A Philosopher's Blog

The Individual Mandate

Posted in Ethics, Medicine/Health, Philosophy, Politics by Michael LaBossiere on April 2, 2012
United States Supreme Court building in Washin...

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The United States Supreme Court is considering the constitutionality of the Affordable Care Act and this has created quite a political stir. One of the main points of concern is the individual mandate. The gist of this is that individuals are required to buy health insurance. Those who fail to do so will be fined.

Setting aside the rabid rhetoric, the main philosophical issue seems to be whether or not the state has a legitimate right to impose this mandate. Or, as opponents of the mandate put it, whether or not the state has the right to require people to buy a private product.

On the face of it, I am inclined to agree that the state does not have a general right to compel citizens to buy products even when it would be wise and good to do so. As critics have noted, while broccoli is good for people, the state would seem to have no legitimate right to compel people to buy it. This sort of reasoning is consistent with my own view of liberty, which is roughly based on that of John Stuart Mill’s view. The general idea is that people only have a moral right to compel people when the actions in question can cause unwarranted harm to others. Even if doing something would be good or wise, society has no right to compel an individual into doing (or not doing something) when it is not their legitimate concern (that is, involves harm to others).

Because of my adherence to this view of liberty, I would be against the state compelling people to buy broccoli, to exercise or to quit smoking. After all, in such matters the individual is sovereign. Since I endeavor to be consistent in my principles, I also oppose the illegality of recreational drugs as well as any law that would ban same-sex marriage. After all, if it would violate liberty to force someone to buy broccoli because it is good for them, it would also seem to violate liberty to force someone to forgo marijuana because it is bad for them or to forgo same sex marriage because some people do not like it. Not surprisingly, some folks are not quite consistent in these matters: they scream for freedom when an individual mandate is on the line but are quite happy to impose on others when the issue turns to same-sex marriage.

Given my view on a broccoli mandate it might be suspected I would oppose the individual mandate.  However, this is not the case-I actually support it. Naturally, some folks might accuse me of supporting it from blind liberalism. However, my reasons for supporting it are classic conservatism. This should not be at all shocking since the individual mandate actually has a fine conservative pedigree.

Given its origin, it might be tempting to argue that the conservative assault on the mandate is misguided. However, to claim that something is good (or bad) based on its origin would be an error (specifically the genetic fallacy). It might also be tempting to argue that the conservatives are being inconsistent in attacking the mandate given that it was supported by conservatives in the past. However, this would be a mere ad hominem tu quoque.  However, it is certainly interesting to note that the conservative opposition to the mandate seems to be driven by their opposition to Obama rather than the result of a reasoned repudiation of the conservative arguments in favor of the mandate. As such, one might suspect that the rejection of the mandate is motivated in part by an ad homimen attack amounting to “Obama and the Democrats are for it, so it must be bad.” However, my goal is not to consider the history and psychology of the matter, but to present conservative arguments for the mandate.

One stock conservative principle is that people should take responsibility for themselves. This principle is often taken to entail more specific principles, such as the one that people should pay for what they receive and the one that the state should always endeavor to avoid providing welfare and its ilk.

These principles seem eminently reasonable. After all, if I fail to take responsibility and because of this I get aid from the state that I have not paid for, it would seem reasonable to regard me as a thief. To use a specific example, if I decide that I am tired of working and quit my job to go on welfare, then I would seem to be stealing from my fellows. After all, I could support myself and merely would have chosen not to do so. To use another example, if my company gets subsidies from the state when it is profitable on its own, I would thus seem to be robbing my fellows. After all, my company can easily support itself without sponging off the taxpayers.

At this point, one might be wondering what these principles have to do with the individual mandate. After all, it has been cast as the state imposing on liberty by forcing people to buy a product. However, this is not the proper way to see the mandate. To see that this is the case, consider the following.

Back in 1986 the United States Congress passed the  Emergency Medical Treatment and Labor Act. This act mandates that hospitals cannot turn away or transfer a patient unnecessarily when there is an emergency condition. While hospitals can ask about the patient’s ability to pay, they cannot delay or refuse treatment based on a lack of ability to pay. Hospitals can, of course, refuse to provide treatment or examination in non-emergency situations. Hospitals that violate the law can be fined as can doctors who are complicit in declaring a patient’s condition to be a non-emergency when it actually was.

Since people know that hospitals cannot turn away emergency cases, people who do not have insurance often turn to emergency rooms for medical treatment. In some cases, they do so even for routine care on the assumption that the medical personnel will provide at least some care even in the case of non-emergencies. While there has been some dispute over the exact numbers, this has been a problem in many hospitals for quite some time.

Obviously enough, when a hospital provides “free” medical care to the uninsured, it still must be paid for. After all, medical personnel do not work for free nor do the supplies and equipment needed for treatment come free. While hospitals do try to collect from the uninsured patients, this often does not cover the bill. After all, most people who are uninsured are without insurance because they cannot afford it  rather than as a matter of choosing to forgo it. As such, the costs must be passed on to those who have insurance as well as on to the state. It is estimated that covering the bills of the uninsured adds $1500 to a family’s insurance premiums and about $500 to that of an individual.

As such, under the current system hospitals are required to provide services to those who cannot pay and the insured and the taxpayers are compelled to pay the bill. Thus, some people are not taking responsibility by paying for what they receive and others are left to pick up the tab-including the state. This is exactly the sort of situation that one would expect a conservative to rail against. After all, it involves people getting something for nothing as well as other people being compelled to pay more. And, of course, it also involves the state in providing “handouts.”

In this situation, there seem to be two main legitimate conservative options. The first is to ensure an end to the free ride and the government handouts by compelling people to get insurance. This way they would be paying for what they received and not being free riders. This, coupled with the Affordable Care Act,  would also have the benefit of allowing people affordable access to non-emergency preventative care which would be better for their health and also reduce the strain on emergency rooms. There is, however, a second option.

A second way to address this problem is to repeal the part of the  Emergency Medical Treatment and Labor Act that requires hospitals to provide emergency care to people who cannot pay. If those without insurance or money were not treated, then there would be no extra cost to pass on to the insured or to the state, thus solving the problem at hand.

Obviously, while the second solution would save some people money, it would not come without a price. It would require accepting that people should be left to die if they lack the financial resources to pay for vastly overpriced medical care. I would certainly hope that this is not a value that my fellow Americans would endorse, but perhaps this is not the case. Perhaps we should be free of the burden of caring for others and they should be free to die on the curb of a hospital because the job creators did not create an adequate  job for them.

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15 Responses

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  1. ajmacdonaldjr said, on April 2, 2012 at 7:53 am

    According to your logic,

    A = we legalize the individual mandate

    because A is true, and because broccoli (B) is good for people, the state now has a legitimate right to compel people to buy B

    therefore:

    the individual has no rights; the collective state is all powerful

    • magus71 said, on April 2, 2012 at 8:41 am

      AJ,

      That’s pretty much the guts of the argument.

      Most Americans polled oppose the Individual Mandate; in this case it seems that what the people want should be heavily considered. I think the will of the people is the way we should be deciding on laws that protect people from themselves. Though, there’s some excellent arguments that this law doesn’t really protect people in any way they are not already protected, it only empowers government and when government is as distant as Washington, things are bound to become even more inefficient.

    • Michael LaBossiere said, on April 2, 2012 at 1:11 pm

      Well, not by my actual reasoning. In fact I argue the exact opposite of that:

      On the face of it, I am inclined to agree that the state does not have a general right to compel citizens to buy products even when it would be wise and good to do so. As critics have noted, while broccoli is good for people, the state would seem to have no legitimate right to compel people to buy it. This sort of reasoning is consistent with my own view of liberty, which is roughly based on that of John Stuart Mill’s view. The general idea is that people only have a moral right to compel people when the actions in question can cause unwarranted harm to others. Even if doing something would be good or wise, society has no right to compel an individual into doing (or not doing something) when it is not their legitimate concern (that is, involves harm to others).

      Because of my adherence to this view of liberty, I would be against the state compelling people to buy broccoli, to exercise or to quit smoking. After all, in such matters the individual is sovereign.

      My logic would be more like this. Imagine that people sometimes needed broccoli to avoid dying or serious suffering and that some folks have broccoli insurance, so they have paid for their broccoli when they need it. Imagine that other folks lack broccoli insurance and they have to go to emergency broccoli stands. They cannot be turned away if they cannot pay for their broccoli and the rest of us have to pay their broccoli bill either by getting it tagged onto our broccoli bill or to our taxes.

      If we don’t require people to get broccoli insurance and still require broccoli stands to provide “free” broccoli, then we are mandating that those with insurance and the state pay for what other people have used. That is, we are being forced to buy people broccoli. If we do require people to get broccoli insurance or pay a fine, then we are requiring people to pay for their own broccoli.

      It might be countered by saying “well, I do not want to buy any broccoli insurance nor ever eat broccoli.” That is a viable option-as I argued, we could avoid the individual mandate by allowing hospitals to turn away people who cannot pay. Alternatively, we could allow individuals to exempt themselves from paying and also from medical care that they cannot pay for. They would need to be micro chipped or something to ensure that they did not steal services from the rest of us when they were injured or sick and could not pay.

  2. urbannight said, on April 2, 2012 at 9:47 am

    The problem with the Individual Mandate is that it does not address the real problem. People are not purchasing private health insurance because they do not want it or see the need. They are not buying it because they cannot afford it.

    Creating pools of specials policies where people can get help purchasing them is most likely going to result in cut rate policies that cover very little. People will be forced to get them in order to avoid the fines but when something serious really happens, they will not only not be covered, they will have even less money for it than they might otherwise have had.

    People who have good coverage through work are still going broke and losing homes when something major happens because the 20% they have to pay for themselves has gotten so expensive that even good insurance isn’t enough anymore. T

    he real problem is the fact that medical costs go up ever year three to four times as much as the average inflation increase each year. Only part of this is because of uninsured patients. Part of it is based on getting more money for research and part is to increase profit since the country had become focused on the shareholder to the detriment of people, employees, and sometimes the actual business itself.

    The moment the act was passed, insurance companies started changing existing policies. Ours at work doubled the cost of the co-pay for emergicare offices and multiplied the co-pay cost of ER visits by five. Image how much more it will keep going up as more parts of the act go into effect.

    • Michael LaBossiere said, on April 2, 2012 at 1:14 pm

      True-a core problem is the fact that medical care is vastly overpriced in the United States. While the very wealthy can afford the best care in the world, that level of care does not “trickle” down. In fact, we pay more while getting less results relative to other 1st world countries. Of course, it is worth noting that our obesity rates are high and this would tend to result in lower overall health statistics for the United States.

  3. dhammett said, on April 2, 2012 at 6:11 pm

    So, exactly what is wrong with refusing emergency treatment to someone who is brought to the hospital with a fatal wound or illness but has no insurance to cover his costs?. Or people who have decided they don’t need insurance but find themselves wrapped up in their wrecked motorcycles and suffering from dire injuries that they can’t pay for? Why don’t hospitals simply turn such people away? It obviously drives the costs of insurance up for those of us who are responsible or financially capable of purchasing our own coverage. Yet, I hear it referred to all the time as “something that we do”. Why do we do it? Is it a legal obligation? If it is, how did that happen?

    Same goes for people who have insurance but are suffering from illnesses that require treatments that are much costlier than their policies can afford.Surely there are enough private agencies out there that could intervene on behalf of the deserving ones among those mentioned above. And certainly they’re qualified to determine who is deserving.

    • Michael LaBossiere said, on April 2, 2012 at 7:25 pm

      Back in 1986 the United States Congress passed the Emergency Medical Treatment and Labor Act. This act mandates that hospitals cannot turn away or transfer a patient unnecessarily when there is an emergency condition. While hospitals can ask about the patient’s ability to pay, they cannot delay or refuse treatment based on a lack of ability to pay. Hospitals can, of course, refuse to provide treatment or examination in non-emergency situations. Hospitals that violate the law can be fined as can doctors who are complicit in declaring a patient’s condition to be a non-emergency when it actually was.

      • dhammett said, on April 2, 2012 at 7:29 pm

        And the question remains: Why did Congress pass such a law? Did it require President Reagan’s signature?

        • Michael LaBossiere said, on April 3, 2012 at 4:21 pm

          Perhaps because they thought that letting people die because they lacked insurance was wrong? Presumably Reagan did sign it. I don’t recall it being passed over a veto, but I am just going on faded memory here.

          • dhammett said, on April 3, 2012 at 8:40 pm

            Passed by a group of compassionate conservatives. . .
            This requires further research.

  4. T. J. Babson said, on April 4, 2012 at 1:14 am

    There is really nothing wrong with the mandate apart from the fact that a plain reading of the constitution makes it patently unconstitutional. The constitution gives the federal government a small number of enumerated powers, with other powers left to the states.

    • Michael LaBossiere said, on April 4, 2012 at 12:06 pm

      While I think a reasonable case can be made against the mandate, there is considerable precedent for expanding the power of the state and plausible legal arguments in favor of the mandate. Right or wrong, there is a multitude of laws that are accepted as constitutional yet seem to go beyond the enumerated powers. For example, the strip searching of anyone who is arrested was ruled to be legal, although stripping down citizens seems to go beyond the enumerated powers.

      • T. J. Babson said, on April 4, 2012 at 1:18 pm

        “Right or wrong, there is a multitude of laws that are accepted as constitutional yet seem to go beyond the enumerated powers.”

        I agree. It is amazing how words can be tortured to mean what they plainly do not mean🙂

        • Michael LaBossiere said, on April 5, 2012 at 10:36 am

          Or what they seem to mean to some people. Words are rather flexible things.

          • T. J. Babson said, on April 5, 2012 at 10:39 am

            Look at what the Nazis did to Nietzsche.


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