On the Individual Mandate: A Debate with Vic McCracken

Is it ever morally defensible to force an American to purchase anything, including health insurance?  That’s a question that Dr. Vic McCracken and I have been trying to answer in a debate on his blog, christianethicsbites.  Vic is an Associate Professor of Theology and Ethics at Abilene Christian University in Abilene, Texas.  Vic graduated from Harding University in 1995.  He graduated with the Master of Divinity degree from ACU in 1999, and he received his Ph.D. in Theological Ethics from Emory University in 2008.

Vic is a friend of mine, and it’s a true pleasure to participate in this debate with him.  It’s a great way to launch this blog.

You may find Vic’s first blog post in this debate here on his blog.  It is also republished below:

I began this blog a few years back as a way of forcing myself to write regularly.  After an extended period of weekly blogging I got away from it, mainly to focus on my own academic writing.  Recently I’ve felt the pull to jump back onto my blog, in part because a college friend of mine, Jeff Hammond, has asked me about the possibility of collaborating in an online discussion on healthcare reform. Jeff is a law professor at Faulkner University who specializes in healthcare law. Jeff earned his law degree at Emory University  where I finished my PhD, so in addition to overlapping at our undergraduate alma mater we have some common connections in our graduate programs.  That said, Jeff is more conservative than I am on a variety of things, including healthcare and healthcare reform. This conversation is an opportunity for us to hash out our respective views. While we may not reach agreement I respect Jeff enough to know that I’ll learn something from the conversation.  Perhaps readers will as well.

So why healthcare? In many ways the topic recommends itself in the current political moment, where talks of healthcare reform and the repeal of Obamacare are front and center.  Rather than jumping into the political fray, I want to resist the temptation to offer a detailed exposition of the American healthcare system and focus instead on some broad principles that, I argue, offer some common ground for our conversation. I suspect that much of the sound and fury of the healthcare debate stems from differences over the merits of specific policies and programs, not these principles.  I’ll be interested to hear if Jeff agrees.

So to start the conversation, I suggest that amid our disagreements about healthcare policy there is substantial agreement about three moral principles that define the sort of healthcare system that all of us desire:

  •  We want members of our community to be able to receive the healthcare that they need. That is to say that all of us–conservative and liberal alike–desire a system in which people who need the care of a doctor are able to receive it. We don’t want people who, in the words of President Trump, are “dying on the streets.”
  • We want a system that is sustainable, that doesn’t collapse by promising things it cannot achieve. That is to say that all of us–conservative and liberal alike–agree that in a healthcare system defined by the problem of moderate scarcity it is impossibly utopian to promise everyone everything. There are limited resources, so we need a system that recognizes these limits and still strives to provide high quality healthcare.
  • We want a system that incentivizes good healthcare decisions. That is to say that all of us–conservative and liberal alike–agree that it is beneficial for all of us when healthcare providers and consumers have reasons to act in ways that encourage healthy habits and that reduce healthcare costs for all of us.

These three principles seem morally basic to me.  Jeff might suggest some revisions, or he might disagree. In many ways the direction of a conversation about healthcare will depend on whether or not we are arguing about first principles (i.e. if not the principles above, then what?) or about the mechanisms that best realize these principles in practice. If we agree, for example, that ensuring access to healthcare is a guiding principle of reform, then our debate is really about what reform plan best realizes this shared goal. Our conversation will be entirely different if we don’t agree that access to care is an important aim of a healthcare system or if either of us is indifferent to the problem of sustainability.

Note here that there is some tension between the first two principles.  We might all agree, for example, that access to care is an ideal aim for our healthcare system, and yet because no healthcare system can promise everyone everything (that is not sustainable) we need a system that can adjudicate the claims of consumers when there are conflicting needs for the same healthcare resources. What do you do when 16,000 people need liver transplants and there aren’t enough to go around? Or what do you do when the urgent needs of emergency patients outstrip the capacity of hospitals to provide important but non-life threatening hip replacement surgeries? These tensions are intrinsic to any healthcare system. Healthcare resources are not like air molecules.  They are limited, and these limits impact the ability of any healthcare system to provide the care that every person needs.

I’ve got much more to say on this, but I also have a lot of time and space in which to say it, so I’ll close out this blog post for now.  I look forward to Jeff’s response.

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