There has been released, up to this point, a great deal of heat but virtually no light on the issue of the individual insurance mandate. No surprise there, this being a presidential election year, but perhaps it is time for a bit more analytical assessment.
1. In spite of what some few extreme ideologues might prefer (see e.g. Mr. Justice Scalia in oral argument on health care reform at the Supreme Court), we in this country have not yet deteriorated so far morally that we refuse care to those who come to the emergency room lacking money or insurance. We provide the care required, even though in some cases it may run to several hundreds of thousands of dollars. Hence the dilemma:
A. Hospitals are not allowed to issue currency. To do so would be a federal felony. (18 U.S.C. §471)
C. If a hospital fails to pay its suppliers, it will soon not have any supplies (electricity, for example).
2. Therefore, the hospital being required to achieve a balanced budget, several things happen in response to its caring for those who have neither money nor insurance:
A. The hospital raises right out of sight the prices it charges everyone who comes in with money or insurance (although the insurance companies negotiate a somewhat reduced rate not available to patients generally). This shifts the financial burden to those who have money or insurance, and who get sick or hurt, but not to anyone else. (Of course, this artificially inflates insurance companies' premiums.)
B. The hospital receives some payment from Medicaid for the care of the truly poor. This shifts the financial burden to everyone who pays federal and state taxes.
C. Municipalities and counties often contribute to these hospitals directly from their budgets, on the grounds that it would not be beneficial to their communities for a hospital to be closed down. This shifts the financial burden to everyone who pays local taxes.
3. The net effect is that virtually everyone in America (including the very poor: they pay local taxes) is paying for the care not only of the very poor, but also for those who may not be so poor but who lack insurance. (The average middle class family, even with decent health insurance, can easily be wiped out financially by a major medical misfortune. How many people do you know who could absorb twenty percent of a few hundred thousand dollars?)
4. Because of the bizarre structure of this system, we don't notice these costs. If the amount involved were totaled and divided by the adult population, and we each received a bill each month for our share, our awareness would increase dramatically.
5. To summarize: we are already paying the entire cost of the care for those without (lots and lots of) money and without insurance, but we are doing so in a totally irrational way that masks most of the impact.
6. The only sane way to solve this dilemma is to see to it that absolutely everyone is covered by insurance, from birth to death. This would distribute the costs in the same way that other insurance works: everyone pays a modest periodic premium and is protected from catastrophic misfortune. (The premium for those too poor to pay it would be paid from the public purse.)
7. Probably some (but not all) employers would elect to pay all or part of the premium for their employees (exactly the present situation); some people would need assistance in paying the premium; and for some people the entire premium would have to be paid on their behalf.
8. In practice, though, being certain that everyone is insured would require some form of individual mandate. In the absence of a universal requirement, some people who would be able to afford the premium (but unable to afford care for a major illness or injury) will choose to behave irresponsibly, spend the premium money on the good life, and let everyone else step in and foot the bill when the worst happens.
9. Here's the great irony:
A. There are people in America who are bitterly and implacably opposed to anyone expecting others to shoulder what should properly be their own responsibilities
B. There are also those in America who are bitterly and implacably opposed to anyone being forced to buy health care coverage.
And THEY ARE THE SAME PEOPLE! They somehow manage to walk around all day with two totally irreconcilable ideas in their heads at the same time, without causing themselves injury. Surely this is a phenomenon worthy of serious scientific study.
Joque Soskis is a humanist, retired attorney, retired professor of criminal justice and a former law enforcement officer.