The Individual Mandate

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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  1. Please check out my blog it’s part of a college project based on the philosophy of a perfect society. aperfectworldproject.blogspot.co.uk

  2. Dennis Sceviour

    “…the rabid rhetoric,” What do you mean?

  3. I have to run to class in a minute, but what I mean is that the rhetoric being used in the “discussion” tends to be hyperbolic. Check out some of the video clips of the crowds around the Supreme Court and what some folks say.

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