from Kevin Williamson in National Review, Plans, Trains, and Automobiles

Question: Do we want our health-care system to be more like the spontaneous order that produces both awesome cars and terrible traffic, or do we want it to be more like the New York City train system, a system that works well enough when it is working — which isn’t often enough?

The passage of the Affordable Care Act was a vote for trains, and the House Republicans’ recently unveiled and remarkably modest attempt at reforming it is a vote for a train system with a slightly different fare structure and schedule.

We should think a little bit about why cars — and not just cars for the rich — are so much better than they used to be.

The short answer, of course, is competition. Competition is a spur to innovation, and it is a spur to — more important — investment. What transformed Karl Benz’s first primitive automobile into the wondrous machines we see before us on the road every day was the massive deployment of capital. If you think not only of all the machinery, financial assets, and human ingenuity that are at work making automobiles today but also of all the machinery, financial assets, and human ingenuity that have gone into the incremental development of the modern automobile over the centuries (many of the technologies that make a modern car run far precede the first automobiles) — it is beyond comprehending.

Of course that has happened with trains, too — modern trains really are superior to their 19th-century counterparts — but in a very different economic context, one with markets driven not by individual consumers but by governments and large enterprises working not from changing individual preferences but from various kinds of central plans, a market in which new equipment is purchased not every few years but every few decades. At the high end of the automobile market are buyers who get a new car every other year — and who want something new and better every other year.

That part is key. There is something egalitarian about trains and other forms of mass transit, but it is in the individualistic automobile market that we really see a massive transfer of wealth that no one ever notices. In cars as in mobile phones and many other consumer goods, new technologies, new materials, and new concepts are developed most often at the high end of the market, with the associated costs borne — enthusiastically — by early adopters and high-end purchasers. Things like cruise control and automatic windows begin as luxuries for Rolls-Royce owners and Cadillac drivers, but end up as everyday conveniences for working stiffs with Hyundais, who enjoy an invisible subsidy from the high end of the market.


This economic reality, this invisible subsidy, is the most neglected part of the arguments on health care policy.  It is the core reason that the poor in America with all of its inequality are far better off than many countries with much less inequality.  It is the reason you can see people on welfare with cell phones. Our health care debate is too willing to sacrifice innovation to an egalitarian access, noted most in Medicare for all or a single payer system.