“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 The New 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 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 60 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 – after all, isn’t that why we have hospital emergency rooms? – is irrelevant to the legal issues but 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.



Michael Millenson
Michael L. Millenson, president of Health Quality Advisors LLC, is a nationally recognized expert on making American health care better, safer and more patient-centered. Michael is the author of the critically acclaimed book, Demanding Medical Excellence: Doctors and Accountability in the Information Age, and he is also an adjunct associate professor of medicine at Northwestern University’s Feinberg School of Medicine. Earlier in his career, he was a health-care reporter for the Chicago Tribune, where he was nominated three times for a Pulitzer Prize. A respected presence in health policy and strategy, Michael has lectured at the National Institutes of Health and the Harvard Business School and served as a faculty member for the Institute for Healthcare Improvement. He has testified before Congress and written for publications ranging from the British Medical Journal and Health Affairs to The Washington Post and Forbes.com. Michael has consulted with policymakers and with a broad range of clients from all segments of the health care industry, providing services ranging from strategic planning to developing specific tools to improve care. He currently serves on the board of directors of the American Medical Group Foundation and in an advisory board capacity to the American Journal of Medical Quality, Johns Hopkins’ Armstrong Institute for Patient Safety and Quality and several health care start-ups.


  1. Thanks Michael for another great post. USA Today recently had a front page story about an anti-government Texan who is holed up in his compound, armed to the teeth. He committed a crime a number of years ago and is wanted by the police, but they are afraid go after him because they fear he would take out a lot of people during any attempt to arrest him. It is a tyranny of one.

    It seems to me the extreme right has decided that “liberty” trumps all and that they should not, and in some cases will not, follow “rules.” They are like naughty, selfish children. It is all about them.

    A civil society does need to have some rules that its citizens need to follow. One such “rule,”- currently under attack, is that people should purchase (or pay a tax for) health insurance so others do not have pay for them, via the cost shifting that has helped to make health insurance unaffordable, when they get sick –and make no mistake everyone is going to get sick sometime-insured or not, anti-Obamacare or pro.

    Every other country in the developed world has some form of universal coverage – often paid for by a tax of some sort. Why can’t we?

  2. In responding to Pat’s comments about why can’t we have some form of universal coverage: of course we can if it is voted on by our Congress in a way that reflects the will and desires of the people. The issue for those of us, like myself, who are big believers in the personal responsibility argument, is that the federal government does not have power granted to it by the Constitution to mandate these types of purchases. Nor should it, in my opinion. And the Obamacare issue goes to the heart of this matter.

    Yes, most people get sick at some point, but that does not mean that we should have a universal health care system. Over the last 70 years we, as a society, embrace more federal government intrusion and oversight and regulation in our personal lives. For many this is great and so why not have the federal government run a universal health care system–we all need it, right? That argument is based far too on emotion and does not give enough credence to the notion that the very act of the federal government mandating the purchasing of anything is in violation of our individual rights.

    What is never talked about in this debate is the notion that living a healthy life takes time, energy and money. It is a personal choice. But it must be a choice. As much as I would love for my patients to follow my advice all the time, they don’t because it is their choice. It is their individual right to have that choice. And if you start to mandate how they make those choices, then you are slightly, but ever so, taking away that individual right.

    Sure, having everyone be healthy and covered all sounds good, but it comes with a price–for those of us, like myself, who are believers in personal responsibility, that price is indeed too steep.

  3. Michael–

    A great headline and lead.

    As psalber notes in this thread, every other developed coutry in the world believes that it has an an obligation, as a civilized society, to ensure that everyone its population receives needed healthcare.
    To say that, in the U.S. this is a “vainglorious delusion” that violates sensible economic theory suggests that in the U.S. we are happy to let money trump morality.

    Craig K’s smug assertion that “living a healthy life takes time, energy and money. It is a personal choice” ignores the fact the major cause of premature death in this country is not a lack of personal responsbility, but poverty. A great many people don’t have the personal choices that he takes for granted.

    As Dr. Steve Schroeder pointed out in this landmark essay http://www.nejm.org/doi/full/10.1056/NEJMsa073350
    for the poor, environmental factors (including air pollution that leads to respiratory diseases, lack of access to affordable healthy food and safe places to exercise), as well as the depression, anxiety and sheer despair associated with poverty (which leads to to self-medication in the form of alcholism and drug abuse) explain why the poor are sicker than the rest of us–and die sooner.

    Then there is the fact that in the U.S., we have a higher percentage of children living in poverty than in any other developed nation in the world. Many go to bed hungry, or are malnourished.

    I guess these kids just aren’t taking responsiblity for their lives.

    Michael, as you write: “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.”

    Yes, this not a debate over the constitution. This is a debate over moral values. It seems that not all of us believe in “Do Unto Others” or “There, but for fortune . . .”

  4. While a family physician in Colorado I saw many artists without insurance and asked my physician colleagues to trade, such as obstetric care and delivery, for original art. While I could help with physician fees, when one patient needed a c-section, I could do nothing about laboratory, operating room, anesthesiologist fees. And I wasn’t trained as a broker. The US is the only developed country without universal coverage, which contributes to US companies’ unequal competition in the world market. We all end up paying anyway, whether it’s at the front end, or the back end (emergency rooms), which is more expensive and, ultimately less humane.

    John Komlos wrote “The best measure of a just society is whether you’d be willing to be thrown into it at random.” Which of us with medical insurance would be willing to be thrown in without health care and without the means to buy it?

    History is full of examples where the rich get richer and the poor get poorer until there’s a revolution and they switch places.

  5. To repeat: if the debate was about how to provide access to health care to all and the proper role of private market forces versus government, that would be an enormous step forward. In fact, the problem in this country has been the lack of a feeling of a social compact in which we are responsible for each other. GOP candidates who assure voters that the emergency rooms and “safety net” are adequate are demonstrably wrong. That social forces and inequity is felt in health problems is demonstrably correct.

    There are models of private-public cooperation in covering the entire population that we could draw upon. Conservative politicians cast Britain as the bogeyman, but thoughtful conservative intellectuals know that Switzerland and Germany provide different, and more appropriate, models.

    “Are there no poorhouses?” was the response Scrooge gave in Dickens’ time. Updated, it is no more acceptable morally today — and no less an indicator of moral failure, not conservative economic principles.


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