Individual Liberty and Health Care

Recently I had conversation with a college student on the subject of a national health care program. The student objected to “Obama Care” because it limited his “liberty.” Being required to participate infringed on his freedom to choose not having health insurance. He also objected to paying for other people, especially those who might do unhealthy things.

I suggested to him that we are all members of a society. No man, or woman, is an island and no one is free to do, or not do, anything they want. All civilized societies impose necessary restrictions on people. Often these are “thou shalt not” restrictions but they can also be positive norms to promote the public good. People come together to do things they cannot do well by themselves. The private insurance industry began as non-profit mutual help organizations. Government is a tool used to produce these “public goods.”

These arguments were not accepted. We parted agreeing to disagree. But the conversation got me thinking about our national obsession with “liberty.” We frequently pontificate about “freedom” and we idealize “rugged individualism.” But what is real freedom? In a modern, complicated, technological society are we well served by sink-or-swim, individual liberty? Would we all be better off with a broader definition of liberty?

It seems to me a national, universal, public health insurance program would be EMPOWERING. It would LIBERATE people and provide more individual choice not less. Liberty is not just the absence of restraints on one’s behavior. In a modern society social supports like education, healthcare, equal employment opportunity, unions, and retirement security are what creates real freedom. These provide substance and reality to the empty rhetoric of individual “liberty.”

I have known many people trapped in jobs they hated because of employment based health insurance. They couldn’t risk their family’s health by changing jobs. I have known single mothers forced to choose between public medical insurance for their children and the entry level job with no benefits. If we had a universal national health care program people would be free to go back to school, start a small business, quit that dead-end job, retire, or simply seek more rewarding work. Rather than national health insurance restricting your liberty, it provides the security to set you free.

Libertarians, like this student, quote John Stewart Mills, the 19th century economist and philosopher. In his famous work On Liberty, he states the classic criteria for government restrictions on individual liberty,

“…the only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others.”

In other words, your freedom to swing your arm stops at the nose of your neighbor. Society only has a right and obligation to restrict your freedom when it negatively impacts others. But society needs laws and regulations to organize society, establish the rules of the game, and to protect public health and safety.

When it comes to heath and healthcare insurance an individual’s behavior DOES impact on other people and this impact can be very harmful to other individuals and to society as a whole. Like running red lights or driving under the influence, people are not free to do dumb things. Thinking that because you are young and healthy you don’t need health insurance is not just a dumb individual economic choice. There are many ways in which this choice harms others.

A basic principle of insurance is to spread risk. The larger the population participating the greater the risk sharing and the lower the costs. The largest possible risk pool is everyone. This mathematical reality is why national, single payer health insurance systems work better than private insurance. Our lack of a universal, national program is one reason we pay much more than any other country in the world for health care and health insurance.

Another basic insurance principle is “adverse selection.” When the insured population has too few healthy people or too many old sick people everyone’s health insurance (and the cost of health care) goes up. When young people don’t contribute, the cost for everyone else increases. When uninsured people wind up in the emergency room it costs all of us more. We all pick up the tab with higher insurance rates and higher medical costs.

Being part of a national system is also better for the young and healthy. Even the young and healthy have accidents and illnesses. All of us will need health care, and preventative care can save everyone money. People tend to forgo needed healthcare and preventive healthcare when they have to pay for it directly. It is foolish financially and from a health standpoint to think you can go it alone or that decision doesn’t impact other people.

Another problem with the rugged individual philosophy is we have “been there and done that.” It didn’t work well for most people. For most of our history we have had limited government that did not respond to social problems. People were on their own for illness, getting hurt on the job, unemployment, and old age.

Family and private charity didn’t have the resources to fill the gaps. As a result many people lived in poverty. More recently we have learned that many things are done better, more efficiently, and cheaper when done COLLECTIVELY. Health insurance and other social insurance programs are examples of our PROGRESSING as a society.

Despite this obvious common-sense approach to making all our lives better, conservatives insist that the private sector does it better. They malign sensible, universal, national social insurance as “socialism.” They insist people should be free to manage their health care and retirement on their own. But the examples of Social Security and Medicare prove them wrong. Both programs are hugely successful because they filled real needs in real people’s live that the private sector, driven by profit motive, was unwilling to address. Both programs are very popular with most of the public.

We will not solve our national health care crisis with rugged individualism. Nor will the “free” market, for profit, corporate model produce good solutions. You can’t solve problems with the same thinking that created them.