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Young: What's really wrong with Obamacare

Photo Credit: Illustration by William L. Brown

The fight against "Obamacare" -- which played out before the Supreme Court this week -- has galvanized libertarian and conservative critics of big government. The 2010 bill, particularly its requirement that nearly every American buy health insurance or pay a penalty, is seen as a symbol of socialism and loss of freedom.

The legislation unquestionably has serious flaws that illustrate the pitfalls of government overreach. But in many ways, the champions of liberty have picked the wrong battles -- ones that may yet backfire against their own cause.

For one, much libertarian and conservative rhetoric seems to assume that before the Affordable Care Act, we had something like free-market health care. Not so. Since 1986, federal law has required hospitals to treat anyone at risk of death or severe physical impairment, regardless of ability to pay. About half of emergency-room care is now uncompensated -- costs that are shifted to other patients and insurance policyholders. Throw in Medicare (from which recipients typically get far more than they ever paid in) and Medicaid, and "socialized medicine" is not the scary future but the status quo.

Yet no serious politician, activist or policy analyst seeks to end government-mandated medical care for the indigent, and efforts to curb Medicare costs have been often demonized by conservatives in the anti-Obamacare crusade. (Few things can top the absurdity of Medicare-age activists waving "No government health care" signs.)

Tellingly, legal challenges to the law have focused on the individual mandate, which imposes obligations on current and potential health care consumers, not the clauses that burden providers -- such as forbidding insurers to deny coverage for pre-existing conditions or allowing adults younger than 26 to be covered by their parents' policies. The individual mandate is also the one provision most unpopular with the public. But is this about freedom, or about a "something for nothing" mentality?

Does requiring Americans to purchase a private service they are not currently using exceed the limits of government power? While this is not a frivolous argument, the law's defenders make a strong case that no one can predict that he or she will never need health care or permanently waive the right to government-mandated treatment. And Americans today overwhelmingly agree that condemning people to death or disability because they cannot afford medical care violates common decency. That consensus won't change -- and Internet posters who suggest that people who can't pay for their own health care should have the grace to die achieve little except to play into stereotypes of right-wing heartlessness.

Yet critics of the law are correct when they point to excessive micromanagement of markets and consumer decisions. For one, the law's standards for mandatory coverage reject catastrophic health insurance that would solve the problem of free-riding and cost-shifting. Instead, the mandate is for high-premium plans that cover routine medical services with no co-pay -- which is likely to drive up their costs. Challenges to these aspects of the legislation would have been more constructive than attacks on the mandate itself.

Whichever way the court rules, we'll still face the question of how to pay for health care -- and curb its runaway costs -- while maximizing personal choice, minimizing bureaucratic interference and preserving innovation. If the Affordable Care Act is struck down, the eventual outcome may be better health care reform -- or it may be a more socialistic road, such as a single-payer system.

Libertarian and conservative voices are essential to the health care debate. But they should be careful not to lapse into a defense of freeloading or unconstrained spending on expensive (and not always beneficial) medical procedures. Freedom is a key conservative and libertarian principle; so is responsibility.

Cathy Young is a regular contributor to Reason magazine and Real Clear Politics.