The Ones Who Walk Away From The Lottery in Omelas
The theme that members of a society will willingly and ritually sacrifice the life, liberty or happiness of one of their own to ensure the continued prosperity and happiness of the rest is, alas, not limited to the occasional short story [and they're very short, you should go read them, even if you think you remember them].
[Omelas] In a basement under one of the beautiful public buildings of Omelas, or perhaps in the cellar of one of its spacious private homes, there is a room. It has one locked door, and no window. A little light seeps in dustily between cracks in the boards, secondhand from a cobwebbed window somewhere across the cellar. In one corner of the little room a couple of mops, with stiff, clotted, foul-smelling heads stand near a rusty bucket. The floor is dirt, a little damp to the touch, as cellar dirt usually is. The room is about three paces long and two wide: a mere broom closet or disused tool room. In the room a child is sitting. It could be a boy or a girl. It looks about six, but actually is nearly ten. It is feeble-minded. Perhaps it was born defective, or perhaps it has become imbecile through fear, malnutrition, and neglect. It picks its nose and occasionally fumbles vaguely with its toes or genitals, as it sits hunched in the corner farthest from the bucket and the two mops. It is afraid of the mops. It finds them horrible. It shuts its eyes, but it knows the mops are still standing there; and the door is locked; and nobody will come.
[Lottery] The children had stones already. And someone gave little Davy Hutchinson few pebbles.
Tessie Hutchinson was in the center of a cleared space by now, and she held her hands out desperately as the villagers moved in on her. "It isn't fair," she said. A stone hit her on the side of the head. Old Man Warner was saying, "Come on, come on, everyone." Steve Adams was in the front of the crowd of villagers, with Mrs. Graves beside him.
"It isn't fair, it isn't right," Mrs. Hutchinson screamed, and then they were upon her.
The preliminary results of The Great Oregon Health Insurance Experiment [original]are out , and the universe of bloggers, pundits, scribes, wonks and Very Serious Persons is all atwitter, and along the predictable lines too.
If the child were brought up into the sunlight out of that vile place, if it were cleaned and fed and comforted, that would be a good thing indeed; but if it were done, in that day and hour all the prosperity and beauty and delight of Omelas would wither and be destroyed. Those are the terms. To exchange all the goodness and grace of every life in Omelas for that single, small improvement: to throw away the happiness of thousands for the chance of the happiness of one: that would be to let guilt within the walls indeed.
The OHIE establishes only that there are some (modest) benefits to expanding Medicaid (to poor people) (after one year). It tells us next to nothing about the costs of producing those benefits, which include not just the transfers from taxpayers but also any behavioral changes on the part of Medicaid enrollees, such as reductions in work effort or asset accumulation induced by this means-tested program. Nor does it tell us anything about the costs and benefits of alternative policies.
Reduction in work effort?? This would be really funny if Cannon weren't so deadly serious. Providing health care to poor people means that more of them are just going to spend their days hanging out in parks, yakking on their cell phones, I guess. So, Libertarians are in favor of liberty for themselves and wage slavery for anybody else. Good to know.
The morning of June 27th was clear and sunny, with the fresh warmth of a full-summer day; the flowers were blossoming profusely and the grass was richly green. The people of the village began to gather in the square, between the post office and the bank, around ten o'clock; in some towns there were so many people that the lottery took two days and had to be started on June 26th. but in this village, where there were only about three hundred people, the whole lottery took less than two hours, so it could begin at ten o'clock in the morning and still be through in time to allow the villagers to get home for noon dinner.
In 2002, about 110,000 people were enrolled in Oregon’s Medicaid program. By 2008, budget cuts had reduced that number to 19,000. In fact, so many people were driven out that the state realized it had the money to cover 10,000 more residents. In the interest of fairness, officials set up a lottery -- and, quite accidentally, kicked off the most important health-care policy experiment since the 1970s.
The gold standard in research is a study that randomly chooses who gets a new treatment and who doesn’t. That way, you know your results are unaffected by differences in the two populations you are studying. That’s hard to do with health-care insurance: Are you going to randomly refuse to give people access to medical care just to see how much worse than the insured they fare? Is that even ethical?
But in Oregon, it was happening anyway. The state, due to overwhelming demand and limited resources, was going to randomly give insurance to some via a lottery and leave the rest uninsured. So a team of health-care policy researchers proposed the first randomized experiment to compare Medicaid -- or, to their knowledge, any form of insurance -- to being uninsured.
Money can’t be our only concern in the health-care system, but neither can it be something we can simply ignore. And though the Oregon project’s results can’t tell us much about how to save money and improve care, they underline the need for experiments that can. After all, we are only now seeing the results from the first gold-standard study examining whether being on Medicaid is better than being uninsured. We can’t wait that long for the studies showing which forms of Medicaid -- and Medicare, and private insurance -- deliver the most effective care for the least amount of money.
“The broad characterization of what we’ve learned is Medicaid matters,” Baicker says. “It improves your health, increases utilization, and reduces the financial strain against being insured. But what is the best way to provide Medicaid? That’s not a question our study answers.”
There have been attempts to answer this question. In the 1970s, the Rand Corp. conducted a huge randomized experiment that gave people insurance with different levels of co-pays and found that more generous insurance didn’t appear to improve health except for the poorest of the poor. What we need now are many more randomized studies looking at different types of insurance and care.
"They do say," Mr. Adams said to Old Man Warner, who stood next to him, "that over in the north village they're talking of giving up the lottery."
Old Man Warner snorted. "Pack of crazy fools," he said. "Listening to the young folks, nothing's good enough for them. Next thing you know, they'll be wanting to go back to living in caves, nobody work any more, live that way for a while. Used to be a saying about 'Lottery in June, corn be heavy soon.' First thing you know, we'd all be eating stewed chickweed and acorns. There's always been a lottery," he added petulantly. "Bad enough to see young Joe Summers up there joking with everybody."
"Some places have already quit lotteries." Mrs. Adams said.
"Nothing but trouble in that," Old Man Warner said stoutly. "Pack of young fools."
The Oregon Medicaid lottery provided a great if disconcerting opportunity for policy researchers. It would be unethical for them to have designed and carried out a study that randomly provided health care benefits to one group while leaving uninsured another group serving as a control. This unique opportunity arose when Oregon received more funds for their Medicaid program, but not nearly enough to cover everyone eligible. They decided to randomly select by lottery those whom they could fit into the program while leaving many more out in the cold.
It is ironic that politicians created a study opportunity that is clearly unethical by policy research standards, yet doesn't seem to violate the ethical standards of the politicians. If you need any more proof of that, just look at the Affordable Care Act (ACA) where policy decisions were made that will leave 23 million individuals without any health care coverage, but they can go to the emergency room.
Before we start celebrating the fact that Medicaid is better than nothing at all, let's keep in mind the facts that Medicaid lacks the capacity to meet the expanded coverage through ACA, that eliminating cost sharing does improve access, and that expanding Medicaid will do nothing for the 23 million remaining uninsured and the tens of millions more who will underinsured through low actuarial value plans with very high cost sharing.
There is a far better way - a single payer national health program that provides comprehensive benefits for everyone with no cost sharing barriers to care. Other nations have adopted such programs at a far lower cost than our dysfunctional system. We can do it too. (You've heard this before.)
Why does that crazy young fool Don McCanne want us all to go back to living in caves, eating stewed chickweed and acorns?
At times one of the adolescent girls or boys who go to see the child does not go home to weep or rage, does not, in fact, go home at all. Sometimes also a man or woman much older falls silent for a day or two, and then leaves home. These people go out into the street, and walk down the street alone. They keep walking, and walk straight out of the city of Omelas, through the beautiful gates. They keep walking across the farmlands of Omelas. Each one goes alone, youth or girl, man or woman. Night falls; the traveler must pass down village streets, between the houses with yellow-lit windows, and on out into the darkness of the fields. Each alone, they go west or north, towards the mountains. They go on. They leave Omelas, they walk ahead into the darkness, and they do not come back. The place they go towards is a place even less imaginable to most of us than the city of happiness. I cannot describe it at all. It is possible that it does not exist. But they seem to know where they are going, the ones who walk away from Omelas.
we need studies to prove that it makes sense to provide people with health care?
the advantages of access to health care is one of those things that do not require a “scientific” study to make sense
what’s the purpose of this study?
19 comments [as of this writing] on Austin Frakt's post, and this is the only one that says maybe we should just... provide health care to everyone.
The purpose of this study, of course, is to prove that we still need to keep some poor souls living in utter misery, or sacrifice them outright, to keep Ezra Klein, Katharine Baaicker, Michael Cannon, Austin Frakt, Matt Yglesias, Megan McArdle, David Leonhart, Gina Kolata, et ilk alive and happy in their shining city or cozy village.