Wanted to address the “I am being forced to buy private health insurance” argument I keep seeing on liberal blogs, because I don’t think it gets us where we want to go.
I start with the difference between health insurance and health care. For sixty-some years, liberals have been advancing the argument that health care is unlike other goods and services. We won that argument, essentially, at the most basic level, with this:
In 1986, Congress enacted the Emergency Medical Treatment & Labor Act (EMTALA) to ensure public access to emergency services regardless of ability to pay. Section 1867 of the Social Security Act imposes specific obligations on Medicare-participating hospitals that offer emergency services to provide a medical screening examination (MSE) when a request is made for examination or treatment for an emergency medical condition (EMC), including active labor, regardless of an individual’s ability to pay. Hospitals are then required to provide stabilizing treatment for patients with EMCs.
We don’t have any law like that for access to an automobile. Health insurance may be a little like car insurance, but a person is nothing like a car. We won on that.
Health care (not health insurance, but health care) is different. That’s the crux of the liberal argument, and it’s what all the other liberal arguments are based on: public option, single-payer, etc. If we abandon that, in pursuit of defeating the health insurance mandate, and start conflating health insurance with health care, we lose. That’s where conservatives need to go. That’s not where liberals need to go.
Here’s the Michigan judge who upheld the health care law:
“The health care market is unlike other markets. No one can guarantee his or her health or ensure that he or she will never participate in the health care market. Indeed, the opposite is nearly always true,” wrote Steeh, who was appointed by President Bill Clinton.
That’s why the conservative- libertarian argument fails. I can’t ensure that I won’t be participating in the health care system. I can opt out of health insurance, but I can’t opt out of health care, unless I have a crystal ball, and I’m never going to end up in an emergency room. The whole country recognizes this, or we wouldn’t mandate emergency care regardless of ability to pay, and we do.
Do liberals really want to adopt the conservative-libertarian arguments that conflates health insurance with health care? Don’t we inevitably end up there if we advance the conservative-libertarian argument that we are being “forced” to purchase health insurance, rather than “forced” to cover the cost of the health care we will receive, if we need it?
Here’s the mandate:
The individual mandate will be phased in between 2014 and 2016. The new law says that if you don’t buy health insurance, you’ll have to pay a fine of either $695 or 2.5 percent of your income, whichever is higher. People who don’t earn enough to pay income tax or who, if forced to purchase health insurance, would end up spending more than 8 percent of their annual income, are exempt.
You don’t have to buy health insurance. You don’t have to pay a private insurer. What you do have to do is contribute to the costs of covering the pool called “the uninsured” because if you don’t purchase the subsidized policy and instead pay the tax penalty, you’ll be uninsured. And it costs to provide emergency care to “the uninsured”. A lot. And the federal government reimburses part of that cost.
Mnemosyne
Thank you! It amazes me how many people seem to think that health care is actually free or that current taxes can totally pay for all of it.
When you pay that “penalty,” it doesn’t go into the general fund. It goes into a fund that will reimburse doctors and hospitals when your ass does get sick and needs help. Because health care is not free and somebody has to pick up the tab. Why is anyone supposed to be exempt from paying their share?
arguingwithsignposts
Recently, I broke my arm. Costs for ER visit, x-ray, etc. alone were more than $500 (pain meds). I will end up paying ~$75 (including pain meds).
That’s a very tiny example of exactly why we should have health insurance _at the least_ (although I’d rather Universal Care).
Now where is our resident young person who is always complaining about paying that extra money for insurance?
The Grand Panjandrum
Bravo! Elegant argument for a topic that confuses many people. I love it.
Kay
@Mnemosyne:
I think it’s a trap. I don’t know how liberals go from “there is no public interest-duty that allows the feds to charge me on access to emergency health care” to single payer.
I see the objection. I understand it. I just don’t think it hangs together, ultimately. It works beautifully for conservatives. Liberals are going to hit a big wall at some point, though.
Violet
I’m not the resident young person, but I was a young person once. I had some health coverage through the university I was attending. I never gave it a second thought. Then I fell off my bike and busted open my chin. Had to get it stitched up at the ER. I can only imagine the cost if I’d had no insurance. As it was, it cost me zero (still not sure how that worked, as I think I had a $300 deductible).
That’s just a very small example, with a very minor injury. Many much worse things can happen. It’s ridiculous to think you shouldn’t have to pay. No one is so special that they are immune from getting ill or injured. Even Superman has kryptonite.
Hunter Gathers
Bitching about the mandate is just the latest in the Firebagger Butthurt Chronicles. Want to know what happens if you don’t buy the insurance, and then don’t pay the fine to the IRS? NOTHING. The IRS cannot go after you for it. But the Hamshers of the left bitch anyway.
The Grand Panjandrum
Bravo! Elegant argument for a topic that confuses many people. I love it.
EDIT: Kay, do you know if the money collected by the government will go into a general uninsured fund or will it be part of Medicare taxes? Or has that been decided yet?
Chyron HR
@Hunter Gathers:
I dunno, man. I saw a photo of a SWAT team, and somebody wrote “Armed IRS Auditors??” underneath it. That’s a pretty ironclad argument.
E.D. Kain
That’s a very good point, Kay.
Sentient Puddle
@arguingwithsignposts:
I’ll take up half that role.
When I was on summer break from college one day, I was eating dinner with my parents. I didn’t chew my fajita quite thoroughly enough, and so a piece of chicken got lodged in my throat. After a few hours of hacking and wheezing and attempting to get the damn thing to come back up, I decided that we needed to go to the emergency room.
Yeah, shit still happens when you’re young.
Campionrules
I think it’s wishful thinking that if you don’t the pay the mandate penalty the IRS will just say ‘ no problem dude, we understand’. If there’s one thing I’ve learned about our government, it’s that they’re going always to get theirs in the end. Regardless of what the current legislation says. Try opting out of contributing to Social Security sometime and see how that goes.
Kay
@The Grand Panjandrum:
I don’t know. I hadn’t even considered it, honestly, but it’s a great point, and I’ll look into it.
Sherrod Brown came to see us here, in the middle of the day. I noticed he was hitting this hard: “it costs 1200 per person to cover the costs of the uninsured”. He’s a liberal. He thinks that’s right and good and true, that the uninsured get health care if they need it. His question is “who pays for that?” Right now everyone who pays does. If we have dissenters, people who object to the idea of a mandated purchase, okay, but shouldn’t they contribute to that access they will get? If not, why not, and how do you square that with the bigger liberal position?
Omnes Omnibus
In essence, it is a tax to provide health care. If you have health insurance, you get a tax exemption. If you don’t have health insurance, you pay the tax. I don’t see a problem with it.
The Grand Panjandrum
@Kay: Framing this as a matter of fiscal responsibility is actually a very compelling argument and one that should be made over and over again.
Davis X. Machina
“Kill the Bill” fit on a bumper sticker.
Kay’s argument, succinctly and elegantly put as it is, doesn’t.
And that’s the country, and the internets, and the Left, we’re stuck with. You can Rumsfeld that on your own….
burnspbesq
@Chyron HR:
The only IRS folks who are authorized to carry firearms are special agents in the Criminal Investigation Division. But if you think the IRS lacks resources to collect the “penalty,” watch your pay stubs and your bank accounts carefully if you don’t pay it. Legally, it’s an excise tax on the “privilege” of not having insurance. The IRS can, and will, use all of its collection resource in appropriate cases, including levying on bank accounts, garnishing wages, and seizing assets.
Bill Murray
Isn’t this the argument for universal care from the government? Well except for the use of the term uninsured. Health care does cost money, the cost is lowest when spread over the greatest number of people. The cost is also lower when you don’t have to pay for the middleman’s profit and CEO salary; thus, government universal care
Kay
@Omnes Omnibus:
I like that argument a lot, and I think the DOJ end up advancing it, in a sense, as an alternative to the “public interest” line of argument. It’s handy that the fine is in the tax code.
Because I get a mortgage interest deduction, and you don’t, are the feds forcing you to buy a house?
burnspbesq
Back in the day, when we were arguing about a helmet law in California, it was noticed that there was a strong and statistically significant positive correlation between riding without a helmet and not having health insurance. The “why should I pay if you get in an accident and spread your brain all over the payment” argument was pretty persuasive.
If you can talk about negative externalities and free-rider problems in terms that people understand and relate to, those are usually winning arguments. People intuitively understand the free-rider problem.
Davis X. Machina
@Bill Murray:
Yeah, this is exactly the argument for universal care from the government. Run for the US Senate, and you have my vote.
Kay
@Bill Murray:
It is. That’s why the liberal line on opposition to the mandate bothers me. I think they inevitably end up destroying their whole larger premise, to the absolute delight of conservatives.
burnspbesq
“Pavement,” not “payment.” No, that’s not Freudian, that’s FYWP. Whaddayoutalkinabout, I can’t edit?
The Grand Panjandrum
@Kay:
Another excellent point. This could be effectively used against conservative critics of the HCR legislation. By the same logic they employ to argue against this bill shouldn’t they also argue FOR the repeal of the homeowners mortgage interest deduction?
Brachiator
That a person is uninsured does not mean that they will either need or will not be able to afford health care. The idea of paying for someone else’s health care is fine for some, but sticks in the craw of others, and this is where the problem is, as is the idea of forcing a person to pay for health insurance even if they decide that they do not want it or need it. To say that they must pay for it today because they might need it tomorrow again sticks in the craw of some people.
The argument here has not been won, and the push back is obviously fierce in some quarters. You gotta come up with a better argument.
Massachusetts has an insurance mandate, and the people there appear to be happy with it. Perhaps feedback from actual results might be useful.
Otherwise, the individual mandate appears to be easily open to challenge.
cat48
Excellent post, Kay…..I, too think they really don’t want to go down this road to nowhere except repealing health care. Once they do that, Medicare, Social Security, minimum wage, labor rights, etc. Some teabaggers are openly running on eliminating minimum wage, labor protection laws, and at least 2 are running on eliminating public education all together!
There’s a good article in the NYT about campaign finance reform and how the rethugs have been chipping away at it for years and are now going for political orgs like the RNC next so they don’t have to disclose anything either.
So one has to ask these liberal bloggers, Whose side are you on? They need to pick one!
Stillwater
In the years leading up to the passage of ACA, weren’t wingers incessantly focusing on how uninsured illegals would use the guaranteed ER services as a basic medical care provider, which in turn drove up costs for everyone who was not a free-rider? And aren’t they now arguing that measures to prevent free-riders from overburdening the system constitutes an assault on our freedom?
Even tho these two views appear inconsistent, for the
wingercontemporary conservative, they just feel right. QED.BGinCHI
@Kay: GREAT post, Kay.
The only thing I’d add, and I’m sorry if it’s here somewhere and I’m repeating it, is that we ALREADY pay when the uninsured get treatment. What reform is supposed to do is address this and make the system work more efficiently (and more equitably).
What Libertarians and the GOP do is pretend that we’re going from paying nothing to paying something. That’s bullshit.
arguingwithsignposts
@Brachiator:
Unfortunately, under our current system, your argument fails mightily. The whole _point_ of insurance is you have it _in case_ you need it, and not everyone _will_ need it, or else it wouldn’t be _insurance_. That’s not just health insurance, that’s *any* kind of insurance. You pay insurance on your house because you might need it tomorrow. You pay insurance on your vehicle because you might need it tomorrow.
The weakness in your whole argument is this: “you are being forced to pay for someone else’s health care.” No. No. No. You are paying against the probability that _you_ will need health care and won’t be able to pay for it out-of-pocket.
Davis X. Machina
Only in a no-fault state. Here you pay insurance on your vehicle because I might need it tomorrow.
kay
@arguingwithsignposts:
Well, what he’s saying is if he opts out of the insurance mandate, and pays the fine, he (might) be paying for someones health care.
But he’s paying for health care for the uninsured every time he pays for health care. The costs don’t disappear. Even if medical debt incurred by the uninsured is discharged in bankruptcy, the service was provided and someone has to cover the cost. The cost isn’t quantified, per person, but it has to be there.
Steve
@burnspbesq:
Section 5000A(g)(2) of the Affordable Care Act provides:
So, actually, all of those things you mentioned are prohibited by law.
Steve
@Brachiator: How much of your paycheck and mine goes to pay for disability insurance for other people, let alone health insurance for a bunch of old people? Yet the payroll tax has not inspired a revolt.
What percentage of Americans either have health insurance coverage or would love to have it if they could afford it? A really high number, right? So where do you find all these people who object on principle to paying for other people’s health care? That’s exactly what you do when you buy insurance!
arguingwithsignposts
@kay:
should be stapled to the head of every GOP candidate who rails against “Obamacare.”
Mnemosyne
Part of the free rider problem, I think, is that it’s been totally normalized by the “tax protesters.” It’s actually expected that everyone try to duck as many of their collective responsibilities as possible, and if you don’t, you’re a sucker and a fool. So the very idea that someone would voluntarily pay today for a service to be there in the future in incomprehensible to a lot of people, and it’s affected the left, too. How many times have we seen people say on here that expecting the government to live up to its responsibilities is a sucker’s game?
kay
@Brachiator:
Okay, but liberals should watch where they’re going, because this argument is going to lead them right into a box.
A person is a person so might need an emergency room that is open, and that costs, health insurance or no health insurance. “Health care” isn’t an abstract proposition. It means buildings, and staffing levels, whether you use it or not. It has to be there.
Jim
One certainly doesn’t have to like the individual mandate. Obviously, the bill is flawed. But for a liberal to say that it is unconstitutional is full circle wingnuttery.
I have to agree with Greenwald that the degree to which what people think is “unconstitutional” aligns with which policies they personally oppose is way too widespread.
JGabriel
Kay: good explanation of an important but little considered distinction. Thanks. Nicely done.
.
Kyle
@Mnemosyne:
Ask the guy who watched his house burn down because he didn’t pay the firefighters’ fee.
KDP
@Steve: Thanks Steve. Additionally, the way the penalty will work is as an embedded part of your annual tax filing. On your 1040, 1040EZ, or whatever form you use, there will one or more new entry boxes. One will be for you to enter your insurer (and possibly insurance number) at which point, you are done. The other will add the 675 to the taxes you owe if you did not fill in the insurer box.
Most people in the United States get a refund on the federal taxes. According to Kiplinger in 2006:
.Kiplinger today claimed the average refund as $2900
What most people who do not choose to buy insurance are more likely to see is a reduction in their total refund, or a tax due if their overpaid taxes were < 675. All of the arguments about this 'tax' seem to presume that the IRS is going to send a separate bill for $675. So, if you choose to pay the penalty rather than buy subsidized insurance, even that payment model will be reasonably painless and embedded in activities that you already perform annually.
As far as enforcement goes, I suspect that if you owe taxes at all the same enforcement strategies as are currently in place would be in effect. That is, they won't come after you specifically for this penalty, but if you fail to file and pay, you are subject to existing collection policies.
Wonderful post, Kay, I wish our politicians and media talking heads would spend more time talking about the practicalities of how this works and less going over mindless and uninformed opposition.
Brachiator
@arguingwithsignposts:
This gets interesting, but doesn’t quite address my objections. I’m not sure whether all states require that you get homeowner’s insurance in order to purchase a home, but I know that in California homeowners often omit major fire or earthquake coverage because they deem it to be too expensive, even though there is obviously some risk that their homes may be damaged or destroyed in a fire or earthquake. But they are not required to make these purchases even though the risk is not trivial.
In car crazy California, a person is not required to purchase auto insurance. A person is required to have proof of financial responsibility, which can be a cash deposit of $35,000 with DMV; a DMV issued self-insurance certificate; a surety bond for $35,000 from a company licensed to do business in California; or plain old auto insurance.
A person who doesn’t own or operate a vehicle is not required to purchase auto insurance for the benefit of other people, or even if he rides in someone’s car.
There is an obvious benefit in having as many people as possible participate in a health insurance pool. But this is a benefit to the ovearall system. It is still a stretch to force someone to participate in the pool to benefit others even though he or she does not want to, or has made other arrangements. And yes, we do this with many other programs, but you still have to justify it.
And clearly there are many people who are not sold on the argument.
Sorry, this doesn’t wash, and even proponents of health care know it. I tend to be in favor of health care reform, but I still have to be honest about what is being proposed. People who are healthy, whose personal histories and risk assessments indicate that they would be unlikely to need health care or who have the resources to provide for their own medical care would still be forced to kick in for an individual mandate even though every available actuarial analysis would indicate that they will not need or benefit from having health insurance.
The only reason for the mandate in this case, is to help keep the larger system afloat and to pay for other people’s health care. This may be a worthwhile social goal, but at least be honest about what you want.
KDP
@KDP: Oops, sorry, my blockquote broke and I got distracted during the edit interval.
Steve
@KDP: As I understand the statute, even if you owe the IRS a bunch of money, they wouldn’t be able to use any of their enforcement remedies with respect to the $675 that’s attributable to the penalty. They can still go after you for the balance of your tax bill, of course.
Nick
@Mnemosyne:
Some douche on OpenLeft one said to me that I didn’t understand the British healthcare system was free (hence single payer is free).
I lived in Britain for eight years.
Midnight Marauder
@Brachiator:
Right, but again, those actuarial analysis are no guarantee of anything, and that’s why this remark from the judge in Michigan renders a lot of what you’re saying moot, I believe:
It may be highly unlikely that the people you are describing participate in the health care market given their histories, but is by no means a done deal. And that’s the biggest endgame this entire argument has to face.
Pangloss
Photo IDs. You can’t really function in society without a photo ID. While it may not be an actual mandate to purchase and maintain a valid photo ID, it’s an effective mandate. Isn’t it?
arguingwithsignposts
@Brachiator:
You are filling up your car with gasoline. Not looking, you step over the gas hose to check your windshield to see if it needs cleaning. You find your foot somehow entangled in the gas hose and suddenly you are falling face first toward the concrete.
There is fuck-all actuarial tables that will show you are going to have that accident.
Or this: You are a young woman fresh out of college. You meet a young man whom you think is attractive. The two of you do what men and women do. And somehow, you didn’t include protection in the heat of the moment. For whatever reason, you (and the young man) decide to have the baby. It’s *at least* a $5,000 (and I’m lowballing it here) trip to the hospital for a delivery.
So fuck you and your actuarial tables. Shit happens to people. You can say the odds are in your favor (and I’m well beyond realizing that the odds played out in my favor) but that isn’t always the case.
And if you want to point me to all those young 20-somethings who have the money to pony up for their own health care (without being on their parents’ insurance), then please do so. If you’ve got a $50,000 savings account that will pay for your med bills, don’t pay the mandate.
Otherwise, bite me.
Emma
So let’s see. You are healthy, unlikely to need health care within the next year, so the government gives you the option to opt out. Then you are unlucky enough to have a kidney malfunction and you are put on a transplant list. In the meantime, there’s three-times-a-week dialysis. Then you get lucky and a kidney becomes available and you have surgery, plus whatever therapies, etc. are necessary afterwards
And here you are. You’re in hock for over a million and a half dollars (I’m not making that up; I have personal reasons to know how much it cost, ok?). Unless you’re lucky enough to have that much sitting around in a bank account, you’re broke. Wiped out. The hospital arranges for a payment schedule. Twenty years later you die and you haven’t made even a dent in that amount.
EVERYTHING you don’t pay gets passed on to the rest of us. Higher premiums and hospital co-pays. But even then, hospitals can’t keep up. I read somewhere that last year in San Diego alone, hospitals absorbed $650 million in unpaid emergency room bills. So the government steps in and subsidizes the hospital. And that means the rest of us are paying twice for your “freedom.”
Thanks bunches.
Brachiator
@kay: RE: That a person is uninsured does not mean that they will either need or will not be able to afford health care.
It should lead them into a box, a position that they can then rationally defend or advocate for. I am for health care reform, but one of the things that has continually bugged me, and that I have written about here, is that some liberals assume that just because they won the presidential election, then they could implement all their dream proposals without making a strong case for them to the American people, or even to other liberals.
They also assumed that as long as the overall goal of health care reform was achieved, then details didn’t matter. The individual mandate is a weak link, and is an obvious target. Proponents see it as much the same as the Social Security tax or other payroll taxes, or for paying for public schools even though you have kids in private school.
There is obvious merit to these positions. But you have to be careful of overreaching, especially during these hard economic times.
My general income taxes, and other taxes I pay, keeps emergency rooms open. I don’t have a problem with that. You can’t conflate this with health insurance or the individual mandate.
different church-lady
Respectfully put, it is you who is conflating insurance with care.
I do not have insurance. I do have care. I pay for it out of pocket.
You also make the assumption that if I have insurance, that will guarantee that I have care. Now, I may not know everything about the current law, but I don’t believe there are any guarantees in there regarding denial of care once one has insurance.
I would get behind the mandates if only they had fixed the system they were mandating you buy into. They fixed some little things, but not the big problems. Costs and premiums will continue to go up. Insurance companies will continue to abuse captive “consumers.” Ten years from now we’ll be trying to fix this reform with smarter mousetraps because we continued to allow insurers to behave like rodents.
arguingwithsignposts
@different church-lady:
Are you paying for that bypass surgery? That hysterectomy? That appendix removal? Out of pocket?
If so, you are indeed a wealthy woman, and I envy your riches.
different church-lady
@Emma: I’m going to make a horrible, utterly taboo suggestion here: if you don’t have insurance… (wait for it…) you don’t get the transplant.
Now let me modify that: I’m all for subsidies for people who would like to have insurance, but are too poor to afford it. What I am against, on principle, is the idea that private insurance has become the only way that health care will be paid for in this country — instead of fixing that model, we codified it.
Perhaps I am the only one in the world who feels like if my kidney fails then it is MY tough luck, not society’s, and that society has no obligation to protect me from myself. That’s about a libertarian as I’ll ever get, I suppose.
arguingwithsignposts
@different church-lady:
Yep, I’m not going there. You can have that society to your own self.
different church-lady
@arguingwithsignposts: I will be, if it happens. Or I won’t be, and it will be my tough luck.
ShortWoman
The problem with
the mandatemandatory health insurance is that I am forced to choose from among a group of for-profit entities with a long history of screwing their customers! I don’t have the option of a non-profit or mutual health insurance option that doesn’t make lots of money by charging me for services I don’t need, denying services I may need, and passing on the difference to executives. I don’t have the option of a state-run insurance agency. I don’t have the option of the “Cash/Visa/MasterCard Health Plan” for medical services. I don’t have the option of “voting with my dollars” against the very same highly profitable corporations that got us into this mess of ever increasing premiums for ever decreasing services. These same corporations — to whom I will be forced to give my money under penalty of law — are already trying to come up with ways to follow the letter of the law while circumventing the purpose of the law.So while I agree that everyone needs a way to pay for health care, I disagree with mandatory health insurance as it is currently written.
different church-lady
@arguingwithsignposts: Yes. Death is so taboo in our society that nobody can be allowed to accept it, even for themselves.
different church-lady
@ShortWoman: Indeed, that is my problem too — I’d be perfectly happy to pay into a public system.
But we can’t have that… no, no, no, it violates the capitalism clause in the constitution that half the country imagines is there…
arguingwithsignposts
@different church-lady:
Who said you can’t accept it for yourself? My great-grandfather committed suicide at 90 – in full robust health – because he couldn’t stand being apart from his wife of 50+ years. I’ve never begrudged him that choice.
But I’m not so keen on accepting death for people who aren’t yet ready to go there when there are adequate means to give them a productive life.
Chyron HR
@different church-lady:
Yes. When they’re not collecting Obamacare fines, the armed IRS agents will be dragging sick people to the hospital and forcing them to get dialysis and kidney transplants. It is 1984 come to life.
(If only we had listened when the Tea Party warned us of the No-Death Panels.)
different church-lady
@arguingwithsignposts: OK, so then let’s not use any examples that involve my paying for my own health care, and let’s get down to cases: the mandates are a crazy-quilt way of bolting public welfare to private industry, and the reason I need to purchase insurance is so that everybody else can get care, not so that I get care.
And you know what? I’m not even against that necessarily. I just wish if this were going to be a public mandate, it would use a public mechanism. Just freakin’ tax me, and let get care at a public clinic. Let’s stop this nonsense where private consumption (and let’s face it, that’s exactly what private insurance is) is mandatory.
Nick
@ShortWoman:
they won’t be allowed to do some of this anymore.
arguingwithsignposts
@different church-lady:
Camel’s nose in the tent, DCL. With the amount of industry $$$ involved here, I’m surprised there’s even a mandate. If you think the insurance cos. wanted that (along with the no-preexisting conditions bit), you’re deluding yourself.
FWIW, I don’t necessarily *like* the mandate. I understand it, and I think it will benefit us all if it moves us toward universal health care through a taxation system, but I don’t think it’s the best system.
But the idea that it’s being set up just to make sure *other people* get health care is just wrong. Most of the country has some form of health insurance already. If anything, it’s making sure the people who *don’t* already have it are paying for their own coverage.
Cathie from Canada
@different church-lady: Well, your argument is sort of ridiculous, really, isn’t it. Sure, why should the rest of America care if you’re too cheap to spend your money on health insurance — but will your family also not care?
What about vaccination you didn’t get, and then you get sick and you infect your nearest and dearest? What about how your nearest and dearest will have to look after you as your fractured ankle gangrenes because you didn’t have it set? Are you planning to get them to cut your leg off because you refuse to see a doctor? And will your nearest and dearest let you die on the street after a car accident because “this is the way Mom wanted to go”?
Ridiculous scenarios, I know. But this is where the “you just don’t get the transplant” argument goes.
Here is “single-payer nivrana” AKA Canada, by the way, we have had an “individual mandate” since the beginning of medicare — our provincial and federal income taxes.
different church-lady
@Cathie from Canada:
DING DING DING DING!!! WE HAVE A WINNER!!!!
But other than that, what makes you think that (a) I have a family, and (b) that I don’t get vaccinated?
Once again, conflation: “no insurance = no vaccination”. That’s what I’m harping on.
Perhaps to have the argument make sense we need to distinguish between regular health care and catastrophic illness. Yes, most people don’t have the cash to pay for their lung cancer treatments, but for crying out loud, a flu shot?
Sentient Puddle
Why do people continue to think that the only reason one would need health insurance is illness? I’m pretty amazed at that.
BTD
@Kay:
Could you link to one of those “liberal” arguments you are supposedly refuting?
This is a “some say” post. I hate that.
Brachiator
@Midnight Marauder:
RE: People who are healthy, whose personal histories and risk assessments indicate that they would be unlikely to need health care or who have the resources to provide for their own medical care would still be forced to kick in for an individual mandate even though every available actuarial analysis would indicate that they will not need or benefit from having health insurance.
Actually, in the aggregate, it is close to a done deal. This is how the mathematics of insurance works.
A friend of mine is incredibly wasteful with his money, always saying that “who knows, you might die tomorrow.” But when you looked at an actuarial table of people his age at the time (35) social class, etc. you did not see that 50% of them had died the next day, of any cause. Or 20%. Or even 10%. My friend is not dead yet either. You can invent all kinds of horrible hypotheticals. In reality, few of them actually happen.
And people who advocate the individual mandate depend on large numbers of healthy people who do not need expensive health care participating in the system. This is one of the ways you try to keep costs down.
There might be other, less potentially disagreeable ways of getting this done. The Obama Administration is going to have to be smart enough to have some alternatives ready.
I’ve noted that I suspect that they thought that they could get away with the individual mandate because of the experience of states like Massachusetts, which has an individual mandate as part of their health care plan. Here is how they do it:
Note that Mass has had to tinker with their mandate since its inception, and it also may be open to some challenges.
I don’t know how proposed federal mandates will interact with any existing state mandates.
arguingwithsignposts
@Brachiator:
This is getting incredibly close to the kind of argument that makes 10 percent unemployment (using gov’t numbers) “acceptable.” You see, it’s really a small percentage of the total population, and those are just numbers in a large aggregate.
Yeah. Not accepting that argument at all.
Emma
Church Lady: Your choice. What if it is your twenty two year old son? Should he die too? Or your 16 year old daughter whose decision you made for her because she’s a minor? Will your equanimity last through months of her agonizing pain, seeing her turn into a skeleton, peeing blood, insanity setting in?
I don’t know how many parents would be brave enough to withstand that.
arguingwithsignposts
@Emma:
You just need to stare harder at those actuarial tables.
different church-lady
@ Emma: So people with children who feel like that should have insurance. They should also have affordable insurance. I’m willing to chip in on that, but the individual mandate on me to hold private insurance
will have no impact on thatis not the right way to accomplish it. It’s not the goal that’s fucked, it’s the mechanism.I also really wish people would stop using my nonexistent children as an example. And appeals to emotion usually don’t work on me. But since this is politics, knock yourself out.
Sloegin
The government can conscript me into forced servitude, slap a green uniform on me, put a gun in my hand, and essentially order me to commit suicide by attacking an enemy machine gun. This is normal.
The government forcing me to buy health insurance? This is crazy!
different church-lady
@Sloegin:
What country are you posting this from?
Sentient Puddle
@different church-lady: Yes, America still has conscription. But just for men.
arguingwithsignposts
@Sentient Puddle:
lolwut?
America has registration. We haven’t had the draft since the Vietnam war.
different church-lady
@Sentient Puddle: No, we have registration. Nobody’s been conscripted since 1973.
Sentient Puddle
OK, terminology fail.
Still.
Brachiator
@arguingwithsignposts:
RE: You can invent all kinds of horrible hypotheticals. In reality, few of them actually happen.
No. It’s not. But thanks for trying. But your argument here is as weak as your previous examples:
You are filling up your car with gasoline. Not looking, you step over the gas hose to check your windshield to see if it needs cleaning. You find your foot somehow entangled in the gas hose
and suddenly you are falling face first toward the concretebut you deftly step out of the hose and go about your business.Or this: You are a young woman fresh out of college. You meet a young man whom you think is attractive. The two of you do what men and women do. And somehow, you didn’t include protection in the heat of the moment. For whatever reason, you (and the young man) decide to have the baby.
It’s at least a $5,000 (and I’m lowballing it here) trip to the hospital for a delivery. A UFO swoops down and beams the two of you up and you live happily ever after with your baby on a planet in the Alpha Centaurii system.Worst or best case fairy tales are not very useful when discussing health care reform.
I am in favor of health care reform. I think the provision in health care reform that allows adult children to be covered by their parents is a huge, and humanitarian advance. In the real world, a fellow commuter’s daughter, age 25, has developed lupus. That she can be included in her parents’ insurance is a huge relief to them.
But the hard fact is that the greater number of otherwise healthy people in their 20s and 30s are not going to need a lot of health care. And people may choose to forego buying health insurance for all kinds of reasons.
Is this the argument you want the government to use if the individual mandate issue goes before the Supreme Court?
Sloegin
Lolz. What is registration. It’s registration for the draft.
We don’t have a draft *right now* because for wars of convenience it’s political suicide. I’ve been around since there was a draft, and I’ll probably still be around when we have one again.
It’s not some historical argument. It’s current law on the books.
arguingwithsignposts
@Brachiator:
Neither of those are hypotheticals in the purest sense of the word, B, they are anecdotes. Not worst or best case fairy tales.
And, fwiw, we’re not _at present_ discussing health *care* reform. We’re discussing health _insurance_ reform.
And the hard fact is that – despite your actuarial tables – we don’t know for sure _which_ of those 20s or 30s people are going to need that health care. We can guess, and make a pretty educated guess, but it’s still a guess.
arguingwithsignposts
@Sloegin:
FTFY
Emma
Church-Lady: I wasn’t trying to appeal to your emotions. I was trying to point out that there are many, many people, those of us whose feelings are perhaps more foolishly engaged, who wouldn’t let a child die even if the parent was an arsehole who decided to take chances. So the society bears the brunt anyway.
NR
This argument is a complete and utter failure because of one simple fact: Insurance does not mean care.
The private, for-profit insurance model, which the HIR bill perpetuates and strengthens, is not designed to provide care. Its purpose is to make profits. The way it makes profits is through denial of care.
Under the HIR bill, you are forced to give your money to a private insurance company, which they will then use to pad their bottom line and increase their profits. If you don’t pay, you are forced to pay a tax penalty, which will then go to government subsidies of private insurance company profits. So either way, you do have to pay a private insurer, which will take your money for profits and then do everything it can to deny you (or someone else) critical health care when it is needed most.
This is the system that you fought like hell to preserve and entrench, so I hope you’re happy with it, because there will be no real reform for at least a generation.
arguingwithsignposts
@NR:
Thank you, firebagger.
ETA: What part of “I start with the difference between health insurance and health care.” do you not understand?
Mnemosyne
They will not need or benefit from having health insurance at that moment of payment. Believe it or not, 25-year-olds do not stay 25 years old forever. Like the rest of us, they get older. They start developing chronic diseases. They have children, with all of the healthcare needs that entails.
Sure, if we lived in the world of “Logan’s Run” and everyone was executed at 30, your plan might make some sense, but in a world where everyone gets older, with all of the potential health problems that entails, your plan makes zero sense whatsoever if those 25-year-olds expect there to be a health care system when they need it 10 or 15 years down the line.
ETA: And that’s leaving aside preventative care and screening — it makes more sense to do a pap smear on a 25-year-old and treat her precancerous condition than it does to wait until she has full-blown cervical cancer at 40.
Just Some Fuckhead
Jesus, we’re using the draft now to justify the health insurance bill? How about going all the way: the president can have you fucking killed so what’s the big deal with a little extortion?
Martin
@NR:
Quit trolling, or learn something. The majority of health insurance providers in the US are non-profit or more likely not-for-profit. And the for-profits primarily handle group and not individual policies.
ACA doesn’t require you buy insurance from a for-profit. You want a non-profit or not-for-profit policy, there are plenty to choose from. Most regional insurers are non- or not-for-profits. If you want a policy that is more care oriented, shop for a good HMO.
The regulation side of ACA is going to knock out most of the widespread problems. Foremost, ACA empowers regulatory bodies to do a LOT more than they could in the past. Washington state told their insurers that because of state law, insurers could not drop plans for children as that was age discrimination. The insurers either need to offer the no-preexisting conditions policies, or get the hell out of the state.
This wasn’t really an intention of ACA, but it was a possible outcome that they didn’t fight very hard, but ACA will most likely drive all of the for-profits out of selling individual policies. In effect, the bill will probably end up creating public insurance pools in most states simply by driving the existing companies out of the individual market. They’ll instead exist through group plans, which are also mandated for most employers. People with group plans tend to have far fewer problems with their insurers because they can’t change the policies based on how one employee or group member uses their insurance. And if companies get tired of dealing with these insurers, they’ll start lobbying for employees in the state to join the public pool – and states can go that route so long as they cover all the bases that ACA is designed to cover.
Policy making is all about creating incentives and penalties to extract a certain outcome. You can’t see the result of that until those things have had time to affect the behavior of individuals and companies. So yeah, it all looks like shit now, but that’s because you don’t understand (and apparently aren’t interested in learning) how the various pieces are going to work. Either that or you’re just a dick. I can’t tell at this stage.
Mnemosyne
@different church-lady:
You know what happens if you don’t get insurance and you get hit by a bus tomorrow? I have to pay for your healthcare, because I do have insurance.
This is exactly what I was talking about up above: you want to free ride on the system and have other people pick up the tab for your care if you need it in a pinch. Sure, you talk big about wearing a “Do Not Resuscitate” medic alert bracelet so the ambulance crew knows to take you directly to the morgue even if you’re not quite dead yet, but you know the law prevents them from doing it. They have to try to save you and, whether they succeed or not, I have to pay for it.
I don’t mind paying my share if I know everyone else is pitching in, too. I only get pissed off when irresponsible people blithely assume they can count on my contribution to their healthcare so they don’t actually have to take responsibility for themselves.
Martin
Oh, and another point that HHS will raise in any defense of the mandate.
Since ACA was designed to address the affordability of care *for the government* over for individuals in this first pass (sorry, but this is at it’s core entitlement reform and not consumer reform), one of the long-standing problems with Medicare and Medicaid is that people without insurance hold off on dealing with quite a large number of health issues until they land on one or the other plans. Medicare isn’t just treating the care of 65 year-olds, but also the residual health problems of those 65 year-olds from when they were 60, 55, 50 years old sometimes. Once they get decent coverage, they go and get these problems fixed up and they haven’t paid enough into the system to cover all of that. The mandate is designed to minimize the amount of care shifting that takes place.
60% of all health care spending occurs after age 65. From 55-64 year olds to 65-74 year olds, spending jumps 50% per capita – and that’s against the overall lower-cost Medicare plan. Too many people are deferring care until age 65, or people working that are lacking insurance are leaving problems untreated until they lose their job, qualify for Medicaid, and then get all of their conditions treated. That’s got to be fixed or else we’re quite simply going to have to tear down Medicaid and Medicare. Social Security isn’t in bad shape at all, but Medicare/Medicaid is in real trouble.
Lurker
@different church-lady:
You may truly feel like this now, but you will change your mind if you ever (Lord forbid) have kidney failure.
I recently read about an American in New Zealand whose kidneys are failing. He has lived in New Zealand for too short a time to acheive residency, so he is not covered under their national health care system. As I understand it, he can’t buy private insurance because of his preexisting condition. He could theoretically move here to the United States for “free” dialysis paid for by Medicare, but he would have to leave his wife of ten years behind in her home country of New Zealand. Trouble is, she’s not only his caretaker, but also a potential kidney donor.
His wife keeps a blog about how they got into this situation and about his health:
http://csmuse.blogspot.com/
They cannot afford to pay for his health care out-of-pocket, but they are not libertarian about this issue.
Martin
@Mnemosyne: One thing that would have cleared a lot of these objections up was to handle hospitalization and medical very distinctly in ACA. Hospitalization is the right we’ve granted everyone. If you’re hit by a bus, the ER *will* take care of you. That should have been done with a simple expansion of Medicare Part A to everyone, and a corresponding expansion of payroll and/or other taxes. Everyone can just go for major medical when it happens. Full stop. That’s a very easy proposition for everyone to defend.
Separate from that would be how to handle medical insurance, which is much more voluntary by individuals and much more socially controllable (don’t smoke, don’t be overweight, etc.) That could be done as a much more free-market solution because the consequences there are typically much lower.
The insurance companies were part of why things got muddled – many of the HMOs have their own hospitals. What do you do with those? And with everyone on Medicare A the hospital groups are pretty much totally fucked. Medicare would provide the overwhelming majority of their payments, they’d be fixed. There’d be some elective treatments and other insurance coverage, but the system would come pretty close to just going the full VA route and having the government run those too since there’d be no profit in running a hospital, and if there’s no profit, most of the reason for it to be a private sector operation is gone. That’s a VERY disruptive change, but that’s where we’re going to end up eventually. Just not in this move.
wobbly
It’s not health care we’re paying for, it’s MEDICAL CARE.
We are not talking about health care here, are we?
Health care is what you for yourself-eat right, sleep, exercise, and so on….
Medical care is what you need if you get sick, pregnant, or have an unfortunate accident.
Greg
On my first trip to Europe, many years ago, I fell ill in Amsterdam. The hotel called an ambulance and I ended up in the hospital. I saw a doctor who determined that I was just severely jet-lagged and dehydrated, maybe a touch of the flu and sent me back to rest. I was in a panic because I didn’t have very much money. When I asked the doctor who I should talk to about payment, he looked truly baffled. He told me just to leave. No paperwork, no forms, no admission, no insurance quizzes. I went to the hospital in an ambulance, got treated, and left. The End. Ever since then I have realized just how pathetic our health care system really is.
Martin
@wobbly: The long-standing distinction in the US has been:
* Hospitalization
* Medical care
Part of the problem we face now is that distinction used to be quite clear. Anything that involved cutting you open or setting a bone was hospitalization. Everything else was medical. With outpatient procedures, urgent care clinics, hospice, and more and more procedures being done in the doctors office what falls in what category has gotten very messy. That’s good from a cost standpoint, because we’re taking things that required a surgeon and 3 weeks recovery in a hospital and turning them into something requiring a GP or a day of recovery. Just look at how much orthroscopic surgery has lowered costs.
Medicare makes these distinctions relatively clear as A and B cover specific things. Blue Cross used to be exclusively hospitalization, Blue Shield exclusively medical. That distinction is lost now in almost every market.
But it’s important to combine health care in with medical care. Two of the biggest long-term contributors to our medical costs, particularly once people hit Medicare are type II diabetes due to poor eating/exercise habits and lung/heart conditions stemming from smoking. If we’re trying to reduce *medical* costs, in those two areas in particular, they need to be tackled at the *health* level.
cckids
Lucky you. Here in NV, if you don’t have insurance, many doctors (especially specialists, like OB/GYN) won’t even see you. You can’t even get an appointment.
kay
@NR:
You pay into a for-profit health care system ever single day.
You stopped thinking at “insurance”. That’s easy to argue, because everyone hates insurance companies. You never addressed paying for health care. That’s hard, because then we have to talk about who earns what and who pays what.
Oh, and incidentally. It isn’t a liberal position to argue against the federal government regulating through the Commerce Clause.
That’s the conservative position, and has been since FDR.
If you want to argue on behalf of dramatically limiting the reach of the commerce clause, you may do that, but recognize that you’re attacking the basis of every social and regulatory program since 1937.
kay
@BTD:
Sure. Sorry. I didn’t want to make it about individual commenters, because I read it in the comments here a lot, so I kept it broad.
I’m just happy to rebut it, because I don’t think it’s a good liberal argument, long term. Actually, I think it’s worse than that. If we get to the commerce clause, and we will, I think pursuing this general argument is disastrous for liberals.
In other words, I don’t want to make it about some liberals versus other liberals, which is what this always degenerates into. As you know :)
I was trying to stick to the actual policy.
Here’s one.
NR
@kay:
There is a huge difference between doctors and hospitals making profits, and insurance companies making profits. Doctors and hospitals make profits by providing care. Insurance companies make profits by denying care.
Martin
@NR: And what about not-for-profits? Most insurers are non- or not-for profits. Where do they fit into your black and white world?
And insurers can’t deny care because they don’t provide care. At most they can deny payment. Doctors and hospitals will deny care if you cannot provide means to pay. Small, but not without meaning distinction.
My insurer is a not-for-profit that works exclusively with a physician-owned for-profit medical group. Premiums are low and I’ve never been denied care, nor have I ever heard of someone that was denied care by them. It is the very model for individuals that ACA is trying to advance nationally.
Nick
@NR:
Yeah, at extravagant prices most people cannot afford, which insurance companies (or the government if we had your public option) have to pay for.
Bill H
Why are we still debating a law that has already passed?
slightly_peeved
Those guarantees – in particular, the restrictions under which insurers in the exchanges operate – is half the damn law. Try reading it.
ccham44
Late to the party, but want to jump in because, while I disagree with different church-lady, I find that most of the people arguing against her are totally missing the point of her argument.
As I see it, there are four, and only four, ways to deal with emergency care for the uninsured (please tell me if I’m missing something):
1) Let the hospital deny care for people who can’t pay.
2) Require the hospital to provide care, but provide no reimbursement. The hospital must eat the costs, and will pass them on to patients who can pay.
3) Require the hospital to provide care, and provide reimbursement from the government. The costs are passed on to all taxpayers.
4) Require the hospital to provide care, and require the uninsured to pay into a fund to cover the costs.
DCL seems to be in favor of 1. This (in theory) forces everyone to insure themselves, put aside funds to pay for themselves in the event of accident or illness, or live with the consequences of not doing so (i.e. suffer and/or die). She also favors subsidizing people who want to insure themselves, but cannot afford it.
The problem is, some people (more likely the young and stupid) will choose to not prepare themselves financially, but will nonetheless be unwilling to accept the consequences. I (and, I imagine, many others) find it unconscionable to force those consequences upon them if they do have an accident or illness. For that reason, I cannot support position 1 under any circumstances.
2 and 3 clearly create free-rider problems. If a person is too poor to pay, I have no problem with this. However, I (and, I imagine, many others) have a big problem with free-riders that are able to pay.
4 forces free-riders to pay up, but at the expense of forcing someone like DCL to pay up too, even though she prefers to make the choice to turn down care that she cannot afford. Sorry, DCL, but I am quite happy to make this trade-off. There are a lot more free-riders out there than responsible people like you, and the free-riders cost me money.
So, anyone who is against the mandate (option 4): specify which alternative you prefer, and convince me it’s better.
Aleshia Nockai
Nice. Thanks for posting this. Its always nice to see someone educate the community.