The New Yorker had an interesting article in the current edition. Ezra Klein is the author, and the sub titular question, "why do politicians reverse their positions?" pinpoints the content. The answer is psychological -- that is to say, in-group loyalty leads us to use what has been called "motivated reasoning." I suspect all reasoning is motivated, but nevertheless, it does help explain why the Republicans can attack with such vehemence what was originally and essentially a Republican idea -- the individual mandate.
I won't touch on the actual constitutionality of the individual mandate under the commerce clause -- that is for legal scholars and the Supreme Court to debate -- but the premise of the argument against it is simple. It is an infringement on our liberties, not of the negative sort where government tells us what we cannot do, but of the positive sort where government tells us what we must do. We are slightly more tolerant of infringements of the negative sort, and for most morality consists of obedience to infringements of the negative sorts -- that shalt not commit adultery or homosexual acts or the like. We are slightly less tolerant of infringement of the positive sort, and it might in some psychological sense have something to do with being bullied as a child. Its someone making us do something, by force, that we do not particularly want to do -- like pay taxes -- even though, at some fundamental level, the more meaningful moral imperatives -- thou shalt love thy neighbor as thyself -- is cast as a positive infringement on our liberties.
I make this distinction for a couple of reasons, but mostly just to point out that morality is demonstrated not only by what we might refrain from doing, but what we actually do, and then not only individually, but collectively. First, as a premise, I should point out that I think health care is not a commodity, but a moral right. If I cannot afford an iPad, and Apple refuses to provide me with one, I don't necessarily want to accuse Apple of immoral behavior. On the other hand, if I cannot afford health care, and say Intermountain Health refuses to provide me with care, I do want to accuse them of immoral behavior. It is one thing to deprive me of a toy, another thing to deprive me of care. The market treats both equally as a commodity, which is why the invisible hand of the market might be a fine thing for commodities, but not for moralities. If I am a hospital, or care giver, your inability to pay does not relieve me of my moral responsibility to do what I can and must to save your life, even though that positive obligation is an infringement on my liberty and comes at a cost to me.
Second, as a premise I do not particularly believe in redistributive justice, if by that we simply mean "taking from the rich to give to the poor." I do, however, believe that each of us individually and that governments collectively have moral responsibilities, and that others have the right to expect moral behavior of each of us individually and governments collectively. A fundamental moral right is the right to life, and we have the moral obligation not only to refrain from murder, but the obligation to preserve life the life of others if we can. Individually, we may not be able to do much. I am not a caregiver, nor do I work at a hospital. As a member of a collective, however, I have an obligation to do what I can, and for the most part that means paying taxes that go to pay for the care of those who cannot afford care.
We have, in short, a moral obligation to do what we can to preserve the right to life, and in the case of most Americans that means the moral obligation to pay taxes to support a health care plan. We can, and should, of course, debate the efficacy of a plan, but the inefficacy of any particular plan does not relieve us of the moral obligation to have a plan. It seems clear enough that the so-called private option of employer-based insurance isn't working well. We have heard the numbers of Americans that fall outside the employer-based system, and it's reasonably clear why they would. Not all Americans are employed, and not all employers, even very large employers, offer health benefits. Consequently, we have medicare and medicaid to cover those who fall outside the employer-based system. As it stands, we are meeting our moral obligation, but the general consensus has us doing it rather poorly. If we dismantle medicare and medicaid, we would fail to meet our positive moral obligation to do something unless there is something better -- that is to say, something more efficient -- to replace it. The question is not "whether we should" -- we should -- but rather "how to do it better."
This brings me back to the individual mandate. It is a tax. It is a particular type of tax, but it is a tax none-the-less. I pay a similar tax for the right to drive my automobile -- the mandate that I carry liability insurance in order to operate a motor vehicle on the roads of my state. There are of course differences in the justification for the mandate and the universality of the mandate -- I can forego the privilege of driving on public roads and thereby forego the obligation to purchase automobile insurance -- but the premise is roughly the same. If I carry insurance and you do not, I also carry a disproportionate share of the risk and the cost of my insurance goes up. It is, in effect, unfair unless we all carry insurance and share more or less equally in the the risk.
A crucial difference, however, lies in the up-front moral obligation. I do not feel the same moral obligation toward your "right to drive" as I feel toward your "right to live." There is a not-so-subtle difference between "I cannot afford car insurance and so cannot drive" and "I cannot afford health insurance and so cannot live." The former might elicit sympathy. It might even elicit some tax-supported subsidy for public transportation. But it is unlikely to elicit the purchase of a Mercedes on your behalf. I cannot forego the need to access health care in quite the same way that I can forego the privilege of driving on public roads. I will access the health care system, and there is a public benefit in my doing so, if for no other reason than helping curtail the spread of infectious disease. Moreover, when accessed, if it takes a Mercedes-level effort to cure you, a Mercedes-level effort will be made on your behalf. Anything less would be unconscionable.
I have the expectation that every effort will be made on your behalf in part because I have the expectation that every effort will be made on my behalf. I can be sanguine about your inability to afford care, but cannot be equally sanguine about my inability to afford care. I can stand in the crowd and shout "let them die!" but the one who did that, in the throes of the moment, might not be quite so quick to shout "let me die!" if he were having a heart attack and his insurance couldn't be verified, or if he were to find himself unemployed and uninsured, and in reality the vast majority of us are a pink slip away from being without coverage. If I bear that expectation, however, then I should bear my proportionate share of the risk. I have an obligation to you because you have that obligation to me -- an individual mandate to do my share, an individual mandate that infringes on my liberty to ignore your needs, just as your individual mandate infringes on your liberty to ignore my needs -- and it is ultimately this reciprocity of individual mandates through mutual obligation that makes of us a moral society.
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