By Andy Mukherjee
EVEN if everyone in a society agrees with the old adage - an apple a day keeps the doctor away - is it still acceptable for a government to make a daily intake of the fruit mandatory for citizens?
That is the somewhat philosophical question Republicans in the United States are asking about the 2010 Patient Protection and Affordable Care Act, better known as 'Obamacare', whose constitutional validity was recently the subject of oral arguments before the United States Supreme Court.
If health insurance is like apples - or broccoli, as one of the judges likened it to during hearings - in other words, a commodity bought and sold in the marketplace, how can President Barack Obama frustrate free choice and force millions of uninsured Americans to either buy coverage or pay a penalty to the government?
It's an outrage, say the Republicans, a travesty of the idea of limited government. Democrats have a ready counter: Insurance is different from other goods because while it is possible for someone to not be in the market for broccoli, everyone is willy- nilly a buyer of health-care services.
A citizen who does not have insurance will still fall sick, and may still show up in the emergency room of a hospital. That's the point where the society - especially a prosperous one like the US - will find it hard to look the other way. Since 1986, it has been illegal in the US for hospitals to refuse to care for, or send elsewhere, patients who need critical intervention but cannot afford it.
But there is no free lunch. The cost of this additional burden on the health-care system from free riders is borne by paying insurance customers. Their premiums are higher than they would otherwise be. All that Obamacare seeks to do is to redistribute the costs.
Illegal immigrants and those who earn so little that health-care premiums will account for 8 per cent or more of household incomes will be exempt. Medicaid will expand to cover the indigent elderly (and US states resent the extra financial burden that this expansion will impose on them). But out of 50 million uninsured Americans, some 16 million will either have to sign up with insurance companies or pay penalties for not doing so.
The conservatives hate the penalties. But they are there for a reason. The advantage Obamacare offers to consumers is that it takes away the power of insurance companies to deny coverage on any pretext, including that most obnoxious one: pre-existing conditions.
To view Obamacare as an encroachment of government in private lives is silly, Democrats say, because the only way insurers can be forced to cover everyone at a fair price is by requiring individuals to get cover.
So who's right? Judging by the kind of questions the justices asked, odds that Obamacare - or at least its compulsory individual mandate - will be thrown into the garbage dump have risen in markets where traders place bets on uncertain future events.
A defeat for Obamacare will close the doors on a compromise between Republicans and Democrats and leave the US with two stark choices, one in which millions of Americans remain uninsured and vulnerable, as they are now, and the other in which everyone gets health-care services paid for by taxes.
Democrats will bristle about the injustice of the former and Republicans will not support the latter. What is so different, Republicans will ask, between Mr Obama requiring all individuals to eat an apple a day and the government taxing everyone, buying apples with the money raised and then giving away the fruit 'free' to all citizens?
The debate has no easy answers, but as for Obamacare being an intrusion into free choice, surely there is something inherently 'un-free' about a parent having to worry about the financial consequences of children falling sick?
There is also something deeply immoral about the tyranny of insurance companies that all of us - anywhere in the world - must suffer. Denying coverage to someone who has high cholesterol but no other manifest health issues? That's awful. And it gets worse when every insurer follows the 'industry best practice' and leaves people uninsured.
This kind of discrimination may make insurance companies worthy of their shareholders' admiration. But if the whole point of insurance is to avoid payouts, then people may as well demand that their government move towards a Canadian-type, mostly tax-funded health-care system. Today, it is seen as un-American. Maybe that view will change; maybe it won't.
To the extent that health is a subject in which every society has a keen interest, the world will pay attention to the US Supreme Court, which is expected to announce its decision in June.