenas
" displays a severe ignorance of what fascism is, and is also deeply insulting to the TPA and, by the baseless extension that Crippen has drawn, to the Libertarian Party.
As someone who is a member of both of these organisations, I consider myself vaguely insulted: apparently your humble Devil is, in fact, a "fascist hyena"
and not someone who feels that his liberties—both financial and civil (for they are inextricably linked*)—are being eroded on a daily basis.
Well, thanks a bundle, Crippen.
On Friday, the good Doctor decided to attack the Libertarian Party's Health Policy
. As you can see for yourselves, the policy is little more than a placeholder at present
. There is a simple reason for this: health is a very difficult subject and, before committing ourselves to any specific policy, we want to spend the time researching the other available systems.
It is early days for the Libertarian Party. Funding healthcare is the single biggest problem facing the western world and so the party must be allowed time to formulate detailed policies. But the portends are not good. Already they make some fundamental errors.
And what might these be? I can't wait to hear them...
You cannot apply market economics to the provision of universal health care. Universal health care is not an economic proposition. It is an indulgence. An expensive indulgence which has to be funded by taxpayers.
Really? So, it has to be funded by taxpayers through government, or could it be, in fact, that it could be funded by taxpayers through insurance (the question of whether you make this insurance compulsory or not is one of those questions which we are discussing).
Almost everything else in this country is delivered via the market. Essential items such as bread, or milk, or tax services or... well... anything is delivered via the mechanism of the market. So, what makes health provision so very special?
What makes healthcare provision special in his country is the fact that it is an effective monopoly. The government takes the money to pay for it (or you go to prison), it then decides how much of that money is spent on health. Then it pays that money to government-sponsored QUANGOs (the Primary Care Trusts) who then disburse that money to government-run hospitals, in which the staff are paid by the government (in National Pay Deals that kill patients
If there is one thing that even most on the Left agree on, it is that monopolies are a bad thing; where those of us on the Right disagree with the Left is that we believe that government monopolies are just as bad (or, actually, worse) than private monopolies.
Healthcare in this country is, effectively, a state near-monopoly. And so much faith does Dr Crippen, an NHS GP, have in the NHS, that he has opted out by buying private health insurance (as has your humble Devil: it costs less than £50 per month currently).
You can make a profit by selling sophisticated health care to the rich but you can only make a loss by providing the same health care for the poor. Successful entrepreneurs are driven by the profit motive.
This is perfectly true, but also extraordinarily disingenuous. There are always companies who can find a way to make their services affordable; one that springs to mind is Direct Line Insurance. They decided to offer cheaper car insurance. They were able to do this by cutting the cost of delivery (making ample use of the internet) and by taking a smaller profit on each policy but getting more people on board.
There was a report a few months ago, on supermarket ready food lines. Essentially, the ready meals came in two different lines: the low priced "value" and the high-priced "luxury". However, they were both the same product, except with different packaging.
The rich bought the "luxury" product and the poor bought the "value" product. The supermarkets make a profit on both products but the rich effectively subsidised the poor. Surely, this should appeal to Crippen's egalitarian mindset?
Why should the same not apply to medicine. The treatment would be exactly the same, but the rich might get silk sheets on their beds whilst the poor make do with linen. In this way, the rich—feeling that they are getting a better service (although the actual procedure is exactly the same)—will be willing to pay more and thus subsidise the treatment of the poor.
If you believed people like Doctor Crippen, the picture that you might have of the time before the NHS is of the poor dying like flies for the want of a quid. But charities took up much of the slack.
These days we are used to pointless charities like Greenpeace, which we are forced to fund through their massive government subsidies. But, before the Welfare State, charities fulfilled a rather more practical function: the care of those who could not (or would not) care for themselves.
Sure, these days we have lost the art of charitable giving but, when you are already losing 45% of your income, it makes one somewhat disinclined to give more. It is no accident that charitable giving in (relatively) low-taxed America dwarves that of high-tax Europe.
But, in the Victorian era, big businessmen tended to give large amounts of money to charity. Many of them did so out of what was ultimately a profit motive—those entrepreneurs who built housing for their workers in order to maintain a tied workforce, for instance, or just for the pleasure of seeing a plaque above a ward that they had built—but is there any quintessential reason why should this not happen again?
Just think of all those colossal City bonuses being put to use to built and run new hospitals (many individuals could do this many times over). And whilst some people will sneer and say that that will never happen, well, to you I say, "it did in the past. Has the nature of man fundamentally changed from that time?" The answer, of course, is not that man has changed, but that the state has changed the attitude that men have to their fellow man.
In this way, the state has allowed people to be insulated from their fellow man. Now when we see poverty we don't ask what we might do to alleviate it: we say, "why isn't the government
doing anything about this?" Far from uniting us with our less fortunate fellows, the state has allowed us to isolate ourselves; it is no longer our problem, you see, but that of the state.
There were many mechanisms that allowed the poor access to medical care, such as the Friendly Societies
, private philanthropists and charities.
Would I prefer to return to such a system, one that does not need coercion? Yes. Am I naive enough to believe that it would happen overnight? No. But, we do wish to have an orderly transition and this is why we need to think very carefully about how that might be brought about.
An independent “not-for-profit” organisation will not survive unless it is government subsidised and thus insulated from the realities of the market. And if it is so insulated, no private company can compete against it.
This is, of course, absolute crap. A "not-for-profit" organisation is allowed to make a profit (see almost all private schools and the vast majority of charities) but that profit is not allowed to be disbursed to the directors (above and beyond their agreed renumeration). The profit must be ploughed back into the organisation. This absolutely does not mean that every "not-for-profit" organisation has to be government-funded.
However, it is true that government-funding does provide a barrier to private enterprise.
An insurance based system merely substitutes a private, profit driven company for a government run organisation.
This is a particularly flippant line; yes, a private health insurance system replaces the government one, that is the entire point.
Now, Dr Crippen who has, as I have mentioned before, private health insurance for himself and his family, obviously believes that he gains from that insurance. He gains a better service than that which he himself works for.
So, why is he slamming a private insurance system that he himself is taking advantage of? Two-tier health-system? We already have it, John; and you have happily ensconced yourself in the upper tier of that system.
I don't blame you for doing so, at all. However, it is rather hypocritical of you to criticise a particular system when you believe that that system is going to provide you and your family with a better standard of healthcare and then deny access to that system for everyone else.
Doctrinally motivated health care economists will argue for one or the other, but there is no moral, or economic, absolute.
Well, I quite agree. What we should look for is the way that best delivers care to the customers who require it, as we do in any other area. A national monopoly doesn't do that.
It doesn't even terribly matter as to whether or not our spending as a proportion of GDP rises as long as there is a commensurate return in terms of productivity. What has been so irritating about the money poured into the NHS is that productivity has dropped.
But no system is perfect so what we want is a proliferation of many systems and a state monopoly does not help that at all.
Take a look at this article in Fortune magazine which describes the anomalies thrown up by a private insurance based system.
Indeed it does. But what that article also makes clear is how much government interference in free markets has led to the less than satisfactory state of the US healthcare industry. It is, for instance, the fault of the government that most healthcare plans are tied, not to individuals, but to jobs. Here's a taster:
McCain's main pillar is the elimination of a tax break that employees receive if their employer provides their health care. That may not sound like a shocker, but it is. The exclusion dates from World War II, when the federal government imposed controls on wages, but allowed companies to compete for workers by offering tax-free health benefits in lieu of pay. The law is largely responsible for the nightmarish patchwork of corporate-provided medical plans we enjoy so much today. Employees and their unions demanded richer and richer packages, and employers complied, since they could buy far more benefits for their employees than workers could buy with after-tax dollars on their own. Americans have paid a steep price, however, by sacrificing their raises as corporate insurance bills exploded, never more so than now.
Inevitably, this has also cut the choice of insurers and the flexibility of the consumer. Not an ideal situation and certainly not one that LPUK would endorse. But, let us return to the good Dr Crippen's piece...
We need a fresh start, free of doctrinal absolutes.
Well, OK. And your suggestion is...? Oh, you don't have one. Fine.
What, in any case, are "doctrinal absolutes"? Do i believe that the free market works best because that is my doctrine? Or, do I believe that free markets work best because all of the evidence that is available shows that they do?
In my case, it is the latter. Free markets are not perfect
, but they are the best
option. We have tried most combinations of the other options and they simply do not work anywhere near as well.
I have never really understood the UK medical profession's hostility to trying another system; after all, they as much as anyone, are shafted by the government's monopoly.
Nurses in London are substantially worse of than nurses in the middle of Yorkshire, for instance.
Junior doctors are churned out of medical schools only to find that, due to the state's incompetence, there are no training places or jobs for them.
The state's inability to plan has meant that we have been forced actively to import foreign agency prfessionals; and this not only denudes poor countries of much-needed trained staff, but linguistic misunderstandings lead to an overall diminshing of the reputation of all medical staff in the country.
Above all, we need to admit the fact that no country can afford to provide the full range of modern health care for all its citizens. Health care has to be rationed. We need a front end charge, appropriately safety netted, to stop the worst of the abuse.
Well, OK. But who is going to abuse the system the most: those who get it for free or those who pay for it?
We need to find a politically acceptable way to explain to the citizens that they can no longer have it all “for free”. Free health care was always an illusion, buttressed by the NHS with its ludicrous "free at the point of entry" mantra. The illusion has had dire consequences. It has fuelled the demand for health care to unsustainable levels.
Well, yes, Doc; that's fine. And the relevance to the LPUK policy is...? We would abolish the NHS; that is no secret. Do we think that we should look into feasible alternatives? Yes. That is why we decided to develop policy in our forums
. Amongst other things, we have a few medical doctors and medical managers in there who can give us their opinion from the front lines.
You are welcome to join in and contribute, my dear Crippen; you do not have to sell us your soul, nor even join the party in order to join in the discussion: we will happily accept advice from anyone.
The choice is simple. Acknowledge the inevitable and take control or bury your head in the sand, pretending all is well, as stealth rationing and the surreptitious erosion of health care standards allow the NHS to lapse into a two tier system in which only the rich can access good medical care.
Now, this is a slightly bizarre finishing paragraph; the good Doctor appears to be contradicting everything that he has said previously.
Crippen has acknowledged that we need to ration healthcare, and that we need to charge for it. Presumably, he would also not object if people paid for additional treatments. But surely this would "allow the NHS to lapse into a two tier system in which only the rich can access good medical care"
What is "good medical care"
? Presumably, we want everyone to access adequate medical care; as I outlined above, if the rich are happy to pay more for silk sheets, thus allowing the hospitals to subsidise the care for the poor, is this not a god thing?
But the main point is that if people are actively paying for their health insurance, then they are going to take more care of themselves. As Crippen correctly points out, the "free at the point of use mantra" is completely stupid because it makes people think that it is, in fact, free.
Of course, for those who don't work and will never work, the health system is
free. For the rest of us, however, it is very expensive.
Is it right that someone who has paid 11% of their salary for the last thirty years should get the same treatment as someone who has paid absolutely fuck all for the same time? Of course it isn't. We wouldn't think that was fair with any other system, so why with health.
At the same time, is it right to leave people dying in the streets because they have never paid a penny towards any medical facilities? No.
And that is the difficult tightrope that one has to walk and, as far as I am personally concerned, the solution is private charity. Let those who care about our fellow man (and, yes, I would give money voluntarily were I not losing vast amounts in tax, just as I have given to various bloggers who have appealed for cash (and other bloggers have shown the same courtesy to me, at times)).
Because I believe that all of this rubbish that Cameron comes out with, about the "broken society", has been caused by the state, and the state cannot fix it. Take away that monolith that has allowed us all to retreat from our fellow man and I think that you will find people to be unexpectedly generous.*
This is a theme that I have amplified before
. However, the gist of it is that the reason that the government feels that it can dictate what we eat, smoke, drink or otherwise put into our bodies is because the state "pays" for our wanton lifestyles through the NHS.
Actually, it is we taxpayers who pay for the NHS and that applies even if you have private insurance. I have private health insurance, but I am still not allowed to opt out of the NHS completely, so the state still feels that it can tell me what to do.
In this way, the financial lever that the government holds also leads to their hold over the civil liberties lever too.
Labels: blogging, campaigning, medical care, NHS, UK Libertarian Party