There is only one health care plan that makes economic sense. The plan would look like this: Every person is covered from cradle to grave and everyone pays into the insurance plan. Period.

The principle that is the bedrock of any insurance plan is this: Risk is spread so that everyone gets the potential benefit of the insurance should they need it. Most people probably never have to use their car insurance, so it could be argued that for most people car insurance is pointless: Why should I, who most likely will never have a catastrophic accident pay into a system that will cover someone else who might? An individual could save hundreds of thousands of dollars over a lifetime by not paying for car insurance. Drive carefully and limit even more the chance that you will ever have an accident. And for those who do. well they can find a way to pay the tens or hundreds of thousands of dollars out of their OWN pocket if they do. Or if the accident causes serious injury, it could cost millions. That would be  THEIR problem, not “ours.” Shoot, let’s take the argument even further: NOT having insurance would probably force more people to drive even more carefully since they would know that a catastrophic accident could ruin them financially. So it could be argued to be strongly favoring not carrying auto insurance.

I pay about $3000 per year to have car and motorcycle insurance. Over 10 years that is $30,000; over 60 years $180,000. Just imagine what I could do with that money if government didn’t force me to have auto insurance! It doesn’t take a math wizard to figure out that for me, this would probably be a good bet. I’ll drive carefully, stay off the roads in bad weather and pocket the money I would save on car insurance to buy things I really want. Dictatorial governments should not be able to tell me how I spend my own money or try to legislate indemnifying me against bad behavior. But heck, how about the government allow me to have a car insurance savings account: i put that $2000 a year into a CISA and get a tax credit for doing so. And if I have an accident, I use THAT money to pay for my OWN misfortune. And again, anticipating the argument, the chance that I will be hit by one of the irresponsible people who drive irresponsibly is fairly minuscule, and if that happens, I’ll have my CISA to cover my misfortune. That means I TOOK CARE OF MYSELF, and the oppressive government didn’t make me do something I didn’t want to do. And also, poor people are probably poor because they lack the motivation or energy to make more money. Why should I reward their lack of initiative?

Now a brief comparison between car and health insurance: Of course only people who actually drive vehicles on public roads would need to make the choice to purchase a CISA. What about health insurance? It is not arguable that at some point in every person’s life they will need health care. For a brief illness, for allergies, for a fall, for a wrenched ankle or broken wrist. Or of course, for a long, debilitating illness: cancer, diabetes, autoimmune disease, etc. So health care is a universal need. But again, why should I be forced to pay into a system that protects OTHER people from the vagaries of poor health? Why shouldn’t I be able to just sock money away and take care of my own health care issues–like, let’s say an HSA (Health Savings Account). Making me pay for someone else’s potential health care needs–which could well be caused by poor choices: smoking, risky behavior, alcohol or drug abuse, etc., which actually RAISES the cost of insurance I have to pay for while living a more risk averse life. And most of all, why should the government have the power for FORCE me to buy something that I do not want?

Shouldn’t the principle of freedoms, enshrined in the Declaration of Independence and Constitution allow me the option to live the life I want and pay for it myself, prevent the government from forcing me to have insurance of any kind?

And doesn’t having insurance actually incentivize people to behave badly? If I have car insurance that will cover me no matter what happens, wouldn’t that make people engage in much riskier behavior? If I am insured and drive recklessly, my insurance will cover me if I cause an accident no matter why it happened. I may have to pay a ticket and higher insurance rates, but still, an accident that potentially causes hundreds of thousands or millions of dollars won’t break me. Same for health insurance: If I have full coverage health insurance I can smoke, drink, engage in risky behavior with no fear of having my choices ruin me. Sure I might get cancer or get injured, but it won’t ruin me financially. So, insurance creates a false sense of security and encourages people to live riskier lives. Right?

Is there a fatal fallacy that undermines this entire line of reasoning?

When nations form, they establish communities unified by a set of articulated or forced principles (in the case of dictatorial regimes). The systems we are born into establish to varying degrees a set of expectations as to how we are expected to behave. Were we born into a jungle the rules would be rigid and unchangeable–you live in whatever manner you have to in order to survive. But civilizations are built upon more “civil” and rational principles. Communities have expectations that limit the rights of individuals in order to create order and a measure of stability. Communities and rampant individualism are antithetical to each other. To some degree we are all expected to give up some individual freedom in order to serve the interests of the larger community. And we gain benefits from being a member of the community. There is order based upon a set of clearly stated and enforced rules. And we are protected from the brutal reality of living in an environment that creates constant anxiety about the most basic struggle for survival. If we are the strongest individual in the jungle, though we may survive longer than most, we also have to fight unendingly to maintain our dominance.

So what does insurance of any kind have to do with this? If we drive a car in America or get sick in America, insurance provides everyone a basic level of protection against or mitigation of catastrophes of either our own or others’ ill fortune or bad choices. Every single person who drives a car in America has a chance of being involved in some kind of catastrophic event of our own or others’ making that could destroy us financially.  A small chance, yes, but nonetheless a chance.  If we get ill in America, universal insurance means everyone pays something in order to do one of two things: Either protect us from financial ruination or other members of our community from the same eventuality. It is peace of mind that we are purchasing. And there is also an economic benefit that accrues if it is done properly: Everyone paying into a system that everyone will use spreads the cost and the risk for everyone. Failing that, the wealthy purchase the very best care for themselves from their vast resources: they do not need health insurance because their wealth gives them insurance. For the middle class, their own health insurance will be much more costly because the pool of payees will be smaller, made even more so by the fact that the poor cannot be able to afford insurance so they will get care the most expensive way possible-by not getting preventative  care, allowing illness to advance to more critical levels, and then resorting  to using the Emergency Room, which taxpayers or hospitals have to support. And though the most Social-Darwinist among us would say that we should just allow the poorest and most vulnerable among us to die if they get sick and cannot afford care, that is simply not an option in a “civilized” society.

The “mandate” of purchasing health care in Massachusetts under Romneycare (put forth by the Heritage Institute and implemented by the Republican Governor, Mitt Romney) was designed as a market-based government policy by a Conservative think-tank. It acknowledged the unarguable reality that everyone will use health care so everyone should pay something for it (and, or course, in a civilized society the poor would be subsidized by everyone else). When that became the Affordable Care Act, or Obamacare, suddenly Conservatives hated it for reasons that need another blog to explain. Obamacare established that each year, penalties for not purchasing health care would increase to the point that the last holdouts would eventually find it easier to purchase health insurance rather than pay the penalty. And of course, in order to make any insurance system work, those least likely to need health care–the young and the healthy MUST pay into it in order to provide the indemnification for the older and sicker that the insurance system provides for in principle. It does not take a rocket scientist to figure out that any system that fails to include a mandate (and to control costs) will ultimately fail to do exactly what insurance is designed to do.

So, what does Trumpcare, as drafted by Paul Ryan–claimed to be one of the best thinkers and most principled members of the GOP leadership–do first and foremost?

It eliminates the mandate to purchase insurance (the government should not be allowed to force people to purchase insurance). And it keeps many of the elements of the ACA in place that increase insurance costs.

In other words, it defeats the most fundamental principle undergirding insurance policy–that of spreading risk by including all potential consumers of insurance as payers into the system. And it does so because Paul Ryan does not believe that people who have money should be forced to support those who do not, beyond a cruelly minimum level of care. Remember–one of Paul Ryan’s “bibles” is Ayn Rand’s book, “Atlas Shrugged,” which he used to purchase for all of his staffers and require that they read. It is an overlong screed by a militant Atheist who immigrated to America from Communist Russia with an irrational hatred for any conversation that involves discussion of “community”, and enshrines rampant, selfish individualism as its highest principle.

This nation either believes one thing or it believes another on health care: Decent, affordable health care is either a birthright, or it is not. If it is, then we as a nation demand that our politicians work together to provide for a financially sound, basic program to provide health care coverage to every citizen of the nation. And if it is not–if we believe that people who cannot afford to pay for their own basic health care coverage do not deserve it, then we plant the seeds for the eventual dissolution and fragmentation of our nation. Communities are nurtured by people who are committed to providing a certain level of civility and selflessness in order to advance principles beyond our own selfish needs and desires. Rampant individualism like that advanced by the the leaders of the current Republican party is the cancer that will kill our nation.

On that, History is clear.