On Morality, Prudence, and the Health Insurance Mandate: A Reply to Jeff Hammond

[Note: this is my reply to Jeff’s latest post on healthcare, available here]

Once again, my thanks to Jeff for participating in this conversation. I’m going to focus my attention here on this specific comment from Jeff’s last post:

Nevertheless, EMTALA and the individual mandate may be connected, not for moral reasons, but for merely prudential reasons.

I think Jeff is wrong. My goal in this post is to explain why I think this is so and why I believe acknowledging the moral import of the mandate is important. Let’s first situate this claim in context. Jeff and I agree that there is a solid moral and prudential basis for EMTALA. I appreciate Jeff’s apt description of EMTALA as a “compelled Good Samaritan” mandate.  Remember that Jeff and I support this mandate on moral grounds.  At this point Jeff parts company with the parallel that I draw between EMTALA (a “supply-side” mandate) and the individual mandate under Obamacare (a “demand-side” mandate placed on patients, not providers).  In his view, the individual mandate if it is justifiable at all is so only on “prudential grounds.” The moral logic that we both embrace for compelling emergency care providers to provide uncompensated care does not apply to patients who are the recipients of that care, or so he argues.

I share Jeff’s conviction that prudential reasons offer one basis for justifying the insurance mandate, though one should notice that Jeff himself is not persuaded by the prudential argument. He describes the ACA as a “disaster” because of the unaffordability of the insurance that individuals are required to buy. I know that this is one of Jeff’s major concerns, and not an unreasonable concern to have.  My anticipation of this concern is what prompted my foray last week onto the healthcare.gov website to scope out insurance options for my imaginary family of 4, details of which can be found here.  However, I think Jeff overlooks something basic about the moral connection between EMTALA and the individual mandate.

Let’s rephrase the moral logic of EMTALA this way:

It is morally permissible to use the power of the state to compel private healthcare providers to provide emergency health services, even when these providers know that they will not be compensated for this care.

Based on what Jeff has said so far, he affirms this, as do I.  But Jeff does not embrace the moral logic that would mandate that individuals purchase insurance; he sees this as a “demand-side”mandate that does not parallel the logic behind EMTALA. But if this is so then I find the conclusion of Jeff’s latest blog post quite curious, for Jeff himself frames the outcome of the EMTALA mandate absent the individual mandate in explicitly moral terms:

What if the prototypical 28-year old, who hasn’t bought health insurance, because “she never gets sick” and because “the government can’t tell her what to do” gets run over by a bus, and it’s her fault? She’ll accumulate hundreds of thousands of dollars, at least, in medical bills, and if she doesn’t have a six figure net worth, those bills will likely be eaten by the hospital. That’s hardly a just outcome. So, yes, in the abstract, our hypothetical 28-year old should (an “ought,” a moral statement) procure health insurance so as not to be an unnecessary burden on her fellows in the community, even for contingencies (like getting run over by a bus or developing cancer) that she finds highly improbable.

If the logic behind the individual mandate is, as Jeff describes, “merely prudential,” then how are we to make sense of Jeff’s own assessment that forcing a hospital to eat the expenses of the care it provides is “hardly a just outcome?” The moral logic of these supply-side and demand-side mandates is more tightly woven than Jeff’s last post would suggest, and his own language illustrates how this is so. The 28-year old who lacks the foresight to purchase health insurance, or who would simply prefer to spend his hard-earned money on a convertible instead of health coverage, burdens the hospital that will be required to care for him when he crashes the convertible. The 28-year old also burdens the rest of us, indirectly escalating the cost of healthcare. If we already agree it is morally permissible to use the power of the state to compel hospitals to provide uncompensated emergency care to the 28-year old, why should we not deem it just as morally permissible to use this same power to compel the 28-year old to cover himself in the event of an emergency?  

To the extent that conservatives have stereotypically been the forceful defenders of business owners, entrepeneurs, and other actors on the “supply-side” of market exchanges, I find myself in the strangely curious position of being the one who is drawing attention to the disproportionate moral weight being borne by healthcare providers in a system that mandates that they provide uncompensated care but does not mandate that consumers take steps to minimize these costs. The moral logic of the individual mandate recognizes the costs of healthcare as social costs that are borne by communities, not merely individuals.  The uncompensated care that I receive from the hospital is borne by other members of the community, albeit indirectly. My choice to not purchase health coverage does not affect me alone; it affects every other healthcare consumer.  For this reason, there are sound moral reasons to expect me to live up to my responsibilities to other members of our community. In a healthcare system, no person is an island. My decision to refuse insurance affects you.

As for whether or not we treat the financial mechanisms that compels individuals to purchase insurance as a “penalty” (as the law was initially intended) or as a “tax” (as SCOTUS declared it to be), Jeff is correct that I find the distinction to be moot. Whether or not a consumer experiences the government stick as a “penalty” or a “tax,” the mandate survives, and there are sound reasons for us to agree that it should remain so, as long as health insurance is reasonably accessible and affordable for every member of the community. The last qualifier is absolutely critical. Jeff closes his post by arguing that the ACA mandates that ordinary Americans purchase insurance that they cannot afford to buy.  If Jeff is correct, then I agree with him that there are sound prudential and moral objections to be raised of the individual mandate. As Immanuel Kant reminds us, ought implies can. To insist that individuals have the moral obligation to do the impossible is irrational; thus, Jeff correctly draws our attention to this question: is the health insurance that individuals are required to buy affordable? While we may disagree about the means necessary to assure access and affordability, this shared goal provides a path forward for our conversation.