Europeans are fascinated by the hurricane-force intensity around the US creating and ultimately passing the Affordable Care Act (ACA). Where European and US historians agree is that individual liberty has always taken priority in the US over the trend of European legislation to be crafted for the greater collective good.
Why is this?
Well, America was founded by an anti-authoritarian population emigrating from dozens of countries, this population swelling over the next three centuries. The result is that Americans never (ever) like being told what to do. Furthermore, a subset of the early colonists who really didn’t want any government authority simply left the East Coast and settled in the Midwest and South. These “super-bastions” of individual liberty have been the strongest proponents of states’ rights, endlessly voting against what would seem to be in their best interests. Not surprisingly, these states were also most vehemently opposed to the ACA.
But three bioethicists (we used to call their field medical ethics) from the National Institutes of Health have, in this week’s Journal of the American Medical Association (JAMA), taken a new stand on this. They suggest that the Supreme Court’s decision to uphold the ACA with its mandate to purchase health insurance is not an issue of rights being trampled, but rather a moral obligation for each person who chooses to live in the US.
In today’s health tip I discuss the JAMA article, but beyond the mandate itself I won’t address where I think healthcare will head because of the ACA. That’s for another time.
What these bioethicists ask is this: however you personally greeted the life-changing ACA legislation–whether with cheers and hurrahs or hand-wringing despair–consider an alternative perspective. They ask you to think out of the box. Rid yourself of the idea that ACA forced upon us the European concept of passing laws for the collective good. You need to do that because otherwise we’ll soon be talking about laws for mandatory health club memberships and broccoli eating.
Instead, think about the health insurance mandate in terms of two specific moral obligations you may not have considered:
- First, that we are obligated as a civilized nation to help anyone in our borders who is in acute distress. Of course, we volunteer to help people beyond our borders too (like travelling to assist Haiti’s earthquake victims), but we should give priority to our own.
- Second, that we must try to lessen the potential burden of ourselves as citizens on everyone else in society. No individual rights language anymore. Convert the language to “moral obligations to each other.”
The first moral obligation is straightforward. We pretty much accept without question the obligation to help someone in acute distress. We don’t debate “Shall I throw a rope to that drowning person?” “Shall I call an ambulance for someone having a heart attack?” We don’t withhold the rope because he can’t pay for it or pay you for the time you spend throwing it.
The second obligation is a shade more complex. Just as the rescuer acts under socially accepted moral obligations, the person being rescued also has certain obligations to fulfill. Let’s face facts. It’s wrong for that drowning person to have put himself in such harm’s way that the rescue endangers the rescuer. You really shouldn’t go swimming somewhere if the only person around to save you doesn’t swim well and drowns in the act of saving you.
Now consider both obligations in terms of health care
First, we in the healthcare system are morally obligated to help anyone needing emergency care regardless of citizenship, race, sexual orientation, zip code, or insurance status. Moreover, it’s an obligation that’s legally enforceable. Hospitals can be severely penalized both by existing laws and private lawsuits for denying emergency care to anyone.
But now, second, if we’re all obligated to help you then are you, the potential patient, under any obligation to us? Are there any precautions you should be taking to reduce any risks to us, the rescuers?
The answer is “yes” and that precaution is the mandate that you have health insurance.
People (especially young adults and healthy people in general) have argued that they don’t want to buy something they don’t need. They’re healthy, jobs are scarce, they could use the money elsewhere. Except of course the young and healthy get pregnant, have asthma, are rear-ended by trucks, become HIV-positive, or get multiple sclerosis or Hodgkin’s disease. Statistics show 25% of people in their teens and 20s required an emergency room visit in the preceding twelve months. Most were uninsured.
The costs of our uninsured population are staggering, well into the billions. And the accumulated financial burden not only reverts to you the uninsured patient (as debt), but is also spread out among hospitals, physicians, and the entire insured population via ever-increasing insurance premiums.
The question to be asked then becomes: Does our uniquely American concept of individual liberty allow you the liberty to choose to make yourself a burden on everyone else?
And the answer is “No, morally you do not have the right to deliberately choose to be a burden.” (I know people do choose to be burdens, but let’s not go there).
Without mandated health insurance—and, it must be said, in the absence of a national health insurance program—there’s no way for you, the uninsured American, to be anything except a danger to yourself (medically, financially) and a financial burden on the rest of us. You cannot be allowed the option to force the rest of us to carry your load if it can be legislated otherwise.
This defense of mandatory health insurance also allows for a different perspective on such safety measures as mandatory seat belts and motorcycle helmets and even tobacco restrictions. To the numerous bikers I see on Illinois highways with no helmets, the argument becomes, “It’s not your head I’m worried about anymore. Wear the helmet because when you’re comatose on a ventilator, I don’t want to be forking over my hard-earned dollars for your 24/7 nursing care.”
One thing about the ACA–everyone has an opinion about it, and usually a pretty vociferous one. I doubt this JAMA article is going to change anyone’s mind. But I think you’ll agree it’s an interesting perspective.
David Edelberg, MD