Bryan Caplan  

The Love Potion of Socialized Medicine

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During my flight to Italy, I read Barbara Demick's outstanding Nothing to Envy: Ordinary Lives in North Korea cover to cover.  Even if you've studied Communism for decades, you'll be appalled: In the 90s, North Korea basically moved from total state control over the economy to having no economy at all.  The government stopped paying salaries and stocking the stores - without relaxing the near-prohibition on all private sector activities.  For most, the only way to obey the law was to sit still until you died of hunger.   The exiles Demick interviewed, starved and imprisoned, were the lucky ones.  All had friends and family who perished in this absurdist hell.

Yet after all their suffering, North Korean exiles who made it to South Korea still had good things to say about their homeland.  The most striking:
There were things she [Mrs. Song] missed about North Korea - the camaraderie among neighbors; the free health care before the system broke down.
Frankly, this makes about as much sense as ex-cons pining for their prison hospital.  The North Korean government turns a country into a prison, starves millions to death, and yet escapees still think "free health care" is worth mentioning?  What's wrong with people? 

To me, this reveals a lot about the world-wide appeal of government-run health care.  Socialized medicine is like a love potion.  The government can treat you like dirt, but as long as it slips a little of this potion into your drink, you'll probably think "How wonderful - the government loves me so much that it takes care of me whenever I'm sick without asking for a thing in return."  And who would be vile enough not to love such a government back?

My point: Whatever you think about socialized medicine, it's not that great.  It's not remotely enough to, say, redeem North Korea.  The fact that anyone would imagine otherwise reveals a strong human tendency to judge socialized medicine like a bad boyfriend - with our hearts instead of our heads.  When someone says, "Dump him - he's just not good for you!" we really ought to calm down and listen.

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COMMENTS (31 to date)
Vake writes:

Stockholm syndrome. Love thy captor.

jh writes:

Maybe she was never really sick and in need of anything significant.

Also, notice it says "before the system broke down". How long was that? Maybe, for a brief time, all her medical needs (and those of the people she knew) were met. Maybe that's what she's referring to as "before the system broke".

RobF writes:

Is the lesson here intended to be: Average people hold silly and irrational beliefs about what is good for them, so they need right-thinking people to re-train them for their own good? That may not be a crazy notion, but it doesn't seem very libertarian either.

Tracy W writes:

I think this post is unfair. For a start, from the extract, it doesn't sound like Mrs. Song was a fan of the North Korean government overall, from your description, she, like all the other people interviewed in the book, escaped to South Korea, which implies that she didn't love the system that much. One can think a situation was bad overall, and still see some good points in it.

Secondly, thinking free healthcare is good is not the same as thinking that the government overall is wonderful, or loving the government back, or thinking that it redeems the government. I know plenty of people in the UK, NZ and Australia who think that free health care is great but hate the government of the day on other grounds.

Floccina writes:

I heard a similar thing from a Polish immigrant that I knew. He hated living under the communist but said that he missed the socialized medicine.

nazgulnarsil writes:

RobF, read Caplan's post about charter cities. The point isn't anti-libertarian. Only that groups with different ideas about how to run things should all freely compete. let people vote with their feet rather than other people's money.

William Rinehart writes:

I think this is a great example of afterwardness or deferred action. Even if things are really bad, people will still give them a positive attribution.

Clay Davis writes:

No one is imagining otherwise. She's just saying there are assets and debits, not that they square. Also, your last graph is poorly written. It should say: There is a strong human tendency to judge socialism like a bad boyfriend - with our hearts instead of our heads. Our hearts focus on the "free" health care and our heads diminish the starvation, violence, invigilation, etc. But that is a very weak claim. How many people in socialist hellholes don't leave their "bad boyfriends", free health care and all, when given the chance?

David N. Welton writes:

Your post is a bit here and there. Most countries with government provided health care are not North Korea. Not by a long shot.

The appeal to me of the system here in Italy is that not only is it cheaper (yes, counting what they take out in taxes), it's also *so* much simpler.

You, as a tenured professor, may not have much of a hassle with US health care, but every time I hear from my folks back in the states spending hours looking at different plans, trying to find the little ways that each one gouges them, I'm glad for the system here.

Of course it's no panacea, has problems of its own, and could probably use a dose of 'market' in some form or another, but generally it's nice because you don't have to waste a bunch of time thinking about it.

tom writes:

Doesn't this get to the primary weakness of libertarianism as opposed to conservatism or modern left-liberalism? For many people, the sense of being in something together with a community, even if it is deficient and stultifying, is better than being on their own.

Belonging, social unity and social equality are real values separate from freedom.

MCS writes:

That's a nice trick, there, eliding the difference between socialized health care provided by an amoral human rights violating dictatorship helmed by a crazy person and public health expenditures by a democratically elected government.

Also, the last paragraph is the best bit of Nice Guy(tm) style sexism I've heard in a while. Bravo!

Barry Loberfeld writes:

Dear Tom,

People are not "on their own" under libertarianism. They are in communities of their own choosing — e.g., their religious affiliation (versus a state church).

squiggly writes:

tom - Even if that's entirely true, libertarianism doesn't prevent people from forming communities as deficient-albeit-together as they fancy. The advantage conservatism or modern left-liberalism has is for people who don't want a sense of community as much as those who want a government reassuring them that they're a community.

Marcel Doru Popescu writes:

What I interpret Bryan to mean (and what most people commenting here clearly confirm) is that most people don't give a flying flick about liberty - they have higher values. Which is, unfortunately, true, and we won't get a free society until that changes. No, we shouldn't force them to change, as RobF seems to imply; I'm just stating what is the case now.

If most people like to sacrifice children to Moloch, sacrifices won't stop; if most people like to use drugs, drug use won't stop; if most people are racist and consider the black to be inferior, the black will be slaves; and if most people prefer "free" health-care to paying for their own, that's what we'll get.

I live in a former communist country; a lot of the older people claim that "it was better before". I find that repugnant, but that's the way it is.

Floccina writes:

squiggly agreed, a free society does allow the creation of communal communities with community paid for health care but it does allow exit which everyone knows makes it difficult.

Troublesome Frog writes:

That's the lesson you're taking from this? I would be more concerned about the fact that refugees from North Korea like my health care system less than the one that they had back home.

When a starving man prefers dumpster diving over your cooking, check your recipe book before speculating about what great food people must be throwing away.

Squeeze writes:

What makes her statement so odd is that South Korea also has universal health care.

N. writes:

I'm afraid I have to concur with the majority of commenters. Different people have different preferences. I know plenty of people who claim they would gladly sacrifice liberty for security -- they really aren't all that fond of liberty to begin with. They seem sincere.

I hesitate to say it, but I think there are many -- perhaps a majority -- who would choose a hateful tyrannical parent over having no parent at all.

Gene writes:

I think what a few of the commenters here are highlighting indirectly is that libertarians rarely address the ways in which a libertarian society requires more from the individual--which many people will interpret simply as a harder life.

David Welton got at it with his remark about how he "doesn't have to worry about" health care. When there's a system that automatically takes care of you, for many people the absence of that particular hassle is positive enough to overcome the weaknesses of the system. Libertarians need to get out in front of that by acknowledging some increased hassle in a world where people are more responsible for their own well-being, but make the case for why that's a worthwhile price to pay.

Evan writes:
I know plenty of people who claim they would gladly sacrifice liberty for security -- they really aren't all that fond of liberty to begin with. They seem sincere.
People are very fond of liberties that they're using at the moment, but disdainful of ones they aren't. That's why in the USA we have movie stars defending free expression while supporting efforts to regulate business out of existence, and also have executives giving money to keep the government from regulating them, while also trying to criminalize gay people.

Ideally the two cancel each other out. This happens to some extent, our country is still pretty free relative to other ones, but it doesn't happen as much as principled libertarian types like me would prefer.

This is one theory as to how freedom evolved in the West in the first place. All the different Christian factions were forced to adopt it as a second best alternative because none of them could defeat all the other ones.

Buzzcut writes:

You know, it isn't even just totalitarian regimes and universal health care. How many people put up with awful jobs just because they get health insurance? How many people don't become entrepreneurs because of that?

What's the big deal with paying for your own health care out of your own pocket?

And what is so great about modern health care (or not so modern, as is probably the case in North Korea) that you would put your liberty, or even just a job you actually love to do, behind it in terms of your priorities?

Methinks writes:

Never been to NK, but I did spend years in and out of Soviet hospitals.

The only people who can possibly miss that kind of hellhole are the kind that have never had to visit it.

Sure, different people have different preferences. But, when people's "preferences" are not rooted in experience, I tend to take them less seriously.

blink writes:

What kind of question elicited the positive statements? What was the woman's exact reply? If asked (for example), "Did you have any positive experiences?" even a kidnap victim might come up with something like, "Well, my captors did provide some ointment when they saw their rope was cutting into my wrists." That this woman mentioned free health care, something quite trivial in the context, shows she had to struggle awfully hard to find *anything* positive to say.

SpotCash writes:

You wrote: In the 90s, North Korea basically moved from total state control over the economy to having no economy at all.

That has to be one of the best pithy comments about Communism that I have ever read or heard.

PrometheeFeu writes:

In a horrible situation, what little is good may seem amazing. That's probably what was going on here. And honestly, if you are relatively poor, socialized medicine can work better for you. No guarantee that it will, but it can.

To finish, I think that healthcare is one of those things we care a lot about because it has an immediate and obvious effect on our very survival. If you are very sick, everything else becomes pretty much irrelevant because without healthcare, you will just die. So at that point, the fact that you won't eat 2 weeks from now is unimportant, since without healthcare, you just won't make it to 2 weeks from now.

Methinks writes:

If you are very sick, everything else becomes pretty much irrelevant because without healthcare, you will just die.

If you're seriously ill in NK, you're toast. They don't have the kind of health care that allows those people to survive anyway.

A UN doctor returning from NK in 2002 reported that the NK doctors were growing their own cotton because they could not obtain it any other way. They made their own tongue depressors too and the only "medicine" a their disposal (at least for the ordinary Korean) was folk medicine. Do you really think they had chemotherapy for the seriously ill?

cliff styles writes:
Frankly, this makes about as much sense as ex-cons pining for their prison hospital.

Theodore Dalrymple, who worked as a doctor in British prisons, ran across cases of drug addicts and petty criminals who were so buried in their destructive routines when they were out of prison that they would seriously compromise their health, and welcomed intervals of imprisonment as a way of getting their weight and health they could repeat the self-destruction.

PrometheeFeu writes:

I do not claim that NK health care is in any way something to envy, admire or even just respect. (Though you have to admit that the doctors taking such a DIY attitude is a credit to their entrepreneurial spirit) But the blog post quotes someone remembering the free health care "before the system broke down." That seems to imply that the situation you are describing is not what is remembered fondly. What is remembered fondly is a time before that when the doctors probably had the supplies needed to carry out at least some medical procedures. Was their health care system as good as that of some of the industrialized countries? I seriously doubt it.

When quite sick (even with a non-life threatening condition) people often feel despondent and hopeless. In that situation, any help feels like someone saved your life. I remember getting mildly dehydrated and slightly sun stroked in the middle of summer in Prague. I don't know if you've ever been there but it is a very hilly terrain with many pedestrian only areas. (no taxi) I rapidly became hopeless of ever making it back to my hotel. I was in fact so tired (jet lag probably helped that) that I was completely incapable to formulate any sort of a plan. When someone helped me get to the nearest pharmacy to get an aspirin and a glass of water, I thought I would kiss them. This is what I am talking about. Sickness often makes us feel so powerless and hopeless that we fall hopelessly in love with whatever gave us the relief we needed. That's my interpretation of why despite profoundly disliking the NK regime, people could still mention free healthcare.

PrometheeFeu writes:

Also Bryan, you're wrong. Free health care would be an amazing thing. The issue is that it's not free.

Methinks writes:


You might be right. She may have never used the system. Life may have been so horrid that the ability to obtain aspirin seemed like a miracle. We are left to guess since she didn't elaborate on the health care system. While I appreciate your story and I understand what you mean, I don't think getting help finding aspirin can be considered "health care".

BTW, in the Soviet Union, socialized medicine worked least well for the poor and unconnected. Doctors were so severely underpaid that they would only see patients who could pay them "bribes" (that is, compensate them for their services). Ambulance drivers would demand a bribe before taking the patient to the hospital and they would simply leave without the patient if they didn't get one. The only way to gain entry into well-stocked hospitals and competent specialists was to have connections within the party. I am alive today only because of those connections. By all accounts, it is worse in NK. I can't imagine this system of socialized medicine worked at all for the poorest and least connected among them.

I don't think the doctors were unusually entrepreneurial. In countries like the Soviet Union and North Korea people did what they had to do to survive. That doctors have to spend their time whittling tongue depressors and growing crops is an indication of what a disaster NK is. I'm sure we don't disagree on that.

Jacob writes:

Funny, this USA Today article about transition camps for DPRK escapees in the South says the following:

“A medical clinic and a dentist office provide care many were denied in the impoverished North…

Many need special attention paid to their health. Malnutrition is the most common affliction for new arrivals. Many also have contagious diseases, particularly tuberculosis and hepatitis. Nearly all have missing teeth.”

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