Obamacare, Citizenship, and Neighbor Care

As debate over the upheld Affordable Care Act (ACA, or Obamacare) remains intense, I’d like to enter the fray by focusing on the individual mandate and the terms associated with the cost levied at those who opt not to purchase health insurance.

Two key words—tax and penalty—are primarily used to describe this cost, and the most intense debate I’ve heard has been over which of the two the levied cost is. There’s actually a third term for the cost, which is unfortunately and all-too-often neglected.

As Supreme Court Chief Justice John Roberts says in the case’s majority opinion, the ACA initially designated the levied cost a “shared responsibility payment.” The payment was classified as a penalty since the IRS, which is responsible for collecting the payments, had to find an existing category for it. To simplify Justice Roberts’ argument, the fact that the IRS collects the penalty through annual income taxes allows for the penalty to be considered a tax.

Those who criticize the individual mandate as an interference with freedom and rights almost always use the terms “tax” and “penalty.” People against the mandate raise this basic question: “Why should I have to pay for other people’s healthcare?” To return to the ACA’s core term for the cost, we could rephrase the question to this: “Why should I have to be responsible for other people’s healthcare?” They feel their freedom has been limited by penalizing them for making a personal choice and for not wanting to pay for other people’s healthcare.

Things look differently when we reverse this question about being responsible for others. When reversed, the question becomes: “Why should we, the insured, have to pay for your healthcare once you finally need it but don’t have insurance?” If one prefers the question “Am I my brother’s keeper?” (Genesis 4.9), we should also reverse it to ask: “Is your brother your keeper?”

These questions and counter-questions point out that people will almost certainly have to absorb the cost of other people’s medical costs either way—it’s essentially a issue of who pays for whom.

If we think about what the long-term consequences would be if the individual mandate hadn’t been upheld, we have to admit it is nearly impossible to be solely responsible for your health. Those who would forego healthcare insurance would end up either causing those who have healthcare insurance to pay or severely draining their financial resources (and quite possibly their family’s resources, too).

Hospitals are obligated and under oath to treat anyone who comes needing medical assistance, even if they can’t afford help. So someone else has to pay for the treatment. As Justice Roberts explained, hospitals pass on costs to insurers through higher rates. Insurers then forward costs by raising insurance premiums for the already-insured.

It’s simply unfair for someone to forego insurance for years, using her or his money however he or she sees fit—and eventually end up needing medical care with nowhere near enough funds to pay for vital care.

Some might argue that those foregoing healthcare insurance could instead save enough money to pay for their medical care once they need it. But this seems unrealistic, given that a large percentage of Americans live in debt, and very few Americans save money as they should. The idea that they will not just save money but also set aside a specific amount of saved money for a health emergency is improbable, especially amidst the current economic downturn (which isn’t expected to improve in the near future).

Even if those foregoing medical coverage do save, there is little guarantee that they will have saved enough. They might easily be able to cover the cost of what GOP presidential nominee Mitt Romney has called “a 1,000 repair,” but covering the cost of a long-term illness like cancer would be far more difficult, if not impossible. Most of those who opted to save on their own would see decades of savings quickly dwindle in a matter of months or a couple years.

I appreciate and commend those who reject the individual mandate for their desire to preserve freedom. We should be ever-watchful against threats to freedom. But it’s important to remember that freedom and responsibility are intricately connected. But in the case of the individual mandate, we may actually be experiencing a step toward responsibility rather than an erosion of freedom. The individual mandate drives people who might take serious risks on their health to reconsider the importance of spreading risk and costs through healthcare insurance.

As Christians wrestle with finding where freedom and responsibility intersect at the individual mandate, four things are worth thinking about.

Christ’s instruction to give “to Caesar the things that are Caesar’s, and to God the things that are God’s” (Mark 12.17) should be kept in mind. Chief Justice Roberts’ logic for the shared responsibility payment qualifying as a tax and thus being constitutional is indeed a stretch, but nonetheless the chief judicial authority of America has decreed the individual mandate legal. Christians can vote for Mitt Romney, who has promised to begin repealing the ACA on the first day of his presidency (even though he has said “I like mandates” in the past). But they cannot evade paying their taxes even if they disapprove of the individual mandate.

Christians should also rethink how they approach debt, having realized you might cause financial hardship on others if the individual mandate had been struck down and you were entitled to forego healthcare insurance. It’s well to keep in mind the instruction given by the wife of one of the prophet Elisha’s sons: “Go, sell the oil and pay your debt, and you and your sons can live on the rest.” The individual mandate pushes you to protect yourself by purchasing insurance rather than gambling on your well-being.

We must also keep in mind that governments have the task of protecting their citizens. When the Israelites demanded a king (I Samuel 10.17-27), the central concern was finding someone who could deliver Israel from the Philistines (I Samuel 9.16-17). But protection isn’t confined to defending a population from external threats (i.e. enemies). There’s also domestic protection, providing for people’s material well-being (what’s known as biopolitics in political theory). The individual mandate may even end up protecting you, even if you dislike it. If you choose not to purchase health insurance and pay the shared responsibility payment, the mandate may end up allowing you to get insurance once you need it. Without the mandate, many insurers could turn you away due to your illness, which they would consider a preexisting medical condition.

Finally, let us not forget Christ’s warning that “whoever says to his brother, ‘You good-for-nothing,’ shall be guilty before the supreme court…” (Matthew 5.22). If you think of the disadvantaged poorly because they are unable to afford medical care and resent having to pay for them, Christ’s warning gives you reason to examine if you need to repent for hating your fellow Americans. The Supreme Court’s ruling on the legality of the individual mandate is a chance to reconsider your fellow Americans’ worth as you abide by this new legislation, even if you dislike it (see Romans 13). Perhaps the passing of this legislation may, strangely enough, even lead to your heart being changed and becoming more loving toward others.

Further CaPC coverage of the Affordable Care Act/Obamacare:

- Ben Bartlett: “Obamacare, the Supreme Court, and the Darkness of Hearts” (April 2012) and “Watching Politics from the Pew: The Cost of Healthcare and Wisdom” (November 2011)

- Podcast: ObamaCares? (March 2010)

Illustration courtesy of Seth T. Hahne. Check out his graphic novel and comic review site, Good Ok Bad.

About C. Ryan Knight

C. Ryan Knight teaches English at Randolph Community College in Asheboro, NC, and he lives with his wife outside Greensboro, NC.
Email: knight.cr@gmail.com

  • PS

    Interesting thoughts. Just a quick question.

    Are you saying that we should support this health care law if we truly care for people and love people?

  • http://www.alienman.blogspot.com Brad Williams

    I think the best point you made here is to remind people that we are paying for the healthcare of the uninsured anyway. People forget that.

  • http://www.alienman.blogspot.com Brad Williams

    Well, that may not be the best point, but I really liked it.

  • Casey

    It may be true that this law will force some people to make more responsible decisions about thier health and finances, yet as Americans we should not be forced to pay for anything. It doesn’t matter what the government, or anyone for that matter calls the penalty, it is a payment that some don’t want to pay yet they are forced to pay it. The choice is pay for healthcare or pay a penalty. The Declaration of Independence , Constitution and market economics are founded on the principle of private property. The government should not be able to take our money even If, and especially if, thier argument is to make decisions for us. Absolute monarchies,socialism, and communism all are based on this argument and depend on the people letting the government make decisions for them.
    I understand people wanting preexisting conditions to be eliminated. There Are companies that have hidden behind this excuse to deny healthcare even when the conditions weren’t preexisting. But there are other alternatives than to having the government run healthcare. Look at the United States Postal Service. It can not be managed well because of the excessive beauracracy. The people working there are good hardworking people, but when the government runs things it tends to be too top heavy to be efficient. Does anyone truly think the government can do better with healthcare, which is much more vital to people’s lives?
    Finally I would like to point out that when thinking through this as a Christian we have to pay our taxes and give to the church. However, if you look at Rome many of the emperors before Constantine wanted to destroy Christianity. One reason they couldn’t was because of the church’s reputation of being generous. If we really understood the gospel and took seriously giving to the poor, the government would never even have to consider such a law.

  • Daniel

    @Casey, I understand the principal that your defending, but on the surface, the reasons you give could be applied to paying ANY tax. Want national defense? Buy an F-22 or an aircraft carrier, but don’t be forced to pay for it. And wouldn’t private companies provide defense more efficiently than the market, if the market is always better than the State?

    Want a court system? Fine, pay for it..but don’t force anyone to pay for it. I don’t plan to use the courts any time soon, so why should I be forced to pay for it?

    There must be a better set of arguments to defend what a government should and shouldn’t do, other than that people should be forced to pay for certain things and not forced to pay for others, or that the private sector is always more efficient than the government.

  • http://paintedwithoutmakeup.wordpress.com Amanda Beck

    Ryan, the previous comments deal with the two things I want to say, so forgive me for rehashing them.

    Firstly, you do make a good point in saying that we are already, indirectly, paying for the healthcare for the uninsured. Thank you for pointing that out.

    Secondly, your post supposes a dichotomy that I have a problem with. Your words: “If you think of the disadvantaged poorly because they are unable to afford medical care and resent having to pay for them, Christ’s warning gives you reason to examine if you need to repent for hating your fellow Americans.” Based on the tone of your post, it seems that you equate this stance with not supporting the ACA. However, if one can disconnect this level of accusation, there can be some fruitful discussion, I believe–a discussion that needs to be had especially by Christians who love the poor (those who cannot afford healthcare) and still have a problem with the ACA. Namely, this: we agree that while part of the overall picture of quality of life, government regulation is not our salvation. Don’t get me wrong–it is important. It is necessary.

    But in your post you seem to link doing something for the underprivileged WITH the ACA alone, as if it is a mandate from heaven. You all but rule out the possibility of respectfully disagreeing, for example, with the economic aspect of the act (which, by the way, I disagree with). I’m not saying that I have the answer, but you can’t in one breath blame someone with a political stance like mine to hate my brother, my fellow American, and then say that I need to accept it as rending to Caesar what is Caesar’s. It leaves no room for political or philosophical discourse in charity and love. Let’s do something–yes, political–to help the poor. But not Obamacare. Precisely because I acknowledge that political action is not my salvation, I can have this discussion without accusation against my liberal brothers and sisters. And precisely because I love my neighbors, I do not think that this (ACA) is the best solution. This is not hatred of my fellow American. It is deep respect for the political system (while acknowledging its severe limitations) and for our ability to come up with a better solution, one that does not abridge the freedom* we posses by the Constitution and Bill of Rights.

    *The freedom threatened in my purview deals less with economics than with religion. There is no way around it that as it stands, the ACA requires me to financial support, through tax money, birth control and abortion, two things against which I am morally and religiously opposed. I am not asking for birth control to be outlawed, although I am fighting for the end of abortion. This is loving my neighbor–the smallest, innocent, most helpless. I will not stand for their deaths, politically correct as it may be. That is the major reason why I will never support the ACA as it currently stands.

  • Casey

    @Daniel I understand that my argument could be used for any governent service. I know there are other arguments againt this law. For instance there really isn’t any tort reform in this law. One of the main reasons doctors preform “needless” tests is to protect themselves from malpractice lawsuits. If there were limits all our healthcare costs would be reduced. Another argument is what we will be forced to pay for like abotions. Finally i could argue against this law because of how it was forced on the american people. The Speaker of the House at the time said that we need to pass it before we can know whats in it. As a elected reoresentative they are supposed to know whats in a law before they vote on it. I could also point out that the party in control knew it couldnt pass in a tradtional manner so they used a strategy not usually used for such a big law in order to force it through congress. But I wanted to argue about forcing payments because it amounts to behavior modification. If they can punish me for not having healthcare they can force us to change any behavior they deem bad or unnecessary. What’s to stop them from outlawing x-game sports because they increase the number of broken bones raising healthcare costs. I’m not a skater but they should be able to have their recreation without government interference. I know it’s ridiculous argument but taking the argument to the absurd helps is see how intrusive this law really is. Communist governments use arguments like this to make decisions for their people. Even if my decisions are irresponsible I should be able to make them without having to worry about the government interfering. I have health insurance and I pay taxes because I want to be tried by a jury of my peers if ever I need them to protect me from biased judges. But the point is that as an American the government has never been able to force me to buy any service that was previously handled by the private sector. Healthcare wasn’t perfect and things needed to be changed but the law says the government is the answer. My point about the Postal Service shows that the government running things can’t be the answer. For another example look At veteran healthcare. It tries to meet needs to service men and women who need and deserve great healthcare because of their sacrifices. But it can’t always do what it needs to because of beauracraies. I am in now way trying to criticize the doctors, nurses, veterans, or even the administrators. By being under a government beauracracy their work is hindered. The mere fact that the government can’t manage things efficiently is proof enough for me that I don’t want government healthcare. In time the healthcare we receive will deteriorate. It’s not a scare tactic its cost benefit analysis. At some point in order to keep costs low the government will have to put limits on expensive theropies.
    I also think there is and should be a dichotomy between services a government should and shouldn’t provide. I hope every citizen would agree that it is not the purpose of government to ensure that we all have jobs. It is governmen’s job to ensure we all can have jobs, but they can’t force companies to hire people. Nor can they provide jobs for everyone. One of the reasons Geece is in the trouble they are is because so many people are employed by the government. The math just cant add up. I know im probably in a minority here, but I believe healthcare should fall into this category. The examples you cite have to be enforced because without them our country, and every country for that matter, would be in utter chaos. But for almost 230 years our government has run without government healthcare and for the most part there isn’t chaos. I believe the government should help when possible, and to a limited extent that is what social security, Medicare, and Medicaid are for. But to ensure that everyone in the nation has healthcare is something we can’t afford. Again it is another reason Europe is in the crises that it is in. If you want to see into the future as to what our economy will look like ten years after this law is in effect look at what Europe is facing. Again punishing Americans for not purchasing a service is enough of a reason to me to be against this law.

  • Daniel

    Thanks for your response, Casey.

    “@Daniel I understand that my argument could be used for any governent service. I know there are other arguments againt this law. For instance there really isn’t any tort reform in this law. One of the main reasons doctors preform “needless” tests is to protect themselves from malpractice lawsuits. If there were limits all our healthcare costs would be reduced.”

    Tort reform might help some, though I find this analysis interesting: http://www.nber.org/bah/2009no3/w15371.html

    Direct costs of medical malpractice suits and insurance are 1-2 percent, fairly insignificant. And the reduction of unnecessary tests is–and can coninually be–accomplished by private insurance refusing to pay for these unnecessary tests. Though I think Tort reform might have some value, I do not believe that the facts show it is a signficant factor in medical care costs. Further, I am leery of unintended consequences of insulating incompetent health care providers from malpractice damages.

    “Another argument is what we will be forced to pay for like abotions.”

    I, too, hate abortion…but my current PRIVATE insurance pays for it, and likely yours does, too. Indeed, most private insurers pay for abortion, yet most Christians in these plans say and do nothing about it. The AHA doesn’t change this dynamic.

    “Finally i could argue against this law because of how it was forced on the american people. The Speaker of the House at the time said that we need to pass it before we can know whats in it. As a elected reoresentative they are supposed to know whats in a law before they vote on it. I could also point out that the party in control knew it couldnt pass in a tradtional manner so they used a strategy not usually used for such a big law in order to force it through congress.”

    Much legislation is passed in this manner–or resisted in this manner. Playing with procedural rules in order to pass or block legislation is quite commonplace. That doesn’t make it right, but it would be inconsistent single out healthcare reform alone as something done in this manner…likewise, other legislation and/or government action, both “conservative” and “liberal” is done in this manner, so if we are willing to criticize something we dislike because of the process, we should be willing to criticize other things because they used the same processes. For example, the Senate Republicans once again blocked legislation to allow more sunshine on campaign donations, even though the majority of the Senate wanted it. (See http://www.bloomberg.com/news/2012-07-17/disclose-vote-leaves-trail-of-broken-republican-vows.html
    )

    As far as legislators not actually reading what their voting on, that is also nothing new. Even the writing of legislation is often done by Congressional staffers, not by Congressmen themselves.

    Do I like this state of affairs? Of course not. But singling out the AHA for this, as if it was passed in a uniquely bad way, is implying that it is uniquely bad. In the end, the majority of Congress passed it, the President signed it, and the minority was unable to use procedural rules to stop it.

    “But I wanted to argue about forcing payments because it amounts to behavior modification. If they can punish me for not having healthcare they can force us to change any behavior they deem bad or unnecessary.”

    That’s pretty much the whole purpose of the law. Laws against murder, theft, fraud, assault, etc–all are aimed at modifying behavior, to keep people from killing, stealing, defrauding or assauling others.

    “What’s to stop them from outlawing x-game sports because they increase the number of broken bones raising healthcare costs. I’m not a skater but they should be able to have their recreation without government interference. I know it’s ridiculous argument but taking the argument to the absurd helps is see how intrusive this law really is.”

    Actually, the government–both conservative and liberal governments–make laws against certain types of recreation all the time. Probably the most obvious case is the use of recreational drugs. Many libertarians argue that this is not the proper role of government, and I understand their argument (even if I do not agree with it). However, if we agree that the State has a proper role in limiting certain kinds of behavior (such as using drugs recreationally), then it is a question of “what” the government can regulate, not “if”.

    “Communist governments use arguments like this to make decisions for their people.”

    ANY kind of totalitarian regime–not just communist–does this. And even Republics–like us–do this. A State that declares war is making a decision for its people (and a very consequential one), but no one is arguing that the State does not have the authority to declare war.

    “Even if my decisions are irresponsible I should be able to make them without having to worry about the government interfering. I have health insurance and I pay taxes because I want to be tried by a jury of my peers if ever I need them to protect me from biased judges.”

    But you’re stating that you WANT to pay for a justice system because you might need it some day. What if I DON’T want to pay for it? Why should your WANT for a justice system make it a requirement that I support your want?

    It may be an irresponsible choice, but it is a choice nonetheless. Indeed, it is probably less irresponsible than not paying for medical care, in that many of us can live our lives without going to court, but very few of us will ever go through life without a visit to the doctor.

    “But the point is that as an American the government has never been able to force me to buy any service that was previously handled by the private sector. Healthcare wasn’t perfect and things needed to be changed but the law says the government is the answer.”

    Actually, 30 years ago, when Ronald Reagan signed the EMTALA, the State mandated that hosiptals take care of all emergency patients. This wasn’t mandating that anyone PURCHASE anything, but that someone PROVIDE something without a guarantee of payment–in my opinion a far more serious encroachment of governmental power than requiring that someone pay for something that they can use. This created an unsustainable “free rider” problem, that the AHA attempted to address. It’s solution may not be ideal, but it at least tried to do something about this.

    And I would challenge the claim that the AHA says government is the answer. I think if there was a public option in the AHA, you might have a point; but since it required people to buy health insurance from the private sector, the claim is not very strong.

    “My point about the Postal Service shows that the government running things can’t be the answer. For another example look At veteran healthcare. It tries to meet needs to service men and women who need and deserve great healthcare because of their sacrifices. But it can’t always do what it needs to because of beauracraies. I am in now way trying to criticize the doctors, nurses, veterans, or even the administrators. By being under a government beauracracy their work is hindered. The mere fact that the government can’t manage things efficiently is proof enough for me that I don’t want government healthcare. In time the healthcare we receive will deteriorate. It’s not a scare tactic its cost benefit analysis. At some point in order to keep costs low the government will have to put limits on expensive theropies.”

    If government is inherently inefficent, why do we entrust the defense of our nation to it? Why not depend on private companies instead?

    “I also think there is and should be a dichotomy between services a government should and shouldn’t provide. I hope every citizen would agree that it is not the purpose of government to ensure that we all have jobs. It is governmen’s job to ensure we all can have jobs, but they can’t force companies to hire people. Nor can they provide jobs for everyone. One of the reasons Geece is in the trouble they are is because so many people are employed by the government. The math just cant add up. I know im probably in a minority here, but I believe healthcare should fall into this category. The examples you cite have to be enforced because without them our country, and every country for that matter, would be in utter chaos.”

    I understand this distinction, and it is a topic worthy of discussion and there is plenty of room for disagreement.

    “But for almost 230 years our government has run without government healthcare and for the most part there isn’t chaos. I believe the government should help when possible, and to a limited extent that is what social security, Medicare, and Medicaid are for.”

    With VA, Medicare and Medicaid, as well as state and local government programs, already accounts for half of all healthcare spending in the United States. (See http://www.healthpaconline.net/health-care-statistics-in-the-united-states.htm )

    And Social Security is not “government help”. It is old age and disability income which is funded directly by taxes paid by individuals and companies that employ them. There is nothing charitable about it. In many ways, it’s like your private Health Insurance, in that risks are pooled and some will “benefit” (survive to retirement or become disabled) and some will “lose” (die before collecting any benefits.)

    “But to ensure that everyone in the nation has healthcare is something we can’t afford. Again it is another reason Europe is in the crises that it is in. If you want to see into the future as to what our economy will look like ten years after this law is in effect look at what Europe is facing. Again punishing Americans for not purchasing a service is enough of a reason to me to be against this law.”

    Again, we can agree to disagree about this. One could easily point to the Nordic countries or Canada, where a strong “socialized” healthcare industry exists, and yet their economies are in many cases in better shape than ours. (As of this year, for example, the average Canadian is richer than the average United States citizen…and they have lower levels of government debt, lower crime, etc.)

    Casey, I think you bring some valuable points of view concerning the proper role of government. For what it’s worth, I am no fan of the current Democratic regime, nor am I fan of the Republican opposition. I will be voting third-party this year to send the message that I am disgusted with both major parties…I’ll probably vote for Goode.

  • Mark Hagerman

    The article takes for granted that the existing mandate that medical facilities provide treatment for those who can’t pay must continue. I disagree. Let those who choose to go without medical insurance take the consequences of their choices, for good or ill.

  • Daniel

    Mark, consider: if we took the consequences of the choices we made, we’d all be in hell. The wages of sin is death.

  • C. Ryan Knight

    Thanks, all, for the thoughtful comments and the respectful dialogue thus far. I’ll make just a few comments and then leave the conversation to you. I’ll try to be brief.

    PS: No, I wouldn’t say Christians de facto must support this law. I simply think they are able to abide by and follow it more than they think.

    Casey: I understand where you’re coming from with your resistance to Americans being forced to pay anything. It’s an objection rooted in a strong American tradition of rugged individualism (not the only tradition, but certainly a prominent and important one). I think what we’re seeing with the debate over the healthcare bill is the principle of private property (i.e. money) being challenged by the current situation where private property isn’t always enough anymore to carry people through their entire lives. I’m interested to see how these two factors (private property and the current situation) contend with one another in the coming years.

    Amanda, I’m still mulling over your thoughtful criticism. At the beginning of my feature, I do state that I focus specifically on the mandate. Perhaps this was unwise, and I shouldn’t have isolated it from other issues. I also tried to distinguish what I wrote by not rehashing all the same arguments found all over the blogosphere, but to offer something unusual — a thought-experiment of sorts (“What if the healthcare bill hadn’t passed and someone would still be able to forego healthcare? Is it possible that that person might be infringing upon the freedom of others down the road?”). If this approach, which was meant to generate new thoughts and dialogue, actually stifles opposing opinions, I would consider that a regrettable fault. Thanks for bringing this to my attention.

    Regarding the sentence you quoted, Amanda, I see why it can read off-setting, and I should have worded it more clearly. As is, though, it’s wrapped up in two conditionals: IF you think of fellow Americans poorly” and “IF there is hatred in your heart.” Anyone who answers negatively to either or both of those conditionals is exempt from the criticism. One opposed to the mandate might think poorly of her or his fellow Americans, but that does not necessarily equate to hatred.

    Mark, thanks for your input. What you propose is certainly “fair.” What I try to show in this piece is that many who would forego healthcare if they could wouldn’t be able to “take the consequences of their choices.” The consequences — most notably, exorbitantly high prices for treatment — are far too high for most Americans (see the paragraph on Americans being in debt and not saving adequately).

  • Greg

    Mark, you say, “The article takes for granted that the existing mandate that medical facilities provide treatment for those who can’t pay must continue. I disagree.” What happens if you’re found unconscious in need of medical attention (e.g. you’re jogging without your wallet (and thus your insurance card although you have insurance) and jaywalk (so are at fault and wouldn’t necessarily win a battle in court against the driver) and are hit by a car and knocked out). If you’re rushed to the hospital should the hospital not treat you even though you may die because they don’t know if you have insurance or means of payment, and for that matter, should an ambulance even take you or just let you die on the spot?


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