Thursday, October 15, 2009

About that Individual Mandate

What are your thoughts on the proposed government requirement that everyone purchase insurance? My Physicians Practice column for November is on the mandate, a version of which is included in every major reform legislation. In it, I argue that "most Americans, including those who are currently insured, [don't] have the slightest idea how this new mandate will affect them or what it will cost them. And I doubt that they’re going to feel good about it when they find out."

Is it the government's place to require people to buy something? Some have argued that such a demand is unconsitutional. I realize states require automobile owners to purchase car insurance, but they don't require people to own a car.

Especially with health insurance, which is very expensive, what obligation does the government have to make sure people can afford it? Most mandate proponents would say that there must be adequate subsidies for low-income people, yet it's clear to me that the Senate Finance bill passed this week does not contain adequate help.

Is it possible, in the absence of an individual mandate, to achieve universal health coverage? Or is that the wrong objective? Perhaps it would be better to strive for universal access -- that is, making sure it's available and affordable for everyone, and perhaps encouraging its purchase but not requiring it?

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For the record, I have previously argued for a mandate. I don't think universal coverage is possible without one, and I don't think effective health reform is possible without universal coverage. But any mandate should come within the context of a robust market where ALL people have choices about which insurer they want covering them, same as with car insurance, homeowner's insurance, etc. Make the health insurers compete for individual consumer business. But that would require shaking up the employer-based coverage system, something no one is proposing.

Your thoughts, please ...


  1. If there is no mandate (or universal health care- single payer) then providers should be able to turn away patients at the door who cannot show an ability to pay without fear of liability, just as a car dealer can turn away someone looking to replace a car that was wrecked when they had no car insurance The other option would be to allow doctors and for profit institutions to write off that care as a charity contribution and have government reimbursement to non-profits.

  2. The government should not be allowed to mandate anything. If I am 22 and in good health, the chances of healthcare being on my radar is non existent so why should I be mandated to pay for it. The mandate would exist to put me in a pool to pay for those that do need healthcare but would rather spend their money on cable, beer, cigarettes and the lottery because they know they can go to the E.R. for free. Solution: If you don't want to buy healthcare, don't buy it, but when you can't pay for the services you thought you did not need a mandate for poor planning should kick in. That mandate should put you in an audit pool to see how you have spent your money in the past and how you are going to repay the debt you owe going forward. If I don't buy car insurance and get in a wreck the government does not and should not step in and pay for my lack of planning. Healthcare should be no different. Healthcare has problems but the problems are not being addressed; politics is being addressed. If 4 companies control my State, they control my price. If that control goes away and all companies can compete for my business the price comes down and services that I want are included. This is a free country, we are not universal and we have a whole generation of people that think that the government is the answer when it is the problem.

  3. Medicare requires everyone who is working to pay, and then everyone who was required to pay receives good health insurance after they reach 65. This is a popular and effective program--people over 65 are likely covered at a higher rate than any other cohort in the population. This is a structure that prevents people from spending their money on cigarettes and beer, then taking their whole family down with them when they get sick.

    I am not saying we must have single payer, where everyone is required to sign up for Medicare-for-all. However, if the government requires citizens to carry health insurance, the government better make sure that the insurance is affordable and comprehensive, otherwise there will be BIG TROUBLE. The best way to do that is to allow people who cannot find good, affordable insurance to voluntarily buy into Medicare with premiums based on income.

    If you don't think Medicare pays you enough, you are of course free not take take Medicare. However, in primary care, where there are often many providers and only a few insurance companies, so they can push down fees, Medicare pays pretty well.

  4. Healthcare "reform" is just another step towards facism/socialism. If the government can force you to buy health insurance they can force you to do a lot of other things. Medicare is nearly bankrupt. Medicaid pays so poorly that many providers no longer see Medicaid patients. What's the government's answer, create another program. Something I learned as a small child might apply here: There is no magical money tree. Providers will have to be paid less. Care will have to be rationed. Further controls will have to be placed on Americans' freedom. There's no simple solution to "fixing" healthcare and big government is the LAST place anyone should look for a solution. Unfortunately, it appears healthcare will soon be subject to even more regulation. It's the last thing we need.

  5. Government Health Care reform will be like a toilet seat that the last person po0ped on. You may not like it, but you'll use it if you have to.

  6. You people on comments are stupid. Universal healthcare is good. It is free and is for greater good. You must accept this as it is plan of Obama, plan of change. If you do not accept we will crush you like grape!

  7. The working class already pays into healthcare for the poor or disabled in the form of taxes, yet it's not accessible to the working class if it's needed.(Medicare/Medicaid)Why would I, a working class mother of two, want to pay more taxes for healthcare when my paycheck is being eaten by taxes and healthcare premiums for a private plan as it is? Nothing is free, especially when provided by the government. It comes out of my paycheck every week in the form of taxes, and I do not reap the benefits of it. If government were to make healthcare universal, then they control the market. They decide what services will be covered and what will be paid to physicians. In a way, they are determining what physicians will and will not be able to do. And whatever a physician does that is not covered, the patient has to pay for. I work in healthcare in a rural area. 60-70% of our practice is Medicaid based. Medicaid does not reimburse physicians very much (unless you are considered a rural health clinic) or for very many services. If something in the way claims are processed changes, it takes Medicaid several months to sort out the problems. Meanwhile they hold any payments to providers regarding those specific claims. Just think how this will be on both sides of the spectrum if all healthcare was nationalized and run by the government. The more government controls, the worse off we are. They should stick to their primary goal: protecting this country; Not controlling its citizens.