If there was ever any question that “The Patient Protection and Affordable Care Act,” a.k.a. Obamacare, would be a major issue in this year’s presidential election (and there never was), then Mitt Romney’s selection of Paul Ryan as his vice-presidential candidate ended it. By selecting as his running mate the GOP’s chief spokesman on budgetary matters, Romney ensured that Obamacare would remain front and center in the campaign. Within days the Democrats were attacking Ryan’s position on Medicare in particular, clearly expecting this to be a winning issue for them. Ryan’s elevation to the ticket, of course, came roughly a month after the Supreme Court had allowed Obamacare’s most controversial provision—the “individual mandate” requiring all persons to purchase health insurance—to stand, not as a legitimate exercise of Congress’s power to regulate interstate commerce, but rather, unexpectedly, as a de facto tax in support of the general welfare.
I have to admit that I do not really understand health care policy very well. It always strikes me as presenting a more or less insoluble dilemma. The chief problem with our health care system is rapidly spiraling costs. But those costs appear to arise due to the combination of a potentially limitless increase in our medical capabilities (or more precisely, an increase, the limits of which are impossible to foresee) and a definitely limitless demand for whatever new medical advances we can create. This combination seems guaranteed to produce a continuing cycle of increasing costs. Without a sudden stop to technological progress, which seems improbable, or a conscious decision by many consumers to forego available technologies and simply accept inferior health or a shorter life, which seems even more improbable, I am not sure how we can alter this situation.
Nevertheless, the confluence of Obamacare, the Supreme Court’s decision, and Ryan’s entry into the presidential race make it hard for anyone with an interest in politics not to make at least some effort to figure out what he or she actually thinks about these issues. As I have sorted through them, I have gradually reached two conclusions. Unfortunately, the first conclusion will anger all the conservatives reading this, while the second will anger all the liberals, so by the end of the essay I will have no remaining allies. I’m not sure whether this makes me a lonely genius or just lonely, but at least it should spark controversy.
I am among those who would have preferred to see the Supreme Court simply strike down the individual mandate as an unconstitutional exercise of the Congressional commerce clause power, rather than resorting to the muddied tax argument. But to say that Congress is constitutionally forbidden to pass the mandate is neither to say that the mandate is unconstitutional per se—the states, after all, have more extensive regulatory powers in this area than does Congress (so that the earlier Massachusetts version passed under then-Governor Romney was certainly constitutional)—nor that it is a bad idea. To the contrary, I have come to think that the Republicans’ earlier position on the mandate—they were for it, after all, before they were against it—is more compelling than their recent opposition to it.
The individual mandate was initially a Republican reform proposal, promoted by conservative pundits and think-tanks such as the Heritage Foundation. The rationale for the mandate was grounded firmly in the principle of personal responsibility. People without insurance tend to seek medical care less frequently and as a result often do so only when their problems become extreme. And the urgency of their medical problems leads them to visit an emergency room. Emergency room care is very expensive to provide, and many problems can be handled more effectively and at a lower cost if caught earlier. So if we treat such people despite their lack of insurance (and I assume that most of us prefer not to live in a society in which we simply choose not to provide emergency treatment to those in need when we could do so), this treatment will impose significant costs on the rest of us. In fact, the situation imposes a kind of double cost on us, because the absence of young and relatively healthy people—those most likely to decide they need not purchase insurance—from the insurance pool drives up the cost of insurance for everyone else. First, the rest of us pay higher premiums than we would if others took appropriate responsibility for their own medical needs, and then we have to pay for their care anyway if they run into an emergency. Instead of allowing people to go without insurance and effectively forcing the rest of society to bear the financial costs of their decision, we should require all citizens to have insurance and thus to take responsibility for their own potential health needs.
This argument is further buttressed, I think, by the logic of a free market. This may sound surprising, because market language has been the chief form of opposition to the mandate: in a market society, opponents say, government has no business forcing people to purchase a product (here, health insurance) they would prefer not to purchase. In the abstract, this objection is certainly correct. But the situation we are dealing with here is not a normally functioning market in the first place, since we as a society have decided not to deny people emergency treatment, whether they are insured or not. In a normal market, I am free to choose whether or not to undertake a specific economic activity. At the same time, however, I bear the consequences of whatever risks I thereby incur. If my actions pay off, I reap the benefits; but if my decisions prove imprudent, I also suffer the loss. That is not what happens here, not as long as we provide emergency care to all who need it. The young or healthy person who elects not to purchase insurance does not in fact bear the risks of his or her own decision. Instead, the rest of us are forced to bear them—the opposite of how a market ought to work.
Even if Congress lacks the power to impose one, then, state-legislated mandates seem to me to be a very sensible and just policy. A society that undertakes to guarantee emergency treatment to all who need it must in fairness also ask its members to shoulder their share of the cost of that guarantee by insuring themselves. This conclusion, however, should be paired with another, more radical one: a society that requires its members to purchase health insurance should also refuse to let the government play any role in providing that insurance. The individual mandate, in other words, must be paired with an entirely private health-insurance market—no Medicare, no Medicaid.
We have increasingly strong reasons to take this position even apart from the mandate, I believe, but the imposition of a mandate—which will increase the number of those with health insurance, and thus the number of those receiving their coverage through the government, if such is available—makes matters that much worse. It is difficult to overestimate the threat to liberty posed by government-supplied health insurance. The reason for this is actually quite similar to the logic justifying the individual mandate. The mandate is reasonable because it is unfair to force some people to bear the cost of others’ imprudent health choices. Government-provided health insurance is problematic for the same reason: it is unfair to force some people to bear the cost of others’ imprudent health choices. Yet this is precisely what publicly-funded health insurance does. If a person eats an unhealthy diet, leads a sedentary lifestyle, becomes obese, develops heart disease and diabetes, and then requires costly medical treatment, it is patently unfair to force other citizens’ to pay for that treatment—the avoidable product of some other person’s own foolish decisions—through their tax dollars. It is one thing to ask citizens to contribute, say, to the care of unfortunate people who suffer terrible accidents through no fault of their own. But it is another altogether to make them pay for the foreseeable consequences of people’s own foolish choices. The same logic of personal responsibility that underlies the mandate also militates against public health insurance: fairness requires that people take responsibility for the risks of their own decisions.
We see this logic playing itself out already, and we should expect it to do so with greater force in the future. Consider the recent flap over New York City Mayor Michael Bloomberg’s proposal to ban the sale of super-sized sugary drinks by local restaurants. This, of course, is one of the worst, most offensive, and dumbest proposals ever to have been made by a public official, and it richly deserves every ounce of ridicule heaped upon it. No society with the slightest modicum of concern for individual liberty could plausibly entertain such a notion for even a moment. In a free society, government has no business whatsoever paying attention to what size soda pop its citizens choose to order. (I say this as someone who has, I believe, never purchased a super-sized pop and has no particular desire to do so.) But those of us who realize the absurdity of Bloomberg’s idea must also recognize that in a society with government-provided health insurance, his proposal is not only legitimate, it is actually a moral obligation. I cannot justifiably be forced to pay tax dollars to underwrite someone else’s foolish health choices. Where the government supplies health insurance, we must—we are morally required to—ban Big Gulps.
It is clear enough how this logic could extend itself in a myriad of ways, depending upon which unhealthy behaviors society feels strongly about at any point in time. Smoking, of course, is already a subject of near persecution. (No, I do not smoke, either.) Drinking may enjoy a certain immunity due to the historical precedent of prohibition, but I would not want to rely on that for long. These days, of course, obesity is the sin du jour, with “O” in line to become the next scarlet letter. And if I am going to be asked to pay with my tax dollars for the increasing medical costs of caring for a society of people who endanger their own health through foolish decisions, then of course the government ought to regulate their behavior in various ways, in order to avoid unjustly depriving me of my hard-earned income. Banning Big Gulps is only the beginning. We should also ban all super-sized food products. Probably we should just simplify matters and ban french fries altogether. Clearly people have no business buying candy bars (perhaps we could make an exception for dark chocolate, given its health benefits), or chips, or anything at all containing high-fructose corn syrup. Probably it would also be good to require a certain amount of daily exercise. Why should I pay for your heart disease when you could have avoided it? Come to think of it, we might just adopt a mandatory Spartan exercise regimen, along with Sparta’s famous diet of black bread and broth.
Obviously, I do not actually want to do any of these things. To the contrary, I find them appalling intrusions into personal liberty. (Though I don’t think they are terribly far-fetched in a world where healthism seems to have replaced religious faith for so many people, and where many folks even take Bloomberg seriously.) Unfortunately, to the extent that we fund health care through public revenues, we really ought to enact these sorts of measures—not to do so is unjust to taxpayers. But enacting them would also be unjust. So to avoid either injustice, we need to avoid the first step, and keep the government from becoming involved in paying for health care in the first place. We can mandate the purchase of health insurance, but the market for providing it should be entirely private.
Let’s call it the Platform of Personal Responsibility: the individual mandate, plus the abolition of Medicare and Medicaid. Now there’s a winning agenda for this election season.
Peter Meilaender is Professor of Political Science at Houghton College.