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Go Home Health Care As Consumption

TIMOTHY NOAH MARCH 30, 2012

Health Care As Consumption

BY TIMOTHY NOAH

Antonin Scalia’s now-famous comparison of compulsory health insurance to compulsory consumption of broccoli has been widely criticized on many grounds, but not on its implicit assumption that health care (as opposed to health insurance) constitutes consumption. Conservatives like to portray health care as no different from any other good, and emphasize that if  you make it too readily available then people will want to consume too much of it. There is some truth to this. There are a few hypochondriacs out there who adore going to the doctor and would go again and again and again if the cost of doing so were reduced or eliminated. Most of us, however, typically dread going to the doctor, because it’s not actually a very pleasant experience, even if—as I am—you’re rather fond of your doctor. Those of us who haunt doctors’ offices and hospitals the most (and run up the lion’s share of medical costs) do so because we are very sick, and to whatever extent we have a “choice” it’s between accepting medical intervention and committing suicide. Part of this group includes people who are unconscious or otherwise so incapacitated that they are at best only dimly aware that they are engaged in consumption. They end up in hospitals because someone else is presumptuous enough to compel them to go there by calling an ambulance, an activity that any sincere libertarian ought to condemn.

When my wife was being treated for the liver cancer that eventually killed her I used to break the gloom now and then by contemplating that I had managed to become the highest-paid person at the magazine I worked for. Not even the editor or the publisher was costing the parent company as much as I was, simply by virtue of being married to an unusually conspicuous consumer of extremely pricey medical care. The parent company was (at the time) Microsoft, which had a fabulously generous health care plan because it was (at the time) an astonishingly profitable near-monopoly with an unusually youthful workforce. The only disease common to Microsoft employees, I used to joke, was megalomania, for which there was no cure. 

When it became clear that my wife was no longer responding favorably to chemotherapy her doctor informed her that it was time to stop consuming his services and to start consuming instead the services of a local hospice. Hospices are, from consumers’ point of view, the biggest bargain in the health care market, because they provide services at absurdly cheap rates (insurers adore them) and because they never fail to deliver the promised outcome, which is death. If health care were a real marketplace delivering goods and services comparable to the rest of the market people would be lining up to get in.

If my wife had not had any health insurance, then the prohibitive cost would have limited severely her consumption of health care, and to the extent she consumed any of it at all the cost would have been paid by you, dear reader. She would have been what economists call a free rider. Her health care costs, to the extent we did not pay for them ourselves, would have incrementally raised everybody else’s health insurance, but market discipline would have probably caused her to die within three or four months instead of the three and a half years she managed to give to me and our young children. That’s the way it typically goes for people who lack health insurance and become very sick.

Poor people who have health insurance coverage are unusually greedy consumers, because they are more likely to get sick than rich people. This fact, combined with the uncontrolled growth in medical costs, may be the most powerful force for wealth redistribution in the current economy. The catch is that you only get to enjoy this redistribution if you get sick, and to enjoy a lot of it you have to get really sick and probably die.

To whatever extent third-party payments increase consumption of health care, the fault lies principally not with patients, who typically don’t relish being probed or cut open or being subjected to any number of other physical ordeals. It lies with doctors, who profit from excess care and don’t have to endure the accompanying physical discomfort. This is a real problem, discussed at length by Shannon Brownlee in her excellent book Overtreated. But the same conservatives who condemn the individual mandate requiring mandatory purchase of health insurance also condemn (as “government rationing”) any and all attempts to limit doctors’ and hospitals’ profit maximization through performing medically unnecessary tests and procedures on the elderly (the only segment of the population about whom this is even discussed). What market fundamentalists seem to expect is that patients will tell their doctors to stop being such spendthrifts. But to make this aspect of health economics work you’d have to send every medical patient to medical school so he or she would know which procedures were worth the money and which weren’t. The whole conversation gets pretty idiotic pretty quickly because health care is not, in fact, consumption, any more than your inhalation of oxygen is consumption. It depresses me to contemplate how stubbornly Scalia and many others insist on believing otherwise.

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45 comments

Maybe our only hope is that Scalia reads this excellent piece!

- ballston

March 30, 2012 at 12:21pm

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Heartbreaking stuff. I am sorry you have to write about your loss as I am sure it must be horrible to relive so I admire your courage to do so. 2 of my children have a congenital condition (a mild one for boys which I luckily had) that is more common in Ashkenazi Jews, Eskimos, or Hispanics. (And I figured a white man marrying an Asian would avoid this kind of thing). As my wife and I both have recessive genes finding out about the condition for my older one was trial and error and for over 2 years my concerns mentioned to my doctor were ignored as being just part of normal development. Eventually we had to go through a battery of tests to find out just what he had (for the younger we knew just what to look for) so the notion that I would have had the requisite knowledge years ago to ask for the exact test is absolutely effing insane.

- blackton

March 30, 2012 at 12:30pm

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All very true, but it implicitly accepts Scalia's boneheaded point. Scalia picks broccoli to make it appear ridiculous, as if the reason for the Constitution exists to prevent the government from imposing ridiculous, hugely unpopular solutions to non-problems, just the sort of thing democratically elected governments are elected to do. But, indeed, there is nothing wrong with the federal government requiring everyone to "buy," as in pay for, broccoli if that were somehow in the national interest, as we all pay for roads we don't use, schools we don't use, and on and on. The entire purpose of taxation is to make people pay for things they either cannot or will not pay for on their own. Every tax takes money from some group of persons and distributes it to some other group of persons. We have all sorts of agricultural subsidies that have us paying for products we ourselves may never consume. Ethanol for just one. I am taxed to subsidize ethanol whether I consume it or not. I am not being forced to consume it. No one is being forced to use health insurance. They can pay the tax, they can buy the insurance, and, either way, they can continue to pay for their healthcare out of pocket if that is what they choose to do. The notion that only state governments can make you pay for stuff you don't want is a fabrication out of thin air. Scalia is a tendentious liar and judicial fraud. We should call him out on his scam, not credit it.

- roidubouloi

March 30, 2012 at 12:49pm

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Jefferson observed that whenever two or more physicians gather, buzzards can't be far. By which he meant that there was too much health care; an obervation that Washington would have agreed with, if he hadn't suffered the fatal consequences of too much health care. Noah is making an essential point about this issue: different people see a different problem and, therefore, very different solutions to fix it. Is it a medical problem, an economic problem, a legal or constitutional problem, a moral problem, a philosophical problem, or a political problem. I happen to believe it's a political problem, but that doesn't mean others who differ are wrong, they just see it from a different perspective, usually according to their own life experiences. Let's assume that health care is so fundamental that it is a right, a right that the government is obligated to see is fairly delivered, and ACA is a reasonable means of delivery. I reside in a region that includes many physicians representing most specialties. Unfortunately, their reputations are so dismal that we have lots of buzzards, so my fundamental right to health care would be denied if I were to get sick or injured. By comparison, someone living in, say, Boston, would have access to some of the world's leading physicians. The solution to my problem is a fairer distribution of the physicians, moving some of those leading physicians now in Boston down to my region, and moving some of those less qualified physicians now in my region to Boston, along with some of the buzzards. Problem identified, problem solved. [Disclosure: both my parents died young from cancer, at a time (the mid-1960s) when treatment was primitive at best but had the advantage of relatively low cost and very poor results, so life expectancy for those getting the disease was mercifully short. My sister died young from cancer, at a time when treatment was better but had the disadvantage of being very expensive, so expensive that insurance benefits soon ran out, along with her bank account. My brother has leukemia, the chronic variety, which (as compared to the acute variety) has the advantage of not killing you quickly and the disadvantage of not killing you quickly. Unfortunatley for him he didn't work for Microsoft but a locally owned bank with a group health insurance plan that his employer would have been forced to drop if my brother hadn't done the "right" thing and quit so the others wouldn't lose health insurance benefits. A depleted bank account and a bankruptcy later, my brother lives with me. He is alive, and some days he even feels pretty good.]

- rayward

March 30, 2012 at 12:58pm

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What is a non-tendentious liar? This looks like a pleonasm to me.

- liberalref

March 30, 2012 at 1:15pm

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ten·den·tious/tenˈdenSHəs/ Adjective: Expressing or intending to promote a particular cause or point of view, esp. a controversial one: "a tendentious reading of history". There are many reasons to tell lies. Furthering a particular point of view is but one.

- roidubouloi

March 30, 2012 at 1:42pm

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Wonderful piece. Thanks.

- josh_y

March 30, 2012 at 2:24pm

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Thanks for sharing your experiences, Rayward. I would quibble only with your comment about physicians attracting buzzards, because physicians in the 18th century truly cannot be compared to physicians in the 21st century. When Jefferson and Washington walked the earth medicine, for all practical purposes, didn't exist. They were more like today's faith healers, and they got results that were roughly the same.

- Timothy Noah

March 30, 2012 at 2:34pm

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Mr. Noah your column is moving and heartbreaking but also reveals the sheer ridiculousness of regarding health care as "consumption." Health care should be regarded as a national right. That it isn't seems to me in diametric opposition to our national ideals, the whole basis of which support the right of the person to life and liberty, etc. A person who can't afford health care can't afford to live. Why isn't that unconstitutional?

- Sophia

March 30, 2012 at 2:36pm

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There are some pretty heavy duty chronic consumers of medical care who aren't insured, too. Work at any ER at any major city, and you'll get to know the mentally ill homeless REAL well.

- miceelf

March 30, 2012 at 2:55pm

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My wife and I have seen too much of the inside of cancer hospitals, too, and, as was the case with Ms. Williams, the interventions did not work for our foster daughter. She died a few months after turning 20. Most of the time she was fighting the disease, we had hope that the treatments might work, but they didn't. Ralita died three days after her physician said there was nothing else that medicine could do for her. Thank God for hospice. Ralita took her last breath in our den, with my wife on one side and me on the other, cradling her in our arms. We could afford insurance for Ralita, and although our policy was probably not as gold-plated as Microsoft's, it paid for everything - two surgeries, two different courses of chemo, countless MRIs, CTs and PET scans, and three hospitalizations. Every infant, every child, every teenager, every adult and every senior should be able to access the same care Ralita had, and should be able to obtain the care without jumping through hoops or enduring indignity. I can't imagine anyone with a shred of human decency who would think otherwise. I realize this sounds like a sad story, but if you knew Ralita, it wouldn't be. She brought more joy into the world, into our world and the worlds of the people lucky enough to know her, than most of us ever will, no matter how long we live. She would kill me if she thought I was moping around thinking about what we lost instead of what we had, and still have.

- GeoffG

March 30, 2012 at 3:05pm

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What a beautiful and touching post, Geoff!

- liberalref

March 30, 2012 at 3:20pm

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Both my maternal grandparents were physicans. My grandmother was way ahead of her time. I tell people she was a product of the 60s. The 1860s, she being born in 1868. She graduated from Smith, and then Women's Medical College of Philadelphia in 1898 (women weren't admitted to the men's medical schools). She then studied in London, Vienna, and Berlin for her specialty, EENT, where she trained under the leading physicians of her time in her specialty, and where she met my grandfather. They returned to Pittsburgh around 1908-10 and set up their medical practices. Unfortunatley, he died shortly after my mother was born, from a staph infection he contracted much earlier while serving in the military as a surgeon in the Phillipines during the Spanish-American War. After his death, my grandmother moved my great grandfather, my great aunt, and my mother to Palm Beach County, where my grandmother practiced until she was about 80 years old. I have spent my career working with and representing physicians, who I have found to be dedicated professionals, not money grubbers as they are often depicted. My grandmother has been the inspiration for whatever I have achieved professionally. I wasn't born yet, but my oldest sister accompanied my grandmother to her 50th medical school class reunion in 1948, an event that my sister, who is still alive, vividly remembers for the enormous pride my grandmother felt on the occasion. I used the buzzards as a device, to identify the differing problems in health care in the late 18th century and today, the problem today being the unfair distribution of not only health care but of quality health care, and that finding a solution to the former won't solve the latter. Some, including some on the Court, would simply say that life is unfair, get over it. My grandmother spent over 50 years practicing medicine, which I suppose was her way of making life a little less unfair.

- rayward

March 30, 2012 at 3:22pm

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I should have mentioned that where I work and where I choose to reside are not even in the same state (and they have very big differences in the quality of health care). Which creates a health care problem for me (besides in terms of quality) because private insurance is, as we know, state-based.

- rayward

March 30, 2012 at 3:30pm

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I second all the praise for this wonderful piece. Also brava to Sophia's succint point that health care is a right and " a person who can't afford health care can't afford to live." Why do we have this absurd and paternalistic system in this country that healh care insurance is provided by your employer? Are fire and police protection provided by our employers? If I lose my job or leave to find another, will the police or fire department not respond, perhaps because my home had some pre-existing condition? Do I have to go out and buy some COBRA-like policy to fill the gap? No, these vital services are provided for by state and local government, and paid for by taxes. And of course we're paying for each other's health care, but instead of paying taxes to the govt, we're paying higher costs for whatever products we buy from companies that provide health insurance benefits - be they Microsoft's sterling products or penny nails.

- dubyadoubte

March 30, 2012 at 3:43pm

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I liked this piece too. If we can't do mandate and we can't do single payer, then can we flood the supply of medical care to lower the cost of medical care, like we pretend to do with Oil? Should we create medical care credits like we do with energy, research, child care and building rehabilitation credits? Can we lower the price of medicine by creating more doctors; more nurses; more medical technicians; more medical institutions; and more medical technology?

- Nusholtz

March 30, 2012 at 5:56pm

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Libref Where do you find these esoteric words? I am still trying to remember the last one you provided me which was dead on.

- Nusholtz

March 30, 2012 at 5:58pm

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A very moving piece thank you TN. Scalia's comment will live on in infamy as the day the Supreme Court, as designed by our forebearers, officially died. It displayed a level of smug intellectual laziness, disrespect for America and blind ideological bias that not even the most fevered Supreme Court cynics (of which I am obviously one) could not have dreamed of - breathtaking really.

- WandreyCer

March 31, 2012 at 11:45am

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Thank you too Geoff, just amazing.

- WandreyCer

March 31, 2012 at 11:47am

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Mr. Cohn's emotional appeal is refuting a position Mr. Scalia never made. Typically the appearance of emotional appeals signify that logical arguments have been exhausted and rational discourse on the issue is at an end.

- Nicomachus

March 31, 2012 at 1:14pm

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" . . . a position Mr. Scalia never made" ?? From the linked article: "Could you define the market -- everybody has to buy food sooner or later, so you define the market as food, therefore, everybody is in the market; therefore, you can make people buy broccoli," Scalia asked during the second day of oral arguments. It's possible that, given the ambiguities in some of the transcribed dialogue, Scalia was in fact referring to the late Albert R. "Cubby" Broccoli, the famous producer of the early James Bond 007 movies, or possibly the late Matthew J. Bruccoli, one of the leading literary scholars on the work of Scott Fitzgerald. I don't know, but I'm thinking "vegetable."

- ironyroad

March 31, 2012 at 1:44pm

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@ironyroad Justice Scalia never made the argument that it is problematic if health care was "too readily available" or that people will "want to consume too much of it" if Obamacare stands. How Mr. Cohn managed to derive this from the aforementioned quote, which relates to the limits of government reach, is beyond me. Nor is Justice Scalia connected to any of the other personal matters Mr. Cohn related in the article... but, I believe that you already know this, so stop defending the indefensible ;)

- Nicomachus

March 31, 2012 at 2:18pm

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Ok, Nicomachus, now I'm getting annoyed. Firstly, Jonathan Cohn didn't write the piece, Tim Noah did. Secondly, but more importantly, the author did not say that Scalia made that argument. He cited Scalia's analogy to vegetables/food markets and used it to open up a broader discussion about conservative perspectives on health care as a marketable good and a theory of how consumers of such a good behave. He suggested that there are a number of assumptions and contradictions in those arguments that conservatives fail to see. He introduced a personal/biographical example to emphasize the meaning that this argument can carry for real-world life or death decisions. He brought the final turn in his piece back to Scalia to note that there is a certain unpleasant glibness in the use of the broccoli analogy when we are talking about health care provision (no matter what side one takes). Thirdly, this is a news and cultural affairs journal with its subscriber discussion boards. It's neither a classroom nor a court of law, and emotion is a perfectly permissible aspect of contributions to public debate -- indeed, a journalism that consisted entirely of logical propositions and proofs would be pretty much unreadable. So I would suggest that my defending in the indefensible is not the problem here, but rather your confusion as to the location where you find yourself.

- ironyroad

March 31, 2012 at 3:47pm

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I did attribute the article to the wrong author, it was indeed Mr. Noah and not Mr. Cohn who should have been the target of my rebuke. My apologies to Mr. Cohn for this one. ironyroad, would it change your perspective if I were to inform you that I was legally blind and had trouble reading the author's name in italics? Or would you view this as an attempt to manipulate your sympathies? Whatever conservative perspective Mr. Noah articulated, it was not one I would attribute to Scalia or to any notable conservative. It seems like a straw man attack to me. As far as the "unpleasant glibness", I would simply say that I think it is unfair to juxtapose an unrelated comment involving a vegetable against the backdrop of a personal tragedy. Furthermore, ironyroad I have a strong dislike for your "manner".. please defend. (I don't really, I am sure you get the reference)

- Nicomachus

March 31, 2012 at 4:32pm

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I have a hard time seeing this health care issue being about individual "freedom." If Kennedy, Scalia, et all cared about freedom they need to acknowledge what the lack of health care doesn't to someone's freedom when they can't afford health care. A 30 year old with a chronic illness will not be able to live fully till l he or she can manage their illness. A 20 year old who can but won't buy health care isn't being denied any freedoms. If this were the case then money itself would become a commodity with which we buy "freedom." This is the equation that troubles me: seeing freedom as a commodity which only those with money are entitled.

- arnon1

March 31, 2012 at 5:11pm

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Would Scalia call the military draft laws form the 40's to the cold war unconstitutional. Is forcing young man to defend their country and fellow Americans a reduction in freedom?

- arnon1

March 31, 2012 at 6:53pm

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Great posts arnon.

- WandreyCer

March 31, 2012 at 9:09pm

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Furthermore, ironyroad I have a strong dislike for your "manner".. please defend. (I don't really, I am sure you get the reference) . . . to the manner born :)

- ironyroad

March 31, 2012 at 9:29pm

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First of all, life is not fair. Second, try to avoid as much harm as possible in trying to “fair it up.” (In other words, no Inquisitions, no witch burnings, no genocides, no revolutions of the proletariat, etc.). Third, every silver lining has a cloud. Now that we keep people alive longer we sometimes make it easier for them to die longer and more painfully. As I read the personal testimonies by Timothy Noah, Ray Ward, GeoffG (and all I have forgotten and neglected) are indeed heartbreaking, I contemplate that my wife and I are both in good health and (maybe) mind, I contemplate how we are all tied to the railroad tracks and the rails never stop rumbling and vibrating.

- skahn

March 31, 2012 at 11:20pm

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I am not a Christian and I am mostly tone deaf to the appeal of Christianity. As I read the (somewhat crabby) comments by Nicomachus and ironyroad, and their explanations of their relative experiences and perspectives, the thought occurs to me that a person with complete knowledge, empathy, and understanding of all points of view (which might be a way of describing Jesus Christ) might indeed experience total suffering and pain, even without being nailed to a physical cross.

- skahn

March 31, 2012 at 11:27pm

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@arnon1 You have stated a common misconception of freedom. Freedom does not guarantee a favorable result or that all of your needs will be provided for. It does not mean you have a right to health care, day care, night care, and whatever other care someone may want or need. Freedom means that a individual can to strive without being hindered by others. That you own your own life and the associated advantages and disadvantages. What you achieve is yours to do with as you please and cannot be confiscated by others. Freedom means that no one, including the state, can initiate force against you and deprive you of life, liberty, or property. What you seek is security, not freedom. We can have a good debate about which is paramount, but please let us not confuse the two.

- Nicomachus

April 1, 2012 at 12:12am

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'Crabby' yourself, skahn! At least Nicomachus just thinks I'm a bit of a dimwit. He's never accused me of shouting at the kids to get off of my lawn.

- ironyroad

April 1, 2012 at 12:24am

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Nicomachus “@arnon1 You have stated a common misconception of freedom. Freedom does not guarantee a favorable result or that all of your needs will be provided for. It does not mean you have a right to health care, day care, night care, and whatever other care someone may want or need. Freedom means that a individual can to strive without being hindered by others.” Given your chosen ID I suppose you are or are fond of arithmetic. Do you have any medical training too? Anyway, all you did in your post is state the usual right wing catechism about freedom. However, very little of what you said applies to health care. Health care isn’t about freedom it’s about the human body or rather about human bodies. (Health care isn’t only about individuals.) Jacobson v. Massachusetts is the seminal case regarding a state’s or municipality’s authority to institute a mandatory vaccination program as an exercise of its police powers. In Jacobson, the Supreme Court upheld a Massachusetts law that gave municipal boards of health the authority to require the vaccination of persons over the age of 21 against smallpox, and determined that the vaccination program instituted in the city of Cambridge had “a real and substantial relation to the protection of the public health and safety.”9 In upholding the law, the Court noted that “the police power of a State must be held to embrace, at least, such reasonable regulations established directly by legislative enactment as will protect the public health and the public safety.”10 The Court added that such laws were within the full discretion of the state, and that federal powers with respect to such laws extended only to ensure that the state laws did not “contravene the Constitution of the United States or infringe any right granted or secured by that instrument.” http://www.fas.org/sgp/crs/misc/RS21414.pdf Individuals who do not participate in certain health related programs can harm health outcome not only of their own selves but of those around them. In such cases people who refuse to comply with certain medical requirements under epidemic conditions can be quarantined by the Federal government. Now add it up Mr. Nichomacus, are you freer under quarantine or under submission to a vaccination program? Moreover, if one’s freedom from vaccination end up contaminating, and killing innocent people, not only have you robbed them of their freedom but of their lives. In what way is your intransigence helping people achieve freedom of opportunity? Freedom is too narrow a concept on which to hang your desired outcome of revealing individual prowess. Dying from contagious disease is not the proper arena to test your freedom. You are also confusing health care systems with health. You assume that a health is a permanent condition. It isn’t and in many cases today it’s only the existence of health care systems that can come in and rescue you when your health goes. No individual is able to afford a health care system which is why the cost has to be shared. In the same way no individual can guarantee the freedom of his or her community on his own. It takes a free community working together to guarantee individual liberties. This is what you catechism omits. If your community is threatened by outsiders who want to take away your liberty would you object to being asked to help defend it? What if enough members decide that they don’t care if your freedom is taken from you or not? Would you want to force them to fight for your freedom and theirs? You speak of freedom in the abstract. There is no such thing. Freedom is freedom within the context of community and its laws. In the wilds you have no freedom; you are always under the rule of necessity. You like to pretend that freedom is only the ability to stay away from community, to negate its dictates. This is another one of your illusions. Without the community against which you test your freedom you have nothing, neither freedom, nor community, nor law. All you have are random acts. It’s the community you love to hate which makes you free. The community is prior to the individual and it can in some cases impose its will on individuals in order to reach certain outcomes. Requiring you to buy into the health care system is one such felicitous outcome.

- arnon1

April 1, 2012 at 12:56am

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@arnon1 You have mistaken my meaning and continue to confound freedom with security. Freedom does not imply safety, social well being, or the eradication of necessity. You are correct that freedom cannot exist in the "wild", but not for the reasons you have stated. The "wild" is rule by force - the antithesis of freedom. I believe it is not unwarranted to say that freedom is a cultural value in the Unites States. Obviously pure freedom cannot exist within an integrated society. Thus, the question is not total freedom vs total state control, but rather what is the proper balance between freedom and security. I personally value freedom highly and would likely push the pendulum in that direction more than you. Thus, we must negotiate the balance point. In order to have a meaningful dialogue, we have to agree on terminology. If we are to balance freedom against security, then we must first understand the valued characteristics of freedom. People need to fully understand the tradeoffs involved. You may not have read my previous posts in which I have endorsed a health care alternative that would meet the balance (and legal) requirement. A new health care entitlement, paid for by a uniform tax and supported by consensus. My personal preference would be the South Korean model. We are not as far off as may initially seem; however, I will not easily concede freedom. In order for me to trade freedom for security, the reason must VERY strong and we must have national unity on the solution.

- Nicomachus

April 1, 2012 at 1:44pm

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That whole freedom shtick is so lame, so easily refuted I cannot imagine why anyone makes it anymore. I simply feel embarrassed for anyone who does. The federal government quite literally set the prices on the following things: - food: from any and all sources - interest rates - monetary exchange rates - energy of all kinds It makes putting lead in your gas illegal and makes you go stand in line at the DMV. There is such a thing as a commonwealth we all participate in that does not impinge on "freedom" which is an utterly meaningless concept when applied to health care.

- WandreyCer

April 1, 2012 at 2:02pm

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Nicomachus “@arnon1 You have mistaken my meaning and continue to confound freedom with security. Freedom does not imply safety, social well being, or the eradication of necessity.” Freedom is the ground of our activity; it is not the end of our individual activities. In any case, when it comes to health no individual by himself can afford to avail himself of it. This is why large organizations of all kinds are formed to help us cope. I am glad you see that there is no freedom in nature. However, your conception of freedom is still too primitive. If the notion of freedom in nature is meaningless, is also meaningless in advanced organized and technical societies like ours. As we keep creating more complex technical networks the ability of individuals to exist outside them becomes diminished. Your notion of freedom is ontologically meaningless.

- arnon1

April 1, 2012 at 3:15pm

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Good points, arnon1 and WandreyCer. Obsessing about individual freedom as the Holy Grail in a social setting is a waste of time and energy. The individual is life-and-death dependent on millions of others in today's society, and in exchange for that he or she has to automatically give up some freedoms. To focus. laser-like, on individual freedom, especially when technology is in the process of homogenizing us all, is banging one's head against a wall. The only thing the individualist can hope for today is that the State does not have the legal right to come into the home of any individual and drag that person away without any reason whatsoever. That happens in America today, but extremely infrequently, and public opinion will probably keep that nightmare at bay for some time to come. Ironically, people who scream about their individual rights being violated could help to bring this hell about. Remember, not only the Boston Tea Partiers talked about the tyranny of the British state before they commenced the American Revolution. The Nazis and the Bolsheviks were yelling about the tyranny of the Jew-controlled and the capitalist-controlled state on the way to their murderous revolutions. The next step beyond ranting about the tyranny of the state, which seems to heat up in America only when a Democrat is in the White House, is to focus on a group of people who control the so-called tyrannical state. That's when the ranters should begin to fear themselves, too. I'm not addressing any particular comments on this site, which are blessedly moderate, but the extremists who obsess on their individual freedoms to the exclusion of all else. And thanks to the Internet and social media, those extremists are multiplying. Be careful what you wish for, freedom lovers. "Individual rights" may be just another stepping stone to tyranny. And next time you may be the tyrant.

- magboy47.

April 1, 2012 at 3:41pm

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“Freedom does not imply safety, social well being, or the eradication of necessity. You are correct that freedom cannot exist in the "wild", but not for the reasons you have stated. The "wild" is rule by force - the antithesis of freedom.” You are wrong, Nicomachus, the wild means nature. This is what most reasonable conservative thinkers would have said till recently. There is no freedom in nature, since nature is the rule of necessity. People in the wild spend most of their time feeding their bodies or looking for food to feed their bodies. It is society that liberates us from our basic physical needs which gives us time to harvest our “inner needs” including the need for freedom.

- arnon1

April 1, 2012 at 10:11pm

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... you’d have to send every medical patient to medical school so he or she would know... Odd, then, that people buy cars with engineering they can't begin to comprehend.

- karlwk

April 1, 2012 at 11:56pm

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I would argue that characterizing the relevant market as the consumption of health care supports the constitutionality of the "mandate." It obliterates the argument that the "mandate" compels people to enter a market they would not otherwsie enter. Dhurtado

- NR143296

April 2, 2012 at 12:27am

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No one is compelled to do anything by the tax levied on those who do not provide for their own health insurance and thus expose the rest of us to loss. The seeking for some way of avoiding the so-called problem of compulsion misses the point entirely. It is a fabricated problem with no solution because it is fabricated to have no solution. The tax is no different than a thousand others all of which create incentives in one direction or another and hence influence behavior without compelling it.

- roidubouloi

April 2, 2012 at 11:58am

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Actually, roid, my argument is not meant to focus on the word "compel," but on the argument that the ACA requires people, on pain of a monetary penalty, to enter into a market in which they otherwise would not participate. The argument is that if people are not currently participants in that market, it exceeds the government's power under the Commerce Clause to regulate their conduct with respect to that market. To the extent that argument has any force, it is, in my view, obliterated once the relevant market is properly defined: the market of healtcare consumption. Virtually everyone is a participant in the healthcare market. Dhurtado

- NR143296

April 2, 2012 at 12:58pm

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I get it, D. But I think that even agreeing to argue the question whether anyone is being forced into commerce or out of commerce concedes too much to the other side. It is a false premise. If you are prohibited from growing and selling marijuana, are you being "forced out of commerce?" Sure. So what? Does the Constitution say or imply that being forced into or out of commerce is relevant to anything concerning the power of Congress? What you are being forced to do by the mandate is pay money to the government, nothing more, nothing less. We are all forced to pay money to the government all the time for things that, as individuals, we don't want, don't need, and won't use. Again, so what? It is a distraction from the real issues and, by allowing the argument to be conducted on false premises, gives far to much credit to the conservative opponents.

- roidubouloi

April 2, 2012 at 1:46pm

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I don't agree roid. By using, rather than figthing against, the word "compel," and pointing out that our regulatory state is rife with regulations that compel (or cajole, if you prefer) affirmative conduct, we deflate the argument that this is some unprecedented expansion of federal power. The only conceivable come back is that, yes, the federal government already does compel affirmative conduct, but only where the individual or business has already chosen to enter the relevant market. Thus, the argument would be, government can compel automobile manufacturers to install seat-belts in their products, but would not be empowered to require a manufacturer of lawn mowers to manufacture seat belts for the auto industry. Perhaps it would be so empowered under Raich (presumably it could be argued that failure of the lawn mower maker to make seat belts has an effect on interstate commerce), but I think it is a non-frivolous argument that the Commerce Clause does not authorize the federal government to use its power to cajole individuals to enter into a commercial market in which they are not already participants. I therefore think it is helpful to properly characterize the relevant market as the consumption of healthcare. Dhurtado

- NR143296

April 2, 2012 at 3:35pm

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I just read short piece on a Supreme court ruling today allowing for strip searches even in cases of minor infractions. One of the basis on which they ruled was that the courts shouldn't second guess local authorities on issues dealing with security and public health. I hope the court extend that logic to their ruling on the health care bill. They should second guess elected officials on issues affecting public health.

- arnon1

April 2, 2012 at 7:25pm

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