President Barack Obama speaks at Boston's historic Faneuil Hall about the federal health care law, Wednesday, Oct. 30, 2013.
Charles Dharapak/AP

The right attacks Obamacare as “paternalism”

Updated

The ever-shifting line of attack against Obamacare has shifted once again.

A couple of days ago the GOP talking point was: “Hey, Obama lied when he said ‘If you like your insurance, you can keep it.’“

A number of health care reporters, including msnbc.com’s Geoffrey Cowley, explained in response that while yes, it’s true that if it’s a bad policy—i.e., an individual policy (as opposed to an employer-supplied “group” policy) that puts a ceiling on payouts, imposes outrageous deductibles or co-payments, or fails to cover a specified list of ten types of medical services that people on group plans typically take for granted—and you actually enjoy possessing this type of garbage health insurance, then yes, you’re out of luck: you can’t keep your policy. (White House spokesman Jay Carney said this too, albeit more politely).

President Obama was trying to convey that people who got health insurance from their employers (which is most of us) would not be affected in any noticeable way—as indeed they are not—because the prospect of losing existing employer-sponsored policies was one of the things that helped sink Hillarycare back in 1994 (“They choose. We lose”).

But Obama formulated his promise too simplistically, and people ended up thinking they could keep their existing individual health insurance policies even if these policies were crap.

To this, conservatives now reply: Hey, who the hell is President Obama to be telling Americans what kind of health insurance they may or may not purchase? Isn’t he being kind of … paternalistic?

Thus Charles Krauthammer, in the Washington Post, characterizes the administration’s posture as “paternalism,” elaborating:

Sure, you freely chose the policy, paid for the policy, renewed the policy, liked the policy. But you’re too primitive to know what you need. We do. Your policy is hereby canceled.

Because what you really need is what our experts have determined must be in every plan. So a couple in their 60s must buy maternity care. A teetotaler must buy substance abuse treatment. And a healthy 28-year-old with perfectly appropriate catastrophic insurance must pay for bells and whistles for which he has no use.

What’s most striking here is Krauthammer’s overconfidence that the word “paternalism” will be received as a crushing blow. In truth it is neither exceptional nor disturbing for government to place certain limits on individual choice, even when those choices affect nobody else.

It is illegal to kill yourself, or to sell yourself into slavery, or to sell your organs, or to practice prostitution. It is illegal to take certain drugs, either recreationally (because they’re addictive and/or potentially harmful) or as treatment for disease (because their efficacy is not yet proven and/or the side effects are unknown).  State laws place maximum limits on how much interest to charge for a private loan. Polygamy is illegal in all 50 states.  And if a state trooper catches you driving 90 m.p.h., you will be fined, even if yours was the only vehicle on the highway.

There’s certainly room for argument about whether particular paternalistic laws are just and humane. But any notion that government paternalism in general is inherently illegitimate stands well outside the mainstream of practical governance.

One reason society imposes prohibitions on so-called “victimless crimes” is that it’s often hard to tell whether the harm an individual brings on himself might also affect others. The purchase of substandard health insurance is an excellent example. Say I pay $13 per week for a “mini-med” policy with a $5,000 ceiling. Then one day, while crossing the street, I get hit by a speeding car that doesn’t even stop. Suddenly I have to pay tens of thousands in medical bills—money I don’t have—to the hospital. The hospital will extract from me what it can, and then either absorb the loss or (more likely) extract the remainder by raising incrementally its fees, in effect giving me a free ride at everyone else’s expense. No man is an island.

Sometimes, it’s true, Obamacare will require you to pay for medical conditions you know you will never suffer. Krauthammer overstates his case when he suggests a teetotaler can be certain he or she will never require substance abuse treatment, or that a healthy 28 year old will never acquire a chronic medical condition that a catastrophic policy doesn’t cover.

But a couple in their 60s can indeed be certain they won’t require maternity care. That doesn’t free them of the obligation to subsidize, through their premiums, other people’s maternity care.  (For one thing, merely by being in their 60s, this couple is likelier than most young mothers to run up high medical bills for other types of procedures.) Health insurance works only if risks are shared across as broad a swath of the population as possible.

Ironically, if Krauthammer and other conservatives ever succeed in derailing Obamacare on the grounds that it’s too “paternalistic,” they will have exhausted what is probably the last plausible market-based solution to the nation’s health-care needs. Should that happen, it will become much more likely that the U.S. will adopt a Medicare For All “single-payer” model in which the government directly assumes responsibility for paying all medical costs (which is almost certainly more efficient). Such a socialistic system has already been adopted in Krauthammer’s native country of Canada. Paternalism? You ain’t seen nothin’ yet.

The right attacks Obamacare as "paternalism"

Updated