Here’s why health insurance is not like broccoli

By Ezekiel Emanuel
March 29, 2012

The fate of universal healthcare coverage that the United States has been trying to achieve for over 100 years may boil down to broccoli.

The broccoli argument is simple and was frequently referred to in the recent Supreme Court arguments: If the government can require people to buy health insurance, why couldn’t it require people to buy broccoli, which also enhances people’s health? This question, at the heart of the conservative objection to the individual mandate to buy health insurance, illustrates the so-called limiting principle the Supreme Court must rule on: Under the Commerce Clause, does Congress have the constitutional power to compel people to act, in ways they might object to, when their inaction can harm others?

The High Court never got clear on why health insurance is not like broccoli and can thus be constitutionally regulated. There are two important differences that inform the principle for limiting congressional power to compel people to purchase goods and services.

First, as George H.W. Bush made quite clear, you need never eat broccoli. But unless you are a hermit in Alaska, you will use healthcare at some point in your life. Today, it is estimated that the uninsured use more than $116 billion in healthcare services each year. When they will need healthcare is unpredictable. If they are lucky – only at the end of their life. If they are unlucky, an accident, unplanned pregnancy or  cancer diagnosis may compel an earlier need for a physician, hospital services, or both. What happens if they don’t have health insurance? Thankfully, doctors and hospitals don’t turn them away when they most need care. They give them the tests and treatments they need – at least to get over the emergency or acute episode. Thus, while it is feasible that you may never be engaged in the broccoli market, at some point, everyone – including the uninsured – will be engaged in the healthcare market.

Why couldn’t we let people voluntarily decide whether they want health insurance or not, instead of compelling them to buy the insurance with the mandate?

Unlike broccoli, when some people don’t participate in the health insurance market – 50 million people in 2009 – there are direct consequences for the insured who are participating. The costs of caring for the uninsured are shoved onto the rest of us through higher insurance premiums or taxes that hospitals, insurers and doctors must charge to recoup the costs of uncompensated care.

Voluntary health insurance exchanges piloted in several states without mandates all failed because healthy people opted out. Those who are relatively healthy figure the cost of insurance is too high, that they are subsidizing insurance premiums for sicker people and they probably (it is a risk) won’t need the insurance because they are healthy. When some healthy people stop buying coverage, the premium goes up for the remaining slightly sicker people. Then, as premiums go up, more and more healthy people drop out, creating an inevitable downward spiral. This is cost-shifting from the uninsured to the insured, and it is true not just in theory, but in practice. We have tried many such exchanges, and they have all failed. Only the Massachusetts exchange has worked because of its mandate requiring healthy, as well as sicker, people to buy insurance.

The broccoli situation is entirely different. At the supermarket, you cannot get the person behind you to pay for your broccoli. If you don’t pay for broccoli, you don’t get it. Unless you steal the broccoli, you are not influencing the market by not buying it. And unlike healthcare, there is no cost-shifting in the broccoli market. If you don’t buy any broccoli, the price of broccoli for me is the same. Indeed you might lower my price, because demand for the product is lower.

Non-participation in the healthcare market has additional, more far-reaching effects. The market for health insurance is both complex and very fragile. If people only bought health insurance when they were sick, there would be no market. There would be no reason for insurance – you would just pay the doctor and hospital bills on an as-needed basis. The only way we can have a health insurance market, where we pay a set amount but get covered when we need services – is to have a diverse risk pool that includes healthy people, as well as sick people. It is important to notice that in this case, opting out of the market for insurance – inaction – has a profound effect on the market. It is not neutral. It leads to collapse of the market.

Thus, Congress decided to create a broad risk pool by requiring people who did not get their insurance through their employer – or through Medicare or Medicaid – to buy coverage through the exchange. Large employers understand the efficiency of this and basically create these broad risk pools by combining all their employees and insuring them together. That is why they get insurance at lower rates, typically, than small businesses or single individuals.

Again, broccoli is very different. The voluntary broccoli market works just fine today. If people voluntarily do not participate in the broccoli market, it will not collapse. Congress does not need to require people to buy it for the broccoli market to function. More important, unlike healthcare, no one needs broccoli. We all can live just fine without it, as if it never existed. There is a need for a health insurance market – we would all be worse off without it.

Justices Scalia and Alito seemed not to appreciate this crucial difference between health insurance and broccoli. Justice Scalia said: “If I don’t buy a Volt, I raise the price of Volts.” Wrong. The market for cars works fine even if there is no mandate to buy American-made cars like the Volt. There will be no collapse of the entire car market if people do not buy U.S. cars, including the Volt. There may be closure of American car manufacturers, but that does not mean the collapse of the American car market. We would still be able to buy cars. Hence Congress cannot compel purchase of American cars.

These two differences between broccoli and health insurance translate into the important limiting principle that the justices were seeking: As part of its Commerce Clause powers, Congress can compel people to purchase a good or service when, because of market failure, the market collapses as a result of their refusal to participate and when they themselves will definitely need the good or service and would otherwise transfer the cost of using the service to the rest of us.

The difference between broccoli and health insurance is simple. It leads to a clear limiting principle. Congress can urge people to eat their broccoli, but not compel them to buy it, because the broccoli market will function regardless of what people do. Congress can compel people to buy their health insurance because otherwise there will be no health insurance market.

PHOTO: A farmer holds up a head of broccoli at a greenhouse of the Al Sulaiteen Agricultural and Industrial Complex (SAIC) in Umm Salal Mohammed, north of Doha, December 29, 2011. REUTERS/Fadi Al-Assaad

39 comments

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[...] Obama's handling of health care will deeply impact his reelection in 2012Fox NewsReuters Blogs (blog) -Salt Lake Tribune -CNNall 15,011 news [...]

The author engages in the popular sleight-of-hand of conflating “health care” with “health insurance”. They are not the same. Yes, everyone uses health care, and society has a moral obligation to make sure people can get some minimum level of it.

But health insurance – a contract between an individual and some corporation to arrange for advance payment of health expenses – is just one tool for achieving that policy goal. Many advanced countries provide health care without relying on a system of private health insurance. A private health insurance market is just the mechanism Congress happens to have chosen to build on in 2009 as a way to improve the availability of health care.

Posted by mhughes-sanjose | Report as abusive

[...] Associated PressYes Virginia, Health Insurance Is Different From BroccoliForbesReuters Blogs (blog) -Fox News -Salt Lake Tribuneall 14,285 news [...]

It’s amazing how many educated people seem to refuse to look up some pretty basic concepts of insurance and the rule of large numbers. Then look into how rate pools are developed and how rate pools and claim rates drive premium increases. Then follow it upstream to costs. Medical supplies, Medical Equipment, Pharmaceuticals, Specialty care, Education, etc, etc, etc. These are not tough concepts, so should we assume that the educated justices are rather ignorant or just stubborn.

Posted by SeaWa | Report as abusive

Broccoli presents no socialized risk sharing considerations and no national cost considerations as is the case with healthcare coverage.

Broccoli commerce is not going to bankrupt the nation.

It is a ridiculous analogy.

conversely, our national healthcare model should not be chained to private for profit insurance models that add nothing to our healthcare infrastructure. It is a waste and a drain on our collective resources. We need a nationalize single payer system. Get Big Insurance out of the game.

Posted by NobleKin | Report as abusive

I agree with NobleKin, however, in the absence of being able to ‘get insurance out of the game’, this legislation is absolutely necessary. Besides, there might be value in a limited competitive system where the private sector insurance giants compete with a public sector plan. Everyone would have to participate in one or the other. In lieu of paying a healthcare tax, we would all be paying a sliding scale premium. But I digress.

Broccoli legislation and Healthcare legislation cannot be compared. And what kind of cognitively impaired justices are sitting on the bench? Like I said, they are either ignorant or stubborn. Hopefully it would not be possible for a stupid person to raise to the position of supreme court justice.

Posted by SeaWa | Report as abusive

[...] behind closed doorsSalt Lake TribuneYes Virginia, Health Insurance Is Different From BroccoliForbesReuters Blogs (blog) -Fox Newsall 14,593 news [...]

I think Ezekiel is arguing in market terms because it is the interstate commerce clause of the constitution that justifies the legislation. Although I also agree that single payer would very likely be the most efficient health plan, there are lots of politicians who worship free enterprise and think that can’t be the case, because a single payer system doesn’t have competition. The legislation was an attempt to satisfy that argument. I agree that we ALL use healthcare, but there certainly is an element of choice, often ignored. Americans are convinced by advertising to consume as many medical products and services as possible, you can see the impact on the history of medical inflation. The profit motive that drives advertising is a major inefficiency of capitalist medicine, not counted in the 30% overhead figure I’ve seen quoted recently.

Posted by Susanna144 | Report as abusive

I assume they are using broccoli simply as a reductionist representation of a healthy diet or maybe an overall healthy lifestyle. The justices may make odd decisions at times, but can’t be stupid enough to be using broccoli literally in this context.

The ironic thing is that pre-reform you do get punished for not “eating broccoli”; if you live an unhealthy lifestyle you are more likely to get sick and more likely to be denied coverage. This legislation removes that penalty by not allowing insurance to deny coverage for pre-existing conditions.

If health care is supposed to exist without a mandate or a single payer system, there needs to be a way for those who opt-out of the market to be truly opted out. They don’t purchase health insurance and don’t get access to emergency care of any sort without a down payment or proof of collateral. If they get in a car accident and shatter their pelvis they either have the resources to pay for the surgery or get left at the front door.

Posted by spall78 | Report as abusive

@SeaWa

“Private insurance out of the game” should be a rallying cry for every American for the future of this country.

Even most Conservatives I speak with agree the system was failing before Obama and Obamacare is simply a political football with which to score political points. They believe and fear their party will offer no viable alternative solution and they understand the long term problems this presents for their party and this country. The sad thing is most have been affected by soaring premiums and some have existing health issues and know they are in grave danger if/when the law is repealed.

Posted by NobleKin | Report as abusive

Even if you were to buy the author’s argument for why health insurance is fundamentally different from the market for food – how does this explanation a) justify the compulsion to enter into private contracts and b) overcome the dearth of evidence that health insurance is not interstate commerce and outside of Congress’s authority.

Posted by mewster | Report as abusive

This author and this argument, as most, ignore the elephants in the room. We debate the wrong things because it is easier than debating the right things.

Congress and the American people have yet to accept that we can have ANYTHING we want, but not EVERYTHING we want. Priorities, however inconvenient, have today become necessary.

The primary reason the cost of health care in America is on an endless upward spiral is very simple. As more and more is learned about treating chronic conditions, the “standard of care” of the medical establishment increasingly interferes with the inevitability of death at life’s end without regard to cost. Why?

America already accepts that everyone will eventually need dental care, eye care and hearing care; and that the Social Security “system” is unable to provide these services within current statutory funding. Well, guess what? The presumption thus far (without appropriate debate) that everyone has a “right” to endlessly unfolding medical knowledge and/or drugs (which happen to be VERY expensive while initial patents remain in force and drug prices are not negotiated) is ALSO incompatible with current statutory funding! The endless funding at hideous cost of days, weeks or months of additional largely unrewarding institutionalized “survival” is of NO benefit to society as a whole and of questionable benefit to many recipients.

“End of life” care, hip replacements for those of advanced age unlikely to recover, electric scooters, etc. are but the tip of the financial iceberg that has ripped apart Medicare funding originally contemplated and adopted by Congress before WW II to provide retirees with the few relatively basic medical services then available.

We all die, sooner or later. It is long past time to step up to the plate and formalize a reasonable cost-benefit basis for what will be covered at public expense in terms of health care dollars. The current and ongoing presumption that everyone has some “right” to every medical procedure or drug breakthrough regardless of cost is very specifically the primary reason the future of Medicare as we know it cannot be sustained.

As a separate question, can anyone explain to me why “we, the people” provide those on Medicaid at public expense ALL of the above services which taxpayers either fund themselves or go without? Is that not a classic “double standard” largely put forth by the medical establishment that benefits their interests at the expense of the “public interest”?

Our elected representatives have provided themselves and promised us and others more than we can afford to deliver. There is no choice but to review and renegotiate back to a level of services that is both equitable and sustainable. However much we resist, at some point we must acknowledge and accept economic limits on government’s responsibility to fund the ever-increasing expenses of preserving or extending human life.

It is also fascinating to see religious fanatics object to tests that allow prospective parents to discover and abort fetuses whose lives, if born, will forever be an economic burden on society as long as they live. The million dollars spent to care for one hopelessly “special” child could mean countless procedures, or eyeglasses, or teeth, or hearing aids for others in need. We must separate “wants” from “needs” when funds are limited.

Now that society has the means to avoid the obscene lifetime “society costs” of a majority of “special” children, let parents, relatives or religious communities step forward who would impose their personal standards and values on others. The full economic impact of such decisions may bring about an overdue reconsideration among them over time.

Primitive societies understood the necessity to leave those without the ability to contribute “outside” such that nature could take it’s course for the common good. Does recognizing and living within the genuine limits of a given society in any manner diminish the individuals comprising it? I don’t think so.

Posted by OneOfTheSheep | Report as abusive

It is inevitable that one day the U.S. will join the rest of the developed world and provide its citizens with a national system of health care. National healthcare programs are funded by government mandated tax paid by individuals, businesses are a combination of the two. Cost savings occur because fees with healthcare providers are standardized and controlled. Because everyone must participate, financial costs are spread across greater numbers and all levels of health adding additional downward pressure to costs. Is this type of system so bad? Does this type of system infringe on my rights and freedoms? It should be my right to have healthcare when it is needed. It should be my right not to have my rates inflated because of less than even participation across all citizens and no standardization of coverage. It should not be my right to inflict pain and suffering on others!

Posted by abkisa | Report as abusive

Cute, but wrong!

The US Supreme Court has been using the Commerce Clause liberally to justify just about anything it cares to become involved in — including equal rights.

Now, about the broccoli. While it is true people do not need broccoli, it is true people need health insurance (to go without invites disaster), and if the only means of doing so is by using the supposed free market system, then so be it.

I do not agree with Obamacare (i.e a market solution — an oxymoron if ever there was one), but if that is the only way it can be done, then we must do it.

I think a better argument than broccoli would be Social Security. It is a moot point now as to whether the government has a constitutional right to enforce tax collections for Social Security, since they have been doing it for decades.

Whether you agree with it or not, Social Security is arguably much better than putting millions of people on the streets without any support system at all, which is the alternative.

Posted by PseudoTurtle | Report as abusive

The elephant in the room is the cost of healthcare. The simple reason it costs so much is because there are no limits — it’s pure market rate in the US. If a doctor sets a procedure to be $30K then that’s the price.

In the US, doctors make money hand over fist whereas in other countries, while still making a very comfortable living, doctors don’t come anywhere close to what they make here. When I talk to my surgeon friend, he brings up the medical school loans he has to pay and the malpractice insurance and whole litany of costs. But in the end, he zips to Paris and Iceland for weeks at a time while crying poverty. He pulls an easy $400K.

I hate to say it but nothing will change until the actual costs of medicine comes down and that’s the hardest part. No doctor will want to now charge set rates for procedures. It’s happening now with HMOs, which is why doctors are opting out of them but in my opinion, this is the actual source of the problem.

Similarly, pharmaceutical companies do exactly the same thing that doctors do — (I’m a consultant to one, I’m privy to the pricing structure) they charge as much as the market will bear to pay. In other countries, the governments negotiate the price with the companies but here, this is forbidden save for Social Security, Medicare and VA.

They will always tell you that research costs takes the lion’s share but that’s very obviously a lie as the advertising costs account for double that of research. Direct to consumer advertising laws now allow patients to self-diagnose and medicate with name brands. The more pharma spends on ad dollars, the more the drugs will cost to the patient. This is the root of the problem.

Btw, this was a good primer on healthcare costs in the US compared with other countries:

http://www.washingtonpost.com/blogs/ezra -klein/post/why-an-mri-costs-1080-in-ame rica-and-280-in-france/2011/08/25/gIQAVH ztoR_blog.html

Posted by benjamin331 | Report as abusive

Serious question, why couldn’t they have written the law to be insurance mandatory at point of sale? Then the forced commerce obstacle is removed. According to the SG we are all in the market anyway.

Posted by coldstihl | Report as abusive

Health insurance is not like broccoli.
HOWEVER, health insurance is like BROCCOLI INSURANCE

Think about it this way, you should at some point eat broccoli. Therefore if you don’t buy broccoli insurance, the price of broccoli insurance for everybody else will go up, so people have less access to broccoli. This is not good for their health.

This means they should also force people to buy broccoli insurance, after that milk insurance, bread insurance, cloth insurance, etc you name it.

Health insurance price increases is just the surface symptom of the bigger problem. Speaking in economic 101 term, the insurance price increases because the health care price increases. Forcing people to buy insurance is just like band-aid solution.

Why does the health care price increases?
ECO101, supply and demand.

More people needing health care services creating more demand while there is not enough supply capacity increase.

So to fix the problem, the best way is to first scrap as much middle man as possible. This can be done by either eliminate the insurance industry all together or use insurance for only a very small set of highly rare health problems and preventive measures. The vast majority of health services need to be like other things.

People pay directly to the doctor. This forces the people to go to the most efficient and cost effective doctor, encouraging and reward the doctors that find ways to do more efficiently and effectively.

Doctors’ pricing practice also must be regulated to be more transparent so people can go around for the best deal. Of course, this requires better protection for the doctors against those funny lawyers as well.

After that, increase the supply by either having more doctors trained and use better technology or organizing the whole system in a more efficient way.

The way to educate doctors also needs to be changed, the current way takes too much time and money for a person to become a doctor. This can be done by either starting med-school after only 2 years of college or further specialize the field so there is less overstretch on any specific doctor.

This is the only way to fix the root of the health care problem for the whole planet, not just the US, Europe or Canada. No other solution will solve the problem.

A single payer system or any of its variants for anything (not just health care) will mark the irreversible down fall of any country and civilization.
Mark my words!!!

Posted by trevorh | Report as abusive

Comparing the mandate of the AHA to being forced to eat broccoli is a weak analogy.

During the past 60 years the insurance industry peddled their products and made the conditions where heath insurance is nearly ubiquitous now. And the cost of health care has risen enormously during that same time. It was a profitable business for all those years and now the industry faces a crunch of higher costs just like the medical industry. They may have over priced themselves too high for all but the affluent and/or fully and securely employed.

In a way – the AHA is a bit like the bailout of the auto companies.

Maybe a better analogy than broccoli would be one drawn from banking. Nearly everyone needs to use money but one is never obligated to have a bank account. An even better analogy would be electrical or water services. Unlike broccoli, they are very difficult to live without and are even more necessary for a normal life today that auto ownership. And actually one can provide one’s own medical care as long as it is family or oneself (I think). That is not a very practical or high quality option, I’m sure but the AHA pushes the payment (for possible future consumption) of services more aggressively than the provision of them in the present time.

As much as I hope there is a better sustainable health care financing system in place soon, I think the AHA is the worst of all possible worlds because it is so compromised by the present players and stake holders.

I don’t trust private enterprise that it will be honest or even able to stay solvent for more than a few years or decades. The Federal government is not as likely to be absorbed in a merger or be renamed and repackaged by a bigger fish. Debts owed by the government are a matter of public record. The government never really has to spend much on advertising or touting its products or trying to obscure its pricing strategy with marketing gimmicks. Private enterprise may be more limber bur it is also less stable or as durable as the government.

The government may not be as likely to try to sell me more insurance (and to make fortunes doing that) than I want. I was told when I bought homeowners insurance years ago that I must pay for the levels of coverage they recommended but I recently obtained an admission from a sales person that the contents I described when I got the policy got a while lot older and cheaper by the time I thought about canceling it a year ago. They really had no intention of paying off contents I estimated were only worth a few thousand but they insisted were worth several times more. And they would not set a rate for the content value I estimated. It would have not been profitable enough for them to do that I suppose? And as far as I can tell there is nothing in the contested law that really states how it will control the rapid escalation in premium costs.

Why should anyone expect that private health care insurance made mandatory will be anything less than an invitation for the insurance industry to milk profits from an even larger pool of people by all sorts of murky pricing and policy options? And the industry will face what competition to lower estimates of future costs when it is in the interests of all but the captives of the mandate to keep those costs estimates as high as possible?

Posted by paintcan | Report as abusive

An Alternative to Capitalism (if the people knew about it, they would demand it)

Several decades ago, Margaret Thatcher claimed: “There is no alternative”. She was referring to capitalism. Today, this negative attitude still persists.

I would like to offer an alternative to capitalism for the American people to consider. Please click on the following link. It will take you to an essay titled: “Home of the Brave?” which was published by the Athenaeum Library of Philosophy:

http://evans-experientialism.freewebspac e.com/steinsvold.htm

John Steinsvold

“Insanity is doing the same thing over and over and expecting a different result.”
~ Albert Einstein

Posted by John_Steinsvold | Report as abusive

Okay. For those of you trying to apply efficient market theory to a public good/service like health insurance, please learn economics.

/tip: your cunning plan doesn’t work
//’externalities’

Posted by squee | Report as abusive

To save everyone from reading John_Steinsvold’s link and the long article.

The link basically advocates a variant of communism.
Where people get product and services according to their need not according to their ability to pay.

I guess the full blow is “receive according to their need, and work according to their ability”?

It sounds familiar right?

Yep,
“Insanity is doing the same thing over and over and expecting a different result.”
~ Albert Einstein
I fully agree. I just disagree on what is ‘the same thing’.

Posted by trevorh | Report as abusive

[...] more here: Here’s why health insurance is not like broccoli – Reuters Blogs ← "Health Insurance Whistleblower" Speaks in LV Cato’s Michael F. Cannon [...]

The government is out of control. If they can force you to buy heath insurance for yourself…what else can they then force you to buy?

Posted by CF137 | Report as abusive

The government had me register for the draft and buy auto insurance, why cannot not make me buy broccoli if it serves some public good or enough politicians’ pockets.

Health insurance serves as much public good as auto insurance and will line lots of pockets. Without a policy
to create more doctors, hospitals and generic drugs, we can expect pay and pay. It is simple market forces, pay qualified people to try to become doctors, make hospitals and generic medical goods or pay for them later.

Posted by SamuelReich | Report as abusive

As a Cdn I would say that American healthcare has extremely high potential but it’s output is really lower than Canada’s. I think the only true way to meet your potential is a single payer system – not because of the usual arguments, but because the uncovered that come in for emergencies end up with substandard care to save the hospitals money. Also, those without insurance don’t have regular check-ups that would (normally*) catch many maladies before they became serious or life-threatening. That is the real savings! The rest of this nonsense is just about insurance companies being nationalized and the profit motive being squelched for the industry. Not every industry should/need be run for profit, unless you’d like to see what electricity costs/service would look like under pure profit motive….

Posted by CDN_Rebel | Report as abusive

Point granted Ezekial.

But, what about smoking or obesity. Could the government force you to quit smoking as it could certainly be considered more of a necessity than is the consumption broccoli…that is a tougher delineation to make.

Posted by jaham | Report as abusive

If someone receives medical care, they are given a bill. They pay it out of pocket, or they pay via health insurance. If collecting money from people who opt to not have health insurance is too difficult, then those costs are put back on to the population of people who have health insurance.. Wait, no that doesn’t make any sense.

So if the problem with health insurance now is that costs/fees keep going up (and have been going up) because more and more people leave the system, if we mandate everyone gets back into the system.. Those same cost/fees are going to plummet because everyone is back in the system? yeah right, i’m still too jaded to believe that.

Posted by RailBended | Report as abusive

While I am for universal healthcare I doubt whether forcing healthy people to opt into the system will lower costs. The problem is that healthcare simply costs too much. Every politician in America knows that he/she cannot promote cost controls on healthcare. That would be an outright attack on Capitalism, which has assumed the role of God in the American society, thus committing political suicide. So, as usual, we shoot for the smaller targets, which may help some but won’t cure the problem. America is doomed to become a third world country, and it’s citizens lack the strength of will and morality to change that.

Posted by lhathaway | Report as abusive

Switzerland, Germany and the Netherlands are three prosperous democracies in which citizens are legally required to purchase private health insurance. The citizens of these countries enjoy long life expectancies, despite easy access to beer, cannabis, brothels, physician-assisted suicide, and deep-fried schnitzel. If the constitutionality of any of the above is in doubt in the United States of America, perhaps constitutional revisions should be considered. With respect to broccoli, we could even propose an amendment specifically requiring each American citizen to buy one serving of per day.

With reminds me of a story. A woman walks into a green grocer and tells a clerk, “I’m looking for a pound of broccoli.” “Sorry ma’am, we’re all out of broccoli today, but we should be getting more in tomorrow,” the clerk tells her. An hour later, the would-be customer returns, sees the clerk, and says, “I’m looking for a pound of broccoli.” “Sorry, but we’re still out of broccoli,” he says. “We won’t have any till tomorrow.” Ten minutes later, she comes back again and tells the same clerk, “I’m looking for a pound of broccoli.” Deciding to change his approach, the clerk asks her, “What does T-O-M spell in tomato?” “That’s simple! Tom,” she replies. “And what,” he then asks, “does P-O-T spell in potato?” To which she answers, “Pot!” “So then,” he continues, “what does C-O-S-T-S-H-I-F-T spell in broccoli?” Briefly taken aback, she finally says, “There’s no cost-shift in broccoli!” “My point exactly,” the clerk responds.

Posted by TobyONottoby | Report as abusive

If my supreme court wise men and women cannot instinctively differentiate broccoli from health insurance, then we are doomed. How can we trust them to make rational decisions about less complicated issues?

Posted by DrHobbit | Report as abusive

[...] them! The very idea that the insured among us may have to continue unnecessarily paying $116 billion every year because a radical portion of the population as well as some of the “best and [...]

@squee

No, I did not miss externalities.
That’s exactly why I put in there
“preventive measures”
The whole argument for the socialists’ pipe dream of single payer system is based on that as well:
“preventing problem or preventing a problem from getting worse”

I know my post is long, so people might miss it. But it is there, please check it.

Posted by trevorh | Report as abusive

I say so what if Congress were to mandate broccoli? No big deal. Scalia’s whole attempt at ridicule is specious.

Posted by peacebrother | Report as abusive

The grand, unsolved problem with forced participation such as with healthcare is that it puts an enormous burden on the individual for a very, very tiny (if any) benefit to society as a whole.

If making everyone participate would cut the cost of health insurance in half, then maybe the author would have point, but it actually produces a benefit to the whole that is so slight it isn’t even measurable.

Economists always seem to miss accounting for the effect on the individual and the end result is that misguided policies from trade to healthcare end up hurting our society instead of helping.

Posted by PapaDisco | Report as abusive

The grand, unsolved problem with forced participation such as with healthcare is that it puts an enormous burden on the individual for a very, very tiny (if any) benefit to society as a whole.

If making everyone participate would cut the cost of health insurance in half, then maybe the author would have point, but it actually produces a benefit to the whole that is so slight it isn’t even measurable.

Economists always seem to miss accounting for the effect on the individual and the end result is that misguided policies from trade to healthcare end up hurting our society instead of helping.

Posted by PapaDisco | Report as abusive

Interesting article and comments. Too bad almost all of it is irrelevant to the matter at hand. The task of the judicial branch, atop which the Supreme Court sits, is to decide on the legal and constitutional merits of the case, not to decide what is most economical. So, the interpretation and applicability of the Commerce Clause is the crux of the matter, not whether a need for health insurance demands that the Court allows this particular law to stand.

Posted by hoosier_gdi | Report as abusive

Why do I have to buy auto insurance? Because the system won’t work if some (many I would think) driver’s don’t have insurance.

The medical system doesn’t work if some (many) people don’t have medical insurance.

Of course, there are many other reasons our medical system doesn’t work, such as the fact that much of the money flows to profits instead of medical care and research, but that is for another article I guess.

Posted by Pendulumswings | Report as abusive

@mewster & hoosier_gdi. In both Lopez and Morrison, the court reasoned that the absence of interstate/commerce connection to the non-economic and criminal nature of the prohibited conducts–gun within school zone and violence against women dictated the limit on congressional commerce power. Further, in Lopez, the court held that Congress’s commerce authority includes the power to regulate those activities having a substantial relation to interstate commerce. While individuals purchase broccoli at supermarkets, such purchases lack that substantial relation to interstate commerce.

Posted by 0okm9ijn | Report as abusive

This argument seems a bit weak on it’s base. If we are looking at supply and demand dictating market forces. If there isn’t a market for brocoli then the market for it would dry up just as if there wasn’t a market for health insurance it would cease to exist. Perhaps it’d be easier to look at the impact of healthcare (provider side) without insurance (payor side) to backstop the costs.

Posted by cbowen | Report as abusive

I can grow my own broccoli. That heart surgery would really be a tough one to perform alone.

Car insurance is so much less expensive than medical insurance because everyone is legally required to buy it. And we pay for uninsured motorists to cover the costs of those who don’t buy it.

You could argue that medical policy costs could be increased for the insured with a “Uninsured Illness/Injury”

The right winged Supreme Court Justices are making a political issue out of this.

Posted by JL4 | Report as abusive

Too many legal cases rest on spurious arguments and tenuous analogies.

Isn’t there a reason why judges are paid so much more than the average person? Aren’t they supposed to THINK and “DELIBERATE”? Personal experience has shown me that they don’t always do this.

Let’s hope these Justices do justice to their office this time… Whichever way the argument falls, let them make the most valid argument…

Posted by matthewslyman | Report as abusive

People who advocate that an exclusively market driven economy is the wave of the future and the only road to the future seem to forget that there are few frontiers open to grass roots exploitation anymore. Unexploited resources are the unmentioned necessary ingredients to capitalist success.

The fault of capitalism is that is not interested in the total welfare of humanity. That is the dirty and unrewarding work that it always leaves to governments and it always resents it. That is very easy to understand. But the rich don’t necessarily have to worry about costs as much as the poor. Big business is not the marvel of cost efficiency they seem to claim they are. They are inclined to puff their success and to bury their embarrassing mistakes and they don’t advertise their hidden secrets and fudge factors. The market itself is obviously not as full of the well-informed and intelligent market analysts that it is claimed to be or all sorts of very dubious and even fraudulent products and services would never see their day in the sun. Mafiosi are always dedicated capitalists. Madoff and other fund wizards like he are illustrations of the get rich quick mentality of the market place. To be fair, the successful ones do not believe in “get rich quick”.

The most successful capitalists are not necessarily the risk takers as is often touted. An article in the New Yorker several years ago asserted (with good reasons) that the most successful capitalist don’t tend to be the vanguard of entrepreneurial bravery at all. They are those who have found as close to a sure thing and know how to milk it for all it’s worth. In the economies of the developed places, the most aggressive and well funded raise to the top. Intelligence does not necessarily mean that they somehow possess superior brains -it means that they have more reliable information, far more training and experience, better organization and more leeway to pick those most suitable to advance their interests. Access to and construction of that intelligence is their greatest tool. You don’t necessarily have to be “intelligent” or a person with a high IQ either. They are inclined to cling to their personal resources and try to discard those human resources they can’t use. Ruthlessness can work for a time too. They could in fact be just like those they are inclined to consider wastes of time, space and resources but they have funding and the momentum to compete for more. They have not been eager to kick-start the economy with the enormous cash reserves they have. They want a sure thing whenever they can find it. They have a desire always to be monopolists.

Government is the last resort for the unprofitable labor of governments. They also work best when they can write out the difficult and inconvenient costs associated with keeping the mass of the potential labor pool alive and educated at all. They need unexploited resources.

The capitalist seems always to resent the fact that the world isn’t easier for him to exploit. He also tends to want to overlook his own dependency on government largess by way of lucrative contracts (got by fair means or foul), or at the subsidies to keep businesses, such as airlines and public transportation, alive at all. The capitalist generally likes the government to pick up the slack he does not like to deal with and his own sense of superiority tends to blind him to the fact that he often needs welfare as much as the long term welfare recipient. This has been said many times by many people, in this paper and in other comment threads.

The only thing in this society that is concerned with broader issues of human rights for the mass of those business does not want to use, are the governments of the world. And that is why – I think – many of those on the “right” of the health care debate- don’t trust that the mandate will be a golden or even practical road to the nations welfare. It is very much more likely to be the last desperate “frontier” that big insurance needs to keep it’s own house of cards from collapsing. And they tend to be no more honest than they absolutely must be by law.

I just read in the UN news digest last night that the Arab world alone needs 50 million new jobs just to employ its youth. How on earth is that going to happen now? What are you waiting for capitalists? Megamillions await the exploitation but not even the largest mega businesses are able to deal with such an embarrassment of riches. Unfortunately, those mega-millions are time sensitive and can turn to garbage very quickly if they are not incorporated into the productive industries capitalists claim (erroneously) that only they can provide effectively. And if capitalism proves it’s inadequacies – other inadequate solutions are going to look so much more attractive. Roosevelt knew that during the Great Depression. .

China is the petra scandali of the modern world – but they don’t have a national health care system either; with or without insurance protection (as I understand it). That is not at all encouraging that there will ever be an adequate solution to this problem. It will make it more expensive because so many more will be able to satisfy the cash demands for a perpetually scarce resource. Asking private insurance to lower costs is asking one of the contributors to the escalation and sophistication of the health care system to change its ways. They won’t know how. They will have to act like a branch of government but the worst kind of branch. They will become an arm of the government that must always be concerned with making a profit to satisfy the investors. Those investors will move elsewhere if the proposed solution doesn’t work. That is why I mention insolvency of the big insurance companies as a possibility. Other than the TVA or even the government sponsored mortgage financiers, there are few examples of that kind of partnership in the US.

Posted by paintcan | Report as abusive

[...] more than 40 million people without health insurance and the cost of their healthcare is more than $116 billion per year.  So sure you can not participate in the healthcare market – but that will only increase [...]

[...] The Citizens United campaign finance decision, for example, was decided by a court without a single justice holding any experience in how elections actually work (to borrow a gripe from John McCain). And this was a common refrain during the health care oral arguments: Does Justice Scalia really not know the difference between broccoli and health care? [...]

Yes, broccoli is a provocative reduction, a way to belittle the importance of the individual mandate to buy health insurance. In fact, I would say that we are required by law to buy food, although we have our choice whether or not to choose that vegetable over another. If you do not buy food and your children suffer, that would be grounds for the state to charge you would neglect or even abuse. If you as an adult individual refused to buy any food for yourself, then you would likely get in trouble. You could go to a food pantry or a soup kitchen and get by on some days, but you could end up in jail (for stealing food) or you for disorderly conduct if you went to a restaurant and insisted on your right to eat without paying.

The individual mandate is the good old American value of taking individual responsibility for your life, contributing your fair share towards your own health care and realizing that you are part of a health care system. It is very much closer to the requirement to buy car insurance — and there has been some cost shifting there as well because we have an uninsured motorist cost on the car insurance bill.

The individual mandate was a conservative Republican idea to begin with in order to counter the Democrats’ idea of an employer mandate, so it is so obvious that Republicans and Tea Party folks are against it now only because Obama adopted this provision in the law that was passed under his watch as President! The individual mandate is part of RomneyCare in Massachusetts. One of the sickest things about this political season is to see Mitt Romney running against a national health care reform law that is modeled after one of his best achievements as Governor or Massachusetts!

Posted by cathystanford | Report as abusive

[...] Emanuel’s non-religious work is quite profoud. This year Emanuel has also written of: Why health Insurance is Not Brocoli. Another topic is “Don’t fall for fake innovation (IT especially) in Medicine. Eke also [...]

I’ve talked to a dental implant specialist told me that we should be given the choice of what to pick among the present health insurances cause we will be the one whose going to use it, right? Though I think the government only thinks that this will be the best way to provide equality when it comes to health benefits.

Posted by Gracieee | Report as abusive

[…] Here’s why health insurance is not like broccoli | The … – Mar 29, 2012 · The fate of universal healthcare coverage that the United States has been trying to achieve for over 100 years may boil down to broccoli. The broccoli …… […]