The Moral Foundations of the Insurance Mandate

By Tina Rulli*

Republicans’ new plan to replace the Affordable Care Act ditches the health insurance mandate, the requirement for individuals to purchase health insurance or pay a penalty. Instead, their American Health Care Act favors tax credits to incentivize people to purchase insurance.

There are many vantage points from which to assess the health insurance law, including legal, economic, and public health perspectives. My focus is on the moral foundations of the individual mandate, in part, because Republicans have taken moral umbrage at it as an instance of government overreach inconsistent with respect for individual liberty. Moral concerns should and do motivate public policy.

What Republicans fail to see is the moral logic behind the insurance mandate. We have a moral obligation to purchase health insurance because our hospitals and clinicians have a legal duty to provide emergency and acute care to people regardless of ability to pay based on the Emergency Medical Treatment and Labor Act (EMTALA). In 2013, the cost of uncompensated care was a whopping $84.9 billion.

When others have a duty to rescue, a duty to provide aid to those in serious need, individuals can incur obligations to lower the potential costs of rescue. This is a familiar duty: knowing that park services will provide costly tax-payer funded rescue if a mountaineer gets lost, mountaineers have an obligation to mitigate the risks they take by staying on well-traveled paths and out of avalanche areas and by carrying a GPS that makes them easily locatable. In 2011, when an 8.9 magnitude earthquake hit Japan, California surfers were warned to stay out of the path of the resulting tsunami. This was not just out of concern for their wellbeing, but also for the safety of their potential rescuers. When others have a duty to aid, we can incur obligations to mitigate the burden of rescue to them and others.

One might argue that we should drop the provision of free emergency and acute health care. But truly imagine what this would entail. Clinicians would be required to stand back while a car accident victim without health insurance bleeds to death, even though they could administer a simple life-saving blood transfusion. This is inconceivable in a compassionate and minimally decent society. We do not think that one owes one’s life for lack of insurance, whether due to personal negligence or financial hardship. Further, requiring clinicians to deny care would be a great burden to them. Compassionate clinicians, out of their own sense of decency and their allegiance to an ethical code that requires promotion of patient welfare, could not stand back and watch a person needlessly suffer or die.

Perhaps the stalwart moral libertarian would say: “You cannot mandate that I buy insurance, given that I am willing to refuse your free emergency care.” But $84.9 billion dollars in uncompensated costs suggests that such consistent moral libertarians are mythical beasts. People who fail to buy health insurance overwhelmingly accept free emergency and acute care in their time of need.

In short, there is a moral justification for the insurance mandate that the Republican plan overlooks. The moral foundation is an important component in rationalizing good policy to the public. Tax incentives send the wrong message: treating the purchase of health insurance as optional, rather than as a duty of reciprocity for a compassionate health care system that will not allow the most vulnerable to suffer or die for lack of insurance. Surely, conservatives can agree to holding people responsible for participating in a cooperative system whereby some people incur burdens in order to benefit others. This is the paradigm of individual responsibility. It was their idea in the first place.

For related reading, see here and here.

*Tina Rulli is an Assistant Professor in the Philosophy Department at the University of California, Davis.

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