There Is No Conservative Case for an Insurance Mandate

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Former Massachusetts governor and current Presidential contender Mitt Romney says that he favors repealing ”ObamaCare,” with its federal mandate to buy health insurance, but he still won’t renounce his own handiwork, “RomneyCare,” which does mostly the same thing only on a State level. He may take comfort in a recent column by Walter Zelman in the Nov 20 Los Angeles Times entitled “The Conservative Case for Healthcare Reform’s Individual Mandate.”

Zelman, no conservative, was a prominent member of the Clinton Task Force on Health Care Reform and requested a memorandum from the Department of Justice concerning possible ways to circumvent Constitutional problems.

Zelman frames the issue as being a choice between the government’s imposing a financial requirement, or allowing free riders to impose the cost of their care on responsible people who bought insurance.

This type of dilemma is a called a Morton’s Fork, writes G. Keith Smith, M.D., founder of the Surgery Center of Oklahoma. The expression, which is related to tax collecting, is said to have originated with John Morton, Archbishop of Canterbury in the 15th century. Morton said that a man who lived modestly was saving money and could afford to pay taxes, and that a man who lived extravagantly was obviously rich and could also afford taxes.

Both branches of Zelman’s version amount to acceptance of cost shifting. Responsible taxpayers are forced to pay more than their fair share for medical care either before (through insurance premiums), or after the care is rendered, through grossly inflated prices for self-paying patients.

Since responsible people are going to buy insurance anyway, the mandate will have “zero” effect on them, Zelman argues. “The only individuals who may actually be forced to do something they would not do voluntarily are those who can afford insurance but choose not to buy it.”

There’s a little deft sleight of hand there: the definition of “insurance” that one chooses to buy has been changed to a plan that meets the government requirements. This plan you might well decline to buy because it is too costly, forces you to pay for coverage of services you don’t need or want or even find morally objectionable, or constrains your freedom of choice.

Both Romney and Zelman assume that people have a right to force others to pay for medical services they use. They call it a “right to healthcare.” And they assume that the only alternative is to let people die in the streets.

In fact, there are much better ways. Most bills should be paid at the time of service—by the person who receives the service, not by a third party. Medical services should be purchased in a competitive marketplace, with transparent prices. That’s the only way to drive spending down without reducing supply or restricting access. For those who truly can’t pay, there is charity, or government assistance.

But why should taxpayers have to prepay by subsidizing very expensive third-party payment schemes, which are so much more expensive than direct payment for services rendered? Why add at least 15% to the cost, in order to pay the insurance company to move money around? And why impose a costly administrative burden on the providers of services to justify the managers’ salaries?

Casualty insurance (e.g. fire, auto, life) is not in crisis, and the cost of home or auto repairs is not galloping ahead of the economy. What’s different about medical costs is the method of payment. True prices are hidden from the user of services. The real customer is a third party, which collects the money up front and skims off the first cut. True insurance would reimburse the subscriber who had incurred a financial loss.

Zelman and Romney apparently want to keep it that way. That means power to the administrators, planners, and government bureaucracies; control over patients and doctors.

There is no conservative case for expanding government or dictating how medical care is to be rendered and paid for. Those who call for mandatory redistribution of wealth through a health insurance mandate are not conservatives, no matter what they call themselves.


Jane M. Orient, M.D., Executive Director of Association of American Physicians and Surgeons, 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.



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