Opponents of Medicare-for-all aren't murderers

Health care is a major point of contention in the Democratic primary campaign. Bernie Sanders and Elizabeth Warren favor a single-payer system, while Joe Biden and Pete Buttigieg support a federal insurance program to compete with private insurers, also known as the public option.

Some fans of single-payer have begun to deploy a dire-sounding argument: failing to implement Medicare for All, they claim, would be tantamount to murder.

For example, Libby Watson, a staff writer at the New Republic, tweeted: "supporting anything other than medicare for all is tantamount to murdering sick people, which is why leftists support it."

Roosevelt Institute researcher Mike Konczal went so far as to calculate the "expected murders" that would result from pushing for a public option rather than Medicare for All.

It's not clear to what extent these arguments are tongue-in-cheek. News outlets are fond of running articles declaring that the U.S. health-care system is "literally killing people"; the actual content of these articles is almost always only about the well-documented shortcomings of the present system, but the headlines suggest a flirtation with the idea that refusing to reform a flawed system amounts to murder.

That idea has its roots in an old philosophical debate about responsibility. Few would dispute the notion that if you ignore a dying person that you could easily save, you've done something deeply immoral.

But this principle is hard to put into practice because it hinges on the incredibly hard task of assessing how much danger someone would have to put themselves in to help someone else. And equating laziness with homicide seems mushy; few of us would judge a couch potato to be a murderer simply because she's not spending her free time saving lives as a paramedic.

But this time single-payer advocates do more than just rehash this old argument about negligent bystanders. They also invoke statistics, which introduces even more problems.

Assessments of the deaths attributable to various policy regimes rely on statistical calculations of mortality rates. One way to do this is to compare states that implement a policy -- for example, Medicaid expansion -- with those that don't and observe differences in death rates before and after the policy.

Because mortality depends on things besides Medicaid, making an accurate comparison requires that researchers control for various factors. Differences in the set of things that get controlled for, and how the comparisons are constructed, can produce changes in the mortality estimates.

This isn't such a big problem if we're just using statistics to determine whether a policy is helpful. Over time, a body of evidence accumulates that leans toward the conclusion that Medicaid expansion is helpful or harmful. But relying on statistical estimates to determine the precise number of people that heartless politicians have murdered seems highly unreliable.

It also leaves open the possibility that new findings will turn a murderer into a hero, or vice versa. For example, it was long believed, based on credible economic studies, that government-provided health insurance wasn't very effective in improving people's health.

A politician who spent less on health insurance might thus be hailed as a hero if she directed the money to other, better uses. But recent evidence suggests that medical insurance has a substantial beneficial effect on health. Does that academic shift mean the hero is now a murderer? That question is a bit absurd.

Assigning moral culpability for policy decisions is even harder when politics is taken into account. Sanders supporters generally acknowledge that passing Medicare for All will be difficult because of the partisan composition of the Senate. Instead, they see it as the opening gambit in a negotiation, an effort to shift the debate so that a public option seems mainstream instead of fringe.

But their political calculations could be wrong: it's possible that pushing for Medicare for All results in no major health reform getting passed at all. It wouldn't be the first time that the failure of an ambitious health plan led to many years of inaction. Would that mean that pushing for Medicare for All literally killed people? Of course not.

The idea of preventable-deaths-as-homicide runs into another big problem: Should we view any American as a murderer who refuses to reduce their living standard to a bare subsistence level and give all of their remaining income to children in Africa at high risk of dying of disease or starvation?

There are people who think deeply and seriously about this sort of question -- the effective altruism movement -- but they have come up with few definitive answers.

A quick scan of Twitter confirms that there is no shortage of policies -- and lack of policies -- that are "literally killing people." Equating statistical estimates of mortality rates with homicide will lead society in directions that are absurd at best and ominous at worst.

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Noah Smith, a Bloomberg columnist, is an assistant professor of finance at Stony Brook University.

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