Mandatory health insurance?

[pauamma]

so it looks (from what I saw) that the final (signed into law) health bill makes health insurance mandatory. I'm curious: setting aside the "why would anyone in their right mind *not* want health insurance" justification or justification attempt, what are the reasons invoked to make it mandatory? If someone wanted to opt out for some reason (if only because it's mandatory, benefits notwithstanding), what would be their options, and would you consider that wish reasonable?

ETA: should probably get "health insurance" and or "it's for your own good" topic tags, but I can't create new tags.

Comments

[janinedog]

I can see the reasoning for it being mandatory: mainly, having health insurance means you're probably more likely to see the doctor when you're sick/injured, which means you're more likely to not be sick/injured for longer than you would be if you didn't see a doctor. Having the vast majority of people in society healthy is better for everyone, both in terms of making sure other people don't get sick and for keeping people at work/school/etc.

That said, I'm not sure if I think that reasoning is good enough. If someone really doesn't want it, I think there should be a way to opt-out (I'm not sure if there is a way to or not). But I honestly can't think of a reason someone would choose not to have health insurance, except as a political statement (or maybe they see an alternative practitioner that doesn't take insurance?). But again, I don't see anything wrong with allowing them to opt-out, especially since I think the number of people who would do it would be relatively small.

[ex_peasant441]

Well see my comment below - if people can opt out but the insurers are obliged to cover anyone on demand, then every single healthy person with economic sense would opt out until the day they got sick. Then opt in and out as they got better or got sick again. Only the sick would ever be 'covered' and there wouldn't be anything like enough in the pot.

Unfortunately there is no way to give universal cover for anything unless you make universal payment mandatory. Ponies for All! means giving up your right to not have a pony if you don't want one and not pay for a pony if you don't want to pay. On the plus side - everyone gets a pony.

[zorkian]

Actually, no, everyone has the potential to have a pony -- but they won't always get one. When I lived in Iceland I heard lots of complaining about the local nationalized health care system -- people who couldn't get in to have their necessary surgeries for months and months because they just weren't important enough, or whatever the reason happened to be at the time.

[ex_peasant441]

Well it's more that you get a pony but it is a pretty mangy underfed one compared to what you've been used to if you've had private insurance to date. That or everyone has to pay a hell of a lot more in stable fees.

[princessofgeeks]

As far as I can tell, this is aimed mostly at the 18 to 35 year olds who roll the dice and don't buy health insurance if they feel it's too expensive or if it's not offered by their employer.

Getting them to sign up would be a good thing for the insurance industry, because their premiums would be coming into the pool of money the insurance companies have and would balance out the expensive sick and older people. Younger people don't use nearly as much health services as older people. So it's great to have their business.

You have to make it mandatory or people won't do it.

Basically the options were: Make the government the insurer (the "single payer" system that was considered impossible and unsuitable for the USA), put the onus on employers to offer affordable coverage, or put the onus on the individual (like car insurance.)

From what I've been reading, this individual requirement for coverage was something various people from all sides of the political spectrum were advocating throughout these debates about how to cover the uninsured. The analogy to car insurance was used a lot.

[jld]

The analogy to car insurance was used a lot.

But, as various people have pointed out, it doesn't quite work, in that there's a difference between being alive (condition of health insurance mandate) and choosing to own a multiton hunk of metal and hurl it around at high speed near innocent people (condition of car insurance mandate).

put the onus on employers to offer affordable coverage

Just this, without anything else, still leaves people SOL when they lose their jobs, and likely SOL when changing jobs given the pre-existing condition racket. Which is a problem in itself, but I'm also reminded of one of the things the supporters of the health care bill claimed: that having insurance decoupled from jobs would make people freer to change jobs (or try going into business for themselves, small businesses being the lifeblood &c.), and thus increase economic efficiency. I don't know if it'll actually work like that or not (well, I mean, no-one knows for sure yet), but it seemed like an interesting angle.

[princessofgeeks]

well, yes, the analogy to car insurance isn't perfect.

but it was what i hear people comparing it to.

the problem is that if people either can't afford or choose not to buy medical insurance, and they don't have basic medicare or they're not on medicaid, when they do go to the emergency room the rest of us paying customers end up eating their bill, because by law emergency rooms cannot turn anyone away. so figuring out how to make the freeloaders pay was the hard part.

Europe solved it by making medical insurance a government benefit, like, oh, highways or water treatment plants. But of course over here we've been very reluctant to go that route for a lot of reasons.

But if you don't make it a government program, the only way to compel people to do it is to fine them if they don't, or make business do it. Overwhelmingly people got insurance through their companies here; that's the existing system. But like my husband's boss: It's a small, three-person company. They have had a heck of a time finding a policy they can afford. I think they've changed insurance companies once a year, trying to find a better deal.

And I totally agree with what you say about entrepreneurship and small business -- that is totally where the energy and buzz is in our economy. People don't go to work for a big company and stay their entire career like they used to. So portable insurance makes a lot of sense.

I heard, though I haven't followed up on it, that the bill is giving small businesses a tax break for offering medical insurance. I want to know more about that.

[ilyena_sylph]

full disclosure: I tend towards the heavily Democratic side of the spectrum, but I can quote you the Washington Post on the topic of "reasons invoked to make it mandatory".

"The theory behind the mandate is simple: It's there to protect against an insurance death spiral. Now that insurers can't discriminate based on preexisting conditions, it would be entirely possible for people to forgo insurance until, well, they develop a medical condition. In that world, the bulk of the people buying insurance on the exchanges are sick, and that makes the average premiums terrifically expensive. The mandate is there to bring healthy people into the pool, which keeps average costs down and also ensures that people aren't riding free on the system by letting society pay when they get hit by a bus." full source here

If someone wants to opt out, which I have seen quoted several places as being possible in the case of a) extremely low/no income, b) Native American descent (they are exempt due to various treaties, I assume), and c) religious objection.

And the option as I have seen it quoted is that when the mandate goes into affect in 2014 they can simply pay a fine of $95/1% of their income (climbing to $695/2% of income by 2016) and that will be the end of it.

[zorkian]

What is the "it's for your own good" tag? I can add it if you tell me what kind of things will go in that category. I might fudge the name a little, but it sounds like the kind of category we should have but I want to make sure I have the right idea of what you're saying.

[pauamma]

I was thinking of it for anything that someone might want to justify to detractors by saying "you need it, whether you know that or not, whether you want it or not - I know better" (implied: now shut up and take your castor oil/cod liver oil/whatever). IOW, arguments that might be acceptable from parents to young children, but certainly isn't to adults.

(Note: this tag may be for discussion/mention of supporting arguments along those lines, not - or not necessarily - for the substantive issues these arguments are connected to. Am I making any sense?)

[zorkian]

I think I see what you're saying, but I'm trying to figure out a way to phrase that that invokes it pretty quickly when someone reads it, hrm...

[cheyinka]

I'm partial to the idea of "shut up and take your castor oil", actually...

[zorkian]

Alright, we'll try that!

[zorkian]

Personally I keep going back and forth on the whole mandatory issue. I can see why they're doing it (for the reasons people mentioned above), but I still feel that this somehow impinges on our rights. If we don't want to pay car registration fees, car insurance costs, etc we have the choice not to drive. Health insurance should be the same, right?

Of course, then I get to thinking, and my thinking is: sure, while you're young, you might take the gamble that you don't need health insurance. When you get older, though, that's not a gamble you'll take. You will sign up for it. If that's a guarantee (or nearly one, anyway) then forcing people to sign up for it always to make the whole system works is probably reasonable.

Probably. I still feel majorly icky about it, though, and I haven't yet heard completely convincing arguments either way...

[ex_peasant441]

You have mandatory taxes for things like schools, the legal system, roads etc. Why do you feel health cover is particularly different? Not everybody uses the schools or even the roads, but most people will at some stage. It would be a very rare person who never once went to see a doctor.

[zorkian]

They're vastly different!

The argument it seems you are trying to make would require that the person who doesn't want to pay road taxes not only never use them him or herself, but also never buy anything that ever traversed them, never do anything that required the road to exist.

Same goes for schools. If you never went to a school, ever, then I'd say sure - you can not pay the tax. But schools are something that are generally required (and I think education as a requirement is acceptable) so you don't much have a choice there. You have to go to school.

But if someone were to never use the roads or anything that ever needed them, or they never went to school, then sure. I'd say let them skip those taxes.

Realistically speaking, though, those aren't possible situations.

However, it's entirely possible for someone to never go to the doctor. I've been twice in the past decade -- once for a physical required before I went to college, and once for my motorcycle accident. Both of those situations I could have paid for out of pocket. (I realize how easily that could have not been the case, trust me. But that's a choice I think people should be able to make.)

So, to me, the situations are very different.

[cheyinka]

The thing with schools, I think, is the best analogy for why it might be worth funding other people's health care:

even people who homeschool their kids, or send them to private school, as well as people who don't have kids and don't even interact with anybody under the age of 20, fund the public schools - because it's in everyone's best interest that society be populated by people who are at least minimally-literate, minimally-numerate, able to benefit from advanced education should they want a job requiring it...

and similarly it's in everyone's best interest that society be populated by healthy people. Some people never get sick, and other people treat all their own ailments, but some people also teach themselves to read before they ever get to school.

(This is something that just occurred to me when reading this comment, so it may not be the best argument - I'm certainly not sold on this being the best reason or whatever.)

[ashcomp]

There are only two ways to pay for the expense of running health insurance in ways that defy actuarial logic: force mandatory coverage, so everyone is paying something, or raise taxes. If you go for taxation without the mandate, the costs will continue to skyrocket for the reasons mentioned above: well people don't buy insurance. When the costs go up, the taxes will go up. Mandatory coverage is probably cheaper.

[majoline]

Except for being too poor to afford premiums, I actually haven't heard anybody say they don't want insurance, especially now that the companies can't discriminate against people with "prior conditions".

And boy, were the insurance companies starting to really stretch on what "prior condition" was. If anything, I'm glad that a stop has been put to that nonsense.

[ex_peasant441]

Unless you make it mandatory only sick people will pay for coverage at all. If it was optional but the insurance companies were obliged to give you cover as soon as you asked for it then every single healthy person with any sense would stop paying their premiums immediately and sign up the day they fell sick. Then stop paying as soon as they were better, and so on.

Basically the only way to pay for universal healthcare is through a mandatory tax - you can take that tax through the tax system and then pass it on to the health providers, or you can let the health providers gather it for themselves through an insurance industry but either way it has to be mandatory or you won't get enough.

On libertarian grounds I would prefer to let people opt out because people should have the right to do even very stupid things if they want to. But on economic grounds society as a whole can't afford to indulge them.

[hatman]

The weird thing is that the individual mandate was a Republican idea back in '93. Some of the very congresspeople who are now calling it unconstitutional were, in fact, the ones who came up with and cosponsored the original bill that included it.

Democrats were against it then. They compromised on the employer-based system we have now. (Heh. Compromise across party lines. Remember that? And MTV played music. And Windows was a functional shell built around a solid command-line interface.)

Candidate Obama campaigned against the individual mandate, and says he was dragged into supporting it "kicking and screaming."

Funny how just about everyone has reversed position on the issue.

It's sticky. I don't like the idea of forcing people to buy insurance. But 40k people die every year in this country because they aren't insured. And the crippling cost of health care is one of the leading causes of personal bankruptcy. So there is an argument to be made that everyone should have it.

Obama's point was that the system wouldn't work without the mandate. You need everyone in the pool in order to bring premium costs down.

The funny thing for me is that I support single payer. I hate for-profit insurance. What good does it do? They're just acting as middlemen, and they're taking cuts from all sides. They jack up premium rates, do whatever they can to avoid paying claims (including deliberately building up obscene amounts of red tape and purposeful incompetency), strong-arm doctors ("reimbursing" them sometimes at - or even below! - cost), and then turn around and charge crippling premiums for malpractice insurance. And they're making huge amounts of money doing it. Money that's ostensibly being spent on health care (which accounts for 1/5th of our GDP and rising) but is being taken out of the system to pay insurers.

We'd be much better off with a publicly-run system. Government bureaucracy isn't great, but at least they're not actively trying to screw you over for fun and profit.

But when you stop to think about it, single payer implicitly includes an individual mandate. It's just that it would be paid for in taxes rather than to insurance companies. (But I'm convinced the cost would be lower.)

The mandate, by the way, doesn't say that you must buy insurance. It says that there's a tax penalty if you don't. But that penalty is less than the cost of insurance premiums. The figures I've seen for the annual tax penalty were comparable to what I'm paying now every month. (And the penalty is waived if your household income is below a certain threshold. So you're not punished if you can't afford it.)

And the thing is... it's only fair. Because the uninsured put a drain on the system. Emergency rooms are clogged with people who are using them as clinics rather than coming in with actual emergencies. And those costs get passed on to the rest of us. Partly through taxes that subsidize the hospitals so they can stay afloat while running the ERs. So if you can afford insurance and are choosing not to get it, why shouldn't you be taxed extra to help carry that burden?

[habitsofmine]

ERs will still be clogged. Large numbers of non-citizens will still be using it as clinics. Additionally, there will now be a new desk so that non-insured citizens can now sign up for insurance. Pre-existing conditions don't matter anymore so you can sign up as you wait to be seen for broken arm. They will still have to pay for the insurance, but they had the money they saved by simply paying the fine instead of the cost of insurance, which in some cases may be 10% of pre-tax wages.

Due to budget cuts some small community hospitals may close. There's way funds are being given out is changing and some hospitals may not be able to keep up. Physicians may have to cut down on what they spend their money on. The Physician will be paid in a bundle for the outcome, instead of for each service performed. For example a doctor may not buy the up-to-date expensive sonogram machine because it won't change his bottom line. The rate medical technology advances may change.

If you have insurance now, please make sure you have a Primary Care Physician. Once this takes effect it will be hard to find one. People who haven't seen a doctor for years will now be able to have every ache, cough, or phantom pain looked at. True health problems will be looked at, but there will be a lot of overuse. Plus, some older Physician's may decide that they don't want to deal with the new rules and retire. Unfortunately, primary care physicians isn't 'where the money is at' right now so there's not a lot of replacements. The role of nurses and PAs will change to help care for the increased population.

(Sorry for babbling, yesterday I had a lecture on- Health Reform~How this could potentially Impact Physician Practices)

[habitsofmine]

To clarify-Listened to lecture, didn't give it~ thankfully.