Government Mandates And Moral Disagreement

--by Sebastian

Now that the Supreme Court has ruled to uphold the PPCA, a fruitful discussion about government mandates should be more possible without immediate worries of whether gettting it 'wrong' hurts your own side or helps the other side of whichever political divide you happen to be on.

I tend to buy into many of the libertarian arguments against mandates--that the government should generally minimize its decisions about how citizens live their lives.  But an anti-mandate stance has virtues even to those who don't agree with the libertarian critique. 

Government mandates tend to undermine the democratic balance between government action and conscientious objection.  In most modern democratic-style states, we allow for tolerance of moral disagreement by separating taxing and spending.  For the most part, everyone gets taxed and the money goes into a government pool.  That pool of money becomes the government's money.  There are then various government means for determining how that money is spent (direct acts of the legislature, funding through various agencies, etc.).  Nearly everyone has some disagreement with some of the choices made.  Sometimes that agreement has specific and strong moral dimensions (you may believe that the death penalty, or abortion, or crack vs. powder cocaine sentencing disparities are injustices).  You are certainly free to use the political process to attempt to change those government allocations.  But the process allows for some moral distance.  You disagree with how the government is spending its money.  You want to use politics to change how the government is spending its money.  But you aren't generally forced to participate in whatever it is that you object to more than the fact that you have been taxed, and the government later decided what to do with the tax money it collected.  Systemically this allows for diversity and tolerance for many of those who lose out in the political system.  You lost out on your opinion about the death penalty?  Fine, but we don't force you to pull the switch on a murderer. 

Government mandates raise the stakes because they don't allow for that distancing.  They force moral dissenters to choose between personally engaging in the activity in which they lost the political fight, or to defy the government and break the law by violating the mandate.  Even in non conscientious objector cases, government mandates force dissenters to directly participate in the activity that they just lost a political fight over.  It is something worth thinking about when there are non-mandate options. 

Comments

[wj]

In this particular case, it seems like there are only 3 (broad) options**:
- an individual mandate
- single-payer (ala Medicare)
- let people sicken and die when they cannot afford (or are otherwise prevented from buying) insurance.

You can embrace any of those. But if you refuse to countenance any two, just be clear that you are de facto embracing the third.

** everybody feel free to enlighten me as to a fourth option which is totally unlike these three.

[cleek]

in general, i agree with Sebastian's point. but, that kind of ideological purity is a luxury.

we don't have many options here (and wj had listed them). our current system is broken. single-payer is out of the question for political reasons. that leaves a mandate of some kind.

[Dave]

ok, here's my opinion. You don't have to buy insurance, that's fine but if you don't you pay a tax so I don't have to pay for your care when you are sick or injured.

[twitter.com/tobascodagama]

"Government mandates raise the stakes because they don't allow for that distancing. They force moral dissenters to choose between personally engaging in the activity in which they lost the political fight, or to defy the government and break the law by violating the mandate."

Or, you know, just pay the "I don't want to purchase health care" tax, like the bill says.

[Turbulence]

You can embrace any of those. But if you refuse to countenance any two, just be clear that you are de facto embracing the third.

This is only true if you believe that the mandate is necessary to avoid an adverse selection death spiral. Now, the CBO believes that. Every insurance company in America believes that. And every healthcare economist that I've read believes that. But Sebastian doesn't. He's written before that he knows of no experts that agree with him; this is just a case where he's decided that all of the experts are wrong on his own.

[hairshirthedonist]

The only people required to buy health insurance are those who don't already have it through their employer or through a government program (or however else?) and who can reasonably be expected to afford it. Even then, as has been mentioned, you only pay a penalty for not doing so. You don't get thrown in jail or deported or shot. I have a hard time seeing a significant moral dimension in this.

[Snarki, child of Loki]

Re: "mandated actions", there's not so many, but there are some.

Service on a jury for example..although saying "I oppose the death penalty" would certainly get you out of death penalty cases. But if you object to crack vs. cocaine sentencing, it's not so clear that an objection will do any good.

The military draft is another big one, fortunately gone since the early 70s. AFAIK, the 'draft registration' thing is still going on, even if it is a stupid waste of money.

[CCDG]

Reasonably expected to be able to afford it, restricts choice. This creates a moral dimension. No matter how much money I have or don't have, the state of my health, or my willingness to risk my ruin, society has determined the moral thing to spend the money on is insurance. Everything else is rationalization. IMHO.

[Chuchundra]

Don't think of it as a mandate. Think of it as a small tax on individuals who don't have health insurance which partially offsets the costs that the uninsured people impose on the health care system.

[JustMe]

This creates a moral dimension.

The moral dimension is the fact that people lack insurance and thus cannot get health care. That is a morally unacceptable situation.

There are various solutions to this, one of which might be to levy a tax on everyone to ensure that they all have coverage, but a possible mechanism under the circumstances is also to mandate that they purchase private coverage. And that is the solution they went for to rectify this moral dilemma we found ourselves in.

Now, maybe you would find it immoral to be taxed to cover the health care of others, but I find it immoral to be taxed to torture people and invade Iraq. You didn't see me running crying to the Supreme Court over it (though I do think the US was legally liable for some of its behavior, which the courts disagreed).

[CCDG]

JustMe, I appreciate your point of view. I was simply responding to the statement that it was hard to find a moral dimension. Making me pay for insurance rather than making a down payment on a new car, a perfectly reasonable and possible choice, or having just enough to pay down on a house, or having my latte from Starbucks twice a day, imposes a moral decision. Just as much as forcing me to tithe at my favorite church to support their good works would.

It is inherently a moral choice, even as framed by Doc.

[Phil]

No matter how much money I have or don't have, the state of my health, or my willingness to risk my ruin, society has determined the moral thing to spend the money on is insurance.

No, society has decided that you're either going to buy insurance for yourself (if you don't already have it through your employer or family) or you're going to pony up a tax to ensure that you're paying -- even in part -- for your own care when you haul off to the ER for your strep throat.

Because there's no such thing as not consuming healthcare; as noted by Justice Ginsburg in her partial concurrence/partial dissent, First, more than 60% of those without insurance visit a hospital or doctor’s office each year. See supra, at 5. Nearly 90% will within five years. An uninsured’s consumption of health care is thus quite proximate: It is virtually certain to occur in the next five years and more likely than not to occur this year.

If you're going to use it, you're going to pay for it -- whether via your insurance coverage or the tax/penalty -- and not stick the bill to someone else. Personal responsibility. Remember when conservatives believed in that?

[Turbulence]

Reasonably expected to be able to afford it, restricts choice. This creates a moral dimension

I tell you what: if you can find a way to credibly promise that you will never ever need to use medical services while forcing the state to pay part of those bills, I'll grant you your moral dimension.

But the reality is that every single one of us is just one car accident away from needing a million dollars of health care. It doesn't even to be your fault; you could be doing everything right and suffer a hit and run. Since the vast majority of us don't have a million dollars lying around, that means that every single uninsured person is a walking liability.

So CCDG, how can uninsured people who don't want insurance credibly promise to never need the state to pay for their medical care? How can they credibly promise to never ever end up in a bad accident?

[CCDG]

" Personal responsibility. Remember when conservatives believed in that?"

Of course what that leaves out is the fact that I may veyr well have the means to pay for that visit to the emergency room or doctors office, which is not seperated out in those statistics.

What I am being asked to pay for is the people who can't afford to pay either, the insurance or the visit.

That may be morally acceptable but it is not just charging me for something I am going to use, I may be perfectly capable of paying anyway.

[JustMe]

making me pay for insurance rather than making a down payment on a new car, a perfectly reasonable and possible choice, or having just enough to pay down on a house, or having my latte from Starbucks twice a day, imposes a moral decision.

Only in the "taxes = theft" formulation of radical libertarians.

[CCDG]

Turb,

One of the key difference in the famous(now) republican HC mandate and the current law was that the Republican version mandated catastrophic HC coverage.

Directly to your point.

But let's not pretend that 90% of the uninsured are going to have a catastrophic doctors visit in the next 5 years.

[wj]

That may be morally acceptable but it is not just charging me for something I am going to use, I may be perfectly capable of paying anyway.

Just so I understand, are you saying that you would be fine with a third alternative which involved you setting up an escrow account to cover your possible costs? (The value left in the accout would, of course, be part of your estate, when you no longer need medical care. It's still your money, after all, even if it is in escrow.)

[Turbulence]

One of the key difference in the famous(now) republican HC mandate and the current law was that the Republican version mandated catastrophic HC coverage.

My understanding is that most uninsured people showing up at emergency rooms are not being treated for conditions that would trigger a catastrophic insurance policy payout.

And while you may make a distinction between mandates for catastrophic coverage and mandates for non-catastrophic coverage, precisely zero republican national officeholders have endorsed this distinction. They claim that any mandate for any coverage would be unconstitutional. After all, if the government can force you to buy a catastrophic coverage policy, then it can surely force you to buy broccoli!

[hairshirthedonist]

That may be morally acceptable but it is not just charging me for something I am going to use, I may be perfectly capable of paying anyway.

Keep in mind that I wrote "significant moral dimension." If you want to make the argument that there is some sort of moral dimension involved in the purchase of health insurance, go right ahead. But how does that moral dimension compare to, say, the death penalty or killing people in other countries or throwing people in jail for most of their adult lives or torture?

And, if you're willing to "risk your ruin," pay the penalty and let whatever ails you go untreated. That's your choice, morally. No one's forcing you to see a doctor.

[hairshirthedonist]

I mean, if you want to whittle morality down to "I'd rather buy a nicer car than pay for insurance," I'm not sure what to say, other than that you're an interesting kinda fella.

[CCDG]

"And while you may make a distinction between mandates for catastrophic coverage and mandates for non-catastrophic coverage, precisely zero republican national officeholders have endorsed this distinction."

Since I am none of those people, nor were most of them around when the Republican mandate was proposed, I am not sure how this impacts this discussion.

And, yes, my point is most people are not using the HC system under catastrophic conditions. They get a bill, many of them pay it. So the statistics used to justify this mandate are at best suspect.

There is a moral distinction between the current mandate, the previous mandate and no mandate. It is a matter of both degree and kind, both ways that you can measure a moral dimension.

[CCDG]

"I mean, if you want to whittle morality down to "I'd rather buy a nicer car than pay for insurance," I'm not sure what to say, other than that you're an interesting kinda fella"

I was thinking more that I need a car to get back and forth to work and mine is dying, or I have been saving for buying a house and I could probably risk getting sick for a few more months so I can get a house, or, I am 27 in great health and if I need to go to the doctor because I have the flu thats cheaper than insurance.

But heck, if I want a nicer car then me being an interesting person is certainly a value judgement, or a moral one.

[hairshirthedonist]

They get a bill, many of them pay it. So the statistics used to justify this mandate are at best suspect.

Well, that just blows the whole thing out of the water. Who knew?

Many people very well may pay their bill. What that bill actually covers is another question, as is how the provider manages to make up the difference. Are you seriously suggesting that the millions of uninsured are so mostly by choice, and that they're happily paying the full cost of whatever health care they require and not foregoing treatment for things they otherwise would have treated were they insured?

[Sebastian]

"This is only true if you believe that the mandate is necessary to avoid an adverse selection death spiral. Now, the CBO believes that.[etc etc]"

There are lots of other options. You could cover uninsured people with Medicare for example. I think it won't cause an immediate death spiral, and that we would have had the time to deal with it over the next few years. Since the mandate was set to start BEFORE the tax/penalty/whatever it would seem that Congress didn't believe in an immediate death spiral. For a great post by Kevin Drum stating exactly what I mean on this, see here.

[Phil]

I suspect that the Venn diagram of "uninsured persons" and "people who can just pay their doctor bills out of pocket" is a very, very thin sliver.

[hairshirthedonist]

I was thinking more that I need a car to get back and forth to work and mine is dying, or I have been saving for buying a house and I could probably risk getting sick for a few more months so I can get a house, or, I am 27 in great health and if I need to go to the doctor because I have the flu thats cheaper than insurance.

You don't seem to be taking into account the exceptions based on income and/or cost of available insurance built into the mandate. You also don't seem to be considering the concept of risk pooling. The healthy 27-year-olds do help pay for the less healthy 72-year-olds today. Of course, if that healthy 27-year-old lives another 45 years, which is likely (especially if he goes to the doctor before he gets really sick, since he has insurance), he will benefit from that same system as a 72-year-old.

[hairshirthedonist]

You could cover uninsured people with Medicare for example.

And I would be just fine with that, as I would guess lots of other people here would be. But that's got nothing to do with the necessity for the mandate under the actual circumstances.

[Sebastian]

Sure it does. If it is a quick death spiral that will happen tomorrow, it is an emergency that requires a mandate. If not, we have time to deal with it other ways.

[Turbulence]

You could cover uninsured people with Medicare for example.

I don't see how that would help. Is the idea that medicare pays for all uninsured people, but those uninsured people don't have to pay medicare premiums? That would destroy medicare. If the idea is that uninsured people are forcibly inducted into medicare (and pay premiums), then that's equivalent to the mandate now: if you don't have insurance, we're going to take your money forcibly.

If the idea here is that uninsured people are only forced into medicare when they show up for treatment, I don't see how that could address the adverse selection death spiral. I mean, without the mandate, healthy young people have a big incentive to not buy insurance until they have a health problem, at which point, they buy insurance. Letting young/healthy people who suddenly need insurance buy into medicare has the same effect on the market dynamics as the ACA without the mandate; it does nothing to deter free riders and so it establishes a feedback loop where insurance prices spiral out of control.

I don't see Medicare mentioned anywhere in Drum's post. Are you thinking of a different blog post?

[CCDG]

"You don't seem to be taking into account the exceptions based on income and/or cost of available insurance built into the mandate."

I suspect that even people who earn 200% of the poverty level could have the car problem. As for pooling, let's agree to discuss under 65, over that you are in a pretty big pool called Medicare.

And again, 27 year olds paying for 64 year olds is a moral dimension. Which is where this started.

And, Phil, as for the Venn diagram, my understanding is that you believe that sliver would get much bigger without the mandate?

[hairshirthedonist]

And again, 27 year olds paying for 64 year olds is a moral dimension. Which is where this started.

And how does that moral dimension compare with those of the dealth penalty, torture, war, unjust imprisonment, etc.? Most things have some moral dimension to them. So what?

[Sebastian]

Part of the responsibility of dealing with mandates is realizing that they may require better opt outs than if you had just gone through the tax and spend system. An example of this would be opting out of contraception provision if you mandate that employers provide health care plans.

[Phil]

Which, if you are acting as a secular employer, you should not be permitted to do.

And, Phil, as for the Venn diagram, my understanding is that you believe that sliver would get much bigger without the mandate?

No, I believe that under the status quo it's such a small sliver as to be considered trivial.

[Sebastian H]

Why not?

[Byomtov]

27 year olds paying for 64 year olds is a moral dimension.

I don't find this at all troublesome.

Health insurance is unlike other forms of insurance in that it is not useful to think in terms of coverage for short periods of time. The risk is lifelong and in many cases the "event" leading to a claim lasts for years.

Further, as we age, the risk increases sharply, so much so that paying for a policy at age 60, say, that reflects actual risk for that year will be impossible for many.

This implies two things to me:

1. It is foolish to try to match the timing of premium payments to the timing of likely claims over a lifetime. The latter just climbs too fast. Premium payments should be set up to be much more level, and this necessarily means that 27 year-olds "pay for" 64 year-olds. In fact, they are paying for themselves in advance, as HSH says.

2. The 27-year old is paying not just for insurance, but also for the guarantee of being able to maintain insurance even if disaster strikes. That option itself has considerable value, over and above the value of the insurance, so any claims of subsidization must take this into account.

[DaddyD]

"Mandate" is too strong of a word. A penalty tax is levied for those who choose opt out of health insurance. There is also a penalty tax on cigarettes. Does this mean the government has mandated non-smoking? No. They have created monetary incentives for behavior, not mandated that behavior.

[Turbulence]

Seb, would you mind explaining how medicare could be used to prevent an adverse selection death spiral in the absence of the mandate? As I explained in an earlier comment, I can't imagine how this could possibly work. Thanks.

[Phil]

Because, Sebastian, insurance coverage is part of employee compensation, and it isn't an employer's business if an employee spends it on contraception. We've been over this.

[Byomtov]

"Mandate" is too strong of a word. A penalty tax is levied for those who choose opt out of health insurance. There is also a penalty tax on cigarettes. Does this mean the government has mandated non-smoking? No. They have created monetary incentives for behavior, not mandated that behavior.

This is my opinion also. Even using the term "mandate" for this type of policy interferes with clear thinking about it.

Fundamentally, I think, there is no difference between the insurance mandate and any other government policy that says,

"Do X and you will pay lower taxes than if you don't do X."

That the policy is implemented through an additional tax rather than a credit or deduction doesn't change the basic nature of the mechanism.

We can talk bout the wisdom of using tax policy this way - lots of people have - and the wisdom of specific instances, but I think it's wrong to acts as if the ACA approach was some radically new intrusion on individual freedom.

Some opponents of ACA have as much as admitted that had the tax mechanism been set up differently, or even labelled differently, all would have been well. This strikes me as ridiculous. Does the question of Constitutionality really rest on semantic quibbles? If so we should be concerned about the system's robustness.

[bobbyp]

It is something worth thinking about when there are non-mandate options.

Well, OK....then please explain the pure unalloyed hatred of libertarians to single payer or "medicare for all"? And also please explain their incredible ability to sweep aside this oh-so-deeply-troubling "concern" when it comes to their pet government mandates?

Remember, these are the same folks who insist on the absolute government enforced mandate of the private sector to trash the environment, commodify everything about our culture, divert our common resources for private gain, and cheapen our lives.

....and they dare to call this moral.

[bobbyp]

"Do X and you will pay lower taxes than if you don't do X."

Yes. Much like the federal government 'mandates' you marry someone to save on your taxes. You effectively pay a penalty for staying single.

Proponents will reply that this promotes the greater social good, yet will oppose the ACA as an unjustifiable meddling by the federal government....trying to promote the social good.

[Turbulence]

Since I am none of those people, nor were most of them around when the Republican mandate was proposed, I am not sure how this impacts this discussion.

Actually several of them are still around and in fact are leading Republican elder statesmen today. Guys like Dick Lugar and Kit Bond and Orin Hatch and Chuck Grasseley are important players.

CCDG, let's be clear about one thing: this distinction of yours that catastrophic insurance mandates are A-OK but non-catastrophic insurance mandates are constitutionally verboten is a fringe idea. In fact, it is so absurd, that as far as I can tell, there is no one in Congress who believes it. No Republican and no Democrat either. This notion is crazier than Ron Paul's gold standard ideas; at least those ideas have found one adherent in Congress today.

It seems like you've adopted an idea so silly that no one in Congress will back it up even when it would benefit them politically.

[Sebastian]

"Because, Sebastian, insurance coverage is part of employee compensation, and it isn't an employer's business if an employee spends it on contraception."

It isn't a necessary part of employee compensation. I mean, except when the government MANDATES it. In which case they should consider exemptions.

[Phil]

I look forward to your defending the Jenny McCarthys of the world being permitted an exemption from including vaccination coverage in the health insurance they offer employees.

[Snarki, child of Loki]

Some opponents of ACA have as much as admitted that had the tax mechanism been set up differently, or even labelled differently, all would have been well. This strikes me as ridiculous. Does the question of Constitutionality really rest on semantic quibbles? If so we should be concerned about the system's robustness.

Are these the same people that make a big deal about whether the flag in a courtroom has a tasseled fringe?

Or perhaps that you need to enter a SEkrIt KOdE on your 1040 to get out of paying taxes.

Why yes, if such quibbles are legitimate then the US experiment in self-government is a manifest failure. The teabaggers are just the latest eruption of the 'quibbler wing' of the GOP.

[Slartibartfast]

Much like the federal government 'mandates' you marry someone to save on your taxes. You effectively pay a penalty for staying single.

When I got married, it was much more advantageous, tax-wise, for us to remain single. Things might be different now.

That aside, I call bullsh!t on the declaration that people marry to save on their taxes. That is a complete fabrication.

[Slartibartfast]

I believe that under the status quo it's such a small sliver as to be considered trivial.

I agree with Phil, here.

[Hartmut]

That aside, I call bullsh!t on the declaration that people marry to save on their taxes. That is a complete fabrication.

Over here this is actually unlawful and can be punished as tax cheating. It may not be rampant but it does occur and occasionally makes its way through the courts.

[Ugh]

I liked this argument:

Section 5000A(b) is a penalty (or tax) on the provision of healthcare self-insurance. This is not the same as a tax on simply existing, because healthcare self-insurance is an economic decision with real and immediate consequences. The federal government can properly tax (or regulate) self-insurance because healthcare self-insurers are not required to demonstrate financial capacity to absorb the possible costs of their insurance decision, and if that decision proves to be feckless or unwise, the federal government will ultimately absorb a substantial portion of the costs.

That would also provide a basis for upholding it under the Commerce Clause.

Slarti: When I got married, it was much more advantageous, tax-wise, for us to remain single. Things might be different now.

As with most things tax-wise, it depends. If you are both employed, it's generally disadvantageous to get married. If only one of you is employed, then it's generally advantageous

Slarti: That aside, I call bullsh!t on the declaration that people marry to save on their taxes. That is a complete fabrication.

Just like the fabrication that people marry to allow someone to stay in the country under the immigration laws. Or the fabrication that people give up their U.S. citizenship to save on their taxes. Or the fabrication that people might get divorced near the end of the year and then get re-married just after to save on taxes.

[hairshirthedonist]

Doctor: "Your due date is January 4th, Mrs. Jones."

Mr. Jones: "I think we should schedule a C-section or inducement just before the end of the year, you know, to be be, um ... safe!"

[CCDG]

"I agree with Phil here"

This is the part where a cite or even a iirc fact would typically follow. However, if Phil is correct there is absolutely no need for a mandate. We will be adding an enforcement requirement for the IRS that can't possibly pay for itself.

[hairshirthedonist]

Marty, what percentage of people who lack health insurance do you think have enough money to pay out-of-pocket for a reasonable level of health care?

[Slartibartfast]

To the extent that "people" is interchangeable with "some people", Ugh, I agree.

If that kind of thing is ok, then we shouldhave no problem referring to a few or even one Democrat as "Democrats", and so on.

[CCDG]

Turb, just so I'm clear, do you think it is a bad idea?

[hairshirthedonist]

To the extent that "people" is interchangeable with "some people", Ugh, I agree.

And all along I thought he meant everyone.

[Slartibartfast]

if Phil is correct there is absolutely no need for a mandate

I don't see how that follows. The need for mandate question aside, Phil's statement (as I interpret it) is this: people who are uninsured are, in general, not prepared to pay for emergency care; possibly even routine care. But (and here's the key) they avail themselves of that care anyway.

This conundrum is pretty much all of why I've stayed out of the nationalized healthcare discussion. It's a fact that hospitals treat the indigent and pass the unreimbursed cost on to the segment of people who have insurance. They must cost-recover somehow. Would you have them decline to treat?

That's the question that keeps me mostly out of this discussion of what to do in the matter of health coverage.

[CCDG]

hah, we were not discussing a reasonable level of healthcare, nor has anyone actually defined it. The discussion was how often the government pays for noninsured doctor and er visits. It's not clear to me that all the insured people can afford a reasonable level of healthcare by my standard.

[Phil]

Thinking more about this whole opt-out thing, I'd like a comprehensive vision of how this would apply.

Would it only apply to religious objectors? Because that seems like a First Amendment violation.

Would it just have to be something the employer feels really, really strongly about? Even if it's false, like the aforementioned Jenny McCarthy vaccine stuff?

Could an employer offer an insurance package that covers only chiropractic and homeopathy, and nothing else?

[CCDG]

Slart, I don't agree that it is a valid assumption. Especially now when more and more people have access to high deductible policies. Many young people have no or only catastrophic insurance and consume healthcare s la carte. I only asked if there were any facts to support the mental leap from 90% of uninsured people would consume some HC in the next 5 years, and how much of that cost is actually born by the government.

[hairshirthedonist]

Okay, Marty. Let's try again: What percentage of uninsured people do you think can afford to pay out-of-pocket for the same level of care, say, the average state government employee receives? (Is there a reason you're making this fairly simple, easily understandable question seem like like a riddle?)

[CCDG]

Hah, yes there is. I asked a question, or challenged an a assumption about the level of cost assumed or not by the government for ad hoc care. You turned that into a question about the quality of ad hoc care, a tangential point. So i am not letting you obscure my point by asking what is on the face of it a silly question.

[Slartibartfast]

Marty: the thin sliver Phil descibed is the intersection of uninsured and those able to pay out of pocket.

[hairshirthedonist]

Yes. Perhaps there is a fundamental misunderstanding here of what started this discussion.

[Slartibartfast]

That being the case, people [who] have access to high deductible policies makes no sense as a counterexample.

[CCDG]

Slart, pay out of pocket for an er visit? Lots of them, for a doctor visit for a prescription for antibiotics? Lots. Happens every day. For hsh's reasonable level of care? Maybe not so many.

However, my understanding is that the mandate is designed to keep that sliver from growing?

[liberal japonicus]

I believe that hospitals are generally granted non-profit status, which means they pay no property tax, donations are tax deductible, and they can finance themselves with tax exempt bonds, in exchange for providing care to the indigent. This varies from state to state, but it seems that in some senses, taxpayers are already paying for care of the uninsured. However, the hospitals can pursue people until they become indigent, and then write off the remainder. Here is a recent article about the situation in North Carolina. The other articles in the series are also interesting, and this one and this one seem to bear on the discussion.

[CCDG]

Slart, I noticed a few years back that some number of younger employees that had opted out of employer insurance signed up when the much cheaper HD policies were added. I think that's good btw because it covers catastrophic care which, in my small sample was how they viewed it. But they still were consuming HC ad hoc, they got the bill for most of their care.

[hairshirthedonist]

However, my understanding is that the mandate is designed to keep that sliver from growing?

Mine is that the mandate is intended to reduce the number of people without insurance and improve risk pooling to keep health insurance viable. I don't think the intersection between the uninsured and people who can afford to pay for care out-of-pocket is the most relevant metric. I do think things would be a whole lot better if most of the uninsured could afford to pay for their own care (i.e. didn't need insurance). If that were the case, we probably wouldn't be having this discussion, because there wouldn't be a big problem. People would be uninsured mostly by choice and without worry.

[Ugh]

Slarti: To the extent that "people" is interchangeable with "some people", Ugh, I agree.

I see I have fallen victim to one of the classic blunders, in this case never assume your Slarti-fu works 100% of the time.

[Chicagojon]

bobbyp wrote:
""Do X and you will pay lower taxes than if you don't do X.""
"Yes. Much like the federal government 'mandates' you marry someone to save on your taxes. You effectively pay a penalty for staying single.

Proponents will reply that this promotes the greater social good, yet will oppose the ACA as an unjustifiable meddling by the federal government....trying to promote the social good."

I like this comparison - especially in the context of the 'traditional values' movement. Marriage (between a woman and man naturally) is a traditional value, but caring for the destitute isn't and many don't want it to be. Pretty much says it all and goes directly to Doctor Science's post yesterday.

This is why I'll never be a 'true' Libertarian. When given the choice, people don't and won't care for each other. This is proven IMO. I believe that government should have the power to make decisions for the greater good.

[hairshirthedonist]

Check this out. Intro:

Imagine that the US Congress someday decides that as a matter of national security it is imperative for each American adult to be in possession of a smartphone. (Perhaps they believe that we might all need to receive an important text message from Homeland Security in the event of a major terrorist attack.) Suppose also that at the time of this decision there are 100 million American adults still without smartphones, and that the average smartphone costs $200.

According to the Supreme Court of the United States, here is a procedure Congress is permitted to follow:

Step 1: The government levies a one-time $200 tax on everyone who does not possess a smartphone.

Step 2: The government purchases 100 million smartphones from companies of its choosing.

Step 3: The government delivers the 100 million smartphones to the people without smartphones.

But here is something Congress is not permitted to do:

Step 1: The government mandates that everyone without a smartphone buys a smartphone from the company of their own choosing.

Step 2: Nothing else. All done.

In the comments, there is a video of Lawrence O'Donnell on MSNBC discussing the nature of the mandate. Has anyone seen this or heard anything similar? If so, any comments?

[Ugh]

hsh - I think the general response to that is (not that I necessarily agree) there are reasons to have the government jump through certain hoops to accomplish a given result (transparency is one that comes immediately to mind).

[Sebastian H]

I'm not sure I buy into the argument that we shouldn't have constitutional restrictions just because congress could find work arounds if it tries really hard.

[Duff Clarity]

If you choose to have children you pay less tax than if you choose not to. If you choose to buy a house on credit you pay less tax than if you choose to rent. If you choose to get treatment for alcoholism you pay less tax than if you choose not to. If you choose to gamble your money away you pay less tax than if you choose not to. If you choose to take out health insurance you pay less tax than if you choose not to.

So what?

[hairshirthedonist]

So no one has any comment on the possibility (fact?) that the mandate is barely enforceable in that there is nothing the IRS can do if you refuse to get insurance and refuse to pay the penalty, other than maybe withhold funds from future tax refunds? The legislation, in simple terms, says that there are no criminal penalties allowed for non-payment, nor any liens against property. Pretty much, all they can do is send you nasty letters.

[sapient]

Pretty much, all they can do is send you nasty letters.

I don't think that people who are supporting the ACA (like me) are in the mood to consider the possibility that the bill isn't perfect. Trust me, we all know that. For the moment, who cares? We want the bill; we want the bill to stay; eventually, we want it to be better.

[CCDG]

Hsh, the expected solution will be to count the first penny collected as the penalty, thus the liens will be for other taxes.

[hairshirthedonist]

I don't think that people who are supporting the ACA (like me) are in the mood to consider the possibility that the bill isn't perfect.

Well, okay. But I wasn't lamenting imperfection so much as being surprised that no one here brought the issue up in the lengthy discussions we've had, and that I hadn't heard of it elsewhere before today. Just this afternoon I found a Slate article from 2010! quoting the same clauses I heard and read for the first time today regarding the recourse the government had in the event of refusal or failure to pay the penalty. That just seems weird to me, is all.

I'm very, very glad the SCOTUS upheld the law, as I am sure you are, Sapient.

[Older]

ccdg -- "But let's not pretend that 90% of the uninsured are going to have a catastrophic doctors visit in the next 5 years."

Let's not pretend that it isn't a possibility for every one of the uninsured. And for many, that will be a catastrophe.

I'm poor. I never meant to be poor. I meant to be happily retired by now, but due to my foolishness in contracting two types of cancer and an assortment of other ailments, and allowing some of my dependents to be foolishly ill, I find myself in need of a job. Jobs for people my age are not easy to come by, so I am currently employed as a process server. Most of the papers I handle go to people who have bills they can't pay, and almost without exception, those bills are medical bills (and mostly from the ER). A visit to the ER is not cheap, let me tell you.

The main reason people go to the ER and then can't pay the bill is that they have no insurance and are therefore reluctant to go to the doctor before the situation becomes an emergency. Is this a catastrophe? Yes, for some people it definitely is.

Please don't tell me this is not so. I meet these people every day. It is possible that most of the uninsured people who go to the ER can pay the bill "out of pocket", but frankly I doubt it. I had occasion to go to the ER fairly recently, and I would not have been able to pay the bill out of my current income. While there, I did not see anyone who looked to be noticeably better off than I am, and I suspect that, like me, they were counting on insurance to cover the bill, or in the case of the unlucky, some of whom I will be visiting at their homes later, worrying about paying it, but worrying more about their family member or themselves having to go to the ER in the first place. When you can't afford a doctor, you need to worry a lot more than most of us do.

And you know? I think it's weird to hear people saying "Just put the uninsured on Medicare", because, you know, I *have* Medicare. It ain't free -- if I couldn't afford the premium, I wouldn't have it. Premium money for the uninsured would have to come from somewhere, and many of the now-uninsured wouldn't be able to afford it.

[Byomtov]

I'm not sure I buy into the argument that we shouldn't have constitutional restrictions just because congress could find work arounds if it tries really hard.

Even if it's not really hard, and the outcome is identical? Maybe an example would help me understand, but to me it seems as if your thinking turns constitutional restrictions into puzzles to be solved rather than meaningful limits on government power.

[John Spragge]

According to the guiding philosophy of the United States Constitution, as stated in its preamble, does the federal government have a legitimate role in setting standards that ensure as many people as possible have heath care? It certainly provides for the general welfare, ad unless the United States has signed a nonaggression treaty with the tuberculosis bacillus and the HIV virus, it provides for the common defence as well. So I would say the aims of the affordable care act fit with the spirit of the United States constitution. Finding a way to affirm the principle within the limits of the US constitution seems like a worthy goal. In my opinion, the Affordable Care Act does not, by a long shot, qualify as the best expression of that goal, but your supreme court has not affirmed that it does not violate the constitution.

[Sebastian H]

Byomtov, I'd rather having meaningful limits than read the commerce clause out of the constitution entirely (and that isn't even close to a straw man). But if my options are to either have puzzle limits that make congress go through special hoops that might prove politically difficult (remember that the mandate was vigorously denied to be a tax) and no limits at all, I'll choose the former for now and hope for more later.

See for example search warrants. In practical reality, they are super easy to get--far easier than I think the framers ever envisioned and essentially just a hoop for a smart cop to jump through. Nevertheless I don't think dispensing with them outright would be a good thing. Every now and then they provide a meaningful check on police powers.

[Doctor Science]

Let's see if this works:

[Doctor Science]

again, again

[Doctor Science]

Yes? Success!