Ending individual mandate raises questions of morality

The Houston Chronoicle, December 8, 2017

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As Congress debates getting rid of the individual mandate to buy health insurance to better afford a tax overhaul, I’m reminded of one of the mandate’s leading advocates — Uwe (pronounced OOH-vuh) Reinhardt, one of the greatest minds in health care economics.

In 2009, as Congress was debating the Affordable Care Act (signed into law the next year,) he was interviewed by Terry Gross on NPR’s Fresh Air. She asked him about the individual mandate to purchase health insurance, an essential ingredient of universal care.

Uwe Reinhardt speaking before Congress.

He answered that Americans have a cognitive dissonance. “Cognitive dissonance,” he said, “means that you hold two different theories that are in conflict with one another, but they’re both in your brain and in your soul …. Americans say the government doesn’t have the right to tell me to buy health insurance, but the same Americans will say if I get hit by a truck and I lie bleeding in the street, society owes it to me to send an ambulance, and the emergency room doctors owe it to me to save my life. How could both be true? Even a teenager would blush at something this ridiculous. If you believe society has a duty to save your life when you get hurt, you have a duty to chip into a fund that pays for that.”

Gross asked him if health insurance purchase were mandated, how everyone could afford it. He responded that a simpler, more helpful question would be, “What percent of a family’s discretionary income, that is, income after food, housing and clothing, should a family be expected to pay for its own health care?”

He suggested that upper-income people such as professors at Ivy League colleges like himself should be expected to pay 15 percent. Those with lower incomes such as waitresses and waiters, would reasonably be expected to pay no more than 5 percent, with government subsidizing the rest.

Reinhardt, who died of sepsis last month at the age of 80, was a plain-spoken advisor and consultant to presidents, congressional committees, countries, the media, corporations and students of health care everywhere. He taught for nearly 50 years at Princeton University, and he explained the most complex issues in health care in brilliant, bright, easy-to-understand prose in his weekly New York Times Economix Blog.

Reinhardt’s views came from personal experience. He grew up in Germany and told Gross “how good it was that when we were paupers, my family, we had health insurance like everyone else in Germany. I’ve never forgotten that. And I would like the American people to have” that.

Living close to a hospital, he saw enough of the horrors of World War II to emigrate to Canada when he was 18 to avoid the draft and to study. There again he appreciated that everyone in the country had health insurance.

After graduation, he immigrated to the United States to earn a Ph.D. in Economics from Yale University. He became bewildered to see the extent of misery, morbidity and mortality caused by a health care “system” where so many lacked insurance and put off care.

He wondered how a country as rich, resourceful and innovative as America could have failed to develop a system to cover everyone. After all, all the other industrialized countries set up health systems where everyone was covered, their governments viewing health care as a right and a proper role and goal of government to sustain a healthy and productive society.

Without the individual mandate, Obamacare will die. As congressional Republicans contemplate the murder-suicide of getting rid of it, we remember Reinhardt’s words: “What kind of country do we want to live in? One where someone who loses their job loses their health insurance? One where kids coming out of college can’t get health insurance for the next 10 years? One where emergency rooms are packed with people who don’t have access to [primary] care? One where people who have a family member struck by cancer can become bankrupt? One where tens of millions are uninsured?”

These are questions of morality.

Toni Inglis, MSN, RN CNS (retired), FAAN, a lifelong Austin resident, is a retired neonatal intensive care nurse and editor of NursingNews. She also wrote a monthly opinion column for the Austin American-Statesman editorial pages for 10 years.