The Role of the Free Rider in Healthcare Reform


By : Jane M. Orient, M.D.,

Your local spokesman for the healthcare reform that Congress worked on through Christmas Eve 2009 probably makes the same argument that the Obama Administration is making in federal court.

Without the reform, they say, “all of us” get stuck paying the medical bills of The Uninsured. That isn’t fair, say the advocates. And it makes the Affordable Care Act (ACA, also called “ObamaCare”) constitutional, says the Administration.

They don’t use exactly the same words, but the logic is the same.

The issue is the linchpin of the ACA: the “individual mandate”—the requirement that everybody buy “minimum essential coverage,” or else be punished by the IRS.

There are some undeniable truths behind their argument: (1) Medical care costs too much. (2) There is a lot of cost shifting. (3) There are free riders.

And there is a huge emotional appeal. People are easily led to resent perceived Victimizers. Nobody, of course, wants to pay medical bills for irresponsible spendthrifts.

The Uninsured are prominently displayed as Victims of the heartless system. But they are also the irresponsible Victimizers who don’t buy insurance but receive medical care, for which the “rest of us” are forced to pay.

Did you notice that these two ideas contradict each other? Advocates of ever expanding government are skilled in holding contradictory views in different compartments of their brain, and seamlessly switching back and forth in their firm beliefs as the occasion demands. George Orwell coined a term for it in his novel 1984: doublethink. It was the foundation for the totalitarian regime called IngSoc, an advanced derivative of English Socialism, which was destined to endure forever.

The stated rationale for the constitutionality of the ACA is the Commerce Clause. Ever since the New Deal, the federal government has been expanding its power over everything that could remotely be construed as affecting interstate commerce, however tiny the effect. Growing wheat on your own property for your own use might conceivably affect prices in interstate commerce, especially in the “aggregate,” if everybody did it.

One might call it the “butterfly effect,” as in science fiction novels that construe how the fluttering of a butterfly’s wings in a prehistoric forest sets in motion forces that change history.

The ACA takes a quantum leap beyond previous invocations of the Commerce Clause. The mandate is triggered by not doing something. The federal government can’t regulate non-commerce. So it has to turn non-commerce into commerce, failure to act into action. Doublethink.

Once the government forces you to buy insurance, then it can assert its power to regulate the type of insurance you buy. And anything not in its regulatory grip affects the overall regime, so nothing can be allowed to escape.

The possibilities are endless. Food, clothing, shelter, energy, transportation. Education, internet communications, publishing. Healthcare affects life. So does everything else. There is no limit to the butterfly effect, as some federal judges have noticed. And there is a word for unlimited government: totalitarian.

The Administration relies on those free riders. The Uninsured will (almost) inevitably have a medical problem sometime during their lives. They will (almost) certainly use medical services. They might not pay for them. The cost of “uncompensated care”—about 2 percent of total medical costs—is passed along to insured patients through higher premiums or to taxpayers through government “disproportionate share payments” to hospitals.

In order to prevent “us” from having to pay for Victimizers’ medical care after the fact, all of us will be forced to pay in advance for all the “necessary” and “appropriate” medical care that anyone might ever need. And for the bureaucracies who will figure out what is appropriate, and monitor whether it was properly provided. In other words, to prevent having to pay for other people’s care, we will be forced to pay for other people’s care. That is perfectly logical—in doublethink—despite the disproportionate cost. It’s a more than $1 trillion “solution,” which is 23 times the government’s estimate of $43 billion in uncompensated care.

And what is the effect on those undeniable truths? (1) Medical care will cost still more because it will all be “covered” by insurers and bureaucrats. (2) There will be still more cost shifting because more people will be on Medicaid, the biggest cost shifter. (3)

There will be more free riders: bureaucrats and “providers” of services that nobody wants enough to pay for.

The game will be advanced. But the goal has nothing to do with better health.

Jane M. Orient, M.D., On Air contributor speaking on Healthcare Reform. Dr. Orient has appeared on some of the largest TV and Radio networks in the US. Her op-eds have been published in hundreds of local and national newspapers, magazines, internet, followed on major blogs and covered in the Wall Street Journal and the New York Times.

Dr. Orient is the Executive Director of the Association of American Physicians and Surgeons. She has been in solo practice of general internal medicine since 1981 and is a clinical lecturer in medicine at the University of Arizona College of Medicine. She received her undergraduate degrees in chemistry and mathematics from the University of Arizona, and her M.D. from Columbia University College of Physicians and Surgeons. She is the author of Sapira’s Art and Science of Bedside Diagnosis; the fourth edition has just been published by Lippincott, Williams & Wilkins. She also authored YOUR Doctor Is Not In: Healthy Skepticism about National Health Care, published by Crown. She is the executive director of the Association of American Physicians and Surgeons, a voice for patients’ and physicians’ independence since 1943. Complete curriculum vitae posted at Additional information on health-related issues: and

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