Mandating health insurance: Yes or no?

A conservative and a liberal exchange views on health care reform…

Jacob: I listened to NPR’s re-cap of the health care arguments before the Supreme Court the other day. Solicitor General Donald Verrilli, representing the White House, was asked why mandating health insurance was different than mandating the buying of other products or services. He responded by suggesting that this market’s services constitute an inevitable need for most Americans–one to which “virtually everybody” turns throughout their lives.

I also used to turn to medical professionals as central and indispensible to my health…then something changed. It started during years of watching several family members go through intensive cancer treatments. One day while visiting my brother at the hospital as he prepared for a stem cell transplant, I noticed his meal featuring jello and white bread (‘anything to get him calories’). Since my brother was at a desperate point in his battle, I asked the attending physician, “Is there any way to nutritionally bolster his immune system to help fight the cancer?” His answer: “No…this stem cell transplant is his best hope.”

After my brother had passed away, I discovered a range of other studies pointing towards complementary supports such as nutrition for helping turn back cancer–including in the most dire of cases. My days of assuming physicians knew the truth about health, were officially over.

Subsequent dissertation research on anti-depressants at the University of Illinois confirmed an alarming degree that the pharmaceutical industry had exercised influence over the entire process of medical research, physician training and patient education. On a micro-level, my study documented ways that an emphasis on pharmaceuticals as first-line treatment for depression was turning people away from a range of other things they might do to improve their mood (“this isn’t about my life choices…I just have a chemical imbalance!”).

All of this is backdrop, Phil, for why I’m uncomfortable with a core presumption taken for granted in the current health care discussion: namely, that we all depend upon, need and want this kind of health care…so let’s just figure out how to give everyone access!

Are we sure such universal access would be an unmitigated good? I’m not. This is not to say, Phil, there isn’t a meaningful, and yes–life-saving–place for medications, surgery and other procedures. If I ever get in a major accident, you better believe I’ll be grateful for our local hospital. They’ve got remarkable–even miraculous–skills at patching people back together after trauma.

But accidents, of course, are only one issue making Americans patients these days: Low energy, low mood…high anxiety, high blood pressure…dry skin, rough skin, wrinkly skin,…weak sex, erectile dysfunction…wide hips, sagging breasts…feeling discomfort or pain in any way? Put your name on the list.

Medical anthropologists and sociologists such as Peter Conrad, of course, have been writing about these trends for decades. Ivan Illich first wrote in 1975 about the “medicalization” of society–raising concern about over-reaching medical interventions causing harm as individuals “expropriate” and give away care over their own health. More recently, John McKnight (1995) from Northwestern University warned that if professional services expand too much, communities can progressively lose some of their natural capacity to care for each other (The Careless Society).

And that’s precisely what I worry is happening, Phil–largely due to industry control over research and education, and now amplified by Obama’s health care law. As we continue in this direction, I envision a whole society of Americans raised up with little or no control over their own health, going about life being hit by problems out of nowhere that need crucial, life-saving, medical attention.

Phil: Do you seriously think, Jacob, that if you live in the right way then you won’t get a chronic health condition, and thus won’t someday need conventional medicine in order to stay alive or avoid chronic pain? I hope you’re right, because I want you to be healthy, but surely many people who live right do nonetheless get really sick.

Jacob: Sure–of course. And science still has a lot to learn about different factors that impinge on our health. At the same time, it’s well known that a major driver of the increasing rates of chronic illness–from diabetes to heart disease–are modifiable lifestyle patterns.

And more optimistically, there is also a thriving movement in the United States going in the opposite direction–focused on empowering consumers for self-care. If my trips to Whole Foods are any indication, Phil, this movement leans strongly progressive….although admittedly, they may not resonate with my descriptions of their organic-food-eating ways as “taking responsibility for their own health.”

In any case, why does self-responsibility and self-care for our health seem such a strange and foreign concept to so many, Phil? Again, I would argue this says more about the larger conversation than it does about ourselves: “How can you deny me MY health care!” says one side. “How dare you force me to buy this health insurance!” says another. Lost in the middle is a simple question: What kind of health care exactly do we really need or want?

Phil: I agree that we should, as a society, talk more about what health care should look like. Now, what about the meantime, when many people aren’t getting care they need or are being bankrupted by the system? Most conservatives are doing all they can to derail Obama’s effort to do something about that, i.e. to get people access to care even if they cannot pay the entire cost and/or have a pre-existing condition. I realize that it’s lousy to be “forced’ to buy insurance, but for years federal law has forced hospitals to provide treatment to those who need it, with the hope that later they will be reimbursed by someone. And conservatives haven’t been fighting to get to the Supreme Court to strike that law down as unconstitutional. Is that because the law requiring hospitals to treat people was not championed by Obama? Let’s think more generously. Maybe it’s because nobody likes to pay now to protect themselves later, much less from something that will only happen to “the other guy.” And, while people pay for hospitals by paying taxes, Obama Care makes them pay for having a safety net by making them buy a product, and that’s more in their face. But really there’s no significant difference.

Jacob: It’s more than that, Phil: there are many other safety nets available, only one of which is called Big Medicine. If others believe in and want that service, they should be allowed to…but what of those people who don’t? After several years of paying thousands and thousands of dollars in health insurance for so little of legitimate help, my wife and I seriously discussed this week stopping the health insurance–and using the money we save to pay out of pocket for needs that arise. Then we realized…’oh wait, that new health care law means we can’t!’

Phil: The Affordable Care Act doesn’t actually say you have to buy insurance; instead it says that if you don’t buy it then you will have to pay a tax come the next April. And that seems fair given that you clearly want the system to be there, for example should you need emergency care. Absent such a policy, what do we do about those forms of necessary care that cost more than most patients can pay, even over the course of their remaining lifetimes? Such care can only be paid for if we spread the costs out by (a) getting most healthy people to purchase insurance or (b) socializing medicine. Obama, being moderate, proposed the former, not the latter.

Jacob: That helps, Phil. My parents have certainly been grateful they didn’t have to carry the fully burden of cancer treatments. My mother has also seen many without this coverage–so I understand that fear and pain is real. For those who want that safety net and aren’t given the opportunity, my heart goes out to them.

That’s also good reminder that under Obama’s plan, I still have the option of not paying. I just looked up what we would have to pay in penalty–and learned that in 2016 when the penalty is fully phased in, it will be $695 for an individual (up to $2,085 per family) or 2.5 percent of household income, whichever is greater (Andrews, 2010). Rather than being forced to pay into a system I don’t believe in, however, why not let me choose how to charitably contribute my money?

Phil: Jacob, if you want engage in politics to try to move the system in the right direction – towards prevention and exercise, away from excess reliance on C-sections and powerful pharmaceuticals – then please go for it. I hope you do. It’s just that I don’t think that the Affordable Care Act puts any new obstacles in your way.

Jacob: Again, we disagree somewhat. I see subtle, and serious obstacles. A good friend of mine who has become extremely overweight, came to me recently, excited that there was a new complex procedure designed to alleviate back pain offered at a local clinic. Multiplying his experience by millions of Americans who have fallen prey to our societal, corporate-driven obesity ‘epidemic,’ I would ask: what conditions will make it most likely that this sub-set of Americans will get to the bottom of their health crises? What about offering all of them guaranteed, 24/7 access to an array complex procedures designed to manage pain, alleviate symptoms, clean out arteries and even replace or repair their heart?

Having said this, my doctor friends will rightly remind me that the Patient Protection and Affordable Care Act, allocates more funds to preventive measures–which is certainly a good thing. (That is also among the first areas threatened to be de-funded in the current economy, however). Even so, the main thrust of the act is to make our especially expensive and procedural version of care available to every man, woman and child.

This is not to say, once again, these procedures cannot be helpful nor shouldn’t be used when absolutely necessary. But when we institutionalize treatment access and need as an inherent right and demand, we may begin to inadvertently create (or justify) the very conditions that incubate even more of the health problems that prompt their use.

Phil: I agree with much of what you say about the health care system. And I would love to see conservatives line up to do something about it. In the meantime, however, I don’t see how getting more of the currently healthy to buy insurance will make the problems you speak of any worse. After all, even people with insurance must spend money to actually get care (e.g. by co-pays). Also insurance companies are vigilant (and often over-vigilant) in limiting what they will pay for and how much. Thus getting everyone insured is not the same as giving people any care they want, on demand. And, finally, Obama Care will bring new funds directly to insurance companies, not pharmaceutical companies, and those companies do in fact need that money if they’re going to cover all people with pre-existing conditions. True, some people get treatment they don’t truly need, including dangerous but profitable pharmaceuticals. But that’s clearly a different problem.

Jacob: It’s not so clearly a different problem to me, Phil. If big U.S. industries all work in interconnected ways, a move towards dependence on Big Medicine will likewise increase dependence on Big Pharma (and Big Government to some degree). And once again, I would still ask: who is positioned to most benefit from this health care law? Is it really the American people? I’m not so sure, myself. Others, however, are well-positioned to benefit from considerably. Let’s just say that Big Pharma (which has done just fine during the recession) is certainly not raising any qualms about this legislation.

Phil: Sure, Obama’s law doesn’t take on Big Pharma. I wish he would. But I can see why he doesn’t, given that no politician can safely go after the biggest companies without being run out of office as “ant-business” and “socialist.”

In my view this issue is really about morality. We each have a responsibility to help others if we can. And the way I see it, that means that healthy Americans should buy health care insurance if they can afford it, or get help to buy it if they can’t afford it, so that people who are radically sick can get a life-saving operation if they need one and can go to the hospital when they have a potentially fatal infection.

Jacob: This all helps me understand where you’re coming from, Phil. So essentially, you’re suggesting that even if we don’t see health insurance as doing much for us, we might see it as an investment in others’ health and well-being. I get that, and I agree that there is a need to watch out for each others’ health–even while we espouse some different ideas on what this should look like.

On my end, it seems to me that people on the left and right might both agree that there is a danger if Americans categorically come to rely so much on others to take care of themselves. Would you agree to that, Phil?

Phil: Yes, I agree with that.

Jacob: Perhaps then, once again, it’s the kind of health care that seems at issue here, Phil. It seems there could be some agreement that rather than simply debating whether people should be able to access “health care”–we ought to talk a bit more about what we believe that health care should look like, what we value in terms of external professional assistance, and what we have questions about.

There is a new documentary film set to premiere next year at Sundance Film Festival by Matthew Heineman and Susan Froemke, “Escape Fire”–focused entirely on reforming health care in just the direction I’m suggesting (see the trailer: I’ve shown the clip to conservative friends and liberal friends…and they all love it.

Phil: I promise to check it out.

Andrews, M. (2010, June 15). What’s the Penalty for Not Having Insurance? Prescriptions: The business of health care. New York Times

NPR: TRANSCRIPT & AUDIO: Supreme Court: The Health Care Law And The Individual Mandate.

6 Responses to “Mandating health insurance: Yes or no?”
  1. Gary Demeter says:

    This appears more typical of a left/right discussion on this issue than a summation of their most valid points on the subject. Is that what’s important? That the liberal will allow the conservative the freedom to define the argument, to let his feelings and concerns drive the conversation, even if they’re only supported by a selective frame-of-reference?

    When did questioning the “inevitable need for most Americans–one to which “virtually everybody” turns throughout their lives” become: “’How can you deny me MY health care!’ says one side. ‘How dare you force me to buy this health insurance!’ says another. Lost in the middle is a simple question: What kind of health care exactly do we really need or want?”

    No. Not lost in the middle is any need to define appropriate healthcare. And certainly not in context of lost choices or “control over their own health.” I appreciate how Phil continually brought reality back into the discussion by diffusing exaggerated rhetoric and asking appropriate questions and introducing facts, but why not stop being a wimpy liberal and point these things out?

    The Solicitor General’s reaction to the broccoli comparison was equally wimpy. Allowing that false argument to not get stuck in their throat’s isn’t just how he lost the debate, it’s an example of how fears and silliness, properly applied, are as effective as reason against ideology. The premise that a person is not already engaged in commerce, and so is “forced to engage” by the Affordable Care Act, is erroneous. Everyone uses health care whether they buy it or not. Being required to buy coverage or pay a penalty is a recognition that, as a matter of practical reality, there is simply no opt-out for health care.

    Sure, you can suggest that lifestyle choices can be factors in needing certain types of healthcare, and some people will always be more costly to any service, but it doesn’t address the inequities and failings of the present system.

    An interesting point is that it can be argued the current, Righty position on mandated insurance is not even dogmatically pure. One of the essential pillars of their “personal responsibility” arguments is that nobody who can take care of themselves should be taken care of by others. And yet, in opposing the mandate, they are supporting the right of the able-bodied and (legally) sound-minded to leach off of others.

    Phil’s too accommodating just like most Libs IMO. To allow his points to be ignored, and even his “social conscience” concerns to be re-defined then summarily dismissed, is the essence we repeatedly see in this debate and the result of the wimpiness of Liberalism.

    It enables the squealing about socialism as an attempt to find a justification for the Regressive policy of Whatever-Obama-is-for-we’re-against. The Rights has done well in spreading their fear of a popular-sovereignty government, while Obama and Dems have done a poor job in getting out the message that people are paying billions of dollars in premiums to cover those who could cover themselves, but won’t.

    • neissept says:

      Hi Gary. Phil here, in agreement with what you say about health care. Which makes me ask: Why is the failure of others to heed my message (and the messages of other liberals and leftists) the result of us (or at least liberals) being “wimpy?” In other words, Why is it my fault that others deny reality? Why, for that matter, do you find what I say to be wimpy? Maybe it’s because, while I support a single-payer system, I didn’t mention that in my post but chose instead to respond to Jacob on the subject of the Obama law. Or maybe it’s because I used a respectful tone, and toook his starting point seriously. If the latter, please consider that (1) the post is a real conversation between two people, not a “debate, ” and (2) we will never change the world for the better unless we are respectful of each other and we are willing to start talking where others are at.l

  2. I must say, that I am absolutely enamored and captivated by the depth of this discussion. As such, I feel compelled to share some of my own insights and observations on the subject. Let me preface my statements by saying, Jacob (If I may call you that), how profoundly sorry I am for the loss of your brother. I applaud your perseverance in what I’m sure was a painstaking effort to improve your brother’s quality of life, for however brief a time. Since this discourse is rather broad, I will address each facet in the order it was posited. On the notion of using alternative medicine as a preferable substitute to coventional and ubiquitous treatment methods, I understand your concerns, Jacob. Our ever-increasing dependence on the use of prescription drugs for even the mildest pathologies; psychosomatic, natural or otherwise, is certainly an alarming trend. It is true that pharmaceutical companies have a lot to gain when new afflictions/disorders are discovered and recognized. It is also true that it would behoove them to perpetuate and proliferate the use of their products, for obvious reasons. Still, I’m not entirely convinced that businesses, or the medical community at large are to blame for their popularity. Through new advances in research and the advent of technology, humanity has great strides in identifying and treating the vast array of illness and threats to our general well-being. In addition, I think there is a lack of accountability and discretion at play here. It is exhibited in the way we view our own health and that of our youth. We would rather blame some sort of mental of physiological defect than to assume responsibility for how we conduct ourselves, privately and publicly. When we appeal to our doctors, we don’t reveal the full scope of the problem nor are we willing to comply with every aspect of propsed treatment. Therefore, the crux of the problem is ignored, and often exacerbated by our our ignorance. Now, forgive me if I’m wrong, but you seem to suggest that over-diagnosis and misinformation seem to be integral to this problem. To a certain extent, I agree. There are cases where doctors order a battery of tests that you may feel are unwarranted given the nature of the problem, but you acquiesce on the pretense that the professional will render only what’s necessary and nothing more. Thus, you feel as though they have better judgement than you do. Similarly, some doctors have a God complex and so they may not be as throrough in their explanations as you would like. In that scenario, it may appear as though treatment decisions are made unilaterally and not mutually. As a 26 year-old man who has lived with Cerebral Palsy since birth, I can tell you I am cautiously optimistic about the recommendations of most doctors. Bear in mind that I am almost in constant need of medical attention, have had 4 major surgeries over the course of my lifetime, including one where I was sujected to anesthesia twice over a 48-hour period. That last occurence the result of negligence. The doctor was due to operate on both legs but only attended to one because he didn’t review the paperwork before he went in to surgery. I told my mother after he came in to apologize and present my options that, had I had the strength (I was on morphine at the time), I would’ve grabbed him by the collar and dragged him to the floor. Nothwithstanding that incident, I really have no complaints about my interactions with doctors or their treatments. My point is this, most errors that occur during the course of treatment are irrevocably human, and not due to the system or the conventional wisdom that exists within the medical community. If I were to guage my own proficiency in maintaining my own health with that of my doctors, I would entrust my doctors every time without question. That isn’t to say that I am complacent. I scrutinize and inundate my doctors with questions quite frequently. The purpose of that is two-fold: 1) To ensure that I have absolute involvement in my own treatment. 2) To remind him/her that they are there to serve my best interests, not their own, in keeping with the “Do no harm” principle. In regards to your brother, and I don’t mean to sound indelicate, I’m inclined to think the doctor felt that at that stage in his cancer, anything short of a stem cell transfusion would have a marginal effect. Doctors are held to pretty tough standards, from a variety of governing bodies, and must keep abreast of rapidly changing methodologies. It is almost inconcievable to me that any doctor would intentionally withold information that could potentially save the life of a patient, much less one on the verge of death. Your subsequent discoveries were either not widely used or formally recognized as an acceptable, substantial and safe form of treatment, under the circumstances. I’m not suggesting that lapses in judgement don’t occur, but the fact of the matter is every decision they make has implications for their patient’s livlihood, as well as there own. Respectfully, I think your emphasis on self-care is a bit misguided. I think it’s fair to assume that most people don’t have the resources, inclination or the knowledge necessary to be entirely self-sustaining when it comes to their health. You may put yourself in a precarious situation, sooner or later, if you partake in activities and regimens of which you don’t fully grasp the consequences. Most doctors are decent enough that they actually enourage supplemental treatment plans, so long as they are consulted first. I wholehartedly believe that is the most intuitive way to approach the situation. Furthermore, there’s always a caveat when it comes to treatment: You must ahere to and follow through with guildlines set by your doctor for any of it to be effective. Most people falter in this regard as well. I also concur with Dr. Neisser’s assessment that the implementation of the Affordable Care Act with not cause any significant degradations to an already perilous situation. Nevertheless, I do believe there are some pressing issues as to its constitutionality that should not be taken lightly, especially due to the precedents it would establish. Realistically, the Court could agrue either way and be correct. They could argue that people who choose not to pay directly for health insurance, collectively and unchecked, would place undue pressure on the market for those who decide to opt in. That, essentially, would make them subject to the Commerce Clause that Congress is invoking. The contrarians could assert that forcing people to engage in economic activity, either by purchasing health care or via taxation, is to force them to comply with the Commerce Clause they otherwise would be excluded from if the tax didn’t exist. As a matter of constitutionality, I tend to agree with the latter. I liken this mandate to the Sumptuary Tax placed on alcohol and tabacco products. The government is imposing a moral imperative on those who consume such goods, placing a financial strain on them. Those who choose to refrain from consumption of those products remain unaffected. With that said, as a matter of practicality and good will, I fully endorse the law. I should add at this point that I already recieve government-sponsored healthcare at a very small cost compared to the alternatives. This law would not only expand my entitlements, but inject more money into the system. The part that unnerves me is the fact that it increases the client pool dramatically, making legitimate needs like transportation and assistive-technology, that much harder to attain. In that sense, it becomes a hinderance to my well-being. All-in-all, I am willing to sacrifice for the greater good, as I believe this law has more benefits than detriments, holistically speaking. I think the statistics will reflect that, in due time.

    • neissept says:

      Very sensitive and thoughtful, Andrew; thanks. Two comments: (1) adding more healthy people to the group of those who are insured simply makes those people contribute to current costs while in return giving them protection when they in turn become sick or injured, as they inevitably will. (2) the law is in my consitutional because everyone needs a health care system of SOME kind to be available for them, and will in fact use it at some point in their lives, at least to some degree. That’s not true of tobacco or broccoli.

      • Valid points, Dr. Neisser, but I’d like to elaborate just a bit. I understand the concept of the institutionalization of healthcare as an investment, even if the returns you get in the future don’t reflect the contributions you’ve made over time. There’s bound to be some disparity, that’s true of any investment. But again, as a matter of constitutionality, I take issue with this idea that it should be compulsory for an individual to pay into the system over a set period, when they don’t take advantage of services over that period. It becomes all the more complex when the person in question does eventually opt in, and the amount of care they recieve does not justify the previous cost. Is it the within government’s purview to decide what happens to the difference? I agree that it’s akin to a crap shoot insofar as one can never really fully anticipate the future. Still, the point remains that you shouldn’t be subject this manner of law indefinately when it does not yet apply to you. If the legislaure wants to conjure a measure that would remedy this issue and allow it to go through the same motions that this law has, great. By all means. As it stands, though, I feel as though the government is overstepping its boundaries, even if the intent is logical and noble. Now, you might contend that if the situation were reversed, and the said person contracts some grave illness, they may lack the funds for treatment. It’s a conundrum, indeed. Especially since I don’t believe a person should be denied life-saving treatment. To prepare for this contingent, there should be an analogous program whereby one can choose to allocate funds for unforseen circumstances, or make charitable donations. No, that’s not a flawless safety net, but I think the public and the legal community would be more amenable to it. There are underlying questions as to that systems viability, specifically, if costs drastically outweigh contributions. Alas, that’s no different than what’s happening now. I want to reiterate that the argument I’ve presented is a purely legal one, and does not reflect moral standards or my personal sentiments. On the matter of a larger consumer base, I think you misread my initial response because I wasn’t detailed enough. I’m not as concerned about costs being covered under this system as I am more stringent pre-requisites for products and services due to greater demand and the prospect of exploitation. Case and point, there are many intricacies and nuances when applying for goods and services. Often, if you don’t satisfy the credentials or fit a specific template, you are summarily denied. I know I have had to embellish a bit in the past to make my plight, and subsequent needs, more acceptable on paper. I understand why the process is so unforgiving, given the tendency of people to abuse the system. With a greater clientele and a more onerous case-load, I only see that scenario getting worse, and I am overwhelmed with trepidation because of it.

      • P.S. I wouldn’t be the least bit surprised if the argument affirming the mandate’s constitutionality includes some dicta on social programs already in existence. Though, as you so eloquently pointed out, this is much more direct.

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