Some thirty years ago the legislature of the state of Minnesota, where I was teaching at time, decided to enact a seat-belt law. If memory serves, Congress had made the distribution of highway funds dependent upon such a revision of vehicular safety standards. Driving without seatbelts transformed accidents into fatal crashes and fender-benders into emergency room visits. Minnesota drivers and front seat passengers were to wear a lapbelt. (At first there was no fine, only a merry warning from a state trooper).
We considered this law in my undergraduate social theory class, considering the right and the responsibility of a government to restrain the freedom to choose. One of my treasured students, let us call this jeune femme fighter for liberté Marianne, informed us that she used to wear a seatbelt while driving, but as a result of the legislation, she no longer did. She sat athwart her steering wheel as an act of protest. For her, the core of freedom was to say “I won’t” to what she considered state intrusion, and there was much that she considered intrusive. While it might be a suitable coda to announce that I last saw her on a gurney, her survival paid for by fellow citizens, as far as I know she is still on the road. But principled libertarians like Marianne demand that we question the uncertain divide between community and liberty. Some of our fellow citizens instinctively reject any collective mandate.
I recall Marianne when I consider the travails of Mitt Romney and Barack Obama in their desires to defend a mandate for health care. Mandate is from the Latin mandatum, commission or order. As the opponents of mandated health care, whether in the Bay State or from coast to coast complain, a mandate orders citizens to purchase health insurance – with exceptions for those who cannot afford it – or to pay a fine. (A subtle constitutional debate concerns whether states can do what is prohibited to the Feds). The irony is that a single payer system is clearly constitutional. It would not require citizens to purchase a product, but rather it would tax them for yet another government benefit. I imagine that those who object to a mandate to purchase health care would be no more jovial had the cost been swiped from their paycheck.
The visceral opposition of so many Republicans to insuring that all Americans have access to health care: Romneycare or Obamacare, as one will, is a puzzle. For the fact of the matter is that when the government determines that the promotion of the common welfare is required – a moving target as conceptions of rights alter – we determine how that collective good will be provided and who will be responsible for its cost.
The social democratic solution is for the state to be the tax collector of the commonweal, and the distributor of shared mercies to all. As Andrew Jackson put the matter: “There are no necessary evils in government. . . . If it would confine itself to equal protection, and, as Heaven does its rains, shower its favors alike on the high and the low, the rich and the poor, it would be an unqualified blessing.” In other words, if the State would shower medical care on rich and poor, a thousand robust flowers would bloom. One system for all, watered by an efficient and wise regime.
Wishful thinking, perhaps. In contrast is the mandate, bolstering a marketplace in which citizens and their employers select among competing health plans. Some measure of competition is preserved. Given the desire to preserve choice, corporate investment, and private enterprise, this was – and still is – a fundamentally Republican plan showing deference to free-market principles in a society in which prior to national health care the Feds were already picking up over 45% of health care costs. Even Ann Coulter agrees, writing “Three Cheers for Romneycare!” and noting that the Heritage Foundation helped design Romneycare. Perhaps not libertarian, but conservative.
Forcing everyone to purchase health care involves forcing everyone to purchase health care, as Marianne would intuit. And perhaps she would be willing to give up her doctors in order to breathe the rarified air of freedom. However, if deliberately considered, the primary victims of this scheme are young people willing to bet on invulnerability. There would have been logic to the Occupy Wall Street kids opposing mandatory coverage. But why should the middle-aged, middle-class, entrenched Tea Party boosters be so opposed to the mandate to continue to purchase what they have purchased all along. They are the very people who would not consider being without health care themselves. Marianne has reached midlife.
There are reasons to be skeptical of market-based mandated healthcare: suspicions from left and from right. Are all health plans – and, thus, all medical care – equal. Will the accountants of the market call the tune? Even though the mantra of the mandate has dominated opposition on the right, surely one could fret about the over-regulation of the market. Do public bureaucrats know better than private bureaucrats? Will no frills plans be pushed from the market? Will government regulators permit too much care (contraception) or too little (end of life care, aka death panels)?
Yet, these concerns are separate from mandates themselves. Should the government insist that we purchase what most of us purchase anyhow? Perhaps not, but if we recognize the necessity of universal health care, the alternative is a single-payer system. No mandate, just taxes. And taxes are as inevitable as death itself.
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