The Tree of Liberty (or, Nurse Ratched Attacks the Individual Mandate)

March 24th, 2010

The right-wing echo chamber is in full force– this “issue” came up repeatedly in Republican statements on the House floor during the final healthcare debate, and in call-ins on C-SPAN’s “against” line. As I’ve discussed before, this is a tough issue for Dems, who contrary to GOP claims, don’t like to force people to do things they don’t want to do (that’s never popular politically). The irony is that if Dems hadn’t put the individual mandate into the bill, Big Health would have forced their representatives in Congress (the Republicans) to demand it. And, as I mentioned in my earlier piece, it would have been unfair to the insurance companies for Dems to refuse. I know, I know: so what? If we want reform to work, it has to be sustainable, and that means it has to be fair to all stakeholders. Just because insurance companies have been unfair to us doesn’t mean we should be unfair to them. Of course, being “fair” doesn’t mean we give them everything they want, but it does mean we give them what they need to make reform succeed.

You say the individual mandate is an attack on liberty,

But are you willing to continue to water that tree

With the blood of 45K uninsured per year?

(Sorry, but that seems a bit cavalier.)

During the final healthcare debate last night, one of the CSPAN “against” callers (Joyce from Missouri, a nurse, whom I’ll hereinafter refer to as Nurse Ratched, since she reminds me of that character in One Flew Over the Cuckoo’s Nest) made what she thought was a persuasive argument against both the individual mandate and any action to reduce the ranks or the uninsured. She explained that her hospital treats anyone and everyone, regardless of whether they have insurance or can pay with the same quality of care. The CSPAN moderator asked her if nurses knew what their patients’ insurance status was. She said they didn’t.

First, the assumption underlying that question (that if nurses didn’t know a patient’s insurance status, they’d automatically receive the same level of care) is incorrect.  As anyone who has ever gone to a doctor, visited the ER, or been admitted to a hospital (in other words, almost everyone) knows, the first question asked is what insurance do you have (assuming, of course, that you’re conscious, and even if you’re not, whoever comes in with you will be asked that question). No, the nurse isn’t the one that asks that question or decides whether and how a patient is treated: it’s the admitting official. So, Nurse Ratched, I’d bet that your hospital is at least to some extent rationing care on the basis of ability to pay.

But even if Nurse Ratched is right and her hospital really does provide equal care to everyone (in which case, we would according to Nurse Ratched be able to solve the entire healthcare crisis by just having uninsured people go there for treatment), that situation is not representative. Other callers (both nurses and uninsured patients) told story after story about how they or their loved ones (as patients) had been denied care, or (as nurses) forced to deny care to others. And even Rep. Linder (R-GA) gave the lie to Nurse Ratched’s claim when he touted that the uninsured get 70% of the level of care that insured patients do, or in other words, they do NOT get the same level of care that insured patients get. And remember that the 70% figure is an average, so many uninsured are getting much lower levels of care, and some are getting higher levels (the latter are probably the ones at Nurse Ratched’s hospital). But more importantly, healthcare isn’t like college, when 70% gets you a “gentleman’s C” (which, by the way, is how GB2 got through Yale). Healthcare is often all or nothing: the difference between 71% and 70% of care may mean that you die. And for the families of those 45 thousand uninsured patients that do just that every year, the “fact” that they got (on average) 70% of the care they needed isn’t much of a consolation.

But there’s a more basic problem with Nurse Ratched’s and Rep. Linder’s arguments. They are basically saying that it’s OK to force hospitals to provide uncompensated care (much of which is provided at higher cost than it otherwise would be, since that care is ER-based), the cost of which they then pass on either to the federal, state, and local governments (which under the pre-reform system reimbursed hospitals for some of their uncompensated costs) and to people who are insured. That not only is socialized medicine (which the GOP claims to be against—God forbid that the Teabaggers find out the truth), but it’s a very costly, inefficient, ineffective, and immoral form of socialized medicine. And it’s a system that nobody likes or benefits from: not the hospitals providing uncompensated care, not the uninsured patients getting substandard and uncertain levels of care, and not the insured patients and state, local, and federal governments who have to pick up a big chunk of the tab. Nobody wins.

So obviously the system has to change. There should be individual responsibility, Republicans say, but they never discuss what that truly means. True individual responsibility in healthcare would mean that if you get hurt in an accident and don’t have insurance, that’s your problem: the hospital should just let bleed to death on the spot. Is that what you, Brandon, anti-reformer from Alexandria, would want for yourself, your loved ones, or even a perfect stranger? Even Republicans aren’t cold-hearted enough to advocate this position (or at least not politically stupid enough to do so openly). And unless you’re willing to take that position, you are upholding that a sick or hurt person has the moral and legal right (and many states do in fact recognize that legal right) to receive care, even if they can’t pay for it. Republicans have a term for that: it’s called welfare, or (a more politically generic term), freeloading.

That is the problem that the individual mandate addresses. We as a society can’t bring ourselves to say that people should die because they can’t afford care (though that’s often what happens), but we have a healthcare delivery system that does not mesh with our purported values. Short of socialized medicine, the individual mandate is the only way to bridge that gap. That’s why Obama, a very smart guy who was originally against the individual mandate, finally accepted and incorporated it into his reform approach.

The final nail in this anti-reform coffin (and if you think I’m using too much death imagery here, just remember that healthcare reform is life and death) is that Nurse Ratched’s argument that an individual mandate and/or provisions for the uninsured are unnecessary because her hospital already provides uncompensated care is like saying that there’s no need for a law against murder, because I never murdered anyone. Laws and regulations are not to control those among us who already do the right thing, but to deter and punish those who don’t.

A group of 30 odd states (including Virginia, and by the way, I mean “odd” in both senses of the word) is preparing to challenge the healthcare reform bill in court, focusing principally on the individual mandate’s alleged unconstitutionality. Their claim is based on the view that if the government can make people buy health insurance (just like they make people buy auto insurance), then “they” can make people buy anything they want, anytime they want, as argued (yet again, incorrectly) by George Will (Activist judges, please, Washington Post 1/14/10). I don’t believe the individual mandate is unconstitutional: as with most government policy, this is determined by balancing the action’s scope with the public purpose accomplished. In my view, the individual mandate clearly passes that test, since Congress isn’t even requiring purchase of health insurance per se. Instead, Congress is establishing a reasonable, non-confiscatory fine or tax to take effect for individuals who do not purchase health insurance and would otherwise be freeloading on the system, forcing society to bear the costs of their treatment. Not only that, but a constitutional law scholar whose name I didn’t catch pointed out on C-SPAN 3/21/10, (1) the Supreme Court has ruled that states don’t have standing to challenge the constitutionality of federal legislation, and (2) the individual mandate won’t take effect until 2014, until which time no one can justifiably claim they’re “injured” by it. (For more on the subject, read Can the Constitution stop health-care reform by GULC constitutional law professor Randy Barnett, Washington Post 3/21/10).

But if the Supreme Court differs (and they may, given their increasingly apparent ideological drift and willingness to reject precedent), then socialized medicine (whether by vouchers, tax credits, single-payer, a fully government-run system like the VA’s, or some combination of the above) would be the only remaining approach to address the problem that the individual mandate attempts to resolve. Of those options, voucher and tax-credit based approaches (which is obviously what the GOP would prefer) is the functional equivalent of the new reform approach, except that instead of flowing through private insurance companies as they will with Obamacare, payments would flow through the government. Doesn’t it seem strange that the GOP would want the latter instead of the former, which is what they (en masse) have just voted against?

So I have to admit, Nurse Ratched and Rep. Linder make an extremely compelling case. But it’s an argument for reform, rather than against it. Ironic, eh?


Here’s the real Nurse Ratched in One Flew Over the Cuckoo’s Nest (also check out the book by Ken Kesey). Is this the kind of healthcare system we want? Is this the kind of democracy the Republicans want? (Don’t answer the latter question – it’s too obvious. And don’t miss the music in the next two clips.)

And appropriately, here’s your theme music for today (check out the MP3 or CD in our Amazon store).

Here’s the full House session (eleven hours worth, so you may not want to watch it all – you can also just skip this one and watch the out-takes below). I liked the hopefulness that the opening prayer presaged (“The long waiting is over, and hope and spring are in the air”). Nurse Ratched (Joyce from Missouri) is at 610:30, Brandon from Alexandria is at 602:15-603:10, and one more anti-reformer who particularly disliked the individual mandate (James from Wisconsin) is at 604:50-605:17 (search or read the session transcript here). And by the way, that’s Rep. Jesse Jackson Jr. (D-IL and son of the civil rights leader and presidential candidate) chairing the first part of the session (and a great job of it he did of it). Click here for a timeline of the entire session, including votes, speakers, and a partial transcript.

Here’s Rep. John Linder (R-GA) talking about how the uninsured are getting on average 70% of the healthcare insured people get (even assuming that’s true, how revolting that as a nation we’d want to change that). He also manages to get in a jibe against Natoma Canfield. Who does she think she is getting sick without insurance!

Here’s Rep. Ryan speaking out against all the bill’s mandates.

Here’s Rep. Nathan Deal (R-Georgia, and now running for Georgia Gov.), promising to fight against the “unconstitutional” individual mandate.

And here’s the other song referred to in my post—a great one (the song, I mean, but hopefully the post’s OK too), You Can’t Always Get What You Want by the Rolling Stones.

Here’s Countdown’s 3/23/10 report.

Visit for breaking news, world news, and news about the economy

For more background reading, also check out Obamacare’s nasty surprise (Washington Post 11/06/09).

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