By Uwe Reinhardt
In his "The Great American Health Care Divide," Brad DeLong laments the great ideological divide that has so long prevented this great country from developing a coherent national health policy.
I am glad to have Brad's company, because I have whined about the same divide for several decades now, as evidenced by my "Turning Our Gaze from Bread and Circus Games," penned in 1995 and "Is there hope for the uninsured?"
Finally, after a nice visit with my friends at the Cato Institute and reading the often amazing commentary on John Goodman's NCPA blog , I was moved to pen a post on The New York Times blog Economix entitled "Social Solidarity vs. Rugged Individualism." It was inspired by the often hysterical description of the Affordable Care Act (ACA) as a government takeover of U.S. health care or a trampling on the freedom of Americans, as in mandating individuals to have minimally adequate health insurance, lest they become freeloaders on the system.
The basic idea of my proposal is simple.
In 2009, Paul Starr had warned Democrats of a potential voter backlash against the individual mandate and proposed instead a nudging arrangement. Uninsured Americans would be auto-enrolled into health plan, if they chose not to select one, but could opt out of it with the proviso that for the next five years they could then not buy insurance through the insurance exchanges established by the ACA at community-rated premiums, and potentially with federal subsidies.
My proposal is to make that a lifetime exclusion. An individual would have to choose one or the other system by age 25. Should individuals opting out fall seriously ill and not have the means to pay for their care, we would not let them die, of course, but to the extent possible we would cover their full bill – possibly at charges — by expropriating any assets they might have and garnishing any income above the federal poverty level they subsequently might earn. Something like that.
As Jay Gaskill's somewhat opaque reaction in "RUGGED INDIVIDUALLISM is NOT the Essential Value of Freedom" suggests, people who oppose the ACA as trampling on their freedom are not comfortable with my prescription, which does not at all surprise me.
Frankly, I was only calling the self-styled rugged individualist's partisan bluff, knowing how much they actually cherish their or their parents' Medicare and the other many handouts – farm subsidies prominently among them – that rugged individualists enjoy. The New York Times had a splendid article on that issue about a year ago (see here and here).
As Dean Baker noted, there are actually very few rugged individualists in America (my back-of-the-envelope estimate is three). Most self-proclaimed rugged individualists do tend to rediscover government's beneficial side when the going gets tough.
When you Google "rugged American individualist – images,” you will come upon the image below.
One can see these freedom riders on heavy bikes in the Colorado mountains, T-shirts fluttering in the wind, and bandanas as a head protection. Some of them might be uninsured, because the opportunity cost of health insurance would have been the very bike they are riding.
It is a safe bet, though, that even the most rugged uninsured individualists among them would expect a helicopter from Denver to pick them up and fly them to Denver, should they take a severe spill in the mountains. They would expect the finest health care Denver can offer, even if they had no means to pay for either helicopter or health care. It would be presumed that America has a moral obligation to extend them this civic nicety.
And I have only hinted here at farmers and not even mentioned bankers.
Uwe Reinhardt is recognized as one of the nation's leading authorities on health care economics and the James Madison Professor of Political Economy at Princeton University. He is a regular contributor to The New York Times Economix Blog.
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