Ironic, THIS is what conservatives had to say in the early '90's when Clinton and Democrats tried to reform health care. But NOW their words must be discarded. When they talked about personal responsibility, it wasn't meant to apply to THEM.
Personal Freedom, Responsibility, And Mandates
by Robert E. Moffit
The national debate on universal health coverage is the latest incarnation of an ancient, enduring question of political philosophy: reconciling personal liberty and the authority of the State. It is the central problem of American political culture and is at the heart of nearly every major constitutional conflict in our history.
Americans-heirs of a classical liberal tradition, grounded in the political philosophy of John Locke and the spirit of Thomas Jefferson, in which personal freedom is paramount - harbor a deep distrust of governmental authority. We do not automatically assume that the individual is or should be subordinate to society, whether the issue is literary censorship or economic regulation.1 Therefore, any political limitation on personal freedom, regardless of prevailing wisdom, prejudices, or majority interests, must be based on a compelling argument.2
The Taxpayer Mandate
Policy analysts at The Heritage Foundation have wrestled incessantly with this problem, while developing a consumer choice plan for comprehensive health system reform, now embodied in a major legislative proposal.3 Only after extensive analysis of the peculiar distortions of the health insurance market did Heritage scholars reluctantly agree to an individual mandate.
On this point, some observations are in order. First, much of the debate over whether we should have a mandate is, in a sense, a debate over a metaphysical abstraction. 4 For all practical purposes, we already have a powerful and increasingly oppressive mandate: a mandate on taxpayers.
We all pay for the health care of those who do not pay, in two ways. First, people with private insurance pay through that insuranceeven though that insurance is often the property of employers under current law. This reflects the ever-higher costs shifted to offset the billions of dollars of costs of uncompensated care in hospitals, clinics, and physicians offices. Second, if those who are uninsured get seriously ill and are forced to spend down their assets to cope with their huge medical bills, their care is paid for, not through employer-based or private insurance premiums, but through taxes, money taken by federal and state tax collectors to fund Medicaid or other public assistance programs that serve the poor or those impoverished because of a serious illness.
Hospitals also have legal obligations to accept and care for those who enter seeking assistance. No responsible public official is proposing repeal of these statutory provisions, and very few physicians, if any, are prepared to deny treatment to persons seeking their help merely because they cannot afford to pay. As taxpayers and subscribers to private health insurance, the American people pick up these bills.
Aside from current economic arrangements, the entire moral and cultural tenor of our society reinforces the taxpayer mandate. Those who are uninsured and cannot pay for their care will be cared for, and those who are insured and working will pay for that care.
So, we already have a mandate. But it is both inefficient and unfair.
A Snare And A Delusion
Employer-based health insurance in this country is the product of wartime economic and tax policy of the 1940s. There is no reason why health reform in the 1990s should be governed by those unique circumstances and outdated tax policies.
Uwe Reinhardt and Alan Krueger tell us that the tax treatment of employment-based health insurance now is sharply regressive. And, Mark Pauly confirms, it contributes to market distortions, high costs, and lack of portability in health insurance. Americans today get tax relief for health insurance on only one condition: that they get it from their employer. This has tied health insurance to the workplace in a way that no other insurance is treated. It means that if we lose or change a job, we lose our health coverage.
Pauly also tells us that employer-based insurance hides the true costs of health care. Thus, there is no normal collision between the forces of supply and demand on even the most basic level. Most workers do not purchase health insurance; it is purchased by somebody else, usually the company. For most workers, it is a free good, an extra, that automatically comes with the job. At least, we live with that comfortable illusion. But, in fact, it is not free at all, and the employer gives us nothing. Because too many people think that the employers contribution is the employers money and not theirs, the consumers perception is distorted (as is the providers), and health spending is not subject to market discipline. Likewise, because too many people still do not understand this reality, hidden taxes through the employer mandate are politically attractive. Such a mandate thus serves as a psychological snare and an economic delusion.
Karen Davis and Cathy Schoen suggest a payroll tax to finance reform, whereby the employer pays 8 percent and the employee pays 2 percent. If one of our tasks is to make the true costs transparent, this suggestion does not help very much.
In his otherwise enlightening paper, Reinhardt calls attention to the virtues of a mandated purchase of health insurance. And he warns that calling an employers mandated purchase a tax comes close to debasing the English language. But, in a similar context, Reinhardt uses the word contribution to describe suspiciously similar functions. Suffice it to say, the campaign for linguistic precision is hardly advanced by using the word contibution to describe the states forcible extraction of citizens money.
In another context, Reinhardt proposes perhaps the best single reform idea to date. He suggests a simple financial disclosure on the part of the nations employers, requiring every employer to put periodically on the pay stub of every worker in America something like the following: We have paid you X thousand dollars in health benefits. This has reduced your wages by X thousand dollars. We would add: Have a nice day!5
http://content.healthaffairs.org/content/13/2/101.full.pdf
