It's not the same as car insurance

[Charles M.]

It appears likely that Obama and the Democrats will be pushing a new health care bill that, among (many) other things, mandates that everyone purchase health insurance.  In defending this, it is common for people to make the analogy to “mandatory” auto insurance which, presumably everyone is okay with.  There are at least a couple reasons why this analogy, in fact, is a really bad one.

Before getting to the meat of the essay, it has to be said that the mandatory insurance scheme is highly disingenuous.  While excuses and sloppy philosophy will be applied to make excuses for the mandate, the fact of the matter is that the real reason for it is to force the young and healthy into the health insurance system so that their premiums can be used to offset expensive treatment for the old and unhealthy. 

In order to soak the young and healthy properly, the mandate will surely rule out stripped down (catastrophic only, high deductible, etc.) policies that would ordinarily be appropriate for the young.  These types of policies are generally already illegal – at the state level – to provide, which is why many young people forego insurance in the first place.

Back to auto insurance.  The first thing about it is that it is not really mandatory at all.  You only have to have it if you want t drive a vehicle on the public road system.  This is a very important difference from the proposed health care mandate.  If you take the bus, ride public transportation, or live your life purely on private property (difficult, but not impossible), there is no mandate at all.  The proposed health insurance mandate is inescapable.  The mere fact that you exist, even if you live as a hermit in a log cabin in northern Alaska, means that you’re an outlaw if you don’t have health insurance.

The second, and more important, distinction is that of justification for the mandate.  Why is auto insurance mandated?  It’s not because you’re too stupid to understand that if you crash you might not be able to afford repairs to your own vehicle.  The reason is because when you drive thousands of pounds of steel around at 60 miles per hour, you have the potential to cause huge amounts of damage to other people and their property.  To be specific, every time you drive, you probabilistically do damage to other people and property.  An actuary can compute the expected amount of damage you will do to others over the course of a year.  If you apply for auto insurance he will, and that (plus a small upper to pay for business expenses) is your premium.

Notice that mandated auto insurance only includes liability.  They don’t force you to have coverage for your own vehicle.

So, it seems that even a libertarian can make a case for mandatory auto insurance, so long as the mandate is properly worded.  The very wealthy, for example, should be allowed to self-insure or at least have multi-million dollar (or higher) deductibles which would reduce their premiums to near zero.  The point is that the auto insurance mandate is there to assure that you are able to pay your obligations if you do damage to other people or their stuff.

With the above as background, the analogy to health insurance is pretty much destroyed.  Nobody is suggesting that insurance will be mandated to protect other people from you.  The case seems solely premised on protecting you from yourself.  You are too stupid to know that you are “one accident away from bankruptcy”, so we’ll make you get the insurance.  That’s the unstated argument but, as stated above, not the goal.  The goal is to soak the young.

Having said that, there may be a practical (but philosophically flimsy) way to make the case for mandatory health insurance.  The argument is that people are simply too soft-hearted not to pay the medical bills for someone who is bleeding on the street, or even at home slowly dying of cancer.  We could provide a form to fill out, and a bracelet to wear, that says “I opted out of health insurance, you are allowed to let me die”, but even at that the uninsured would be playing a game of chicken with the soft-hearted rest of us.  When it really came down to it, we still couldn’t sit by and watch people die.  We’d have to step in and pay the bills.

I guess the argument is that by merely existing in this society, a person carries with him a level of medical expenses that are inescapable in any practical way.  Either that person pays for them, or someone (everyone) else does.

As I said, this is a philosophically flimsy argument.  But I think there is some truth in it too.  The truth in it, however, in no way justifies the mandating of very high cost “Cadillac” health insurance policies.  At the most, it might be used to justify a high deductible, very stripped down minimal policy.  There is no reason to force coverage for state of the art treatments, let alone chiropractic, hair plugs and breast implants.

If legislators really care about Americans and their financial well-being with respect to health care they should remove mandates, not add more.  Many more people would be insured if they were simply allowed to buy an appropriate policy.  For most people this would mean a relatively high deductible, coverage for things that matter, and limited end-of-life coverage.  Going this route could drop premiums significantly and bring many more people into the market.

[Paul Birch]

Your "philosophically flimsy" argument is not as flimsy as you suggest; you are making the implcit assumption that comparison is with a free market. But what you actually have in the US is a socialised system in which it is obligatory to treat the uninsured; it is unlawful for hospitals to turn away emergency patients and of course there is also Medicare and Medicaid. So an uninsured person is indeed imposing a forced cost on other people (not merely hoping for their charity). Thus the analogy to car insurance is sound (under the current socialist arrangements). Thus either the existing system should be scrapped and replaced by a free market (obviously to be preferred from a libertarian perspective) or health insurance should be mandatory. I agree that this would only justify mandating catastrophic or high excess insurance, not fully comprehensive insurance.

[Charles M.]

I suppose I was thinking from a "blank slate" perspective to some extent, but even in our socialized system, the injured person has to ask for help most of the time.  A guy could reasonably say that he doesn't want to buy insurance, and that he's not free riding because he doesn't want anyone's help and will never ask for it.  He can rightfully say that if he drops unconscious someplace and people come perform first aid, that's not his problem or responsibility.  Maybe he even wears the "I don't want your help" bracelet.  It seems perfectly reasonable that a person should be able to opt out, but would he really not come begging when the reality set in, and would people be able to deny the help?

Wouldn't denying an opt out in this case be the same as saying that since welfare exists it's justifiable to tax you for it, even if you don't want to participate and don't ever want the help?  This could go on endlessly; create an unwanted and unneeded benefit, then use its existence as rationale for more taxation.

[Paul Birch]

I suppose I was thinking from a "blank slate" perspective to some extent, but even in our socialized system, the injured person has to ask for help most of the time. 

He doesn't have to ask. He can demand help as of right (in a wide variety of circumstances if not in all). That's a crucial distinction.

A guy could reasonably say that he doesn't want to buy insurance, and that he's not free riding because he doesn't want anyone's help and will never ask for it.  He can rightfully say that if he drops unconscious someplace and people come perform first aid, that's not his problem or responsibility.  Maybe he even wears the "I don't want your help" bracelet.  It seems perfectly reasonable that a person should be able to opt out, but would he really not come begging when the reality set in, and would people be able to deny the help?

There are several issues here. First, in the US system, he does not need to "come begging" (he can come demanding), and people are not permitted to deny him help by law. And in practice, the majority of uninsured people will and do demand all the welfare state provides. This is very different from the merely moral pressure a beggar exerts. Second, even for wholly honest people unwilling to free ride, to be uninsured is not the same as not wanting help; one may wish to be helped at need, and to pay off the debt later. Perhaps an "I'll pay later" bracelet? Third, one might have to treat "I don't want help" patients anyway (if they were unconscious or incoherent), in case someone had wrongfully put the bracelet on them.

Wouldn't denying an opt out in this case be the same as saying that since welfare exists it's justifiable to tax you for it, even if you don't want to participate and don't ever want the help?  This could go on endlessly; create an unwanted and unneeded benefit, then use its existence as rationale for more taxation.

Welcome to the world. Here, though, health services are not "unwanted" or "unneeded" benefits. They are real benefits that the vast majority of people want (at least as a back up). Granted that a compulsory or socialist health service is bad, the question still remains whether, other things being equal, a system with universal provision through taxation or mandatory insurance is morally better or worse than one in which the uninsured can forcibly free-ride at the expense of the rest. Surely the latter is worse? The former is what we have in the NHS, and what Obama's plan is meant to achieve, the latter what you have now.

[Charles M.]

Welcome to the world. Here, though, health services are not "unwanted" or "unneeded" benefits. They are real benefits that the vast majority of people want (at least as a back up). Granted that a compulsory or socialist health service is bad, the question still remains whether, other things being equal, a system with universal provision through taxation or mandatory insurance is morally better or worse than one in which the uninsured can forcibly free-ride at the expense of the rest. Surely the latter is worse? The former is what we have in the NHS, and what Obama's plan is meant to achieve, the latter what you have now.

It sounds like you are saying that fully socialized health care is the least bad of all conceivable options.  You can't mean that.

The fact of the matter is that free riders will free ride under any system.  In ours they go to the emergency room, in yours they pay no taxes to the universal thing anyway.

I would still much rather have a free market system, and if we need a few ugly patches, so be it.  Maybe we do force insurance with absolutely bare bones coverage and a deductible related to some function of your income and net worth.  Deadbeats would still need to have a policy handed to them for free.  At least having the basic structure of a free system would lead to incentives to use the system sparingly, and provide some incentive to maintaining good health (I think insurers would discriminate on this basis if allowed to).  A market for insurance also maintains some level of "service" and efficiency from insurance companies due to competition.  These ends need to be patched on in an ugly and inefficient way with universal care, through waiting lines and flat out denial of care, plus taxes and fines for politically selected "sins" such as smoking and drinking soft drinks.

Efficiency and service are surely just lost under a government system.  My recent trip to get my driver's license renewed put that into perspective.

I think socialized government systems invite endless nanny-state BS much more than a voucherized market system would.

[Paul Birch]

Welcome to the world. Here, though, health services are not "unwanted" or "unneeded" benefits. They are real benefits that the vast majority of people want (at least as a back up). Granted that a compulsory or socialist health service is bad, the question still remains whether, other things being equal, a system with universal provision through taxation or mandatory insurance is morally better or worse than one in which the uninsured can forcibly free-ride at the expense of the rest. Surely the latter is worse? The former is what we have in the NHS, and what Obama's plan is meant to achieve, the latter what you have now.

It sounds like you are saying that fully socialized health care is the least bad of all conceivable options.  You can't mean that.

I'm not saying anything of the sort. A free market system is entirely conceivable (though at present unlikely). A market system with mandatory insurance is also conceivable. So is a system with tax-funded universal provision plus optional insurance, like the NHS. Neither the NHS nor Obama's plan are fully socialised. What is particularly bad is a regulatory regime in which the optional component is forced to subsidise poor risks and pay for free riders - as in your current system (but not ours).

The fact of the matter is that free riders will free ride under any system.  In ours they go to the emergency room, in yours they pay no taxes to the universal thing anyway.

Not really. Everyone pays taxes - even people on benefits. The basis for taxes is essentially independent of one's health care choices. Obviously the redistributive state cannot be fully just - but the injustice in our system is less blatant.

I would still much rather have a free market system, and if we need a few ugly patches, so be it.  Maybe we do force insurance with absolutely bare bones coverage and a deductible related to some function of your income and net worth.  Deadbeats would still need to have a policy handed to them for free.  At least having the basic structure of a free system would lead to incentives to use the system sparingly, and provide some incentive to maintaining good health (I think insurers would discriminate on this basis if allowed to).  A market for insurance also maintains some level of "service" and efficiency from insurance companies due to competition.  These ends need to be patched on in an ugly and inefficient way with universal care, through waiting lines and flat out denial of care, plus taxes and fines for politically selected "sins" such as smoking and drinking soft drinks.

In the main, I agree. But you still seem to be hung up on a misunderstanding of the current systems. The British system has a comparatively unfettered market in health insurance, supplementing the tax-funded NHS. The US system has a highly distorted insurance pseudo-market in which many of the incentives are perverse, with patchy and somewhat unreliable access to socialised medicine as a fall-back. Mandatory insurance would remove one of the more offensive injustices in the US system (but would not be applicable in the British system).  In the UK, excise duties on tobacco and alcohol roughly match the costs their consumption imposes on the health system, etc., so are not radically unjust. But it is in the US, not the UK, that drinking soft drinks is being penalised; your characterisation of which system embraces health nazism the more is erroneous.

Efficiency and service are surely just lost under a government system. 

I don't doubt it. But what you have now is a "government system", if anything slightly more statist overall than the UK's. It's just set up in a way that looks more like a private, free enterprise system.

[Charles M.]

Efficiency and service are surely just lost under a government system. 

I don't doubt it. But what you have now is a "government system", if anything slightly more statist overall than the UK's. It's just set up in a way that looks more like a private, free enterprise system.

This confuses me.  Educate me on the UK system.  Here in the US, if I become self employed, I purchase insurance from a private company on an open market.  The government intervention comes in that I'm not allowed to pick the policy I really want, as every special interest group has made it illegal to leave their stuff out.  From the doctor/patient perspective, it's pure free market.  I can pay them to provide any service and they can charge any price.  Now granted, they assume I want my insurance to pay and tend to offer only options that are covered, but that's not the government's fault (except for the fact that it is the government that has pushed us into this nearly no deductible situtation).

In the UK, don't the vast majority of people just take what the government provides and live without what it doesn't?  Aren't doctors, in essence, government employees in that the NHS says what it will pay and that becomes the price? Do any doctors, outside of those who cater to the elite rich, do anything but take payment from the NHS at the price it sets?  I thought it was UK where doctors were picketing in the street like garbage collectors or mass transit workers.

There are doctors here who opt out of the government system altogether and deal on the open market.  I think it's becoming a more widespread phenomenon.

[Paul Birch]

Efficiency and service are surely just lost under a government system. 

I don't doubt it. But what you have now is a "government system", if anything slightly more statist overall than the UK's. It's just set up in a way that looks more like a private, free enterprise system.

This confuses me.  Educate me on the UK system.  Here in the US, if I become self employed, I purchase insurance from a private company on an open market. 

No, you really don't. You purchase something insurance-like from a semi-private company on a far from open market.

The government intervention comes in that I'm not allowed to pick the policy I really want, as every special interest group has made it illegal to leave their stuff out.

That is certainly one of the ways the government interfers. It also prohibits companies from turning down applicants willy nilly or charging higher premiums to poor risks, or providing high excess policies, or doing lots of other things they might want to in a free market. Nor is the market open; a limited number of firms are licensed to operate in it, and those firms have to be organised and financed a particular way. There will be whole encyclopedias of rules and regulations they have to follow (that's true in the UK too, but not as bad).

From the doctor/patient perspective, it's pure free market.  I can pay them to provide any service and they can charge any price.

Again, it really isn't. The doctors are highly constrained in what they can do, especially if they work in any clinic or hospital. And of course it's not an open market because only a limited number of persons specifically licensed by the government are permitted to practise. Furthermore, if they take any insured patients at all, they will not be free to set their own charges at will, but will be subject to detailed rules or tariffs. Even if those rules are nominally set by the insurance companies, they themselves are so fenced about with government restrictions that they are effectively more government imposed rules than contractual market agreements. Similarly for Medicare/Medicaid patients.  Purely private transactions, in which a purely private doctor offers a purely private service to a purely private patient, are thus comparatively rare.

In the UK, don't the vast majority of people just take what the government provides and live without what it doesn't?

Not really. The government provides funding; the various NHS trusts, clinics and GPs provide the health care, and people can and do shop around a bit, even on the NHS. And a large minority of people also have private health insurance - the main value of which is in side-stepping waiting lists!

Aren't doctors, in essence, government employees in that the NHS says what it will pay and that becomes the price? Do any doctors, outside of those who cater to the elite rich, do anything but take payment from the NHS at the price it sets?

For NHS treatment, and with some caveats, yes, the government sets the price. But not for private treatment. Most doctors in general practice have at least some private patients or do some private work, as do higher-level consultants, surgeons, etc.,

I thought it was UK where doctors were picketing in the street like garbage collectors or mass transit workers.

I've never heard of this. It sounds most unlikely.

If you compare the total amount of health spending contributed by (or mandated by) the government in various Western countries, as a fraction of GDP, you will find that the US is as socialist as most - and slightly more so than the UK. The overall quality of health care is very similar too, with some differing trade-offs. The UK's weak point lies in long waiting lists for non-urgent operations (emergency care is good), but treatment is almost never refused, and once begun is never cut off. The US system is more responsive initially, but poor for chronic conditions; it is also perceived, in some respects correctly and in others incorrectly, as being less fair.

[heidib7]

Hello, during a google search for something I've now forgotten, I happened across the beginnings of the post of this thread: "It's not the same as car insurance".  Well, I simply had to join if only to enthusiastically agree with this concept, because while I actually didn't put a whole lot of myself into all the "hoopla", if you will, regarding the "health care debate", I was incensed when I heard that analagy being given.  True, it is mandatory for people who CHOOSE to own and drive an automobile to purchase liability insurance, and True - Every State requires this.  But I couldn't believe that it seemed as if I was the only one who noticed immediately that something was a bit off on that analogy.. being that No State requires anybody to own or drive an automobile!   The fact that that was mentioned more than a few times that I heard at least and even though nearly everything else was objected to, unitl I saw this post here, I didn't hear anything about anyone even taking notice of the very obvious difference between requiring auto insurance when people drive by CHOICE, and requiring personal health insurance when people don't really have much choice in whether or not they have a BODY!   So, I signed up to applaud you for having brought this up.  (Of course, I don't watch every news channel 24/7, nor do I happen across every Internet discussion, so I'm sure there are plenty of places where this has been mentioned that I didn't see).  But considering that I was very exposed to much of all the rest of the heated "debates", it would seem that the attention given to this subject is disproportionate to the attention given to most of the other aspects.

O.K., now, obvoiusly since I just signed up, you know nothing about me, so I will tell you the truth, which is that I am not now, nor have I ever been a troublemaker.  I also am not affiliated with any political party because.. well, not to get too much off topic, I'll just say that I have a certain amount of skepticism about what we are told goes on "in Washington" and what really does.. regardless of what party is in power.  I'll leave it at that.  However, if I were to affiliate with a Political Party, the Liberatarian Views are close in many ways to my own.  However, the Internet being well, the Internet, I don't expect you to believe that I speak the truth in regards to my self description just because I said so.  But, at least I tried. 

With that said, I hope you won't be mad at me if I say that once I had gotten in here and was able to read the full article as well as the comments, while I meant every word I wrote in agreement with the ridiculous comparison that was being made, I found during reading the rest, that some sort of "side" issues were brought up as well.  And I fully believe in everyone's right to express their opinion - even if some opinions conflict with my own.  I hope no one will take this wrong if I mention another side to just a part of another issue being discussed here.  I'm talking about where it was being discussed that by law, emergency rooms are not allowed to refulse treatment to anyone, regardless of ability to pay.  And it't not with any of you or your views on this that I take issue with, but it is more of a larger "flaw" in the (seems to me) attitudes of some (I don't speak of all in the least) doctors.  I mean this in the sense that IMO, a person who has the inclination to go into the medicial profession... while the prospect of making a good amount of money which gemerally goes hand in hand with being a doctor is nothing to sneeze at....  still, the first and foremost priority to those in that profession I would think would be the health and well being of the patients who they treat.  And it is with that concept, that I personally don't think it is right for them to be promoting the idea that because they have to treat the uninsured for free by law, that they need to raise the cost of care for everyone else in order to compensate for the "losses" that they take by treating the uninsured.  People seem to readily accept this as fact.  When actually, no other patients should be under any legal, moral or any other obligation to absorb the costs of the uninsured being treated in Emergency Rooms.  If doctors main priority is to heal the sick, ease the suffering, etc... then it should matter not if a certain percentage of their time is taken up by offering those services without compensation by those who for whatever reason (and believe it or not, some do have very legitimate reasons to not be able to pay, and it is through no fault of their own, nor are they all trying to take advangage of the system - sure, some do, but not all).   If the doctors and other medical professionals who promote the idea to the readily accepting public that they are the ones who's costs will go up to compensate for those who are "freeloading", then maybe they should re-think the reason why they chose such a Humanitarian Profession in the first place.  I'm sorry, please forgive me, I'm being repeatitive.  And also, I believe that one (maybe more) of you also touched on this general concept when you mentioned something to the effect that is is human nature to have a hard time just sitting there watching someone dying or suffering and not have an instinctive urge to help, even if done with some feelings of resent.  So, really, is it so wrong for there to be at least the emergency rooms that those with no other means can count on for at least basic medical help?  It has been widely admitted on several news-type documentarys (or whatever you want to call them) by Emergency Room Staff of various hospitals themselves that the uninsured do not get the same level of treatment that is offered to those who are insured.  So again, what really is the harm in this?  One moe thing and I'll get out of here:

Perhaps I feel especially strong about this because of a personal frustration that involves a very real situation with my significant other.  He has worked for an attorney for a very long time, and the firm he works for provides health insurance.  However, he has had a heart murmer from birth that up until a couple of years ago had never had any known ill effect on his health, but because of that murmer, the Insurance Company that offers the Group Insurance to the Law Firm would not insure him under the same cost as the majority of the employees, therefore, he had to pay a portion of his premiums out of pocket.  He accepted that and never made a big deal out of it.  But about 2 years ago, his health deteriorated very rapidly - to the point where he was barely able to walk more than a few feet at a time without having to sit down and catch his breath.  He went to the doctor and after they ran a few tests, he was informed that he had Congestive Heart Failure and at that time, his lungs were full of fluid.  He was hospitalized for a few days, lungs were drained, he was put on several cardiac medications, given a new set of dietary guidelines and released.  Only to find out a short time after having returned to work (part time was all he could physically manage at that point), the Insurance Company for the Law Firm had dropped his coverage completely - the part time status had nothing to do with it, it was the cost of the hospitalization and the fact that Congestive Heart Failure is a chronic condition.  To wrap this up quickly, to this day, he has not been physically able to work enough to make sufficient income that combined with mine can meet out financial obligations.  He is not lazy, nor a taker.  He does though have an ongoing need for continuing medication, which required a doctor's prescription.  He has had to resort several times to the Emergency Room in order to get his prescriptions refilled - which they do with much thinly veiled irritation - always with the "reminder" that he needs to get his own cardiologist.  That being obviosly out of the question, he finally - very reluctantly went to the State to ask for Medicaid assistance.  He was told that because he has no minor dependants, he would have to stop working entirely and go on Disiblity, or they would not be able to help him.    Now, is it just me?  Or is there something fundamentally wrong with such a response?    This might be personal to me, but I would be extremely surprised if there are not thousands of others with very similar stories. (BTW. he is still working what hours he can, rather than go on full disability)

If you read all of this, I thank you for letting me vent.  I will step off the soapbox now.

Thank you all...

[Paul Birch]

... IMO, a person who has the inclination to go into the medicial profession... while the prospect of making a good amount of money which gemerally goes hand in hand with being a doctor is nothing to sneeze at....  still, the first and foremost priority to those in that profession I would think would be the health and well being of the patients who they treat. 

I don't really accept the notion that medicine is intrinsically a "humanitarian profession". A lot of doctors would like you to believe it, because it gives them higher status, but I'm not convinced it's actually more humanitarian than say farming or garbage collection. In an economically efficient free market, all jobs are beneficial to other human beings, approximately in proportion to their remuneration. That's not to doubt that most doctors do wish to help their patients - but not to the exclusion of all other considerations.

And it is with that concept, that I personally don't think it is right for them to be promoting the idea that because they have to treat the uninsured for free by law, that they need to raise the cost of care for everyone else in order to compensate for the "losses" that they take by treating the uninsured.  People seem to readily accept this as fact. 

That's because it is a fact. Not a political stance, or a moral claim, just a simple mathematical fact. The time and resources anyone devotes to unpaid work are time and resources that could have been be devoted to paid work instead; one way or another, they have to be paid for; that payment can only come from the people who are doing the paying. This is true even if you are willing to work for less in order to have the pleasure of helping people - because you're still helping them whether they pay or not. Indeed, in general you will help people more on balance by charging for your services, because, in general, those most willing to pay for a good are those for whom that good has the greatest value (is more helpful). Free medicine crowds out good medicine  (at least to a degree).

When actually, no other patients should be under any legal, moral or any other obligation to absorb the costs of the uninsured being treated in Emergency Rooms.  If doctors main priority is to heal the sick, ease the suffering, etc... then it should matter not if a certain percentage of their time is taken up by offering those services without compensation

The point about charity is that it must be wholly voluntary for all concerned. So if a hospital or doctor chooses to treat some patients for free, or at a reduced price, and other patients choose to purchase full-price services from them, knowing that this charitably subsidises the poorer or presumably more "deserving" patients, that's fine. But if they are forced to do so by law (as at present), or by suppression of free competition, then the freeloaders are wrongfully burdening others without their consent.