07/11/2012 12:40 pm ET | Updated Sep 10, 2012

It Is a User Fee

It is not a bird, plane, penalty or tax, but a user fee -- to be collected from those who seek to rely on the health care system but would rather avoid paying for it, the "free riders." The whole idea of insurance of any kind, as even a diehard capitalist will agree, is to throw some money into a communal piggy bank to cover the costs of those who will eventually need it. Some may end up taking out of the "bank" less than others, some a great deal, but because health care costs can be enormous, it is rational to purchase insurance at a reasonable fee and, as they say, share (or 'pool') the risk.

Most Americans already contribute to the health care insurance pool, either by purchasing insurance themselves or by getting it from their employers. Others are covered by Medicare or by Medicaid, soon to be expanded under the new law. The roughly one percent who are left, and hence are to be charged a user fee if they do not get insurance, must be reminded that unlike most other insurances -- for cars, fire, earthquakes and such -- which one can reasonably hope to never need, sooner or later, we all will need health care.

Those who say they will pay when the bill comes ignore that they may well be unable to cover the costs. In effect, if it were up to me, all those libertarians who want to rely on their own resources, would be welcome to forgo coverage as long as they (a) put up a performance bond of half a million dollars, so the public can be sure that when they are involved in a car accident or develop a chronic disease that they will cover the costs involved themselves, and (b) that they cover their share of repaying the public for all the monies invested by the tax payers into building hospitals, training physicians, and providing ambulance services. They will soon note that a user fee is a bargain.

All this and more has been said before, in much more learned ways by others. Paul Krugman points out that, "when people don't buy health insurance until they get sick -- which is what happens in the absence of a mandate -- the resulting worsening of the risk pool makes insurance more expensive, and often unaffordable, for those who remain. As a result, unregulated health insurance basically doesn't work, and never has." Writing for Bloomberg, Noah Feldman, a professor of constitutional and international law at Harvard, makes the same argument. When healthy people elect not to purchase health insurance, it makes it difficult or impossible for other people to afford it: "if the healthy people fail to get themselves coverage, it becomes extremely difficult -- under some conditions, impossible -- for the insurance market to operate. That is, as the healthiest people leave the pool, the market for health insurance starts to unravel... inaction causes the whole market to break down. By not buying health insurance, the healthiest person is depriving everyone of a public good."

What we need now is for the hapless Democrats to stop shooting themselves in the foot (if not higher) by insisting that 'all' they seek is to impose a penalty on Americans rather than a tax, and call the small amount, to be collected from a small number of those who seek to dodge paying their share, a fair and reasonable user fee.

Amitai Etzioni is a University Professor and professor of international relations at The George Washington University and the author of The Moral Dimension. For more discussion, see