Is Obamacare paternalistic?

Dr. Bob Centor, author of the always provocative and thoughtful DB’s Medical Rants, suggests that the deep divide over the Affordable Care Act is based on “a major philosophic disagreement” over the respective roles of government and of individuals in choosing what is best for them:

The administration and their supporters believe that government’s job is to protect citizens from their bad choices. They want to decide what the people need and thus impose regulations. The opposition wants the right to make their own decisions about what defines good insurance.

(Disclosure: Dr. Centor is chair-elect of the ACP Board of Regents, although his blog posts are his own personal opinions, not ACP policy.  I, of course, work for ACP, as its senior staff advocate on public policy.)

He goes on to cite a New York Times editorial supporting the cancellation of substandard policies, and suggests that, “This editorial, and the law in general, take a paternalistic view of health insurance. This is the philosophical position that defines the problem. The response to policy cancellations and marked increased insurance costs is typified (in the New York Times editorial] … This represents the current talking point – bad insurance. But who should determine what defines bad insurance?”

Is it really paternalistic for the government to set minimum standards for health insurance?  Paternalism means that someone — in this case — the government, is second-guessing the choices that I might make for myself and my family, because it believes that it knows better than me.  But is that what is really going on with Obamacare’s minimum standards for health insurance?

Of course, taking bad products off the market does limit my individual choices.  But the real purpose of Obamacare’s essential benefits and consumer protection standards is to regulate practices by the insurance industry that can cause direct and indirect harm, both to insured persons who is stuck with a bad plan, but also to the rest of us.  The regulations are designed to ensure that insurance companies no longer profit by selling insurance on the individual market that is deceptive and often unsafe and harmful.  The regulations are designed to end the insurance industry’s systematic cherry-picking of who they choose to insure, pitting the healthy against the unhealthy.

How is this any different than the government imposing product safety standards in so many other areas, and appropriately so?   Automobiles that don’t meet federal safety standards — seat belts, air bags, and protection from front end collisions — can’t be sold by auto manufacturers.  Sure, there are “grandfathered” used cars available that don’t meet such standards — fewer and fewer of them as time goes by — but cars sold after such federal standards were mandated have to comply.  Is reducing the number of Americans killed because manufacturers sold them unsafe cars — remember Ralph Nader’s Unsafe at Any Speed book, which started the modern consumer protection movement in the United States — motivated by paternalism?  Perhaps in the sense that the federal safety experts understand that drivers will make mistakes.   The federal safety standards, though, make it far less likely that we will pay for our driving mistakes (and the mistakes of other drivers on the road with us) with our lives.

And yes, by requiring that cars have mandatory safety features, the federal government is forcing us to pay more for them — even features we might think we will never need.  I have been fortunate in my almost forty years of driving to have never had a collision with another vehicle, other than being rear-ended twice by another car (both at low speeds when my car was stopped, and neither seat belts or air bags come into play with rear end collisions).  But I am sure glad that because of government regulation all of my cars have seat belts and airbags, because you never know, they might save my life, or my wife’s or children’s lives.

Is it paternalistic for the government to regulate the safety of our food?    Henry Aaron, a highly respected expert on health care policy, compares Obamacare’s health insurance standards with the federal government setting food safety standards:

Imagine a new law enacted to promote food purity. As it is being debated, you are told: “If you like what you eat, you can keep on eating it.” The new law takes effect, and one day, you find that the market no longer carries certain foods you have been buying. As it happens, those products included elements found to be bad for your health. The pure food act barred their use. Obamacare is analogous to the pure food law. It bars certain common practices of insurance companies that most people find unacceptable at best, outrageous at worst.

Or take the announcement that the FDA proposes to ban trans fats in food because of the evidence that they cause deaths and disability from preventable heart disease.   Is this paternalism?  It does involve the government inserting its judgment into what foods can be sold to us, limiting the choices of what we can eat.  (Although I suppose we could “grandfather” our favorite prepared pastries made with Trans Fats by stocking up on them before they are banned.)  Or is this just another case of necessary and appropriate regulation to protect lives?

There certainly are other government policies that come closer to paternalism, because they limit our choices directly, not just what can be sold to us.  Take cigarettes — they can be legally sold to adults, but the government mandates warning labels because, well, they and we know that some of us will choose to inhale carcinogens that might sicken or kills us, and when we do, we impose costs on everyone else.  Or take state laws that require that motorcycle riders wear helmets — a direct mandate on individual riders that requires that they spend money on something they might not want or feel they need, but that will help keep them alive (and keep them from shifting their health care costs to everyone else if they end up hospitalized from an accident).  But most of us, physicians especially, would agree that these mandates are a reasonable exercise of government regulation.

This brings me back to Obamacare’s regulation of health insurance.  The standards prohibit the sale of health insurance policies that can cause great harm because they deceptively leave people exposed to bills that can bankrupt them.  They prohibit insurance companies from turning down or canceling coverage because they get sick.  They prohibit cherry picking, signing up healthy people at a discounted premium at the cost of charging more or denying coverage to the less healthy. They require that insurers cover ten essential health care categories, not exotic or unnecessary things, but the basics — like prescription drugs, hospitalizations, doctor visits and preventive services, not because the government thinks it knows better than me, but because these are the benefits that evidence shows are effective in improving outcomes.  Because if your insurer doesn’t cover them, and you get sick, hospitals and doctors will treat you anyway, but your “uncompensated” care costs will be shifted to the rest of us. And you will probably go bankrupt in the process.

They mandate that the benefits be pegged to “benchmark” plans in each state offered by large employers or to state government employees, ending the benefit discrimination that now exists against people in the individual insurance market.  They end discrimination against women, by requiring all plans to offer maternity coverage, instead of excluding it from coverage (as is often the case now) or requiring women pay more to get it.  (As far as the argument against requiring men to pay for maternity coverage, well, it isn’t as if women get pregnant on their own, as one women physician tweeted to me a couple of days ago.)

Washington Post columnist Ruth Marcus reminds us that Obamacare is trying to remedy a marketplace for insurance that was doing great harm to patients and society.  She recounts the story of Patrick Tumulty, a late middle age man (and brother of one of her colleagues) with Asperger’s who tried to do the right thing by buying himself coverage on the individual insurance market:

That is where insurance came in — theoretically. “Unexpected illnesses and accidents happen every day, and the resulting medical bills can be disastrous,” warned the website of Assurant Health, which sold Patrick his policy. Its policy, Assurant promised, “provides the peace of mind and health care access you need at a price you can afford.”

Except it didn’t. Assurant balked at paying Patrick’s claims. In just four weeks, he had racked up more than $14,000 in bills.

“And that was just to figure out what was wrong with him,” wrote Patrick’s younger sister, now my Post colleague. “Actually treating his disease was going to be unimaginably more expensive.”

I sympathize with the people whose insurance is getting canceled now because it doesn’t meet the new federal standards.  I agree that the president’s promises that people could keep their insurance plans was misleading, something he apologized for.  I understand that some of the people who had an affordable plan on the individual insurance market liked it and didn’t want to see it canceled.  A small number of them may have had “good” plans that offered most but not all of the benefits now required by Obamacare — but they were plans offered by insurers who were allowed to pick and choose who they wanted to cover and what benefits they would offer to the exclusion of someone else. And for every one of the “winners”  who came out ahead in the pre-Obamacare individual insurance market, there are many, many more who couldn’t get good insurance at any price, or who found that their insurance didn’t really protect them from bankruptcy when they got sick, like Patrick.

I don’t think it is an unduly paternalistic to set safety and consumer protection standards on the sale of  products that can have a direct impact on our health and safety — think cars, tobacco, food, motorcycle helmets, and yes, health insurance.  All such regulation limits our individual choices to some degree, but only to the extent that they prohibit manufacturers from selling something to us that is harmful, unsafe, and deceptive, all of which describes the products that typically were available in the individual insurance market, albeit with some exceptions, before Obamacare. The goal isn’t to paternalistically second-guess our own choices, but to ensure that the products we can choose from are safe, effective and do what they promise, health insurance included.

Bob Doherty is senior vice-president, governmental affairs and public policy, American College of Physicians and blogs at The ACP Advocate Blog.

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  • Anthony D

    The mandate is to fund an increase in government spending, along with an
    increase in government powers over our Constitutional protections,
    period. Those protection which were obscenely violated by this
    Administration and John Roberts through his legislating from the bench
    by the way. When government controls your healthcare, they control you,
    and those like you sadly support them in this.

    As for the mandate bringing prices down…no chance. In order to pay for
    this monstrosity (according to the law itself) people must be forced to
    buy something they don’t want. Those who are forced to buy something
    will almost always choose the least expensive option. Most people who
    are made to buy something will find the cheapest “thing” that meets the
    requirement. In this case, if the “tax” is $695.00 and the
    product/service is $2,000.00, why would anyone ever pay $2000.00? They
    are essentially one and the same. If there is a “tax” option, and I say
    “option” because legally it’s not a criminal “penalty” according to the
    Supreme Court ruling, otherwise it would be unconstitutional and the law
    would have been thrown out (so says John Roberts) then all you have is
    option 1 and option 2. If I pay my tax then I am still covered by the
    law because I chose option 2 instead of option 1.

    Not to mention that states know this is unconstitutional in that the
    federal government is overreaching and usurping states rights by
    attempting to force them to create exchanges which it has no authority
    from the Constitution to do (i.e falls to the state’s authority), not to
    mention the federal government will be coming to the states to fund
    this nightmare and will penalize the states when it fails. If the states
    refuse to play along then the federal government would be required to
    create it’s own exchanges which will never be funded as there isn’t
    enough money in the world that foreign powers would be willing to bestow
    upon a government they know will never be able to pay it back.

  • ninguem


    Like Idi Amin Dada.

  • Margalit Gur-Arie

    I don’t believe Obamacare is paternalistic and I don’t believe it is evil in its intent either.

    It’s just that health care is a zero sum game, with four players: insurers (public and private), health systems, suppliers, and the people. There is no way to give the people a better deal without hurting insurers and/or suppliers and/or health systems.

    Obamacare promised to do just that and now it’s becoming obvious that you can’t beat the math with wishful thinking. Furthermore, it seems to me that some players are taking the opportunity to improve their positions in the mayhem created by this huge and complex legislation, which means that we the people lose something.

    If we are going to “fix” health care in a way that is good for the people, those 3 other players will have to take a beating, regardless of their financial might and lobbying powers.

  • Rob Burnside

    Really, we must ask ourselves what’s wrong with “paternalism”? My dad died fifteen years ago. I’d give anything to have one more day with him, or even one more conversation.

  • Mandy Miller

    When it comes to healthcare, I don’t think the default position should be “always trust the government – they know what’s best and only want to help”. I prefer to “Question Authority”, always.


  • Rob Burnside

    I get your drift and I’m grateful for the heads-up, but I fear your oedipal complex is showing. Fortunately, under the ACA, you’re covered for that. Good luck!

  • Kim

    Totally disagree. ObamaCare solves nothing. Just makes those individuals that have a few $$’s pay for others that don’t. I for one am tired of paying and paying for everyone else. My premium has increased 71% and my out of pocket increase is over100%. The issues that were the problem should have been solved without forcing everyone to comply,
    ie tort reform, out of network charges, out of control hospital costs, unnecessary testing, simplified billing system.

  • Mika

    Quite so.

  • NormRx

    James, we had a state representative in Wisconsin about 25 years ago that wanted to require seat belts on motorcycles. That is just what I want, to get into an accident and have 800 pounds of steel strapped to my butt. How do these people get elected?

  • Mike

    About a third of Californians receive free government healthcare courtesy of Medicaid. No doubt they’re the healthiest cohort of citizens in the country, if you believe that free government healthcare is a panacea.

  • Mike


    If you want to be strictly accurate, it’s not the ACA or the “Affordable Care Act” either.

    The proper name is the PPACA, the Patient Protection and Affordable Care Act. One might argue that to call it anything else — even the “ACA” or “Affordable Care Act” — is “racist”.

    One might also put one’s head in one’s hands and ask, “At this point, really, what difference does it make??!!“.

    Calling it the PPACA rather than Obamacare is not going to fix it. When Obama thought it was going to work, he was happy to call it Obamacare, and so were his fans. It’s only now that the wheels have fallen off it that you want to quickly get the nameplate off it and pretend he had nothing to do with it.

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