The Freedom Premium

77 Pages Posted: 13 Mar 2023 Last revised: 9 Sep 2023

See all articles by Valarie Blake

Valarie Blake

West Virginia University - College of Law

Date Written: July 25, 2023


Most Americans are forced to pay a “freedom premium” for health care, trading measures of control over their personal lives in return for health benefits. For the publicly insured, many recipients must live at poverty levels, forgoing work, marriage, and security in old age to meet strict income and asset tests. People with disabilities, their medical needs routinely pigeon-holed into public programs, have for generations been denied equal opportunity in this way. Private employer-sponsored insurance presents its own freedom losses, limiting the range of jobs people can work, when they can retire, and whether they may divorce.

The problem of freedom loss in health insurance has been minimally studied and in a fragmented way, exploring only facets of the problem. Neither has it featured prominently in health reform. Where legislation has spurred progress, it has largely been a side-effect of other aims like reducing uninsurance rates. For example, the Affordable Care Act’s expansion of Medicaid and subsidization of private insurance freed up some people to choose options other than employer-based plans. Legislation expressly aimed at the problem has been minimal, and piecemeal, concentrated almost exclusively on reducing job lock in employer plans.

This Article is the first to advance a systematic critique of U.S. health care finance that it structurally oppresses personal freedoms in ways that can be comprehensively addressed through health reform. First, it characterizes the breadth and depth of the freedom premium to signal the corresponding need for and magnitude of reform. Next, it highlights where law has made progress and fallen short at remedying the problem, and why. Lastly, it advances a model of health reform that corrects the problem. Universal health care uncouples benefits eligibility from work, poverty, and dependency, and replaces it with neutral criteria like residency, leaving people free to live their lives as they choose. A novel contribution to arguments in support of the adoption of universal health care, the Article offers a meaningful alternative to long-standing rhetoric that universal health care is anti-freedom and anti-American.

Keywords: health reform, single payer, disability, marriage lock, job lock, medicaid, health insurance, social security, marriage inequality, employment inequality, civil rights

Suggested Citation

Blake, Valarie, The Freedom Premium (July 25, 2023). WVU College of Law Research Paper, No. 2023-010, Available at SSRN: or

Valarie Blake (Contact Author)

West Virginia University - College of Law ( email )

101 Law School Drive
Morgantown, WV West Virginia 26506
United States

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