ACA: a mandate because it’s a law. Now let’s say something interesting.

ACA’s “mandates” revisited: fallacies of choice and honesty about benefits.

My post last week on the Affordable Care Act got a lot of attention.  Left Blogistan mostly liked it, though Kevin Drum asked the right question about framing.  The other side not only didn’t like it, but thought I was lying.  I’ll try to answer Kevin, and in the process explain what I think about the others.

Quick recap: I said it was rhetorically awful to describe ACA as an “individual mandate” because that stresses the least attractive and least significant  thing about it.  I proposed, instead, this description:

If you or your family aren’t getting health insurance through your job, the government will pay to get you private insurance coverage, just as an employer would.  You’ll have to contribute something—but the law guarantees, with specific numbers, that it will be no more than you can afford.

..with a bit more.

First, Kevin’s question (he actually has three, but the last one sums up the other two pretty well):

In real life, how would this work? Once we reel off Andy’s paragraph, the next question from the Fox News anchor interviewing you is still going to be, “But it’s not voluntary, is it? You have to get insurance whether you like it or not, right?” What’s the answer?

Here’s my answer:

That’s just the way things work now for people who get insurance through work.  Most people get health insurance along with their paycheck whether they ask for it or not.  Most of them don’t get a choice of insurance, the way they will under the government-brokered exchanges in ACA.  Very few have the option of turning down the insurance and getting cash instead—and if they could, very few would.  ACA just gives people who don’t have insurance through work the same chance to have health insurance that people get if they do—and no less choice.

This is a folk version of the central left-liberal claim: we love choice and liberty just as much as the libertarians, often more, but the government is not the only enemy of choice and liberty.  Before ACA, people didn’t get to choose their health plans: the employer chose.  If you valued your job, you were stuck with the health plan your boss liked, not the one you would have liked.  (This is still true under ACA, and I wish it weren’t.  It will become less true if private employers start to drop their health insurance, as Kevin and I both think would be peachy; insurance shouldn’t track employment anyway.)   Before ACA, if you hated your job but had even a slight health condition, your choice of quitting was effectively foreclosed: you couldn’t go into business for yourself if you wanted insurance.  Before ACA, people with pre-existing conditions who didn’t have jobs with health insurance—maybe because they were, for example, very sick—had no “choice” of health insurance at all: none was available at a remotely affordable price.

As this is America, I don’t expect to win these arguments in the abstract.  I expect to win them by analogy.  Most people don’t currently experience the health insurance market as a realm of liberty and choice.  People who have to buy insurance on the individual market have the kind of “liberty” they wouldn’t wish on anyone (unless they’re quite young and very healthy—the people who least need insurance, and whose outrage, frankly, concerns me relatively little).  Those who get insurance through their employer take the plan they’re given, and if they get good health care out of it, they’re pretty satisfied.  ACA simply makes the government into the same good-enough insurance provider that many employers are now, with no less choice than most people have now.  The insured have to pay part of the cost—but again, that’s something most people experience with their private employers right now.

The libertarians act as if most people wish they were in the pre-ACA individual health insurance market.  If that’s right, my frame will fail.  But I think it’s wildly wrong.  Most people wish they had the kind of jobs that provided good health insurance.  They don’t want maximum choice, which the status quo ante can’t offer them anyway.  They want good health care.

This relates to my answer to those—like Left Coast Rebel/Conservative Generation, Professor Bainbridge, and TrogloPundit—who think that I’m denying the law involves a mandate.  I admit that my original post used an abstruse form of punctuation called quotation marks; some therefore didn’t get that by saying ACA wasn’t a “mandate” I meant that it wasn’t best described as a mandate, not that it wasn’t one.  Of course the law mandates that everyone have insurance, under penalty of law (though the extra 16,000 IRS agents are, once again, a complete fabrication; in fact, under ACA, the usual penalties for violating tax laws, like liens, will not apply).  That’s what laws do.  They mandate things.  Sending my kid to school, obeying the speed limit, paying my research assistants the minimum wage, participating in Social Security: all are “individual mandates,” if you want to portray them that way.  But portraying them that way is a bizarre libertarian frame.  It emphasizes the fact that laws exist on these matters but not the reasons they exist, the substance of the benefits that they aim at.  A focus on the consequences for those who defy the mandate is also technically accurate but conceptually perverse.  If I disobey any law, the government will come after me.  In fact, if I flout the mandate that I use the government-run currency, as opposed to one blessed by the free market, the Secret Service will come after me. But most people pretty much avoid such consequences—by obeying the law.  The free-marketeers are, ironically, evading personal responsibility on a massive scale.  Anybody who chooses to break the law that covers health insurance, will be treated as a lawbreaker.  But whose fault is that?

Short version: I know full well that ACA contains a mandate.  But I don’t care; I don’t think anyone else should care; and I think that once they get used to the new law and hear it explained properly, nobody much will care.  That’s why turning the debate away from mandates towards the fact that everyone will now have government-paid health insurance isn’t denial.  It’s honesty.

Update: Organizing for America shows how the “more choice” frame is done.

Author: Andrew Sabl

I'm a political theorist and Visiting Professor (through 2017) in the Program on Ethics, Politics and Economics at Yale. My interests include the history of political thought, toleration, democratic theory, political ethics, problems of coordination and convention, the realist movement in political theory, and the thought of David Hume. My first book, Ruling Passions: Political Offices and Democratic Ethics (Princeton, 2002) covered many of these topics, with a special focus on the varieties of democratic politics and the disparate qualities of mind and character appropriate to those who practice each of them. My second book Hume's Politics: Coordination and Crisis in the History of England was published in 2012; I am currently finishing a book on toleration, with the working title The Virtues of Hypocrisy, under contract with Harvard University Press. A Los Angeles native, I got my B.A. and Ph.D. from Harvard. Before coming to Yale I taught at Vanderbilt and at UCLA, where I was an Assistant, Associate, and Full Professor; and held visiting positions at Williams, Harvard, and Princeton. I am married to Miriam Laugesen, who teaches health policy and the politics of health care at the Mailman School of public health at Columbia, and we have a twelve-year-old son.

9 thoughts on “ACA: a mandate because it’s a law. Now let’s say something interesting.”

  1. "That’s just the way things work now for people who get insurance through work" — um, no. My employer offers me health insurance through a company of its choice, but I can refuse to take the insurance if I want to. That option will be denied under Obamacare. Right?

  2. "My employer offers me health insurance through a company of its choice, but I can refuse to take the insurance if I want to."

    *Read* the post before you respond, rather than just skim it. Mr Sabl specifically addressed that. If you decide against taking your employer's insurance plan, you don't get that extra money added back into your wages. No employer does that. So you're paying the same amount whether you get health benefits or not.

    But you *are* getting health insurance from somewhere (perhaps from your spouse's employer), or else you're screwed. Those are the only two choices. Insurance, or screwed. Now, are you so masochistic that you'd choose to be screwed? Or are you an intelligent person who'd take decent health insurance if it were offered to you? Please don't answer my rhetorical question; if you really are dumb enough that you'd rather be screwed, then I don't want to know.

    What people against the ACA and in support of the status quo are offering is Satan's choice. For individuals, that is: be screwed by paying more than you can afford for crappy insurance, or be screwed by having no insurance when you get sick. For businesses, that is: be screwed by having to piss away most or all of your profits on your employees' health benefits, or be screwed by not offering benefits and so not being able to hire anyone.

  3. "This is a folk version of the central left-liberal claim: we love choice and liberty just as much as the libertarians, often more, but the government is not the only enemy of choice and liberty."

    "Short version: I know full well that ACA contains a mandate. But I don’t care;"

    The central left-liberal claim is false: You love choice and liberty, but not as much as having people do whatever you happen to want. You really only reliably fall on the liberty side of things where you don't really care what choices people make. Once you've got a preference, your love of liberty evaporates.

    Look, actually being in favor of liberty implies being willing to let people do things you think are mistaken, or bad for them. If you're only going to permit people to make the choices YOU think are in their best interest, you don't love liberty, you don't even particularly like it.

  4. abadaba, that is 100% true. You could have gone without insurance now, and not paid a cent. Now you will need to buy it, and it will be subsidized if you are really too poor to afford it. Understand that the standard now is pay up or get nothing, with no break at all for being unable to afford it.

    So, you don't want insurance and don't have it now, which saves you lots of money. Until you get sick, then you go to the emergency room as an indigent and all the rest of us taxpayers get to pay your bill. That sound fair? Maybe us darned bleeding heart liberals should just say, "no pay, no care" and let you die if you have neither insurance or money, even if that is preventable. That sound right to you?

    Didn't think so. If you don't like it, come up with a better system that does as much or more. Your Republican representatives sure couldn't. Sounds like they could use a few genuine ideas. They seem fresh out.

  5. "Maybe us darned bleeding heart liberals should just say, “no pay, no care” and let you die if you have neither insurance or money, even if that is preventable. That sound right to you?"

    Actually? Yeah. Look, choice and consequences go hand in hand, you don't have one without the other. If somebody is sparing you the consequences of your choices, sooner or later they'll use it as an excuse to spare you the choice, too.

    And you guys don't see that as a problem, that's a slippery slope you treat like a luge run.

  6. "The central left-liberal claim is false: You love choice and liberty, but not as much as having people do whatever you happen to want…. Being in favor of liberty implies being willing to let people do things you think are mistaken, or bad for them."

    The "happen" there is a straw man. It sets liberal government intervention up as arbitrary.

    Better said: you love choice and liberty, but not *if it means they trample on other people's freedoms*. You can go down the list of liberal principles, and everything plugs in. Liberals don't "happen" to want to regulate polluters. They want to protect a common good.

    We won't agree on many premises, but as long as the premise is true, it should fit this model. For instance, take general redistribution – a generally socialist principle. When the government redistributes medical services, education, or general infrastructure it is doing so in recognition of a shared social burden. Putting aside any appeal to compassion or social justice, the consequences of not redistributing resources are often greater than some basic level of government service provision.

    Liberals generally have no problem whatsoever with personal behavior that does not have an externalized cost. The case for smoking and obesity-control rests upon medical costs passed on to society. As do helmet and seatbelt laws. As does the individual mandate. Libertarians love to appeal to a fantasy reality in which their behavior has no consequences for the rest of us – as if they won't clog up emergency rooms or the atmosphere with their mess.

    And once you get into social issues in general of course liberals are going to be the first to go along with your freaky-deaky, right? I mean, its not the conservatives who are gathering evidence on objective externalized risk.

    Sex? Psychology says no evidence of peer-induced homo sexuality. Medicine says prevalence AIDs in gay men is due to physiology not magic badness. Masturbation = good clean fun.

    Religion? Practice your own, the state is separate.

    Drugs? No harm, no foul.

    Minorities & Women? Liberté, égalité, fraternité. (Affirmative action, conservatives score a point on principle, but both sides have strong cases so its a draw)

    I mean, when you get down to business, liberalism has had more than its fair share of defense of liberty. Conservatism? Not so much. If your a rich, white man, maybe. But again – its the social costs.

  7. "Liberals generally have no problem whatsoever with personal behavior that does not have an externalized cost. The case for smoking and obesity-control rests upon medical costs passed on to society."

    "If somebody is sparing you the consequences of your choices, sooner or later they’ll use it as an excuse to spare you the choice, too."

    The medical costs are being "passed on" because society generously assumed them, and there was no shortage of libertarians at the time pointing out that sometime down the road, the government would claim the right to regulate smoking and weight because of that. And getting mocked for it.

  8. But that doesn't refute the principle that liberties can be constrained when costs are actually being passed on. Thus the slope isn't slippery at all.

    We can always disagree on the extent to which costs are being objectively assessed. I'll agree that second-hand smoke might be overplayed. I'll disagree on obesity, though.

    A principled libertarian would refuse emergency medical treatment. Although it might be tricky in severe cases to try and establish a patient's ability to pay before treatment. I find this attitude morally disgusting. But it is principled. However, a strong sociological case can be made that ties income (and thus ability to pay for health care) to social determinism. But I understand that conservatives have trouble dismissing free will.

    Along these same lines, in their embrace of contra causal free will as a cornerstone of liberty, conservatives *generously* assume an absence of the unconscious, and a general environmental and biological determinism. To me, this is the most devastating critique of the underlying premise from which their views on human nature and society stem.

  9. The question isn't whether the costs are being objectively assessed. There are two basic approaches to externalized costs: Either you can use them as an excuse to take away people's liberty, OR you can try to internalize them. The 'liberal' approach has long been to externalize every cost they can get their hands on, and then use the externalized cost as an excuse to regulate.

    And there's no contradiction between free will and causality, as any 'soft' determinist will tell you. The alternative to deterministic behavior isn't free will, it's random.

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