"We are now contemplating, Heaven save the mark, a bill that would tax the well for the benefit of the ill."
That's not a quote from oral arguments at the Supreme Court over the constitutionality of the Affordable Care Act or from one of the earnest conservatives demonstrating against it outside. It's actually the beginning of an editorial in the Aug. 15, 1949 issue of theNew York State Journal of Medicine denouncing the pernicious effects of health insurance. To be clear: not government-mandated health insurance, but all third-party health insurance.
I wrote about that editorial in a July 16, 2009 blog entitled, "GOP to Uninsured: Drop Dead." My blog was prompted by a Wall Street Journal op-ed the previous day from Dr. Thomas Szasz, an emeritus professor of psychiatry, who counseled readers not to confuse ethics and economics:
"The idea that every life is infinitely precious and therefore everyone deserves the same kind of optimal medical care is a fine religious sentiment and moral ideal. As political and economic policy, it is vainglorious delusion....We must stop talking about "health care" as if it were some kind of collective public service, like fire protection, provided equally to everyone who needs it.... If we persevere in our quixotic quest for a fetishized medical equality we will sacrifice personal freedom as its price."
This was a month before Oklahoma GOP Sen. Tom Coburn, a physician, told a sobbing, middle-aged woman that "government is not the answer" after she confessed she couldn't afford care for her brain-injured husband. The crowd of Coburn constituents gathered to discuss health care reform applauded. And it was before Texas Rep. Ron Paul, also a physician, responded evasively when asked by moderator Wolf Blitzer at a September 2011 GOP presidential debate what should be done about an uninsured 30-year-old working man in a coma.
"What he should do is whatever he wants to do and assume responsibility for himself," Paul responded, adding, "That's what freedom is all about, taking your own risk." When Blitzer followed up by asking, "Congressman, are you saying that society should just let him die?" a group of audience members in the Tampa auditorium began audibly cheering, "Yeah!"
The individual's responsibility for "taking your own risk" was precisely what the New York State Medical Society worried that health insurance would undermine. As the Aug. 15, 1949 editorial put it:
"Any experienced general practitioner will agree that what keeps the great majority of people well is the fact that they can't afford to be ill. That is a harsh, stern dictum and we readily admit that under it a certain number of cases of early tuberculosis and cancer, for example, may go undetected. Is it not better that a few such should perish rather than that the majority of the population should be encouraged on every occasion to run sniveling to the doctor? That in order to get their money's worth they should be sick at every available opportunity? They will find out in time that the services they think they get for nothing -- but which the whole people of the United States would pay for -- are also worth nothing."
Of course, today's liberty lovers are not denouncing health insurance per se, nor even calling directly for the abolition of government-funded health insurance for the elderly, the poor and veterans. Still, faint footfalls of this same fend-for-yourself argument, if not so bluntly stated, can be heard in GOP plans to control Medicare costs by turning it into a "premium support" program that risks leaving those too sick, too poor or not savvy enough shoppers for private insurance to fend for themselves.
Certainly, creating a situation where "the great majority of people... can't afford to be ill" is an effective cost-control mechanism. In 1949, when 90 percent of the American population had no health insurance, medical expenditures were a tiny percentage of the gross national product. In our day, when medical technology is far more advanced, the economic principle remains the same. The Great Recession prompted a sharp drop in doctor's office visits and even caused some individuals with cancer to stop taking their medications simply because they couldn't afford it. Someone with Ron Paul's flair for phrase-making might call this a case of "give me liberty and give me death."
The Wall Street Journal op-ed by Szasz was entitled, "Universal Health Care Isn't Worth Our Freedom." That sentiment was vociferously endorsed by the anti-Obamacare demonstrators outside the Court and, oral arguments suggested, by some justices within it. Freedom, too, was on the minds of New York State physicians in this Sept. 15, 1949 commentary advocating what might be termed a robust medical consumerism:
"It is time that someone -- everyone -- should hoist Mr. Charles Darwin from his grave and blow life into his ashes so that they could proclaim again to the world his tough but practical doctrine of survival of the fittest...The Declaration of Independence said that man was entitled to the "pursuit of happiness." Any man who wishes to pursue happiness had better be able to stand on his own feet. He will not be successful if he feels that he can afford to be ill."
That no Republican presidential candidate has ever presented a serious plan to cover all the uninsured -- isn't that why we have hospital emergency rooms? -- is irrelevant to the legal issues, but it is highly relevant to the political context of the legal debate. The difference between Democrats and this generation of Republicans -- unfortunately including even the GOP Doctors Caucus -- is not at its core a disagreement on what government can legitimately do to help create universal access to health care for the 50 million Americans without it, but whether the goal itself is worth pursuing.
(A version of this blog also appeared on www.thedoctorweighsin.com)