Steve knows the world has truly gotten better for human beings. Not enough people recognize or appreciate that. We hope that this episode inspires you to help a neighbor or call a friend.
How does gratitude compare to resentment? Do we have the mental space to be thinking about the welfare of everyone else? How different are you on social media compared to real life? Why do GoFundMe’s work? Is the demand curve for chemotherapy vertical?
00:07 Aaron Powell: Welcome to Free Thoughts. I’m Aaron Powell.
00:09 Trevor Burrus: And I’m Trevor Burrus.
00:10 Aaron Powell: And joining us today is Steven Horwitz. He’s the Distinguished Professor of Free Enterprise at the Miller College of Business at Ball State, an economics editor at libertarianism.org. Welcome back to the show, Steve.
00:20 Steven Horwitz: My pleasure to be here, as always.
00:22 Aaron Powell: One of the themes in what you’ve written, what you’ve talked about over the years, is how amazing the world is and how much more amazing it’s getting, and the stories of why and how that happens. But in the last few years…
00:42 Steven Horwitz: Almost two now, yeah.
00:43 Aaron Powell: Two years, you have had a cancer diagnosis and have dealt with that illness. How has that impacted or changed these views of optimism and amazement that you’ve spent so much of your career talking about?
01:01 Steven Horwitz: Well, it’s certainly the case that it’s tested one aspect of that, which is sort of the expectation that one will live longer than one’s parents or one’s grandparents did, right? And in that sense, I think we all know that statistics are statistics. Somebody is not gonna live that long. So in that sense, I think that’s the hard part, and the hard part really is I still believe that the world’s getting better and better and more awesome and I’m just not gonna see as much of it as I thought I would, it appears. You never know for sure. And that’s sad and unfortunate and that’s the hard part. On the other hand, right, I think two things: One, it has increased my appreciation for the power of medicine and sort of research and technology and all these kind of things and how much that’s changed. I mean, the cancer I have is multiple myeloma, which is a plasma cancer. It’s kind of like leukemia and all those. And then flat out, right, 20 years ago if I was to had this diagnosis, I’d be dead by now. I mean, within two years, I’d probably be, especially with the version I have, I’d be dead.
02:12 Steven Horwitz: And the drugs that have come out, really since about 2002, one drug in particular in 2002, and a series of other drugs since then have changed the treatment of this disease in an incredible way. We still don’t have a cure, but we are able to keep patients alive for… I say we as if I… The medical profession is able to keep patients alive for much longer than was the case, say again, even 10 years ago, frankly. Two or three new drugs every year, there’s all kinds of options out there, and the guys just won the Nobel Prize for immunotherapy type stuff, that’s being used. All the weaponry is sort of being thrown at it. And while there still is no cure, the ability to sort of treat it and manage it is much greater than it used to be. So at one level, that fits, right? I’m appreciative of that. I’m appreciative of those changes.
03:05 Steven Horwitz: I think the second thing is, for me, part of that life is awesome stuff is gratitude. And even before I was sick, approaching the world with a attitude of gratitude, as the kids say, I always thought was a good thing, right, sort of being, recognizing how lucky you are to live when you live, recognizing all the great things that I’ve been able to do in my personal life, my career, all these good kind of things, right, and seeing that gratitude in the bigger picture. I had a conversation a month or two ago with my good friend Don Boudreaux about this, and Don shares this sort of view of the world, right? And as Don pointed out to me, he said, “You know, if you’d been born 100 years ago, you might not have made it this far, right? Or might not have made it past one, right?” And your life as you know, however many years you end up… I’m 55 right now. However long I end up living, right, you’ve got years of quality that human beings in the past have never been able to have and do things that humans haven’t been able to do, and there’s something maybe stoic about that. There’s something… It’s… I think maybe sometimes people might hear that as a kind of weird rationalization, but it’s genuine, right?
04:18 Steven Horwitz: I mean that’s… It’s like, “Okay, I don’t know what’s left on the clock,” but whatever’s left on the clock, all of the things that have happened in my life… No, I won’t say all of them, but many of them, most of them, have been awesome and have been great and I’ve been able to do things that humans just haven’t been able to do before, and so let’s look at it that way. I’d like more. I would love to live to 90 or 100 or whatever it might be, but if not, okay, right? I mean that’s… We’ve still got all of these things that others haven’t had.
04:54 Trevor Burrus: Gratitude as a political idea or maybe I don’t wanna use politics per se, but how do you think it fits in on a broader scheme that perhaps some Libertarians or types of Libertarians, maybe not all Libertarians, but types of Libertarians have gratitude as something that actually animates their political ideas, right? And so, you have… It’s very important to have gratitude and you see it all the time in discussions of good mental health, like make sure you understand what you have, but that often is just confined to having good mental health yourself. But if you bring it out and say, “Well, what about the world in general, or, how shall we approach the world in general if we have gratitude?”
05:38 Steven Horwitz: Yeah, I think it’s tricky, right? Because for me, part of the reason I find all this sort of economic history and reminding people how much better the world is than it used to be, you think about stuff like Hans Rosling’s work and all this, right? Part of it is precisely to cultivate an attitude of gratitude that works. Jonah Goldberg in his most recent book kinda compares gratitude to resentment, right, and that so much of the politics today is a politics of resentment, and I think to that degree, right, shifting towards a politics or a perspective of gratitude, I think is really useful. Resentment doesn’t help us. Resentment is at best a zero‐sum game, maybe a negative‐sum game definitely, and gratitude at least helps us recognize how far that we’ve come.
06:29 Steven Horwitz: I think the danger with gratitude of course is that you don’t wanna go so far that you overlook the things that are left that we can address that aren’t, that understandably people aren’t grateful about. I mean we’ve made incredible advances in dealing with global poverty but there’s still 750 million or whatever folks who are under $2 a day. So we need to think about that, or we look around the United States and we sort of say, you know, we see the problems in a place like Baltimore. The problems are real. So if you attribute them the way the president has, but the problems are real, and problems in rural America are real, again, whatever solutions we might, Libertarians have our solutions to them, but sort of not letting gratitude turn us into this kind of pure rose‐colored glass, sort of Panglossian view where everything, everything’s awesome, Lego Movie and instead recognizing that, “Hey, we’re a lot better than we used to be, often than we used to be, but we’ve still got problems we’ve got to address.” So I think… And I also think, by the way, I’d like to think and I might be wrong, that gratitude sells better than resentment, but it doesn’t seem like it these days.
07:35 Trevor Burrus: But the market’s a little bit low right now.
07:37 Steven Horwitz: Yeah, that’s right.
07:37 Trevor Burrus: But maybe long‐term futures are where you should be looking for.
07:41 Aaron Powell: And I think gratitude… I mean we can have gratitude in a free standing sense, but usually gratitude is towards someone or some people. It’s a fostering connection. I was just over the weekend, we… Talking about like of attitudes of Libertarians or some Libertarians, we tweeted out one of Libertarian’s reports Twitter accounts, tweeted out a link to a story that we published that in part talked about infant mortality rates and how there were parts of the country that had higher infant mortality than others, and someone replied to it saying this isn’t about… Like the state shouldn’t do anything about this. Their report’s not worth talking about. And that, because you know as Libertarians, all we care about is like what the state should do or not do and then anything else is just kind of off the table or meaningless or like a waste of time. And that certainly is just a rather unfortunate view of the world.
08:40 Trevor Burrus: Narrow and…
08:43 Aaron Powell: But it’s also that kind of, like we should care. I mean part of the thing that motivates what all of us do is because we care so much and because we have grat… I mean that gratitude towards others and comes with then wanting to repay them for that to make things better for them in the way that things were made better for us, the kind of cheesy phrase of “pay it forward.”
09:05 Trevor Burrus: Yeah.
09:06 Aaron Powell: But like that should be an animating principle of so much of what we do and we shouldn’t just cut that off when it comes to like, well, the state.
09:16 Steven Horwitz: Right, right. And I also… I mean I think it’s weird, right, sort of the politics of gratitude is not a necessarily a gratitude toward particular people though. It can be, you know in Norman Borlaug, for example, right or someone like that, but it’s a gratitude about institutions, about gratitude to being in a place where mostly the rule of law still holds and sort of those sorts of things and sort of saying the reason why I’ve had 55 years of awesome life is because I’m in a place where that’s possible, where people are sufficiently free anyway, and I think sort of appreciating that and also the infant mortality example is a great one, right? As you say, we should be celebrating that as human beings, right, not Libertarian or not, as human beings. That’s when you know that history and you know what we’ve done in the last 100–125 years to reduce infant mortality, that’s one of the most amazing accomplishments as humans have done to bring children to the world and not assume half of them will die before they reach age 1 or 5 or whatever.
10:23 Trevor Burrus: Have you found yourself feeling more gratitude obviously with the things you discussed but even to people and not taking that for granted?
10:32 Steven Horwitz: Oh yes.
10:32 Trevor Burrus: Like it’s almost the definition of gratitude.
10:33 Steven Horwitz: Yes. Yeah, this is the… Right, this is the hard part, emotionally the hard part. I mean I made a choice early on to be very public about my disease and my experience with it, and the sort of outpouring of support and love and sort of feeling like you’ve got that army behind you on Facebook and wherever else is just incredibly important, and the old… Everyone says this: It shouldn’t take something like this, right? You shouldn’t have to, shouldn’t wait till your funeral for people to say nice things about you, right? But okay, we’re here, and sort of to see that outpouring of support and love and actually an appreciation for my work too, that’s the thing that kinda caught me by surprise. I mean people saying things and people I, and not just sort of friends, people who I’ve, whose own work I respect very deeply saying to me, “We need your voice,” right? “We need you in this conversation.”
11:45 Steven Horwitz: Well, at one level, that hurts. That’s like, “Ugh.” That’s ’cause I wanna be there and I’m not… How much longer? I don’t know. But at another level, it’s, “Yeah, thank you,” right, and that’s that sort of gratitude, and I should mention too, sort of things Libertarians, when we think about Libertarians and the state, we can’t forget civil society and the rest of the world. The outpouring of sort of support and material and other sorts of offers of help from our friends, from family, from my neighbors, right, all these sorts of things have been incredible too. And in the case of my neighbors, we had moved into this development about eight months before I was diagnosed, and so they barely knew us, but yet they’re shoveling our walk and they’re bringing us food, and they’re, “Can we take the dog? Do you need us to take the dog?” So, whatever.
12:36 Steven Horwitz: So that you don’t really understand I think how deeply embedded you are in those social networks and how much people will rise to the occasion until something like this happens. Again, I think it’s an interesting question to think about how we can recognize and activate those systems of support without it having to be sort of in a crisis or a health thing or whatever, right? How do we help people know they’re there and sort of what are the other kinds of situations where that would be really valuable? Do we know family and friends who are, you know someone lost a job or whatever it might be, or has a sick kid, whatever. You can think of a million things, right? How do you do that? I mean I chose to be public and that made it easier for people I think to come forward, but I would love to live in a world where those sorts of things happen more often.
13:31 Aaron Powell: I mean how you cultivate that? Because the things… So your cancer diagnosis or someone dies, and then we say the nice things about them or someone losing… These are all acute and noticeable events and this is why… So one of the things that drives me nuts is when people kind of sneer at the GoFundMe accounts that pop up when something bad happens. And so someone gets sick and this GoFundMe account starts and it raises an extraordinary amount of money and you get this, this like… They don’t take this as a moment of, “Wow, look at the amazing thing that humanity can do and that strangers… ” I mean it’s often just absolute strangers who see a story and decide they want to contribute, but they look at it as like, “This is a condemnation of our way of life because we wouldn’t need this if we had socialized medicine taking care of people,” or, “We wouldn’t need this if we had protections against getting fired or that these kind of moments of genuine and really inspiring humanity aren’t signs of inspiration but they’re signs of decline and decay and corruption and not caring.”
14:45 Aaron Powell: So like on the one hand, I wish we would stop doing that and I think we recognize how amazing this stuff is, but on the other hand, it is the case that this stuff always latches onto acute things and I don’t know how to address that because it feels like part of the reason is all of us have our lives and we’re caught up in them and we’re doing our things and we have lots of stuff going on, lots of stuff pulling our attention, and so we’re not… And I don’t think this is a condemnation of us, it’s just like we don’t have, we don’t have the mental space to be kind of constantly thinking of the welfare of everyone else until there’s an event that then makes it very clear and then we just shift our focus.
15:22 Steven Horwitz: Right. And I don’t know how to do it either, and I’m not… I think you got to the real problem at the end which is our ability to get out of our own lives, right? And in general, the Adam Smith point being we pay much more attention to the cut on our finger than we do to the death of a million Chinese until, even when it’s in our face. Interestingly, right, the transaction cost of actually helping the million Chinese are much lower than they used to be. We can in ways that…
15:49 Trevor Burrus: And they get more help too.
15:50 Aaron Powell: Yeah, they get more help.
15:51 Steven Horwitz: After the earthquake, the Tsunami in 2004, it was an unbelievable amount.
15:53 Trevor Burrus: Yep. Yeah, yeah.
15:56 Steven Horwitz: Yeah, so I don’t know how to do that. I mean I think it’s an interesting challenge to sort of think about whether there isn’t a kind of platform economy type way of doing this where we… I mean GoFundMe is, as you say, acute, right? It’s for specific things, but imagine could someone create something that was the equivalent for particular kinds of problems that people might face but not specific ones that have arisen yet, right? I don’t know. It’s an interesting question.
16:25 Trevor Burrus: Insurance.
16:26 Steven Horwitz: Yeah, yeah. Yeah, well I mean…
16:27 Trevor Burrus: Well insurance can’t love you in the proper way.
16:29 Steven Horwitz: But I do… I do wanna make one comment about… I mean maybe it’s obvious particularly to sort of Libertarian listeners, but the sort of condemnation thing, right, if you’ve ever dealt with the bureaucracy, the government bureaucracy, whether it’s healthcare or whether it’s whatever, right, you wanna talk about not being treated like a human being and sort of… If the argument is the fact that we have to fund these things on the fly through GoFundMe somehow speaks to our lack of humanity that we don’t have these problems taken care of by the state, come on. The reality of what happens when we do try to do those things though the state is way more of a condemnation of us as human beings, right, than the fact that we have to do this, these other kinds of ways.
17:19 Trevor Burrus: It also strikes me that… I mean, I’m a little bit of a cynic. I mean…
17:23 Steven Horwitz: Nah.
17:24 Trevor Burrus: I would say I’m a realist, but that’s what cynics always say, right? But I also constantly tell people that to be, but at least I think the right kind of libertarian, actually requires a significant amount of faith in people that a lot of people on the other side of these debates just simply don’t have, that there’s enough care out there, that there’s enough attention, that there’s enough people who would be willing to fund if we did away with all state‐based medical treatment or just cooking dinner, as you said. I find sometimes when people say we have to… You know people won’t be nice about this and I don’t expect them to give to charity. I think in their mind, they never give to charity, and then they extrapolate to or there’s like everyone will cheat on this and I’m thinking in the back they’re gonna game the system and they’re gonna cheat on this and I’m thinking in the back of my mind, “Do you do that all the time?” You know? Is that… Or are you just extrapolating from your own behavior? So I think finding people to be cynical about how much attention they can have or whatever, but also that when push comes to shove, caring, good people can do a lot on their own.
18:37 Steven Horwitz: I think that’s right, and I think, we don’t have enough confidence in you to care enough, so we’re gonna boss you around and make sure that you… You know, that you have to care… We’ll put care in some quotes, there. Yeah no, I think that’s right. And, it is sort of, one of the great things that has come out of this, for me, over the last couple of years, is precisely this. It is to see… So, how many… That faith in other people has been restored, or sort of built up, in so many ways. And, I wanna make one small little point, here. My neighbors have been incredible, and we’re in this development about 35–36 houses, and all that. And, I looked at that New York Times graphic that came out a while back, that broke down the 2016 election, down to precincts.
19:21 Steven Horwitz: Terrific. And, the precinct which covers my neighborhood was like dead 50–50. And, I take pains to remind myself, as much as I loathe Cheeto Mussolini, half of my neighbors voted for him, and some of that half who voted for him, have shoveled my walk and brought us dinner. And, check… Just, even asked, “How you doing?” And that, I think, is worth remembering, given the fractured state of our political discourse, that there’s some bad people who voted for Trump, and there’s a bad people whom are feeding at the trough, and toasting marshmallows over the fires he started. But, there’s also people who voted for him for other reasons, who are good people in so many ways. And, I think just, that’s been a good reminder for me too, to remember that half those people in my neighborhood voted that way. And, before I start saying things about Trump voters, just let’s remember who we’re talking about, here.
20:21 Aaron Powell: When we were chatting in my office earlier today, we did mention this briefly, but the role that social media, and for you particularly, Facebook, has played in this, was both really interesting, but also one of these things where, that was an avenue for support and an outlet for expression that didn’t exist 20 years ago. That you could’ve written and received letters from people, but BBS’s.
20:50 Steven Horwitz: Yeah, not the same. Yeah. [chuckle] Not even that, not the same. Yeah. So, I think… I had a colleague at St. Lawrence who lost her husband of a short number of years, they were somewhat older than me, and I watched her grieve on Facebook. And, it struck me that her ability to do that, and the support she got from her Facebook friends and real friends through that, and her ability to talk about it and sort of, get those things out on the table over Facebook, was really helpful to her and was treated really respectfully by her friends. And, this was now, maybe seven, eight, 10 years ago. No, not that far, say five, six, seven years ago. And so I’ve always thought about this question of what the best thing that Facebook does is keep us connected to people who we otherwise, we have no idea what’s happening in their lives and they have no idea what’s happening in our lives. And so for me, the decision to be public and to use Facebook as the way to do that. Seemed obvious And again, sort of having that support, having people sort of cheerleading squad, and frankly I’ve got nurses and doctors on there too, right so, that sort of… I’m not looking for advice, but they often will say That’s good. And here’s something to think about. So I think that that’s keeping those connections is really, really important.
22:21 Steven Horwitz: And it helps you. It’s sort of connected to the gratitude thing in a way, right? That There’s I mean at one level. You’ve got more people out there who you, an audience as it were, to sort of reflect back at you, right whatever, whatever it is, but at the same time, it makes you realize there’s a lot of people out there who care about me and who I care about and who I want. I want to be sort of part of this. The other thing that we talked about with social media is to me, the fascinating one.
22:51 Steven Horwitz: And I think obviously when you are facing an incurable disease, though not imminent death, right, you think a lot about death and dying in all kinds of ways? And one of the things that has struck me is that I don’t believe in an afterlife. I mean I’ll be happy if there’s a good one anyway. And as I was saying to Aaron, earlier, I think hell is something like still being conscious and being tied to a chair, and knowing stuff’s happening, but you can’t be part of it right, that’s hell okay but if you’re sort of a materialist, and you’re dead, you’re dead, you’re not, once you’re dead you’re dead right, you’re not dealing with any of this. So the hardest part is what’s happening leading up to that and thinking about the impact that your death will have on other people. It makes me very very sad it’s the hardest part of this sort of thinking about what this will do to my wife, to my children, to my step‐children to my family. It’s not like you get hit by car or something it’s a surprise it’s a shock, but this is a little different, but even so. You just say I hurt for them. For how much they will hurt.
24:03 Steven Horwitz: But the interesting thing about Facebook and other social media is I think the degree of hurt we feel in that situation is related to the presence people have in our lives from day‐to‐day, right? The people who are wives and children, and so on, who we see every day. You’re not there suddenly and boom, how do you even… I was talking recently about spending time in my house without my dog in the house when the dog is not in the house, like it’s getting groomed or something. It’s weird, right? It’s weird. I might have this program that runs where’s the dog. What’s the dog doing. And it’s just weird so and we know when someone dies, you have that. And what social media has done is sort of put more people in our lives that we have these or a more better way to put this I am in more other people’s lives, there are people for whom who follow me on Facebook and interact with me on Facebook who I may not even met personally, right, who I think will feel a loss when I die that before social media, they never would have felt. And I can think about people close to me who died pre‐social media, who you would think I would have been fairly hit hard by but no, not really. I just had a former student of mine who’s a member of Parliament in Kenya pass away this week from cancer, misdiagnosed. And this is a gratitude point misdiagnosed in Kenya with a medical system that’s not so great.
25:27 Steven Horwitz: And this is not a person who I’ve had a conversation with in person in years and years and years, but he set up a Facebook page to deal with his cancer journey and so he was there and obviously I happened to be getting infused at the time I saw it on my Facebook feed, which was really not great timing, but again, the loss has hit me harder than I would have imagined. But again, I think because there’s this presence of the person and so I don’t know if I have a kind of major conclusion about all this. I just think that in a world where we have people who are in our lives digitally, in those ways, who we don’t even know and whose lives we are part of death and grieving, have this additional layer to it that perhaps it hasn’t had before. Is that a good thing or a bad thing? I don’t know, but I think it’s real.
26:16 Aaron Powell: This… You can look at this in the context of when you looked up your neighborhood’s voting data. We… Social media is not particularly popular right now. Everyone’s attacking social media as the cause of basically every problem that America faces and we talk trash about it. I get this, I routinely go through things of like, “I wanna… Should I quit Twitter because I’ll tweet…
26:45 Steven Horwitz: Yes, you should.
26:47 Aaron Powell: I’ll tweet out something and I’ll get a lot of good feedback, but then I’ll get a couple of really ugly sounding people and it’s just like, “Is this not worth it anymore?” But on the one hand, it’s like, it’s some of it’s like, it’s like your neighbors, right? Social media where it’s more performative than where we often admit, and so the person who says, parrots these God‐awful things that they heard on Fox News, they’re just paraphrasing the racist comments that Tucker Carlson has made and shouting them at me is likely performed, maybe some of them are actually that awful, but they’re likely performing and in their everyday lives, they’re real and genuine people who would come and help, mow your lawn, or shovel your driveway. And they’re not actually like that. In the same way that when I’m on these things, I am to a certain extent, I’m presenting a certain version of myself but at the same time, that connection that you talk about that bringing more people into your lives in this really powerful way. And I don’t know if I’ve talked about this on the show before, but… So I’m…
28:02 Aaron Powell: Just about a year ago, a guy I only knew online died suddenly Brock Cusick, who we did an episode of Free Thoughts with, actually, and he was just someone I knew on Twitter and he was just someone who… It was like two or three or four or five times a day, some thought of his appeared like on that thing in my pocket or in my office or on the computer while I was at home. Like, not in a… It’s not like picking up and reading the next George Will column and you’re inviting George Will into your mental space to say, dumb things about the NFL for a little while, but you’re… And it’s not like talking to, it’s not like talking to a colleague, even where I know there’s kind of boundaries of like, “This is when I’m at work and I’m gonna see this person but then it’s like this kind of constant drip, drip, drip of contact with people who you never would have experienced otherwise and are just always there. And there’s a lot of them. That’s the thing, that’s the… The number of p… I don’t how many people follow you on Facebook, it’s…
29:09 Steven Horwitz: I have 5000 friends and almost 6000 followers last I checked.
29:13 Aaron Powell: Quite a lot more than you could possibly know in any meaningful sense in real life. But they’re all there and you are there and this is fostering these connections that even if they’re colored through this performative angle. At some point if they go on long enough, become really genuine and that genuine connection that is… Contributes, I think something really valuable in this expanding sphere of human concern because these are the people who… When Brock died, you contribute to the gofundme campaign and it’s because of these real connections, and I think there’s something lost when we just look at it as… ’cause when he died, it really… It hit me much harder than I thought it would that just this kind of constant drip, drip, drip just stopped, right? And I think we overlook that aspect of it in favor of just seeing it as this ugliness which is frequently there, but that connection and the expanding is I think part of… Part of human progress is expanding our sphere of concern. And I don’t wanna see us lose that. And I think stories like what you’ve talked about with your Facebook thing are exactly why this stuff is so valuable.
30:24 Steven Horwitz: Yeah, yeah, no, I think that’s right and I think… Yes, and the word I like to use is curated, right? It’s a curated version of ourselves that we present frequently on Facebook but I do think what happens inevitably is the real person comes through the… Everyone, whatever people think of my persona on Facebook, no one thinks that’s all of me, right? But it’s enough of me, and if you do enough stuff on Facebook and… People would take me out to breakfast, they know what to order me if we go to a diner, they are getting me hash and eggs, right? So there’s that relaying…
31:08 Steven Horwitz: If only it would knock out the myeloma, it would be good.
31:10 Trevor Burrus: Yeah, yeah, exactly.
31:11 Steven Horwitz: Yes, all those kind of things, right? So yeah, I think that’s exactly right. And I think that used wisely, social media can do exactly what you’re saying and which is to sort of expand that sphere of concern and that’s, as you say, that’s why those gofundmes work and why people contribute to them. I’ve never met her but I know her on Facebook and she seems like a good person, I know how hard she’s tried to take care of this relative of her so yeah, right, if you have 25 bucks, you have 25 bucks. I think that’s right and it has… It comes with a downside. But yeah, I think it’s amazing what it can do when most of the time, much of the time it works.
31:49 Trevor Burrus: You have any insights into the American medical system?
31:54 Steven Horwitz: So let me say one thing, I’ve had incredible care, the quality of care that I’ve had has been terrific. I’m very lucky to have insurance through my wife’s job that has been… I think I’ve had to actually call in the insurance company twice right in almost two years. And in both cases, they actually solved the problem like right away. So I won’t do a pitch for ‘em, but… So in that sense, I haven’t had those battles, but it’s so weird, it’s just so weird. I had this immunotherapy drug that was incredibly expensive and it turns out that the company gives a discount like this huge discount for certain sorts of things. And I said to the people at the hospital, “Is it income‐based?” And they said, “Yeah,” I said, “Well, I’m not sure I’m gonna qualify.” She said, “Send it in.” And I qualified and it’s ridiculous, right? I mean.
33:00 Steven Horwitz: There was another case where I had… This sort of notion that prices have any meaning whatsoever in this system. I was on another drug briefing…
33:08 Trevor Burrus: Might as well be Monopoly money. I’ll have 37 units of…
33:10 Steven Horwitz: Right, exactly. No, that’s exactly right. I was on this other drug that I couldn’t keep taking because it was making matters worse rather than improving them. But it was… Okay again, huge copay on it, and then it turned out that there was another program they had that would pick up the copay for you. Again, would I qualify? It turns out I do. It’s like what? This is just insane. The other… My first hospital stay back in November 2017, I actually saw on the online system, the internal bill that the hospital sent the insurance company before they negotiated. That’s a large number, okay. Then I saw the later number, I’m like okay, what does this number mean now. Then I get a bill for part of my deductible. [chuckle] So I’m paying this, you guys agreed upon this but the actual cost you claimed it was… None of those numbers make any damn sense. The idea that you go in and you get treated and the doctor says, we’re gonna do this. The decision about what treatment to take on, is almost never discussed in financial terms. It’s just assumed that whatever treatment it is insurance will cover it. And sometimes you gotta convince them. It’s hard with a disease like this, with something like cancer to say well wait, we should be asking those questions.
34:45 Steven Horwitz: Especially with multiple myeloma. As I said earlier, there are multiple treatments available for this thing. There’s a protocol and a sequence that if one fails you do this… But there’s options. I’ve always had options presented to me. In fact, I recently got a second and third opinion and shockingly, the transplant specialist said you should do a second transplant. The clinical research guy said well, I’ve got clinical trials. My oncologist who’s a community hospital person says, lets keep going with the standard chemo. Shocked! But sort of figuring out, what do you with that? Then the question becomes, should we have financial considerations here? What are all the trade‐offs and things… For me, the absence of any discussion at all about cost and then to recognize that the numbers people throw around just are meaningless. It’s just crazy, it’s completely crazy. That’s a problem and it’s a problem clearly I can’t fix. I’m lucky to have really good insurance where it hasn’t been a problem for me. The other thing that has struck me is how much… I’m not sure this is an uniquely American problem, but how much you end up having to rely on expertise. You’re buying into what economists call an experienced good, you don’t know what you get until you get it.
36:10 Steven Horwitz: As I was saying before, I’ve got three doctors telling me three different things. How the hell do you decide what to do? How do you triangulate that situation? I’m a smart guy, and I’m sort of struggling with this. I look around and wonder how people for whom this is overwhelming, deal with this. One of the first conversations I had with my oncologist, in fact the first conversation I had with her included a brief discussion of the life expectancy numbers for multiple myeloma patients. The numbers she told me were a little lower than I’d been hearing from other people. I had this look on my face and she kind of waved her hand, she says ah. She says, remember two things. One, these are numbers from people who were diagnosed years ago. We don’t know for sure what stage. Second, your young. People tend to get this disease when they’re older than you, they already have other stuff going on. There’s a lot of low numbers in there that are dragging down the median. I’m like oh, it’s just like infant mortality, life expectancy but in reverse. She says, yes. Okay, I can understand that in a way that… I told that story. A friend said, wow, you have a statistically literate doctor? That’s pretty rare.
37:24 Trevor Burrus: Yeah, I was thinking that exact same thing.
37:27 Aaron Powell: When we Libertarians, Cato, when we talk about healthcare. I was… A couple of weeks ago listened to a talk for our colleague Michael Cannon was giving to some people and talking about free‐market healthcare. This question of… Before always saying introduce price considerations as a way healthcare is wildly inefficient in certain ways, or we spend probably more than we should, or we buy a lot of care that doesn’t actually help us. The problem with that is that all these crazy numbers that you talked about are basically hidden. We just pay a deductible and a premium and that’s it, so we don’t think about this stuff. You might very well be like I was told to get a transplant and to do clinical trials and to keep taking this stuff, why not just do all three? We don’t have a reason. The response to that is, when you introduce the prices. If you were put in the position of there’s three treatments in front of you. This one is likely to be 10% less effective than that one, but cost 20% less. This one has this sort of expectation, but that like… You’re facing cancer diagnosis, this is a tough thing. It’s not like when I go online to shop around for cell phones. If I screw up, then I just have a crappy phone for two years until I can talk my wife into letting me buy another one. That mental space, how would you even begin to address those kinds of things?
39:03 Steven Horwitz: I don’t… I’m not sure it’s all that much different than where you are without prices. Only at least you have something here to sort of figure out, right? Is it worth the risk, is it worth… Is it worth the cost? I mean, I… You know, people can tell me, “Here are your treatment options, and here’s the odds and here’s this and here’s that,” right? But, one, those are all averages, so who knows what’s gonna happen. And this particular disease comes in various flavors, so it matters which one you have. So I’m not sure it’s that much worse than it is now. At least… But the hope would be having those things priced. It’s not so much that the consumer is gonna have to make those decisions, but having those things priced enables producers to sort of be more efficient and effective with the kinds of things they develop, right? This is the thing, right? You know, so a quick story, the textbook I used for teaching intro in the chapter on demand curves has a question in the back that I’ve always assigned to students. It says, is… Basically the question is, “Is there a substitute for chemotherapy,” right? Is the demand curve for chemotherapy vertical? And every… You know, for years, I’ve always make, “Well, you know, there’s other things you can do, blah blah blah, then whoop, suddenly… ” Right? You start thinking, “Right, what are my other sort of… What are my other options?” But… And in fact, there are, right?
40:30 Steven Horwitz: I mean you know… And even… I think more important even within chemotherapy, there’s multiple options. And so at least we get people thinking in terms of how, what are those options, what’s the use of resources and it’s separating my own situation from sort of the observing economist, right? It is true that we spend a lot of resources on end‐of‐life stuff that you probably can’t justify, right? At some level from a strictly sort of economic efficiency standpoint, you can’t justify. But tell that to the patient, right? And now I’m the patient, right? And I get it, if someone comes to me and says, “Well, we can try this new drug, experimental drug. It might get you another year.” What am I gonna do, right? Odds are I’m probably I’m… One, I don’t even know what the trade‐off is, right? The insurance company is the one making that decision, right? But it’s hard to say no to that unless, you really at a point where you think, “I just don’t wanna… ” I think I can imagine being a point where the side effects are so significant where I’m like, “No, you know what, I just don’t wanna live… I can’t… My quality of life has deteriorated so much that, no.” I understand why people stop cancer treatment now, in a way I never did before. Because as you guys have seen today, I’m extremely fortunate to have really high quality of life right now.
41:56 Steven Horwitz: I mean, I have no… I’m not in any pain, I don’t have any other organ issues, I got cancer throughout my skeletal system and I got… I got no hemoglobin, but… You know, and I’m severely anemic, but I could do stuff, right? And as long as I can do stuff, let’s keep treating it, and let’s keep doing these things. If it gets to the point where the treatment is gonna really destroy my quality of life, then you got decisions to make, right? But I think it would be helpful if those decisions were priced, and we really understood what is it that we’re giving up to get you another X months or one year, or whatever. To be honest with you, I dread that moment. There’s nada, there’s things I dread, I really dread that moment where the doctor says to me, “You know what, we can do this, but… ” Right? And I don’t know what I’ll do, it’s gonna depend on where I am and how I’m feeling in that particular context.
42:53 Trevor Burrus: It seems that with these treatment options, one of the issues that comes up when we talk about doing single private healthcare or education, I would say too is this idea that we know, or more specifically the doctors, know what the right answer is for treatment. It’s really just a matter of being like, you have X, that calls for treatment Y. And so I think people are thinking about a lot of medical care like you break an arm, you know. That does call for treatment Y, I guess. Maybe there’s some variants in there in terms of whatever, but it calls for treatment Y. Not [43:31] ____, you set the bone, put a cast on, there you go. And they’ll be like, “Okay cancer requires treatment Y and all these things.” Which I think is a huge… The way you’ve been talking here, it’s one of the myths you have to dispel to try and get over with… How we could provide Medicare, medical care privately. And also the idea that education is just one thing, too. What does a six‐year‐old need? A six‐year‐old needs this, this, this and this, a cancer patient needs this, this, this and this. A person with AIDS needs this and this, but it’s actually more nuanced, it’s your care.
44:00 Steven Horwitz: Yeah, right.
44:01 Trevor Burrus: Right? It’s your… Even without the price, even it’s like, you know this much pain, this much… How long you’re gonna be weak, what the choice is, what the chances are, that kind of thing.
44:13 Steven Horwitz: I think that’s right. And again, I’m very fortunate to have a doctor who… An oncologist who entertains these conversations with me and who encourages them, which is okay. If we… So it’s more like, rather than you have X do Y, it’s okay, you have X. If we do A, what are the side effects? What can we expect and for how long? If we do B, what are the side effects, what can we expect for how long? And the most interesting thing it turns out, is if we do A, what does that rule out doing in the future? It turns out, right, that some… If you do certain sorts of treatments, you eliminate other treatment paths from being plausible. And so what’s [44:55] ____ opportunity cost question, right? What are we giving up by doing this? And in particular, right now? So I can get into some clinical trials both for some of the new drug combinations and for advanced car‐immunotherapy type stuff, but to be eligible for those, you have to have had failure of treatment at some number of treatments, but no more than another number of treatments, right?
45:21 Steven Horwitz: And so, and it varies. So if we do this thing, does this rule out the possibility of doing this other thing? How do we manage that? And it turns out, what I’m doing right now is a very, very conservative treatment path because we decided we wanted to leave open as many options as possible if this can’t push things down to where we’re a little bit happier, even as we sit here, I’m actually waiting for some probably tomorrow morning or the next morning, my test results that’ll show up online that will tell us a little bit more about where things stand at the moment, so I’m a little nervous about that. But sort of keeping options open is another thing that comes into this that people don’t think about, right? How, again, it varies from cancer to cancer, disease to disease, but don’t, you know…
46:06 Steven Horwitz: For me, it’s always been a good decision making rule is, if possible, don’t foreclose options, right? And so here we go, don’t foreclose the options here by taking a treatment that might have the promise of being more effective, but if it fails, now you bocked yourself into a corner and you don’t wanna do that, right? So that’s another part of the story too.
46:25 Trevor Burrus: Do you any advice, both life advice and if anyone find themselves having a cancer diagnosis?
46:33 Trevor Burrus: Yeah, I think what… Two things. You have to pretend that you don’t have it. I mean in some ways, you have to pretend… You have to do your best, to be the you you’ve always been. So for me, doing stuff like this, right? Working, traveling, getting into the office and again I’m lucky to have a doctor who totally gets that in general, but about me in particular, right, and sort of every time I do stuff I’ve been busy today, I flew out here, we walked to lunch, we did all these sort of things. But I’m feeling pretty good and I think it’s because I’m doing the things that I love. So I think that you… The first piece of advice is if you let it take over your head, you’re not gonna do as well. I mean the one thing that every nurse and doctor has said to me, when they meet me and sort of get to know me as your attitude will take you farther than it would for other people. So I think there’s that, I think there’s sort… And the best days are the days you forget, the days where you go through the day, and at some point, like in the afternoon, you suddenly realize, “Oh, I have cancer.” Right? And it’s like… But good, I haven’t thought about it for six hours. And that’s good, it just… Sort of pretending that it isn’t there, again, I’m overstating it a bit but, sort of recognizing you have to continue on with your life.
47:58 Steven Horwitz: I think the other piece of advice is the gratitude stuff, right? It’s better when you do it when you’re not sick, right? And I had it been, even before I got sick, I had been trying… Someone intentionally to be more… To be more conscious about saying thank you to people, and sort of appreciating things that people have done for me and all this. And one of the interesting things about that, by the way, is it buys you this tremendous store of social capital and then when you screw up, right, people are incredibly forgiving if you screw up. ‘Cause you’ve always been the other guy, right? But I think sort of recognizing that and sort of taking on the illness with a kind of spirit of, “Okay, I’m not gonna sit around and moan and complain about how terrible things are, I’m not gonna be that guy who he said, ‘How you doing,” you say, ‘Well, let me tell ya, here’s all my problems,’ ” right? No, you just… You can’t, and you need to find things to live for. I think in Facebook, I called this “The Princess Bride” question if you remember this scene, right? Where Billy, “So what you got to live for?” Right? And you should have an answer to that question, and I think if you have an answer to that question, you will find yourself sort of being able to take things on.
49:27 Steven Horwitz: I had one other thing too that I was thinking about this week. And I’m guilty of this. We often use the language of cancer warrior, and it’s a battle and all this sort of stuff, and that’s not wrong, okay? I mean it, there’s… I’m constantly battling my own body in a way that is not enjoyable but the reality of the lived experience is at least as much role with it, which is, “Okay, here’s what you need to do, Steve. You need to go to get infused every week and take this pill, and go to this… ” Okay, that’s what I’m gonna do, right? Don’t take, every pill, go to every appointment, “Okay your numbers came out bad, we gotta change treatment.” Alright, what are we gonna do? Let’s figure it out. Let’s make… Let’s roll with it, ’cause you’re… I think if you approach it too much as a battle you start fighting back too. You start fighting the things that can help you, instead of fighting the things that are hurting you. So, I’m always careful about those war battle soldier metaphors, even though I kinda like them in some level ’cause it feels that way at times, but it’s also, let’s roll with it, alright, what do we do now? Tell me what I need to do to take the next step to get better.
50:56 Aaron Powell: Thank you for listening, if you enjoy Free Thoughts, write and review us on Apple Podcast, or in your favorite podcast app. Free Thoughts is produced by Tess Terrible and Landry Airs. To learn more, visit us on the web at www.libertarianism.org.