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.
Be well,
David Edelberg, MD
Your analysis of the role our history has played in our health care mess is well formulated. It’s applicable to many of the serious social and economic problems that confront our country. It’s too bad we seem incapable of electing people who understand and can discuss these historical factors.
Don Schoenbeck
Your comments provide interesting reading. The next question that comes to mind is where do we draw the line? Do we tax people who drink too much soda pop or consume sweeteners above an arbitrary government set level? Do we tax wine snobs if they imbibe too much? How about people who watch “too much” television or forget to wear safety glasses when they use a power tool? What if someone forgets to wear gloves and gets frostbite? What about those who enable others to continue their addictions. What about about the coach who witnessed Jerry Sandusky abusing a child and failed to act? Is he responsible for psychiatric care for the child?
It gets crazy real fast. You are correct, this won’t change anyone’s mind. Until people are willing to take total responsibility for themselves and their actions we will have issues like this continue.
A contractor friend of mine stopped by the clinic to get some treatment for the flue. When he got to the counter the clerk told him she couldn’t treat him because his last payment had not been received. Having been refused treatment and in disgust he walked out of the clinic passing about 30 people who had no insurance and were getting treated for free. This was in California.
Tim Rush-Ossenbeck
I was intrigued by the Health Care Ministries comment. What a great core of an idea that is! The issue is how the decision is made about who gets the help each month. I love its, personal yet communal approach, but I it could turn into a popularity contest if participants aren’t careful when more than one or two people are in need. It reminds me of the Caribbean sou sou custom, in which family and friends contribute a specified amount every week or month, and depending on how many are in the sou sou, every stipulated time period one of the participants receives all the money.
Addie
Well said. thank you
Rita Starr
Rita Starr
Extremely well said !!!!
Marie-Pier Guillaud
It’s a slippery slope you are defining as: becoming a burden. Following your logic, I suppose you would do away with alcohol, cigarettes, fatty foods, dairy, red meat, supersize sodas (or all soda), motorboats, cars that go more than 55 mph, swimming pools, mountain climbing, skiing, sedentary lifestyles, motorcycles WITH helmets, power tools, and then an argument can be made, farther down the road for just about anything being potentially burden-some, including old age itself. That’s the ultimate, inevitable and most costly “health condition” most people will contract. As most-heavy users of the heath system, they will be marginalized more and more by insurers. I think the polemic here is: by whom and where are the lines being drawn? Right now it’s by the deep pockets and by those whose pockets are being lined, paving the way for abuse.
Maybe the problem is on the front end, that aid is required by law at all, by, BTW surprise! the very institutions that will benefit . . .
My friends in Canada and Italy don’t even use the system they pay for, they pay extra that they often can afford only with difficulty, for adequate, meaningful, valuable care, and therefore are much more conscientious than the serial patients.
I am not denying there is a care-crisis in this country, I simply don’t think legislating it in the manner being proposed fix will fix it.
diane Leib
Well put. Can we send you to Congress?
Roger Lamb
You nailed it, Doc! Three cheers
Andrea Holliday
Your reasoning was behind the so-called “mandate” proposed well before Obama took office, when “Hillarycare” was being fought over. The whole idea was that people should not get a free ride – we’re all in this together. It is a huge irony that the party that proposed it is now opposed to it! (BTW, I am persuaded by the commenter who feels it is unfair for health-conscious citizens to foot the bill for irresponsible lifestyles. But that is what insurance is all about — pooling the risk. Once in place, perhaps incentives and discounts can be put into the equation — a discount for low blood pressure. That would get results!
Jim Morrin
Right On! I could not agree more with the line of reasoning and the conclusion.
Austin Stern
Apparently the only legal option to Obamacare – and one that would let you keep your freedom to choose the best health care for your situation should you need it – is something called “health care sharing ministries.” This is not a new concept; some have been around for quite a long time. This is considerably less expensive than regular health insurance (50% to 75% cheaper, depending on the plan), and since the people who become members are at reduced health risk because of, shall we say, their lifestyle choices, it will probably remain a much cheaper alternative.
Google the term for more information and names of individual plans.
Obamacare will be a real downer to the US economy, coming at a time of high unemployment when we already cannot afford it. If Obamacare doesn’t force me onto the Medicaid rolls due to reduced employment possibilities (I’m both low income and self-employed/short term contract work, and living on the edge financially), “health care sharing ministries” is probably the route that I’ll be taking.
I’m in total agreement with those who say that Obamacare will drive up the costs of overall health care for most people. One major way this will happen is the increased dependence on prescription medications to treat non-life-threatening conditions, when cheaper and safer alternative (diet, exercise, etc.) exist. Take for example, the “FDA New Paradigm” (Google the term) that would limit an insured’s access to a doctor for “routine” conditions such as asthma, hypertension, and high cholesterol, and instead funnel them into “computer kiosks” in pharmacies for tests and medications. This “new paradigm” is being pushed by (no surprise here) insurance companies and Big Pharma; certain physicians groups and patient advocacy groups are opposed. The greatly increased number of patients who are expected to enter into the health care system under Obamacare relative to the number of physicians is cited as a major reason for the need for this “new paradigm”. Physicians who might counsel the cheaper/safer lifestyle changes for such disorders won’t be given a chance to do so. I simply don’t see how this will be either an improvement to our health care system, provide an overall reduction in health care costs, nor of benefit to individual patients, but this will be one of the immediate results of Obamacare you’ll be seeing. If you think Obamacare will give you more access to your doctors, well, good luck with that.
Margo
Dr. Edelberg,
You do have an interesting perspective. I agree with some of your points in principle, but disagree with your conclusions.
We do have a moral obligation to pay our own freight. Yes. But, I think the American way is encouraging a culture of personal responsiblity for people to pay their way rather than relying on the heavy hand of government to force people into compliance. As far as the car insurance objection goes, we are forced to buy liability car insurance only, not comprehensive. In other words, I’m forced to buy protection for you in case I drive like a maniac, but not for myself.
Plus, are the free riders really the ones driving the health care costs out of control? I don’t think so. Rather, I think it’s mainly the disconnect between the patient’s ability to pay and the price of care offered by providers. If providers know they can charge more because the government will pay part of the bill, then they will.
Look at the cost of college tuition. It has skyrocketed exponentially beyond the pace of inflation. Why? Well, because the government is subsidizing college tutition via student loans. The same thing is happening in health care. Transfer payments from the government to the health provider are just driving costs up, which is unfair for everyone, especially the middle class.
Furthermore, you are an expert in natural health Dr. Edelberg. How much less would insurance premiums be if insurance companies were allowed to cover many of the alternative, less expensive treatments and natural supplements than they are currently banned from covering?
For example, how much cheaper would insurance be if people could be covered for niacin or red yeast rice for cholesterol control instead of much more expensive perscription statin drugs? So, I see a major factor in high health care (mostly drug) costs due to the collusion between the FDA and the Pharma industry.
Why isn’t anyone talking about chipping away at that incestuous relationship?
Nick Costello
Most states require liability insurance for cars. insurance. Why should health insurance be any different? It is the same principle: we-whether the state or individuals- cannot be burdened when drivers cause accidents, but have no means to attempt to rectify what they have done in damages to car, life and limb.
sherrykay50
Why should health care be different? Because it IS different in many ways. Insurance is available for just about anything including foreclosure (for banks, that is). Insurance should not even be involved in health care. Insurance is a FOR PROFIT BUSINESS. Why are they involoved in health care? It makes no sense, only lots of dollars. Why is this system ok with people? It is nothing short of barbaric.
Lisa Weinstein
I agree we need a single payer system, and I don’t like being required to support private companies. I’d also like single payer auto insurance. But given the current Congress and our Centrist President, the ACA as seems the only way to prevent more severe economic troubles. I think it will have to be amended soon, especially for the exchange to work. Appealing to Americans on moral grounds doesn’t work. We’re practical and economically focused. Morality can’t be legislated here, as we keep having to relearn.
As for regional differences, the Civil War never ended. If the South had won (and much of the Midwest agreed with them), they’d be all for big government.
Addie
Well stated, Doc. You just put into words the answers to any remaining questions I had about the ACA and reaffirmed the reasons I believe it to be necessary. I lived in Europe for 10 years and never regretted paying (slightly) higher taxes to ensure that I would have decent health care. I was working freelance that entire time, and paying taxes for a freelance artist is always an ugly proposition. But it is also a moral obligation to pay your dues to the society that supports you no matter where you are because you are a part of it. Plain and simple.
Natalie Turner-Jones
Trying to get a handle on the health care crisis by spreading the cost of medical care does not get at the heart of the problem. When the culture of death and illness– an animal based diet– is replaced with a vegan life style, I’ll be the first one to advocate universal health care. Until then, I do not want my tax dollars underwriting a life style that is irresponsible and cruel and abusive to animals. Want to end the epidemic of disease in this country in one generation without a single tax dollar? Mandate that all children visit both an animal sanctuary and a slaughterhouse. One generation is all we need to turn things around.
David
Good piece. I do think we’d have had universal health care as well as a much better education system if the country didn’t have its long history of racism and racial and ethnic friction.
The distaste for helping people who are “different” I think lies at the bottom of much of the opposition, despite all the appeals to freedom and history that obscure this.
janice Trecker
If we had a Single Payer system, I would agree with you that everyone had a moral obligation to pay their share of taxes for it. But people in this country are so brainwashed to reject taxes (levied by the government for the “good” of the citizens) that they would rather pay health insurance companies (who are for-profit businesses for the “good” of the bottom line for their shareholders). I’m sorry, but I do not feel morally obligated to help line the pockets of million-aire and billion-aire executives.
Lisa Weinstein
Bravo…well said.
Sharon Rukin