I’ve been hearing a lot of arguments against mandating the purchase of health insurance, particularly on the right side of the political spectrum (where I spend most of my time, in case you haven’t guessed). There have even been questions raised about its constitutionality. The analogy of a requirement for car insurance, it’s been said, is not applicable as that is regulated by the states and there is no mandate that a person drive. Let’s examine these arguments. 

What is the rationale for an everyone-must-pay-who-can paradigm? Anyone who understands how insurance works realizes that it only works if you have a large pool of people paying who aren’t using the services, to cover those that do. The original idea behind insurance was to allow the sick to afford care should a serious illness befall them and protect individuals from catastrophic losses that would bankrupt them. Somehow, over the years, it has morphed into a pay-for-it-all system that cultivated an I-expect-not-to-pay-out-of-pocket attitude. Of course, this has eroded over the last couple of decades. Since it was unsustainable, premiums have rocketed and co-pays have followed suit. This system also took the consumer out of the loop, allowing the cost of services to rise, at a time when there are more and more elderly, “multi-sick” patients surviving every day to access the health care system. We are victims of our own success. 

Let’s assume that young, or even older healthy people should pay according to their actuarial risk, or opt out. The former supposition implies that they must be willing and able to pay substantially more when they are older and sicker, even when they are no longer capable of earning an income to do so (and assuming the “pre-existing condition” exclusion is abolished). The latter assumes that they will pay out-of-pocket. If they are unable or unwilling to do so, we either have to find resources to pay for it that aren’t there or lock the emergency room doors. 

Of course, we have the messy federal EMTALA laws that prohibit hospitals from turning away anyone who shows up at an emergency room. We could repeal that law, but our legislators are only in the business of creating new and more complex health care laws that suck resources like a Dyson. Or, the hospitals could stop seeing Medicare patients and exempt themselves from the law. I think you’ll agree neither option appears likely. Besides, turning people away, even when they’ve chosen the option of not paying when the grass was greener and the sun shone more brightly, puts a blight on our self-image as a magnanimous and caring nation. In a former era of self-responsibility we could depend on people to purchase insurance or put aside for their health care, and I think the majority still do. But the culture is changing and the system is overwhelmed with the growing number of uninsured that are being supported by those that are, and this can’t continue. We still have the responsibility of providing care for the indigent (a larger group in time of a weak economy); we can no longer provide for the “pseudo-indigent.” 

One of my associates has proposed as the ideal solution that the “death tax” be replaced by a requirement that Medicare be reimbursed for health care expenses after the individual’s death. At minimum, I favor mandatory universal participation for those that can pay with no opt-out and free competition across state lines for insurance companies as a good start. 

What’s your solution?


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