Democrats have a tiger by the tail. It is dawning on them that the people screaming at those town-hall meetings over the summer were not just feigning anger or sublimating their personal neuroses. Cherish is not too strong a word for how Americans feel about what they get out of their health-care plans, however much they grouse about access and cost. According to the Kaiser Family Foundation, 92% of Americans who do have health insurance are very or somewhat satisfied with their choice of doctors and hospitals; 95% are very or somewhat satisfied with the quality of their care more generally. While about two-thirds of Democratic voters (71%) back reform and two-thirds of Republicans (67%) oppose it, independents have moved steadily into opposition. Any party that signed the old system's death warrant single-handedly would be signing its own.
Democratic reform efforts once focused on building a European-style single-payer Utopia. They now focus on enlisting Republicans, if only a few, to share responsibility for a plan that Democrats, if they were sufficiently contemptuous of public sentiment, would have the votes to pass on their own. The centerpiece of the current effort is the individual mandate--basically a requirement that everyone buy health insurance. Worked up in the office of Senate Finance Committee chair Max Baucus and increasingly touted by President Obama, it is modeled on systems of no-fault auto insurance that states began to enact in the 1970s. Back then there was a moral hazard. If someone with insurance dinged your bumper, you could collect. If he didn't have insurance, you were out of luck, unless you wanted to chase him through the courts. So states made it mandatory to insure your own car.
The President sees parallels with health care. If you have insurance and get sick, insurance pays. If you don't, your emergency-room bills get passed on to others in the form of higher premiums. "Those of us with health insurance," says the President, "are paying a hidden and growing tax for those without it." So as liberals see it, conservatives ought to like the individual mandate. It relies on personal responsibility rather than government handouts. It is tough on freeloaders, charging up to $1,900 in fines for not buying in.
For those too poor to buy insurance, there will be a sliding scale of federal subsidies. That is where the problems start. If subsidies are too generous, you get socialist medicine by stealth. If the subsidies are too stingy, you get a huge new burden placed on the middle and working classes. Is it fair to call a requirement that we all buy insurance a tax? Conservatives say it is, although they would. A larger question is whether it is constitutional for the Federal Government to order citizens to engage in private business transactions. It's hard to say. Few governments have had the effrontery to try it.
A human life is a different kind of commodity than a car. Supply equals one. Demand equals infinity. A person who flat-out refuses to insure his car can be deprived of the right to drive it. What do you do with someone who flat-out refuses to insure his body? For reasons that owe more to the Hippocratic oath and the Golden Rule than to the U.S. Constitution, you must treat him anyway. So what does it mean to promise, as the President does, that illegal immigrants won't participate in our new health-care system? It seems to mean they won't participate in paying for it.