In Defense of the Uninsured (Part 1)

by Micah Tillman

“[T]hose who could afford it but don't [purchase] health insurance . . . [get] sick, go to an emergency room, [and] all of us wind up paying for their health care.” So said Wolf Blitzer, reporting a critique of Obama’s health insurance proposal during last week’s CNN Democratic debate.

Blitzer didn’t say by whom this “criticism [had] been leveled,” but it echoes the official 8-page summary of Clinton’s plan. In that document one is struck by the noble goals, semantic finagling, and confusion of it all.

Whether or not Clinton wins (or the legislative package she wants is enacted) therefore, Blitzer’s reintroduction of the “Everybody Pays for the Uninsured” line has made two things clear:

(1) The uninsured need to be defended, and
(2) The national discourse on health insurance needs to be clarified.

Attacking the Uninsured
Clinton’s proposal attacks the uninsured (no doubt unintentionally) in two ways. First, it demands that everyone purchase health insurance (pp. 2, 6). In doing so it applies automotive-type reasoning to healthcare:

If you own a car, you must have car insurance. If you’re alive, you must have health insurance.

The difference between the two is that no one chooses to be born. You know what you’re getting into when you become a car owner. You don’t know what you’re getting into when you becoming human.

Car insurance mandates present you with a choice: If you don’t want to pay, you don’t buy a car or you get rid of yours. But what does this mean for health insurance? If you don’t want to pay, you don’t get a life, or you get rid of yours?

“You have to buy health insurance.” “Why?” “You’re alive.” “So if I committed suicide I wouldn’t have to?” “I guess not.”

No sane person would present her fellow citizens with this choice. And since no one thinks Clinton is insane, she must simply miss the fact that this is what she is doing. How she could “miss it” is explained by the second attack her proposal makes (the one which Blitzer echoed):

By not having health insurance (the document insinuates on p. 6) the uninsured are raising the premiums that the insured pay by “roughly $900.” The uninsured are ripping their fellow citizens off. The poor are screwing the rich.

To back up the “roughly $900” figure, the proposal cites Families USA’s, “Paying a Premium.” But the “key findings” page of that document offers a significant clarification. It is not the uninsured (tout court) who are raising the premiums of others. It is the uninsured who don’t pay their bills who purportedly create the problem.

If you see the issue as Clinton’s document presents it — the uninsured, by being uninsured, are costing other people money — it only seems fair to force everyone to buy health insurance. Thus the proposal’s second attack on the uninsured seems to justify its first. The first attack (“Pay up or die”) no longer seems like an attack, and so Clinton doesn’t see the choice she is presenting us.

One element of the proposal, then, has the effect of punishing people for living. Not only does it cost you money to live (you have to buy food and pay for housing), but you would have to pay an additional life-tax called “health insurance,” whether you like it or not.

The second element teaches those who are insured to resent the uninsured. And that’s not something a Democrat should be proud of. (Not that anyone should be proud of it, but the Democrats are the party of John Edwards, right?) Do they think the poor aren’t listening to how they’re being talked about?

Initial Clarifications
There are three ways to look at health insurance, and Clinton’s proposal uses two without explaining how they work together. Those three views are:

(1) I pay more than I have to so that when I have to pay more than I can, I won't have to.
(2) I pay some so I don't have to pay more.
(3) I pay in so others can take out.

Each of these views is legitimate, and reveals a real aspect of the system. They may not each be true for every person, but at least one of them is true for everyone who has insurance.

By telling the insured that the uninsured are using them, Clinton’s plan is saying that current insurance is like number (3). Right now, it says, some people are paying in just so other people can take out. In fact, $900 of what you’re paying every year covers those who refuse to pay.

But Clinton also uses (2) in an attempt to attract everyone to her future system: Things will be cheaper for all if her plan is put in place. If everyone paid a little, no one would have to pay so much.

What Clinton doesn’t say is that no matter how true (2) is in her plan, no plan can eliminate (3). Taking out a health insurance policy is agreeing to join a group of people who take advantage of each other when necessary. The bills that one person can’t pay are paid by the insurance company using the extra money others put in.

And even if Clinton was able to lower prices for all, (1) and (3) would still be true for some. Some people would still have to pay more than is actually required for their own treatment so that others can get treatment which they can’t afford. The guarantee the over-payers get in return is that if a time comes when they need to be taken care of, they will be.

Since Clinton presents her plan as a way for the insured to stop overpaying, she misrepresents the fundamental nature of insurance. It is possible to pay less and yet still overpay. The world of insurance for patients will always be one in which there is a lot of giving and only some receiving.

(Next time: Further clarifications; and recommendations for those selling universal health insurance.)

Micah Tillman is a lecturer in the School of Philosophy at The Catholic University of America. Links to his articles can be found at http://micahtillman.com/.