A Health Insurance Mandate Libertarians Can Support

Libertarians have generally opposed government mandates to participate in commerce on moral, economic, and constitutional grounds. Certainly, a federal government mandate to buy private health insurance contradicts standard libertarian understandings of the right to property and self-determination and the ability of individuals to decide for themselves their need for insurance (and concomitant skepticism of paternalist justifications for government involvement in health insurance), and runs afoul of textualist interpretations of the U.S. Constitution. A state government mandate would not violate the Constitution, but libertarians would nevertheless still tend to oppose it on the moral and economic grounds already cited.

However, there is one type of insurance mandate to which standard libertarian objections fall short. This is not to say, by any means, that all libertarians would support it, merely that opposition would have to find grounding in contingent, disputable facts. The mandate to which I refer is a requirement that parents purchase health insurance for their children.

The moral objection to health insurance mandates for adults doesn’t hold here. Parents do not have a right to dispose of their children’s lives as they see fit. One could easily argue that health insurance is a virtual necessity that every responsible person will seek to obtain, provided that regulations have not driven its cost out of reach. Adults should perhaps be left to endure the consequences of their own folly (or seek to remedy their condition through voluntary aid) should they fail to purchase health insurance for themselves, but helpless children should be rescued from the gross failures of their parents to provide for them.

The economic objection doesn’t necessarily hold either. Parents usually want the best for their children and will try to provide for them as they would for themselves. But not all parents are good parents, and for bad parents, it may well not be the case that their children’s welfare matters sufficiently. They may not be able to make the best decisions for their children when it comes to health insurance coverage. In economic jargon, lack of sufficient parental care imposes a negative externality on children, and therefore insurance coverage for children will be less than socially optimal in the absence of a mandate.

The main reason for opposing a children’s health insurance mandate is that many states have imposed regulations, such as community rating and guaranteed issue — policies that the PPACA imposes on the whole country, that make insurance too expensive for too many people. Even good parents may often not be able to afford insurance for their children. A mandate might, in theory, bring prices down by bringing in a pool of largely healthy people (children). On the other hand, a mandate increases the demand for insurance, which is normally thought to raise prices. The evidence from Massachusetts is inconclusive. Yet this objection assumes a world of the second- (or third-)best, in which one bad policy (no mandate for children) can be changed, but others (community rating, guaranteed issue, and other restrictions) cannot. A better course is to revise insurance regulations comprehensively.

And there is a good political economy reason for adopting a children’s health insurance mandate: it will reduce the political pressure for more invasive policies in the future, like a universal health insurance mandate or single-payer. If everyone is covered from birth until age 18 (if not by health insurance simpliciter, then by a future “health status insurance“), then no one will suffer from a pre-existing condition exclusion when he first enters the health insurance market on his own. Universal lifetime coverage will be in reach for everyone. Those who subsequently drop coverage, assuming regulations have been sufficiently revised to make coverage affordable for everyone, will in most cases be blameworthy for their irresponsibility. It will be more difficult to gin up public demands to reorganize the entire health system for the benefit of those few who have acted, in the main, irresponsibly. (Obviously, we should do what we can for them all the same if death or suffering is the alternative. But not reorganize the entire health system.)

29 thoughts on “A Health Insurance Mandate Libertarians Can Support

  1. Um, wrong. The standard libertarian objection to a mandate requiring parents to buy health insurance for their kids is the same as the objection to a mandate requiring parents to make their kids go to church or attend public schools.

    1. Not at all. The benefits of church are disputable. No one seriously believes that a responsible parent would refuse to buy health insurance coverage for his child. Right? A mandate to procure health insurance for your child is analogous to a mandate to procure food for your child. You may choose what kind of food or health insurance you want, and you may provide it yourself if you can, but you have to give the child a minimum level (potentially) necessary for survival.

      1. The benefits of health INSURANCE are also “disputable.” The only thing not disputable is health CARE needed to avert an imminent threat to the life of a child. Parents can perhaps be faulted for failing to provide that, but not mere health COVERAGE.

      2. The problem is that unless you’re wealthy enough to self-insure, there’s no way you can guarantee your child’s health care without insurance. What if she gets leukemia? The problem in our society right now is that these irresponsible parents foist the costs of their poor decisions on the rest of us, and then clamor for national health insurance.

      3. I too dispute the viewpoint that insuring children = good parenting. Fact is insurance doesn’t pay for any number of conditions and mediocre insurance routinely runs out on people when they encounter severe health issues.

        I know this isn’t the point of your blog, but it’s my belief that under our current construct the most efficient means of fixing healthcare issues would actually be to make insurance illegal along with the removal of all government medical aide. (as a libertarian type I can’t agree with this, but it’s the only workable solution within the current construct and would never happen) This would force the market to price at serviceable-cost efficient prices. Something outside of our current construct which would additionally aid would be total deregulation of all healthcare industry allowing for people to go to their local pharmacy when they need and buy ‘previously prescription’ drugs at the advice of the pharmacist. The other obvious ‘fix’ for healthcare cost is to fix the money supply/restore value to widely used currency.

  2. Don’t find this even marginally persuasive. And I think it fundamentally misapprehends the libertarian position. And mislabels a failure to insure as an externality, which it is not.

    (There’s a nice line in the above rationale that might even justify taking custody from a parent if he or she were poor.)

  3. I thought I knowed you, Prof Sorens. My children are my wards, slightly higher than chattel. I will mind them as I see fit.

    1. Absolutely. The government will kindly stay out of my affairs or we will have a big problem. Especially as it pertains to my family.

  4. So, I think Tim’s point about health care vs health insurance is reasonably solid, but in the world we currently live in it could well be the case that (for most parents) health insurance is the most effective way to provide health care, and so as a contingent matter purchasing health insurance for children becomes a duty.

    The more interesting question is: what if a government mandate tends to further lock in a health system that needlessly harms people (through inefficiency, lack of innovation, corruption, whatever.)?

    I also worry about how socializing health insurance (through mandates or public provision) makes my health everyone’s business, and I similarly worry that mandating children’s insurance makes what my kids do every parent’s business. Maybe it takes a village, but I’d like to choose the village at least. For me, liberty takes priority over health.

    Perhaps, it is ultimately better it is best to fight against mandates that provide temporary advantages and long term disadvantages.However, as Jason says, there are a lot of questionable empirics floating around in all these arguments.

  5. “…it could well be the case that (for most parent) public schools are the most effective way to provide health care.” Therefore, private schools and homeschooling may be banned, and parents may be forced to send their children to public schools…

  6. John – Those points are reasonable, and I did take care to note in my post that I only think a mandate would be justifiable from a libertarian perspective if the most harmful regulations that drive up the costs of insurance were removed.

    Tim – That’s not analogous at all. A mandate to purchase private health insurance that covers catastrophic risks for your children obviously does not ban private health insurance or even set up any kind of government funded or operated alternative.

    1. Your proposal’s not analogous, but the logic of your argument goes a lot further than your proposal.

      We already have a solution to the “what about the poor” argument: Tax-funded medical coverage for the poor. That’s actually cheaper than forcing a mandate upon everyone. (A mandate, BTW, which covers a lot more than mere catastrophic coverage. E.g., it also covers breast enhancement.)

      Self-medication is quite possible for many people, and would be even cheaper w/ the abolition of medical licensure & prescription laws.

      Your other arguments contain plenty of flaws. E.g., why would insurers not exclude those w/ pre-existing conditions from getting new coverage upon reaching the age of 18, just because the already had coverage? Why wouldn’t they jack up the price of mandatory insurance for children to cover the risk of children getting diseases? Or, conversely, why wouldn’t they offer discount coverage only until age 18?

      1. Self-medication isn’t feasible for cases like the child with leukemia that I mentioned above.

        The mandate would be justifiable on libertarian grounds only if health insurance had been deregulated to the point that catastrophic-only coverage was affordable, a point I made (admittedly obliquely) in the original piece. (FWIW, I’m not aware of any state that mandates breast enhancement coverage.)

        Taxpayer-funded health insurance for the poor violates the rights of taxpayers. A health insurance mandate does not necessarily violate anyone’s rights, since parents do not have the right to deprive their children of catastrophic health care coverage.

        Health insurance works now under mandatory renewal. Insurers aren’t allowed to drop you because of illness or increase your rates. Those regulations are morally and economically problematic, but they help explain the analysis I gave in the final paragraph.

  7. Self-medication’s quite feasible for anyone w/ adequate resources. Expensive childhood diseases like childhood leukemia will simply drive up the cost of mandatory child health coverage, thus negating your cost argument.

    Who defines “catastrophic health coverage”? What gets included/excluded?

    I remember hearing about various states that mandated all sorts of things get covered, including breast enhancement, back during the ObamaCare debate, but can’t search for it at work right now.

    Failure to provide X != denial of X. You are fabricating a positive right to child health insurance, then equating failure to provide that with denial of it. There’s nothing the least bit libertarian about your argument, it is statist to the core. You are simply indulging in the “for the children” argument for statism.

    BTW, why can’t I reply to your replies?

    1. The threaded comment system only goes two-deep, so we have to start a new thread or keep replying to the same message. You should be able to reply to this message, for instance.

      Anyway, leukemia and other expensive-to-treat diseases are extremely rare, and thus they do not drive up the cost of health insurance much. Even in today’s badly distorted marketplace, the median family premium in the nongroup market (which is more expensive than the group market that covers the vast majority of Americans) is just $336 a month, well within the means of nonpoor households.

      State health insurance mandates data.

      Most libertarians accept government mandates to parents to provide food and shelter to their children. A health insurance mandate similarly does not seem to contradict libertarian principles. Again, as I noted in the original post, there may be practical, contingent objections, but none that stand on principle alone.

  8. If those expensive diseases are so rare, then the cost of charity care for them won’t be that high, thus negating your cost argument for mandatory coverage.

    I’ve not been poor in a long time, but until recently an additional charge of $336/month would have been unaffordable to me.

    I’m not familiar w/ the survey research finding libertarians supporting food and shelter mandates for children. Cite, please. There’s also a big difference between not letting your children starve to death or die of exposure and a government-mandated meal plan for your kids. You are equivocating again between a negligence argument and a mandate. Negligence is ex post facto based upon demonstrable harm to a child due to lack of care. A mandate is ex ante forced imposition of costs onto parents based upon the prevention of hypothetical harm that might come to a child due to lack of care.

    1. Were you uninsured? Remember, if you had insurance through an employer, you already paid for insurance with a lower wage, even if your employer actually made the payments.

      I don’t buy that particular distinction between ex ante and ex post determinations. If you put your 6-year-old to work collecting corroded batteries from trash heaps (a common occupation for children in Bangladesh), you’re putting her at risk of serious harm – an unreasonable risk of harm in the 21st century United States, and that can be legitimately prohibited even if no actual harm has yet occurred. By the same token, leaving your child completely without coverage for major health expenses looks like exposing her to an unreasonable amount of risk of death or suffering. What the minimum level of coverage ought to be is another question; I’m merely arguing that there likely is some minimum level.

      The charity point deserves a separate post, I think…

  9. I wasn’t recently uninsured, but my wife was within the past 10 years (we weren’t yet married), and couldn’t afford to buy health insurance. We were poor enough in the SF Bay Area to quality for “affordable housing,” but not poor at all by national standards.

    I think our real disagreement may be over the correct theory of liability to apply. While I said “negligence,” I really favor a strict liability theory, in which no harm means no offense. You seem to favor a true negligence theory, which I see as the top of the slippery slope to positive rights claims and situational casuistry such as conclusions as that children have a right not to be employed collecting corroded batteries from garbage heaps in the USA but not in Bangladesh.

    1. Applied ethics is necessarily situational. Is it morally permissible for X to shoot Y in the face? Well, it depends on the situation; let’s get the facts and apply our principles. Fundamental moral principles aren’t situational, by definition, but the circumstances of a situation affect how one ought to apply relevant principles to come up with a moral judgment in that case.

  10. Yes, but the permissibility of X shooting Y doesn’t change w/ the poverty level of the country in which they’re situated. When it comes to positive rights, that sort of relativism always has to be taken into account.

  11. What about the permissibility of gambling away $100 when you have a family to support? Not a big deal if you make $50,000 a year, and quite probably a permissible form of entertainment. A huge deal if you make $500 a year, and quite probably morally wrong. So sure, the background income level of a society can & should matter for certain kinds of moral decisions.

  12. Now you’re going to cite survey research of libertarians finding most of them in support of a gambling ban for the poor?!? All you’re doing is a reductio ad absurdum of your own argument about how asserting positive rights for kids from their parents can be used to justify all sorts of welfare-statist regulation of parental actions.

    BTW, I note that you’ve yet to come up w/ any survey research of libertarians finding most supporting a mandate that parents buy government-approved meal plans for their children…

      1. “Impermissible” = ban-worthy. You questioned the permissibility of gambling away the last of the money you need to support your family. That implies a ban.

      2. I meant morally impermissible. Lots of things are morally impermissible that ought not be banned (like being rude to people, mutilating oneself, and so on).

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