Of Mandates and Moral Responsibility

Reading the arguments against the health insurance mandate that are being entertained by the Supreme Court this week leaves me feeling as if we are truly a morally-bankrupt nation. The fact that healthcare for over 40 million people is at stake is being treated as an unfortunate side-effect in the contest over who has responsibility for our nation’s health care system. And one of the leading arguments seems to be that we have no collective responsibility toward each other whatsover.

As people split hairs about the mandate, here are a few morally-relevant things to consider:

If we are uncomfortable with the idea that people have to buy private health insurance, which is problematic in my mind only because it continues to allow Big Insurance to broker access to health care for most people, then we need to seriously consider kicking Big Insurance out of the driver’s seat. But somehow, I don’t think the Supremes are going to make that argument. In which case, someone needs to explain how we are going to guarantee access to health care for all. Given that the individual mandate started out as a conservative position, designed to shore up the central role of private insurance in healthcare delivery, I'm not expecting the conservatives who now dominate Congress to come up with any alternative answers to this question. Clearly, they don't care about expanding access to care.

For the rest of us, the over 70 percent who do want to figure out how we cover everyone, and cover them well, this is the mandate we should be talking about: We have a collective responsibility to guarantee quality healthcare for all. The insurance mandate was one of many ways, and the most conservative way, to try and meet the larger, moral mandate.

If we take the real, moral mandate seriously, and we don’t like the insurance mandate, then we have to get serious about the alternatives. How about, instead of making people buy insurance from private entities whose bottom lines are enhanced by denying access to care, we each pay into taxes that go to support a publically-financed system that connects patients with providers, that supports clinics and hospitals, and that supports a range of services that contribute to public health? The taxes for such a system would probably be a good deal lower for most of us than our monthly premium payments (and, if your premiums are paid by your employer, you may think this is not a win-win for you; if so, ask your employer what paying for employee health benefits is doing to the company; it affects you, too). Of course, the basis for the alternative I’m describing already exists, it’s called Medicare. We could have a version of Medicare for All. And we could improve upon the model, making it more democratic and responsive to different community needs.

Okay, I hear some of you objecting to the idea of cutting out big insurance and replacing it with big government. That this cuts against free market principles. Let’s talk about that. Free markets work well for many commodities. But health care is not a commodity. It's not something you can go out and buy when you need it, getting the best deal by comparison shopping. You don't really know when you'll need it, but when you do, it's going to be very expensive. We have to pool the costs, and the risks, in order to have good health services available when we need them. Moreover, the relationship between caregivers and clients, or patients and providers, is not a market relationship. Nor should it be. And, if we get beyond the notion of healthcare as a commodity, we can place it into a broader social context, and talk about the many conditions in our communities and families that contribute to health and wellness.

Still prefer private over public? Consider this, with big private insurance in the driver’s seat, access is controlled by an entity that makes money by denying access. There is a built-in confiict of interest here. With ‘big government,’ at least we have a party whose interests could be, should be, opening up access to care. We can imagine ways of democratizing the public role, making it feel less 'big' and 'remote,' by working with communities to find better ways to provide care. It doesn’t have to be ‘top-down’ and bureaucratic; working in relationships with community, faith, labor, small businesses, charities and other groups, public insurance connectors can improve access to all forms of health and wellness, and target their efforts in ways that address disparities that are rooted in race, class and gender. The possibilities are tremendous, if we eliminate the stranglehold of big private insurance.

In summary, here’s what should be the bottom line, the new bottom line, if you will, in healthcare: our ‘mandate’ is to guarantee good healthcare for all. Ultimately, we will fall short on this mandate as long as the delivery system is driven by Big Insurance (with other big private interests sitting upfront, like Pharma). But if we are going to continue to have big insurance playing a key role, then, can we not at least make big insurance do its job better? That’s what current health reform tries to do. Imperfectly, but so much better than the morally-bankrupt pre-reform status quo. If you don't like it, then get behind some version of Medicare for All.