Mandating insurance is giving people healthcare in the same way slavery is giving people a job.
Part 1:
With regard to health care insurance, there are two diametrically opposed views as to a pricing structure:
1. A pool of insured, all paying the same rate, perhaps sex and age rated, but not race, life style or other risk factors. The concept accepts that some will benefit well beyond their premium contributions and others will not, but the spread of the costs across a pool creates a premium that all can afford. In reality, those with a healthy life style and good heredity are subsidizing the health costs of the rest. It is, indeed, an enforced charity.
2. Spreading the costs of traumatic health events that an individual may encounter across all that individual’s years of premiums so that a single major event does not destroy the economic life of that individual. The plan is viewed, there, as a savings program, with premiums in excess of costs for one year being banked to cover the traumatic event, should it occur. Again, in reality, many will end up not encountering that traumatic health event, but their excess premiums over costs are not refunded. Then, they go . . . where? Into the pool described above.
So, in reality, whether one factors in detailed individual risks or not, all such insurance is a pool where the healthy subsidize the sick.
more . . .
Insurance companies try to cherry pick. We need strong enforcement to eliminate selective risk pools. Insurance works best when we're all in it together. Some of us will stay healthy, some of us will not. But averaging the risk over all of us makes sure no one is devastated by illness. And to those of us who are healthy, who knows what will happen tomorrow.Be happy that if it's not good, you'll be covered too.
3
I'm confounded with this continual allergic reaction to the individual mandate. Every human being eventually becomes ill and has a pre existing condition unless they are hit by a bus and die instantly.
Those patients without insurance are eventually supported by everyone else who has insurance and the number one reason for filing bankruptcy was medical bills.
Sorry folks but everyone needs medical insurance.
2
The insurance mandate is designed to force us to support the medical industry that costs more than twice that of other countries. They were not working for us .
If they wanted to make healthcare, rather than healthcare insurance cards, more available to Americans they could have done so far more effectively by mandating a transition to straight hourly billing by doctors, that all emergency care be billed at Medicare rates, and enforce antitrust law against the pharmacy benefit managers.
3
No one seems to argue that auto insurance liability coverage should be required because yes, if you hit someone else's car, you should be responsible for paying for those damages. However when it comes to health insurance people forget that when someone gets sick they are going to receive medical treatment and someone is going to have to pay for it. People who can't afford expensive health insurance costs are not going to be able to afford medical care either, but that won't stop them from getting treatment. When are people going to wake up to the fact that everyone needs to be covered by an affordable health insurance plan so that they are liable for the costs of their own (and their family's) treatment?
Removing the individual mandate removes an individual's liability to pay for their own healthcare. And then that burden will be shifted to private, state or federal taxpayers. This ridiculous idea to remove the individual mandate only appeals to those people who don't want to take responsibility for paying for their own disaster planning or to people who have affordable health insurance through their group or medicare plans and don't give a fig about the people who don't.
2
OMG. Does anybody REALLY believe that members of congress don't understand the way insurance works? Healthy people need to subsidize sick people, DUH. If the mechanism for funding sick people's healthcare is via premiums, then CLEARLY, letting healthy people opt out of paying for sick people is going to drive up the costs for sick people.
What we're seeing here is MAJOR DENIAL. Republicans oppose a mandate, because they want to scale back the extent to which wealthy Americans subsidize poorer ones. They don't believe healthcare is a universal right. Their fight against the mandate is a fight against subsidies, but they are trying to fool the base into thinking that they are going to do them a favor by not requiring them to buy healthcare.
WHY do so many continue to pretend there are other principles in play here?
The whole idea of the mandate saving money is due to the fact that they assume fewer people who qualify for SUBSIDIZED healthcare coverage under the ACA will sign up for it. The only gov't "overreach" our millionaire congress cares about is the part that reaches into their pocketbooks.
6
Wow - what a country. Where else could a politically motivated tax gift for the wealthiest of the "president's" cronies be passed off as a fairer system for all (a blatant lie) and then a many-times defeated and dishonest attempt to undermine the nation's health system be attached to such a duplicitous bill? Only in Trumpamerica, the Land of Broken Promises, where feelings outweigh facts and doctrine crushes democracy. I'd say to the right-wingers who voted for this horror show that you get what you deserve, but sadly, we who saw through the nefarious charades all along are getting hurt by the Trumpists, too. This bill is the inverse of both real tax reform and the tweaking that the ACA needs - in other words, it is awful twice over.
I'd say this maneuver was the ultimate disgrace of this congress and "president," but I said the same about something last week - and the week before - and the week before that, ad infinitum. Won't the few Republicans in both chambers of congress who still have an iota of self-respect and character stand up to this juggernaut and stop it in its tracks? No bill is better than a bad one, no matter how much Trump "needs a victory," especially one he doesn't deserve.
5
By definition: If you are a member of Congress, you have no self respect. Credit to Will Rogers.
When Obamacare dies because of GOP meddling and millions lose health insurance, I assume you the next iteration of healthcare reform will not be a return to Obamacare.
The GOP is ushering in single payer whether they realize it or not.
2
I only hope that Tibett is right. Single payer is long overdue.
Trying to mess with the mandate to save money is like squeezing a balloon - whenever you make the balloon smaller in one place you will necessarily make it larger somewhere else. Giving people a tax cut by using money from eliminating the mandate is fraud, because what ever taxes they cut in one persons pocket will show up in the increased cost of healthcare insurance in someone else's pocket.
1
Eliminating the mandate is fiscally irresponsible, the politest thing that can be said.
3
The party of fiscal responsibility is fine with the $1.7 trillion deficit this bill causes.
1
When you eliminate the mandate you allow insurance companies to deny coverage for pre-existing conditions. These two issues can't be discussed separately.
7
If Republicans really believe that the government should not compel individuals to buy health insurance or force companies to offer health insurance to their employees, they should enact that, regardless of the fact this will certainly increase insurance premiums, deductibles, and co-pays. Freedom sometimes has costs. The facts are that Republicans could make an argument against Obamacare based on opposition to government compulsion. However, they should admit that allowing some the “freedom” from health insurance, will mean that those with health insurance will pay higher premiums, deductibles, and co-pays.
In the USA we have attempted to deal with the combination of inelastic demand and unregulated medical care prices in various ways. One method of keeping medical care expense as a percent of GDP to "only" double that of other developed countries was to have a significant portion of the population uninsured and denied medical care in some circumstances. The existence of large numbers of uninsured (conscripts in the war against rising medical costs) did moderate the growth in health care costs.
In a "mixed system" with both free-market and controlled health care prices like the USA, prices inexorably are driven upwards to the market level as long as demand is inelastic. Prices such as payments from Medicare that are "controlled" have to be increased continuously with legislation such as the "doctor-fix" to stay competitive..."
http://seekingalpha.com/article/1647632
1
As many others have pointed out, we do not allow people to die on the street. In the US it costs something upwards of $10,000 per year to cover the cost of health care. Someone pays it no matter how we structure it. We can pay it in taxes, in insurance premiums or in out of pocket costs when we get health care.
The non-coverage penalty was structured the way it was partly as a poison pill to eventually kill ACA. The senate is looking to pull the trigger. The supreme court approved it on the grounds that it was actually a tax. If it had been structured as a tax to help pay for health care instead of a penalty we would have a tax credit for those who do purchase coverage.
We can talk rationally about health care policies only if we recognize that what we are talking about is how the costs are shared.
How do other industrialized nations spend so much less than we do? Everybody has a health care provider from before they are born. Everybody receives the routine health care that we reserve only for the relatively well-off. It will cost us all less if we don't treat it as a privilege of affluence.
7
Ah, yes... the go-it-alone "society," where those who angrily proclaim that nosirree Bob, they aren't going to pay for undeserving folks who, unlike them, didn't make good choices or inherit the right genes or make enough money--losers, in other words. Until they're the losers. Stroke, heart attack, cancer, something sudden and no insurance. They'll be right there in the ER with the other losers, and guess who will pay. Not them. That's their health plan: make others pay for their bad choice.
6
Why not get rid of mandatory auto insurance as well? Use the savings to provide every new born with a large magazine Uzi. Also, why have mandatory vaccinations?
4
While we are contemplating dropping the Obamacare insurance mandate by attaching it to another idiotic bill, lets do it right and eliminate more "Americans don't like it" coercive charges.
car insurance, gambling tax, property tax, school tax, gasoline tax and other come to mind. after all i dont have car accidents, gamble is a right, i paid for my property and gasoline is so expensive already. lastly is the argument: why should I pay for sick people? smoking pot keeps me well.
1
The mandate, whether for buying auto insurance, home insurance, life insurance, or health insurance underlies the possibility of making any insurance affordable. Which of the thousand insured houses will be destroyed by fire? Nobody knows ahead of time. Same is the case with personal health.
There are danger to health lurking all the time: road accidents, falls from a roof, snake bites, epidemics, cancer genes, strokes, heart attacks, a tree falling on your head, a bully bashing you up, a terrorist attack. How can you say you are immune to all of them? When one of these things does happen, and most likely it will, you burn up all your savings to pay your hospital bills, or you declare yourself indigent and expect the rest of us to pick up your bill. How selfish, dishonest and unfair!
Eat your broccoli.
7
Paul Krugman has many times explained that the Mandate is like one of the legs of a three legged stool - take it away and the stool collapses. For most Republicans, this is not a flaw, it's an excellent feature.
Sanger-Katz has given us an easily understood explanation of the here and now of this Republican proposal. I had not noticed that the figures they are using for how much this option would free up for tax cuts REQUIRE that 13 million Americans lose health insurance and that the rest of us (including those not covered by the ACA) see our premiums go up by double digits. To Republican leaders, apparently this is not a flaw but an excellent feature. Personally I think that with additional changes the nominee for the Secretary of the Department of HHS is predicted to make. the total number of Americans thrown off insurance will be over twice that. For Republican leaders, this would be a joy meriting much rejoicing.
7
You do the math for something that's so bothersome criticism doesn't have leverage. In a hostile environment including territories outside United States boundaries, uncertainty reign supreme. We should demand a recall if the system need fixing, or remain steadfast to a common denominator.
Oh, Please, does this mean only people who have had a car wreck need auto insurance? Alabama did that until recently and it was a disaster.
If we are all insured it is cheaper for all. And you never need it until you need it and then it is critical to have. Ask me I am a formerly healthy breast cancer survivor.
This is harsh and the headline awful. You can be more compassionate NYT.
5
Harshness seems to be the only thing to get people's attention - and attention must be paid. A version of this rancid piece of garbage masquerading as law could be on Trump's desk next week.
1
I'd suggest that without the mandate, and it's massive deep unpopularity, we'd not have had a Tea Party, not seen the rise of the radical and extreme right, and not such a disdain for what became of the Democratic party and its arrogant officials and politicians. And insurance companies and pharmaceutical companies are still doing just fine, thank you.
1
Well while you are at it Republicans, how about eliminating that mandate that drivers have insurance as well.
The GOP knows why this is part of ACA, without it millions might not get insurance, fewer paying means those who do pay, pay more. It means that millions without wait too long and wind up in the ER which those with insurance will pay for as well.
The GOP has no interest in people's health. These moves to take care away from "merely" average Americans is part of their master plan to end Democracy and replace it with oligarchy. The rich will always have access to care, rest of us are expendable...just here to serve the wealthy class.
Every move the GOP makes is designed to take from the masses and give to the rich.( their owners )
Grand
Oligarchy
Party
http://expendableamericans.com/
5
Sounds like a lot of folks here don’t understand auto insurance either.
2
"According to a recent Congressional Budget Office estimate, eliminating the mandate could lower the deficit by $338 billion over a decade."
All Americans would benefit from a huge decrease in the deficit.
SteveM: Read what's in the proposal for cryin' out loud. It will increase the deficit by $1.3 trillion over several years. Do your research, please!
Sure it will reduce the deficit, but to what end? This is pure Grover Norquist hokum (I'd use a stronger word but it wouldn't get posted): he doesn't want to kill government, just shrink it so much that it washes down the drain all by itself. So yes, SteveMunday, it's true the deficit will shrink, but that's not the immediate problem to be resolved.
1
In the words of Omar of the Wire: "You so busy trying to be devious you done messed up and got yourself caught up in a web?
Single payer. End this nonsense already.
6
"That will make the mandate less central to the success of future health care overhaul ideas. And less valuable as a means to pay for tax cuts."
But this is only an exercise in what-ifs. If the budget office was correct in its original assessment, then lots leave and the tax reformers get the savings. Interesting, but no conclusions can be made.
What will folks do who do not buy health insurance and then get sick? They will head for the nearest ER (resulting in costing tax payers more money then if they had been insured. When it comes to economics Republicans are not only short sighted, they are stupid, stupid, stupid.
5
Health has an inelastic price/demand curve. Price is based on what you are willing to pay. That means pretty much all you’ve got when most of us need care. Similar to water and electricity service the governing solution is to make insurance businesses into a utility where consumer representation has a say in the $margins% that utilities can make. This proposal would keep national government out of the health care business for those who like capitalist solutions and probably satisfy the Bernie Sanders followers who would just like to Nationalize insurance through Medicare for all.
And at the bottom end we shouldn’t make emergency room staff the deciders. If someone decides to pay nothing they should get nothing. I don’t want to pay for their care through crossover accounting.
1
The right worships wealth. Wealth is all that matters to them. Rich donors that empower their agenda so long as they keep steering money to American royalty. Wake up folks the right wing lemmings you gave the reigns to are once again serving their piper in usual fashion. Serving their piper at your expense. At the expense of your bank account and your health. If wealthcare makes you happy then in light of this bill you should feel all warm and fuzzy inside.
2
Be sure to thank your Republican representatives and Senators for the upcoming premium hikes and service drops...
4
Health insurance without a mandate is just like car insurance that you dont have t get until you get into an accident. It is not insurance; it is a handout.
6
Ahem..EMTALA? just cost shifting to hospitals, some, if not all of which cannot absorb such costs...particularly at the community hospital level.
The clowns have totally forgotten the purpose of Insurance and how it works but we know the real purpose is to stick it in the eye of Obama but in the process millions will be hurt by it. That must not happen. This is suppose to be a shared pain and process. This year alone should show necessity of this like what happened to Houston, Florida, and Portia Rico, and then the fires in CA. Projections show that more is to come. So if the mindset goes to every man for themselves when your area is hit with a catastrophic event your on your own. This is not community not the United States. Please people vote these clowns out of office.
3
Because the most efficient risk pool is the largest pool.
2
The gas tax is unpopular, too. What about income taxes? Who loves that? I say begone to unpopular things!
3
Compulsory health insurance is key to its success for every American. The idea that young people, or non child bearing men for example shouldn't have to have what everyone else does is total nonsense. For starters we have one of the highest infant mortality rates in the world - that could have been you Mr. male- but for luck.
Luck is the operative word for every American young or old. Who knows when they will be in need of good healthcare, when the mac truck strikes you, or cancer, heart disease, diabetes?
To deny this truth only means you may be the perfect gullible Las Vegas customer.
Good Luck!
5
Is it too simple to ask if Republicans really want people to have health care, especially those who cannot manage it's costs? Is it too presumptuous to say that they don't give a darn?
The collapse of the ACA, "Obamacare" is such a sweet side effect as we "cure" our ills about allegedly being taxed too much..
Seriously. Bottom line is that almost no one, even the very rich, can self-insure. A person with a $200K income and a million-dollar home in New York would still be flat broke after a cancer treatment that cost $5M and several months out of work. "Insurance" that you buy year by year, that goes away for the rest of your life once you are sick, is not the right tool for the job. It's easy to limit auto insurance: total out the car and you start again from scratch with a brand new one. The paralyzed or cancer-survivor body doesn't go back to scratch.
1
Everyone hates taxes. Everyone loves getting the things that taxes buy.
6
Expanding health coverage for everyone (and making it as inexpensive as possible for everyone) requires everyone to participate - the healthy to offset the unhealthy. No different than car insurance for folks who are safe drivers offsetting the drivers who get into lots of fender benders. Everyone needs healthcare. Let's just accept that we're all in this together, and pay our share.
5
Automobile liability insurance is compulsory. Free choice does not apply. That's because (a) error, mistake--due to sundry causes is always possible--dumb-phoning is just the latest and (b) automobiles are weapons of mass destruction.
Therefore driving one is a danger to others--a case of "res ipsa loquitor"--it speaks for itself. The burden of proof is on defending free choice--why let people put others in harm's way? (Compare gun-freedom!)
Insurance transfers your liability to a large fund--so others will be compensated if need be. Fire departments are insurance companies. So are police--criminals are like viruses.
Health [illness or physio-dysfunction] insurance is obviously in the same boat--regarding communicable diseases. Your infection puts others at risk--you prevent or diminish their harm by fixing yourself. Otherwise you become a WMD--as in epidemics and pandemics. Why should people be free to infect others?
More steps are necessary regarding injuries--these don't "go viral". You can't catch a broken leg. But injuries and all illnesses are necessarily disabilities to some extent--constraining or preventing a range of action--at work, at home, at play. Others must pick up the slack--it costs them--co-workers, employers, family and friends.
Health [illness] Insurance transfers liability regarding these public harms, hurts and costs to general funds.
But private "for profit" insurers would rather pay lawyers than claimants. Thus single payer plans.
3
The uninsured cost the rest of us a lot of money, whether we like it or not - and they cost us a heck of a lot more if their only access to care is through the emergency room door.
As usual, the GOP is all about appearances, ideology, and smoke and mirrors. Why the nonsensical proposals? Because their donors (or should we say owners) are particularly loath to pay for the needs of poor people, and they know that their base is not good at math.
5
Who are they kidding? The Republicans would gladly throw a hundred million people off health insurance if it meant more tax cuts for the rich.
4
A few comments compare mandated health insurance to mandated auto insurance. The two do not compare. First, most states mandate only that the auto insurance cover damage and injuries one might do to another, not to oneself. Second, auto insurance rates are determined on a driver by driver basis; if you have a poor record, you pay more. I don't see the mandated health insurance requiring, for example, that the third of Americans who are obese pay a higher premium in anticipation of their gluttony resulting in higher medical costs. Now that I would support; if you insist on an unhealthy life style, you pay for it -- not me, not this 79 yo whose favorite vacation is hiking the Appalachians.
5
Dear Texan Liberal,
1) auto insurance is not determined on a driver to driver record. I have had 13 years of a perfect driving record and my rates of gone up nearly yearly. Do you err on that point. We spread the liability when all have auto insurance and I pay my share despite having no accidents (so far).
2) Gluttony and obesity are hardly the only reason people become sick. Accidents, cancer, birth defects, aging plus a myriad of other conditions are among some of the reasons people people need medical attention and insurance. In your myopic vision of why people fall ill, -unhealthy life style- you don't support mandated health insurance. You suffer from hubris when you talk about your limber limbs: rest assured, you will become infirm like the others. Like the others you will need medical help. And insurance.
2
muffy:
In my 30's, I weighed 235. Took myself in hand, diet, exercise, then cardiovascular workouts 3 times a week at the Y, distance running. Self discipline had kicked in, not disease.
Now, with all that, a few months ago: I became infirm. Advanced thyroid cancer, required removal of 4 trachea rings as well, lots of continuing pain, long recovery ahead. And I have insurance, have had my entire adult life, would never be without it.
I will be 80 next April. I plan on hiking Shenandoah again next October. Missed last year, prior visit was at age 78.
Why republicans are opposed to the mandate is beyond me. It encourages responsibility and mitigates the dependency of others. Seems to be a core republican principle and what they used to believe limited government should do.
2
It isn't responsibility if you are required to do it. Responsibility can only be exercised where there is a choice to be made after which one accepts the consequences of their choice. It is why free people are more moral--practice.
Of all the big lies Republicans push these days the biggest lie is the claim that today's self-described conservatives and libertarians are closer to the Founders (and Adam Smith, for that matter) than moderates and progressives. Not by a long shot.
The Founders and Smith ascribed to the time proven classical concept of good and bad government. Good governments strive to act for the good of all. Bad governments serve the selfish interests of those in power.
General George Washington mandated smallpox vaccinations. Good thing, because otherwise we would have lost the Revolution, since it was fought in the middle of a deadly smallpox pandemic.
A few years later Congress mandated health insurance for merchant marines and set up federally run hospitals to treat them. Presidents Washington and Adams signed the bills establishing this early system of national health.
5
Broccoli smothered in melted butter is more palatable.
As a practical matter, Republican alternatives to the ACA also encourage people to enroll in insurance coverage, though some envision that the extent of that coverage could vary depending on what’s preferred by an individual or family.
1
Anyone who does not have insurance is a freeloader even if they don't ever use medical care.
It costs the rest of us because the insurance corps have to use the fact of X number uninsured to set our rates. The uninsured still get care when they need it it just costs us more to do so. When they tell you they will pay they lie because the expense of just one emergency is so high. They will go bankrupt instead and of course the rest of us have to pay because the medical provider isn't going to eat the costs even if they deduct them.
5
Health Insurance under ERISA (Employer provided health care) does not contain a mandate to insure. It relies on Open Enrollment periods during which employees can sign up for health insurance. Skip the open enrollment period and you have a tough time buying affordable insurance. Most employees choose to buy the insurance even though there is no mandate. Yet premiums are affordable and less that those under the private market of the ACA. So getting rid of the mandate in the ACA may not be such a bad thing. Like the ACA, ERISA health insurance does not discriminate for pre-existing conditions.
2
The incentive that works like a mandate is this: a healthy employee who opts to get coverage elsewhere faces higher premiums (sometimes), lesser coverage, and additional taxes. So most opt in. Married people often opt out -- but that's a wash; each company trades the opted-out employees for the opted-in spouses of its own employees.
I know it's a rhetorical question, but the absurdity of asking it at all speaks volumes about the jaw-dropping ignorance of the U.S. electorate. Is arithmetic no longer required in schools?
7
We once made a claim to State Farm when faulty wiring burned down most of our garage. We had probably been paying monthly installments for homeowners insurance for 20 years at that point. We considered ourselves lucky.
Do people go crazy when they are required to carry homeowners insurance in order to have a mortgage? Required to carry auto and liability insurance in order to own and drive a car? No.
After Katrina, I remember the criticisms that so many homeowners who lived on the coast had not carried flood insurance. Thinking that you are never going to become ill and never going to be in an accident is a much more foolish gamble than that.
5
I stayed in the Air Force long enough to retire. As a result, my wife, as a military dependent, and I are covered Medicare and TriCare. TriCare costs each of us S100/month, which comes out of our Social Security pensions. We pay no copays, no deductibles, and see any doctor we want, when we want. We are 100% pleased. With no healthcare insurance, my meds for just rheumatoid arthritis alone would exceed $30K a year. I pay zero.
How come other civilized countries seem to handle healthcare and firearms with intelligence? Why do we pretend to have a democracy? We are nothing but serfs, controlled by our wealthy, greedy aristocracy. We do this to ourselves, because of stupid concerns about abortion, birth control, gay marriage and other snake oil issues.
7
Getting rid or the mandate, offering low cost basic insurance is a scam and a cruel joke played on the American public. As one who is retired as a health professional in hospital settings I can assure you we are all vulnerable.
To the young and "healthy," not buying insurance, or buying a basic package will not save your life if you have a horrific accident, or come down with the many insidious cancers that strike the young.
This GOP gang of spoilers should be ashamed of themselves. In the long run our society will crumble under the guise of "saving," money on of all things health coverage. Our nation cannot achieve the heights of global competition in a global society without a health citizenry. This Administration's nearsighted view of how to "make American great again," is way off; denying health coverage, shoddy health plans, and eliminating the mandate will never do it.
2
Restoring America to actual greatness after this time of desecration will be the job of the next - hopefully more intelligent and thus more liberal - administration; that is, if we are allowed to have one by this incarnation of oligarchicans. I don't rule out the possibility of them creating a crisis of such magnitude that they would declare martial law and suspend democracy. At that point, who cares about healthcare? Just staying alive and maintaining one's soul will be a full-time battle.
The Insurance Mandate was a compromise forced on Obama by the filibustering GOP to replace Obama's "Public Option." It was the centerpiece of Romneycare & was first proposed in two papers released in 1989 by the ultra-conservative Heritage Foundation. It has been at the core of several previous GOP healthcare plans & was championed by Newt Gingrich, among other Republicans. It was a desperate attempt by GOP filibusterers to eliminate the only provision of Obamacare that would have given subscribers an alternative to the for-profit healthcare providers.
"First, we established incentives for those who were uninsured to buy insurance. Using tax penalties, as we did, or tax credits, as others have proposed, encourages 'free riders' to take responsibility for themselves rather than pass their medical costs on to others. This doesn’t cost the government a single dollar."
-- Mitt Romney, USA Today, op-ed July 31, 2009, appealing to Obama to drop the Public Option & adopt the Individual Mandate.
The optimal solution is to patch Obamacare to the best of our ability for the short term, while we do what the rest of the advanced world has done & craft a universal, tax-funded, single-payer, gov't managed, cradle-to-grave insurance program.
As long as the armies of lobbyists for the for-profits & Big Pharma own Congress, this is a dream. In 1900, if blacksmiths & buggywhip mfgrs had powerful lobbies, we'd still be riding horses & spending our Saturdays shoveling out the stable.
4
I have a simpler way of solving this debate. Why don't we just get a universal, affordable quality health plan that the rest of the civilized world has instead of debating a mandate between a cumbersome plan like ACA or the de facto criminal republican plan of don't get sick, be rich or don't have a bad life event.
4
The headline to this piece is provocative, and may draw more clicks from those who oppose the ACA and want to see it fail. But the punchline is spot on: dropping the individual mandate would gut the whole system and lead to its collapse.
America, eat your broccoli!
2
I'm tired of eating broccoli and not getting any dessert!
If you're not getting any dessert you must be healthy. Congratulations. Enjoy it while it lasts.
Business people understand free-riders. When uninsured, patients are treated at a hospital, those charity costs are passed along and paid by the rest of us through our own, higher insurance premiums. And since emergency rooms don’t treat the condition but just stabilise the patient, we see the same ones, again and again. Saying “No” to Medicaid dollars ignores the reality of medical economics and increases health insurance rates as much as 8% in NC where 319,000 adults could have been insured if Medicaid's dollars were returned to the State. Price tag for each of NC’s insured, tax paying families: $120
1
Just another reason the entire enterprise was doomed to failure. Until those who claim to know best come to grips with immutable realities, this silly ballet will continue. Something approaching universal health insurance for 300 million cannot be implemented without SERIOUS tax policy changes. That is to say very large tax increases, or loss of all deductions, or both MUST be implemented and at an income level well below "wealthy". Numbers can be fudged, as is the popular practice, but in the end, they don't lie. Politicians however DO lie. And the concoction of this monstrosity began with the lie, "you can keep your old doctor". From there on, it's been one lie after another. So who is being served here? The abject poor, among the sickest cohort in the nation, and a reliable lever-puller for the democrats. Therein lies the entire story. A plot of kindergarten intellectual level, but sophisticated enough for the growing mass of absolutely clueless Americans.
"...abject poor, among the sickest cohort in the nation, and a reliable lever-puller for the democrats..."
The abject poor vote at lower rates than others, so they are hardly a "reliable" lever-puller for anyone.
https://www.politico.com/magazine/story/2015/01/income-gap-at-the-polls-...
One of the main reasons that insurers operate in an "unsustainable market" is that Wall Street is in love with Big Pharma, and Big Pharma continues to exert a stranglehold on perhaps 75 % of health care costs by spending BILLIONS in direct advertising to consumers, a practice that the AMA has stated is the primary reason that physicians get only 8% of the health care expenditure pie, and one that only one other nation in the world, New Zealand, permits. (Read the AMA policy statement from 2015 here : https://www.ama-assn.org/content/ama-calls-ban-direct-consumer-advertisi... ) The insurance tax mandate burden is one that the healthy young have resisted and that has burdened the unhealthy unnecessarily, and in my view unconstitutionally. Finally, the whole Obamacare mess stinks and always has: it is directly responsible for the opiate and methamphetamines pandemic and for the continued demise of affordable health care that is healthy and holistic rather than pill-popping , technocratic, mechanistic, unjust, and invasive
2
Removing the individual mandate will create a "death spiral" for any insurer left in the individual Marketplace and almost guarantee the loss of health insurance for millions of Americans. So here is the new image - no health insurance for millions of Americans so Trump and his billionaires can get a massive tax cut. Have they no shame?
2
I'm having a disbelief problem with the article's extending the idea of saving state money by cutting out the mandate. The only well you can draw savings from is uninsured poor people. There is no economic alchemy here.
I have not read all of the comments but can tell you that the experiment has been done. Both New York and Massachusetts required health insurers to sell policies without prexisting condition limits and at the same price for the same policy for everyone in a fairly widely defined community. Massachusetts also had a mandate; when you filed your Massachusetts income tax return you either included a certificate from your insurance carrier or paid a fine for not being insured. In New York there was no penalty for not being insured. In New York we had exactly the death spiral described in the article with premiums increasing and fewer people buying health insurance each year.
When I retired in 1999 my monthly premium was about $375 a month. The year I switched over to Medicare, 2013, it had increased to almost $2,000 a month. The only significant change in coverage was that my original insurance carrier who did not have any restrictive provider network exited the NYS market and I replaced that coverage with a policy with a relatively wide but restrictive provider network. At one point the insurer carrier and the hospital nearest my suburban home had a standoff resulting in that hospital being out of network for several months. My best friend lives in western Massachusetts; her premiums increased over the years but not nearly as much as mine.
1
The fact that 7.5 years on, we still have to explain to people (voters!) why the individual mandate is necessary? I find it hard to believe that this many people don't understand how health insurance works. This points to a serious flaw in American society in which people only care about themselves. How sad.
5
come to think of it. the mandate on its face is cruel. one has to buy health insurance by paying premium. unless that person's annual income is somewhere under $60,000 or so where the federal tax payers will subsidize the premium; otherwise, the premium keeps going up. so for instance, health ins policy where one has no choice on my doctors (as promised), with lots of exclusions a person is forced to pay premium that keeps going up and up. where will it end? this is why the individual mandate on its face is untenable.
2
i do not think the public has been truthfully informed just what care a hospital must give people if brought to the emergency department if they do not have insurance. i assume the laws require free care if a person needs immediate care for a life threatening problem. other than that, they person can be refused care. if given care under non immediate life threatening threat, the hospital can not be reimbursed by the government or by charging patients who have health insurance.
am i correct or are my assumptions incorrect? will 13 million people without insurance force others, such as taxpayers or people with coverage, pay for the people who CHOOSE not to buy coverage?
4
Here's the big question: is the ACA working on the whole? Is it making access to healthcare affordable? I myself initially resented the mandate because it focuses on a drug-based form of health care that lacks a strong evidential basis for improving health (rather it manages disease). On the other hand, as a small business owner, it was quite expensive to buy health insurance for my family. What I have seen so far is that the government market place has provided very affordable options for basic coverage and also allows us to use an HSA, which creates enough savings to cover the part of the premium we have to pay for. We have been able to get the kind of care we want through local providers who are covered by our insurance. I am a converted skeptic.
On the whole, however, I am frustrated by the dogmatic opposition of a Republican President who seems to define his agenda primarily as undoing everything President Obama did regardless of the costs to our society. This includes health care. The work of this president is not thoughtful, not well-reasoned, constructive and accommodating to the needs of the real people he is elected to serve, but spiteful and selfish--and in contradiction to his campaign promises, bent on serving only the upper class he belongs to. This is not the kind of leadership this country needs.
I would like to see the bipartisan efforts to fix those parts of the ACA which need attention succeed.
9
The solution has always been direct and straightforward: expand Medicare to include every citizen and cover vision and dental. Rich people can continue to pay for the best care possible and the rest of us don't have to worry about huge medical bills.
4
The Mandate's true importance is that it gets to the crux of the money discussion regarding healthcare in America.
First, it requires most citizens to join the insurance pool with defined ("apples to apples") minimum benefits. This is fundamental to our reaching a true understanding of the cost healthcare in America.
Second, it mitigates the financial drain caused by the requirement (Emergency Medical Treatment and Active Labor Act of 1986) that hospitals treat patients in need of emergency care regardless of their ability to pay, citizenship, or legal status....and, accounts for those costs in unequivocal ways. This law is the fundament - the insurance policy, if you will - upon which the Mandate repeal is based. When things get bad for an individual, they can always go to the hospital and receive treatment...at great cost to us all.
We cannot make informed decisions about healthcare until we have all the numbers...which requires that everyone is in the pool at a minimum standard of care.
Anything less - where we are now - is simply guesswork
So. Remove the Mandate...we should also remove the legal requirements regarding hospital emergency treatment...and see how that shoe fits folks.
6
It's the dilemma of the Commons: People of good will sacrifice to pay for creation and upkeep of a great common public space - like a part, on the understand that all of society will help foot the bill. Instead a whole bunch of freeloaders help themselves to the park and mock the poor schmos (can you say liberals?) who pay for it. To make matters worse. and in this case, these legislators want to destroy the park and count on their supporters to not notice the park vanishing.
1
Well, well, well. There was a hue and cry, and the gnashing of many teeth when automobile insurance was finally mandated; the cost of the premiums spread over the registered owner population. Of course, no insurance, the vehicle owner was fined and the vehicle administratively rendered inoperable. Perhaps, a person opting out of mandated health could be deemed unfit to live. (Tongue-in-cheek)
4
It's okay to no tot want to have insurance but you should have to sign a waiver acknowledging your choice which explains that you also will not be eligible for any government assistance with your healthcare and hospitals have the right to turn you away in the emergency room if you can't prove you can pay, regardless of your condition. That is a real incentive.
10
I think anyone opting out of the mandate should have to post a bond just like states do with auto insurance.
It isn’t news that Americans, probably humans in general, are irrational. They want something for nothing, vote against their own self interest, put themselves in imminent danger, etc. Why else would people go nuts for guns for “self protection” when they kill more than 20,000 per year? Guns are a right but healthcare is a choice? In most of the world people don’t think about healthcare because, of course, they have it. It could be said that if Obamacare dies, then people will see the necessity of a single payer plan finally. I doubt it in our age the moneyed class deciding who gets what. We will continue down the road of rugged individualism where those who “choose” not to eat, to live in the streets, to not have healthcare will again be the norm.
4
i suspect the true long-term aim of the republican leaders in congress is to do away with requiring people to save for old age(social security) and requiring taxpayers to help pay for medicare and medicaid. let the rugged individuals survive and the non-savers and people who choose not to save or live a healthy life style die UNLESS THEY HAVE MONEY or are willing to stand in a soup line paid for by a charity(supported by persons who do not get a taxpayer supported tax deduction) or by family members. would this "make america great again"? this is how it was done back in the good old days.
How does repealing the mandate lead to lowering Medicaid enrollment?
1
I have EXCEPTIONAL and AFFORDABLE plans offering a Nationwide Aetna Network PPO that are benefit rich! The market is changing, I can lock in premiums through the end of 2018.
The individual mandate is not important, yet they’ve identified $300 billion in savings by repealing it. Their intellectual dishonesty knows no bounds.
7
The need for the mandate is obvious but observing this from afar and after reading the article I can’t figure out how cutting it would save so much money? Or indeed , any money. Apologies in advance for my ignorance.
1
The article did leave out any explanation of that. A missing information link is that many of the presently healthy people who would drop insurance coverage as too expensive are the very folks that are receiving partial but substantial subsidies of their premium costs. These subsidies extend well into the income levels of the lower middle class.
Also remember that the savings projected are for a 10 year period.
Being in London and not knowing the ins and outs of the kinky US health care "system" requires no apology. I doubt that most Americans would be able to explain where the savings would come from.
1
Forcing someone to do something is what the Progressives' philosophy says is good. That's why the Obamacare mandate exists. And that's why Congress - even one without a Progressive majority - won't get rid of it.
From the Heritage foundation, who first suggested the individual mandate in 1989:
http://www.heritage.org/social-security/report/assuring-affordable-healt...
Quote:
2) Mandate all households to obtain adequate insurance. Many states now require passengers in automobiles to wear seatbelts for their own protection. Many others require anybody driving a car to have liability insurance. But neither the federal government nor any state requires all households to protect themselves from the potentially catastrophic costs of a serious accident or illness. Under the Heritage plan, there would be such a requirement. This mandate is based on two important principles. First, that health care protection is a responsibility of individuals, not businesses. Thus to the extent that anybody should be required to provide coverage to a family, the household mandate assumes that it is t h e family that carries the first responsibility. Second, it assumes that there is an implicit contract between households and society, based on the notion that health insurance is not like other forms of insurance protection.
End quote
Yeah, auto insurance is also unpopular. If you are going to drive a car, the law requires you to have it. It is part of running a civil society. If you do not want to participate, move to Somalia, where the government asks nothing of you. (And does nothing for you.)
Simple enough.
7
And the Heritage Foundation is a conservative group - not a progressive one. So, the ACA should be supported by Republicans but isn't. This is just one example of the R's drive to get rid of the middle and upper middle Americans - but people continue to vote against their self-interests.
3
The reason it’s appropriate to require all who can afford it to buy broccoli, is that those who don’t , will certainly steal it when they are starving driving up the price for those of who come by it honestly.
If you want to take a chance playing Russian roulette, you should suffer the full consequence when your luck has run out.
3
OK. Get rid of the mandate. But, also remove any requirement for doctors to treat those who show up at emergency rooms uninsured and unable to pay otherwise. There need to be a way to make it clear to people who look at the pictures, as opposed to reading the words, what your choices truly are. Taxes are the price you pay for civilization.
6
do doctors and hospitals get paid to treat an emergency patient if he has no insurance by taxpayers and/or are the costs passed onto to patients who have insurance? i suspect the caregivers are paid for their services by someone. thus the druggies, people who choose not to use their seatbelts, bikers who refuse to wear helmets, people who refuse to get their shots, etc FORCE others to pay for their individual choices which are dangerous for themselves. why should i pay for dumb people's choices?
I stopped paying for insurance about seven years ago. I spend the money on quality preventative health care and for things I love to do, which makes life worth living - and seems to keep me healthy.
When I need access to institutional medicine I find doctors who are 'sympathetic to self payers' - a growing group. It's a bargain. One visit is a tiny fraction of my old absurd monthly insurance premium.
I feel we all share a moral obligation to starve the insurance racket and I find it unjust that Obama forces me to pay a fine to live with the risks I choose. Were it not so dysfunctional an industry I'd be happy to participate.
As for my obligation to be one of the older healthy people throwing money into the pool, enriching a rotten and corrupt system - that sounds like a scam masquerading as an moral obligation.
3
A visit is a tiny fraction of a premium? Not in my backyard.
I recently saw my provider for a routine visit and was given a sheet of paper to sign that made me agree that if my insurance did not cover the visit, I would pay $368 for the provider's portion. It was now mandatory of all patients at all visits - no signature, no service, and the visit would be marked as a no show.
Since the visit was routine and the provider was in the top preferred provider tier plan, I asked why there was a new requirement to sign the promissory note, and was told it was because of a sharp increase in claim denials.
I'll grant you that the insurance industry is dysfunctional, but I would have been looking at a promissory note of over $1000 if I needed some lab work, MRI, or other service. That's not a tiny fraction of my monthly single employee premium at all.
Are you immune from getting hit by a car or contracting cancer? You are foolish.
Paying taxes is unpopular so why not just get rid of it?
Taking out the garbage is unpopular so why not just get rid of it?
Getting a flu shot is unpopular so why not just get rid of it?
Doing many things is unpopular but we do them anyway because they are the right thing and they are in our best interest and that's why we don't just get rid of doing them.
Reality is not always popular.
5
I rather resent the undertone of this article. Who says the mandate is so horribly unpopular? Sure, nobody likes having to pay for stuff, but we do it. I've had health insurance through an employer for most of the last 30 years. During many of those years I've had perfect health.
The people who hate this terrible loss of freedom are part of the far-right cabal whose goal is destroy the first real reform in the health care system since Medicaid. What do these freedom-seekers want? I don't pay for health insurance until I get into, say, a car accident and have a half-million dollars with or bills. Then what? Sign up for insurance and pay $200 a month?
Brilliant.
I don't think having a decent, affordable health care system will rob us from our precious Yankee individualism.
Wake up, rank and file GOP members! This is about talking to you about freedom while giving tax breaks to the ultra-wealthy!
6
the insurance that i never have to collect on is the best purchase i have ever made. it means that i have not had a fire in my home, never had an auto accident, never got sick, never got sued for anything, never got disabled, etc. i would be a lucky guy if i never had to collect under my policies.
3
The news story here is that, after eight years of claiming they could do better, including an election campaign during which the winning candidate confidently declared that he would provide far better coverage at much lower costs in a "beautiful" solution, Republicans are offering to wreck Obamacare with nothing in its place.
And wreck it they are. With the sign up period closing in about thirty days, their Wealthcare for the Rich proposals, now with an added potential to end the mandate, are on track to make sure the least number of healthy individuals sign up.
It doesn't even have to be in the final bill. Creating uncertainty at this late hour will do the trick.
And then they will blame it all on the ACA.
The entire Republican leadership should be jailed for organized crimes against the American people.
5
Where do all of you live? Since the inception of the ACA, our health insurance has gone up tremendously. We now pay just over $11k/yr for a family of 5. That is in addition to an employer contribution of $5820/yr. Our deductibles are set at $5k for an individual and $11k for the family. And this year we actually purchased Accident Health insurance. Yes, that's right. An insurance policy for our insurance costing an additional $325/yr to help cover the deductible up to $4500 if something happens. Something always happens and it seems to work out that we just meet our deductible and nothing more. So we get to pay for our health care and an insurance bill.
And the unfortunate souls who do purchase through the Insurance exchanges are not welcome at most doctors offices. A nice little sign is set the front desk saying they don't accept them.
This is the reality of the ACA.
A request.... next time you read an article, please try to analyze the issue at hand. Don't just jump on a democratic or republican bandwagon. It would be nice to read contributions in the commentary rather than snide political comments.
Our nation needs smarter decisions and a realistic approach to our outlandish debt. We can do better.
5
I'm okay with doing away with the mandate as long as those that don't comply are not covered by taxpayer funds when they show up at the ER. If you fundamentally choose not to have insurance (and can afford it) then we taxpayers should not be funding this person's care when they are in a car accident and have two broken legs and a $50K bill from the hospital.
7
So . . . news flash to Republicans: if you end the mandate and continue to try to destroy Obamacare rather than work across party lines to fix its many flaws, it's going to collapse. And if that happens, you will have given the Democrats an opening to make a serious push for single-payer/Medicare for all. (And you will be pushing the Democrats' platform further to the left.) In other words, by working to destroy Obamacare, you are making it more likely that you will end up with something that, to your minds, is even worse. What's more, you'll get the blame for the collapse, and Democrats will get praise for providing a supposed solution. Is that the result you want? If so, congratulations: you are doing a fantastic job of working toward it.
4
We should get rid of it and replace it with something that works.
Medicare for everyone.
1
The Republican health care plan is to divide those who want insurance into groups the healthy with the healthy thevsick with the sick. Rather than community risk it will now be whatever the risk is for your group. The young and healthy will pay less, the older and sicker population will pay more. This was who choose to be uninsured will pay nothing. Of course the general taxpayer will end up subsidizing the sick and uninsured. All this so the wealthy can have a tax cut.
2
Health care is a grand bargain. Healthy people take of sick people (surely we can accept that sick people cannot take care of themselves?) the rest of the bargain is: all healthy beings get old and sick and die. So, the wheel of life, you are born into a world as we each enter healthy with the sick here as we arrive. The newly born healthy take of the current born sick and your life progresses from health to sick to death, you depend upon the healthy to ease you out of this vail of tears as you helped as you helped others—most of the time at maximum resentment.
We all have many inescapable life mandates rough health them how you will. What kind of journey you provide the sick and what kind of journey the healthy provide you is a braked in mandate.
What kind health kindness you provide is up to you, what kind of health care you get as shrivel and die, well that is up to the kindness of healthy strangers—may you be lucky.
Now we can talk about price. You will pay. You may pay: taxes, premiums, ACA mandates, deductibles. CoPays, and hours out of your life to care for a sick mate-child-sibling or refugee.
You can use your healthy life hours to kick as many sick people to the curb as you can, that is indeed a cheaper mandate.
Most of us would like to live a life where we do no harm and do not miss out on the chance to be kind. That is the opportunity the ACA offers. Now I have an appointment in an ICU in Samarra.
Live long and prosper —healthy people.
Proving once again that politics makes for strange bedfellows, our allies for common sense in this struggle turn out to be the insurance companies. The people who actually understand how insurance works.
3
How soon people forget! For many decades before the ACA exchanges began in 2014 we did not have the mandate and insurance companies had pre-existing condition clauses to exclude the sick. That is what we will return to if Congress overturns the mandate.
And remember, Republicans in the House and Senate didn't have a viable plan to repeal and replace the ACA. Why, because their focus was on de-regulation and cutting ACA taxes. Widespread public opposition made it impossible to pass their repeal bills. Now they are focused on the $338 billion they can free up for tax cuts for the wealthy and corporations by eliminating the mandate. And it is fraudulent for them to claim CBO estimates are overblown that 13 million will lose coverage if the mandate is eliminated, but they also are supporting their tax cuts by using CBOs estimate that tax collections from the mandate will drop $338 billion
3
I am a staunch Democrat who has been deeply affected by the current health care policy. Prior to Obamacare I had private insurance which I paid for out of pocket. I am 64, single, and live in San Francisco. My one bedroom apartment is a whopping $3500 a month. This is the median rent here and considered a great deal. I'm self employed and my earnings put me just above qualification for the health subsidy. Without it my premium would be about $900 a month for pretty lousy coverage (high deductible, 60/40). I am not able to afford this so an illness or accident would be a disaster for me. Having to pay a $1000 dollars a year as a penalty adds insult to injury.
2
Reduce the high costs of drugs, doctors and hospitals in the USA. Cover all US citizens with the same health care: why should a 65-year old billionaire get FREE Medicare while a 64-year old working stiff pays for their health insurance? Put in a few co-pays and deductibles to remind all of us that there is no free lunch: hard-working taxpayers foot the bill for ALL government programs. The US is the only Western nation without universal health care.
4
The 65-year-old billionaire had made contributions to Medicare each year worked since the program was instituted in 1965.
Let us revisit this list of mandatory costs. social security, medicare, school tax, etc. It is the same argument - individual discipline to save for something that they need anyway to forcing it on them because the society as a whole can't watch those who have ignored it to suffer. The ACA mandate is no different. Strengthening it with a payroll tax OR a single-payer healthcare system is far better than removing it and going backwards.
5
Where is the protest against car insurance? Most if not all states mandate it, but no one protests. We recognize the requirement for auto insurance as fulfilling a responsibility to society.
Health insurance should be seen the same way. Many people in my area pay as little as $6 a month out of pocket for ACA coverage. For this, they get 10 essential benefits and much more. And they are not dependent on charity or bankrupted if they get very sick.
Yes, some pay more, much more, but they are in families that earn much more.
Personally, I hope we eventually evolve enough to get to single payer insurance, but until then, this bill must be defeated--and not only because of this amendment. It's a bad deal for lower and middle income taxpayers, 1/3 of whom will pay more taxes when it is enacted.
9
The mandate is unpopular because of how it works. If we aren't working we have to pay a premium if we've made too much money. There are co-pays, deductibles, limited networks, confusing language, and no continuity of care. The health care industry won on the ACA while we, the patients, lost.
We are not consumers when it comes to health care. We are patients. As such we can be confused, unable to work and earn money, or even comatose. Yet the receiving of any medical care is made contingent upon having money and that leaves us with a very good possibility of going into debt.
Universal coverage is great idea. Other countries manage it without such punitive costs. Then again, other countries seem to value their citizens and their health more than America.
10
We have to pay insurance premiums for damage and liability for cars, and damage to homes and property. Why wouldn't we pay a premium to safeguard our health against bad luck or misfortune? The number of hospitals and doctors' offices surely indicate that health problems are just as likely to occur as damage to property.
11
The reason that Americans need to enroll and pay for insurance under the ACA is the same reason that any insurance program requires policyholders to be policyholders before they can file claims. It’s intrinsic in the very concept of insurance. The reason that Medicare works at all is that we all pay the Medicare tax to support it.
If we don’t want to compel people to part of the ACA if they want to be covered by it, then let’s change the law that requires hospitals to accept the uninsured. Let’s have the uninsured die at home or on the front steps of the ER so that we can demonstrate the concept of insurance to the voters who choose to elect Republicans. And when we have completed that horrific demonstration, let’s pass a national insurance program and join the civilized world. The ACA was meant to be a step towards making the USA an advanced nation, but clearly the GOP is not interested.
11
Sometimes the least desirable feature is the most important piece of the legislation. Take your daily diet as an example, who doesn't want to have burger and dessert without the annoying dietary fiber, right? But the whole meal needs to be balanced for a person to live a healthy life. Same with healthcare insurance.
The mandate is what make insurance affordable for everyone when everyone contributes to the pool. While the young may want to skip it when money can be used to buy fancy cars or go out every night, they are likely to be the ones getting hurt the most - other than the poor - because the older ones realize they need to pony up additional premium to cover the shortfall. Without healthcare, and when hospitals don't get enough reimbursement, the patient dumping phenomenon will rear its ugly head again.
But of course, Congress will never have that problem because people there are covered
10
This is not rocket science. If we believe everyone should have access to healthcare in this country, there are only two options:
1. A single payer system, which everyone pays for through a tax, just like they do for Medicare.
2. An Insurance mandate that requires everyone to buy insurance, which they pay for out of pocket.
Either system can offer subsidies to help low income people afford to "pay," via a tax break or subsidies. But either way, we have to pay for it. The words are just semantics.
9
A third option would be a system based on need (a/k/a family wealth and income). The government would pay the provider the difference between what someone can afford and the cost of service. Anyone who thinks family wealth should not be a factor in government support (or grossly thinks the wealthy are entitled to more support) has something wrong with their values.
3
Then why not a single-payer system that covers the basics and essentials, and then the wealthy can pay for extra coverage and services if they want. Why make it all income-dependent?
4
So now they will deny millions of Americans health insurance in order to pay for tax cuts for rich corporations and very wealthy families . Sad!
Here is a different way to get the $300 billion they need:
1) Keep the estate tax which only affects a few hundred very rich families like the Trumps. Repeal would cost $269 billion over ten years
2) Keep the AMT which likewise affects rich people like Trump. In 2005, for instance, he would have had to pay only $5.3 million if it weren't for the AMT which forced him to pay an additional $31 million.
But no. The tax cuts for billionaires are sacrosanct. Every one else must suffer.
Reverse Robin Hood for billionaires and rich corporations.
Take from the poor to give to the rich.
15
I do not know one single person who objects to the ACA mandate because we understand how insurance works. The mandate is very popular because we know that it reduces the costs for everyone. We also understand that although we may be young and healthy now, the purpose of insurance is to provide a safety net in case that suddenly changes. Even a minor accident can get expensive even for a young fit adult. If the mandate is unpopular then it is only because of ignorance, fake news, propaganda that has created this alternate world many people are now living in.
15
“The mandate is very popular because..“
Clearly it’s not. Young adults don’t have the means to pay outrageous premiums or deductibles, especially if your earnings are just above the threshold for getting a subsidy.
2
A national health plan is the best answer, or so I believe. All advanced nations have national health plans. There is no excuse for a nation as wealthy as the US for not providing health care for all of its citizens (and non-citizens as well).
5
The young don't like any payroll deductions. Should they have the option of not paying into Social Security and Medicare just because they don't like it? When they retire, what then?
2
I've always had a problem with this mandate. I can't really think of a parallel to it in law. The requirement to have car insurance while operating a car is a regulation. The Obamacare mandate is not a regulation. It has been argued that it's a tax, but again, I see no parallel. Taxes are generally triggered by something you've done, not something you haven't done. I'm not arguing that the mandate is illegal - The Supreme Court already ruled that it's not. But, I would say that it's un-American.
2
Isn't the practical distinction between a law and a regulation virtually nil? Don't regulations have the effect of law? I think you are putting too fine a point on it.
I think it's un-American when people don't pay their fair share, as is the case with un-insured Americans. Aren't they basically free-loaders living on the backs of every one else?
4
If you're so concerned with semantics than call it a regulation. But without it, there will be no viable insurance market.
1
I don't see how an uninsured American with no medical bills is a freeloader. On the contrary, I would say a person with a chronic health condition who signs up for Obamacare today to pay next year's medical bills is the freeloader. Your argument that because we have bankruptcy laws that discharge bills makes uninsured people "freeloaders" is just a twisted way of looking at it. Right now there are older Americans who smoked cigarettes their whole lives and now they want younger people to pay their medical bills and you're calling the person who doesn't want to do it the freeloader. Weird.
Since these days lack of expertise is no disqualification for expressing policy positions, I'll suggest a policy position I've spent no time thinking through: What if we eliminate the mandate, but then reduce the Medicare eligibility age to 50, to move most of the expensive patients out of the private marketplaces. What then happens to the price of private insurance for people under age 50?
4
That is actually how.Medicare was MEANT to work, lower the age by "x" years until ALL were covered by single payer. Somehow this got forgotten.
1
This might be the best idea I’ve heard, and Bill here spent zero time thinking it up. I love it. Perhaps too many parts of the ACA were overthought.
As I recall, the Individual Mandate was depicted as a tax, in order to pass muster before the Supreme Court. So repealing can be depicted as akin to a tax cut. Personally, I am in favor of Universal Health Care, in the form of Medicare for Everyone.
But to pay for it, there would need to be a tax increase.
I am also in favor of tax reform, in the guise of limiting hte number of deductions, because that tend to favor one group over another. But to be practical, I am in favor of the lesser goal of setting a cap on the total amount given to deductions. I am also in favor of lifting the limit on taxable income for both Medicare and Social Security. These are simple and equitable solutions. So why are Repulicans (and not Democrats) so opposed to them?
6
The Individual Mandate was depicted as a tax because there must be some way to make healthy people share the burdon and buy in, so you couldn't go without insurance & only buy it after you got sick. Only then would the insurance companies have a sufficient pool of resources to care for the sick. Romney realized this exact need when he wrote his editorial on 7/31/2009 calling on Obama to drop the Public Policy (which would have given people an alternative to the for-profit vultures) and embrace Romneycare's & the Heritage Foundation's Individual Mandate:
"First, we established incentives for those who were uninsured to buy insurance. Using tax penalties, as we did...encourages “free riders” to take responsibility for themselves rather than pass their medical costs on to others. This doesn’t cost the government a single dollar."
Compulsory health insurance under ACA is unpopular because the premiums for a particular group are expensive. The real culprit is that in order to get ACA approved, the cost of covering preexisting conditions was charged to other insured people rather than covered fully by the federal government. Covering pre-existing conditions is a TRANSITION cost rather than a regular operation cost. The provision of mandatory health insurance is necessary not only to keep premiums down in the long run, but also to make sure the country takes care of its citizens, when they are intent in making risky decisions that affect others (like their families and neighbors). It is the basis for a healthy and productive labor force. It should be kept, but premiums, in particular for young families, should be lowered with higher Federal subsidies. Health care is the highest priority area. Include in the mandate improved mental health and there is light at the end of the tunnel for drug addictions, overcrowded prisons and abandoned or abused children
5
So what’s next? Shall we toss vehicle insurance mandates, tax mandates, unemployment insurance mandates, homeowner’s insurance mandates, physicians’ malpractice insurance mandates? We live in a society, where people are interconnected, not independent free agents. As a citizen, I value all those mandates and accept their purpose, as much as they may squeeze my finances. If anything, I would like to see a mandate enacted for liability insurance for gun owners. Call it the Las Vegas Victims’ Reparations Act.
21
You are absolutely right and make a point that’
may never have occurred to many of us the most important being that we are to a great degree interdependent and not entirely free agents
This is not the old frontier days we have grown up and need to think about that
6
I have a perfect driving record and I hate having to carry car insurance...but that doesn't prevent me from having to pay that premium every month. It's the state mandate. Everyone has to carry it so that we corporately cover safe roads. It's not a perfect system, but it works. It seems we have lost any national identity of mutual support. "Every man for himself" is a sad back-tracking to a more loosely UNITED states.
21
So move to New Hampshire where you DONT need car insurance. Of course it is far MORE expensive o het if you WANT it, or if you have an accident then the State forces you to buy ot. It is also hugely expensive to register a car, and because they have no sales tax their property taxes and registrations are car out of line with other states. To insure a motorcycle here in NY I pay about $160 a year, in NH that would.cost about $800 year.
Without it the cost goes up for all subscribers. This is a fundamental requirement for any kind of insurance, automobile, health, catastrophic event, etc. It is a way to spread the cost of insuring everybody.
7
Here in Massachusetts where 98% of people have health insurance, Romneycare has always included a mandate. How else would you get 98% of people to do anything? You can't make healthcare universal by offering it, you have to mandate it. And when you do, you make healthcare actually universal and universal is the kind that works best.
24
100% of seniors get Medicare; it has no mandate.
They CHOOSE to get their Medicare because its fair -- a good value -- has FIRST DOLLAR COVERAGE -- no huge deductibles -- and everyone can see this.
Mandates are only required to force people to buy lousy, worthless products they don't want.
BTW: Romneycare was a horrible failure. Massachusetts had nearly 95% insured BEFORE Romneycare -- its a very wealthy state -- and Romneycare made costs rise to the point that Massachusetts was (prior to the ACA) THE most expensive health care market in the US, with cost increases of 35%+ every single year.
Without the mandate, we need single-payer (i.e., government-run) health insurance for all.
The alternative is allowing sick and injured people to die without treatment. We all know (as do our elected representatives) that uninsured people end up at the ER when they are sick or injured. Hospitals cannot ethically deny lifesaving treatment to those people, but they also cannot cover the cost of that treatment...so we all help to pay those bills, in the form of higher taxes and increased healthcare costs.
So the mandate allows uninsured people to obtain necessary care at the expense of others. I thought personal responsibility was a Republican value?
13
The trouble with the argument as presented in this article is that it overlooks two things:
1) Just because a mandate might be necessary to make the ACA work doesn't make it right. The mandate is, at best, borderline unconstitutional, and the fact that it was driven through the Supreme Court by labeling the mandate (not a tax) as a tax after the fact is not acceptable. There was a time when sexist/racist/etc laws were allowed due to their perceived "benefits", but that time is past. If it isn't constitutional, it is unacceptable, no matter the good.
2) All this talk occurs under a banner assumption by far too man that health insurance equates to health care, but they are not the same. For many people, the best they can afford under the ACA requires premiums that are still onerous and/or the care provided by insurance is below acceptable quality. Health insurance isn't ultimately what people need - protection for catastrophic-cost care is a part of that, but only a part - so a mandate being necessary to enable health insurance being where it is now shouldn't necessarily even be the goal.
The ACA did nothing to address what is by far and away the biggest problem with American health care today (costs), so we shouldn't be wasting our time championing an unpopular mandate that isn't truly legal.
2
It's called insurance. If only one person bought auto insurance that's equivalent to no having insurance as that person pays everything. It's called law of large numbers. That's insurance.
1
Clearly, the only way insurance of any kind ‘works’ is to have a broad sharing of risk. For truly affordable health insurance, everyone at every stage of life must be in the pool. Mandatory coverage is in everyone’s interest. Taking it a step beyond there is a social contract in my view. We are all in this together-the notion is the very underpinning of a civil society.
12
"Mandatory" sharing of risk is not insurance as the term is commonly understood but really is a tax.
"We are all in this together-the notion is the very underpinning of a civil society"? Such a statement could in like manner be applied to any usual expense including fancy cars, phones, clothes, vacations, housing. It is like normalizing socialism, a concept that in practice has led to the most disastrous results for mankind.
2
This complaint reflects a misunderstanding of insurance. If I could buy auto insurance only after I had an accident, no one would sell it to me. The market works because the expense of paying claims balances against the premiums paid by all the people who buy insurance including the many who, luckily, do not have any or many accidents. That population of premium payers is sufficient because the state mandates that all drivers have auto insurance. The same economic rules work in the health care market. Without a mandate, people who have preexisting conditions or who expect to need coverage are statistically more likely to buy insurance; those who are health are less likely to buy. This is known as the problem of "moral hazard." With a smaller population of premium payers, the premiums have to be increased resulting, inevitably, in a reduced insured population and a spiraling increase in costs. Single payer or Medicare for all would address this problem but a properly calibrated mandate addresses it as well.
22
John, please research the purpose and premise regarding insurance - any insurance - coverage. The current healthcare mandate is no different than other types of insurance. Why aren't you complaining that car insurance and homeowners insurance are also a form of the dreaded and evil "socialism"? While we're at it, we'd also better do away with our fire and police departments, our mail service, our park systems, etc.
3
As a self-employed subscriber to the ACA I was delighted to be able to get insurance that would allow me to get a knee replacement despite a pre-existing condition. I was able to purchase a great plan for about 500 a month with a 2500 max out of pocket. Subsequently each year the plans offered were downgraded and the price raised substantially - the last two years it more than doubled while befits went down. Point being that all the talk about slight increases is baloney.
Aetna, Anthem, Cigna, Humana and UnitedHealth Group reported over 4 billion in net earnings the first quarter of 2017-the most since the ACA went active in 2014. Insurance companies are in business for one thing only, to make as much money as possible, via whatever method available- selling insurance, managing investments, whatever. Doctors, hospitals, insurance companies and Big Pharma are all in cahoots, milking the system for as much as they can.
Living in fear of losing everything you have because you need medical attention is very real for many - not being able to afford health care makes people less healthy because they shy away from taking proper care of themselves. I guess the book is open on the validity of the necessity of the mandate for coverage - and I guess we'll see what these "public servants" with lifetime free health care decide to do for We The People.
16
Victor: did you get $2500 in savings, each and every year? from year one?
Or were you screwed and ripped off, after a phony "first year" with artificial "teaser" premiums?
Obama structured the whole thing to go into effect in 2014, AFTER he was re-elected -- then the worst parts only occur after he left office -- kicking the can way down the street.
Joe Wilson was right after all. OBAMA LIED.
Bet if you check cash prices for a knee replacement ( always ways better than even discounted insurance prices) especially in quality medical destination centers like Zurich or Singapore, you would find that you could have just bought one for what you have spent on premiums and deductibles.
The problem here is not the cost of care which we could easily afford, especially if we got over this obsession with creating permanent family and corporate dynasties.
The problem is health insurance itself, especially the nearly trillion dollars in profits, and unconscionably huge payouts to investors. Eliminate those two items and the system would virtually pay for itself, provide better care, leave no one without access to high quality care, and eliminate lawsuits, hours of slave labor paperwork for patients and medical providers, and result in better health over all.
The problem is the private health insurance industry, which should simply be done away with.
16
The problem is that the 1948 antitrust exemption has kept health insurance insulated from the free market, and the states (government know-it-alls) are the regulators.
3
You can go after "know it all government" all you want, but it is private health insurance that has created this mess.
Our only participation was the idiotic decision to consider health care a 'market', which it decidedly is not.
I shudder to think the position we would be in were it not for the government regulation you so apparently despise.
I am a temp worker struggling to afford to live. The cheapest health insurance is $370 a month with a 5k deductible. I am healthy and haven’t been to a doctor in years. I am drowning in student debt and can’t afford to live near work in NYC. I understand the need for an individual mandate but this means I have to pay a tax as well as take on the risk of not having health insurance. We are fighting over a corrupt system set up for private health insurance companies instead of focusing on a single payer system that puts people over money.
17
And that's why we need a single payer system!
The problem with Obamacare is that it is premised on providing healthcare to the people while protecting insurance companies. These are CONTRADICTORY pulls which makes the initiative perpetually vulnerable.
Single payer is the answer.
22
We already have seen (that is, we who work in insurance) that insurance costs skyrocket when insurers must accept all risks, but folks can choose not to enroll. NY and NJ were examples before the ACA.
There is no problem being solved here, just a shell game being played.
7
If health insurance is fairly priced -- on a sliding scale, according to income -- and has NO deductibles or copays, but is "first dollar coverage" -- so consumers need not fear getting sick or being broke -- than I promise you, EVERY SINGLE AMERICAN WILL ENROLL. No mandate will be needed.
Medicare requires no mandate!!! because it is fair and a good value.
You can't have a system based on for-profit insurance. The very idea of a company profiting on the pain and misery of SICK people -- terrified people -- who have NO CHOICE but to buy overpriced health care -- is despicable beyond belief.
If you work in this industry, you should be hanging your head in shame.
The Supreme Court approved Obamacare only because Justice Roberts considered it a tax, as it was mandatory. If it is no longer mandatory it is no longer a tax. However it's implementation by the IRS has been completely different than any other tax anyway with no consequences for not filling in the details on your tax return, essentially making it non-mandatory. Surely there will be a court challenge on this basis.
3
No, you are mistaken. The SCOTUS case that you are referring to was ONLY about the mandate, not about the ACA in general or in total. The reason it was such a big deal was that it was believed by most everyone that without the mandate, the law and the system it created would fail. Republicans wanted it to fail, Democrats didn't. That's why when SCOTUS upheld the mandate, it was seen as upholding the ACA in general. But getting rid of the mandate won't make the rest of the ACA at risk to be ruled unconstitutional or illegal, it will only ensure that the ACA and the health care exchanges will fail, which is STILL what Republicans ultimately want. And now they want it more because they think it will pay for their tax cuts for the wealthy .
'Healthcare' is an example of a weasel word. A healthy person does not need care. A sick person does. A sick person needs sick care.
We take out insurance policies against the possibility of misadventure. For example, if I'm a ship owner, then along with other ship owners in my port I pay up front into a kitty so that if a ship founders then the rest of us pay the owner for his or her loss.
In most western jurisdictions, driving a motor vehicle in 2017 requires the vehicle keeper to take out a third party liability insurance policy so that if the driver injures another person or livestock the policy will pay out on the incident.
It used to be the case that an individual household subscribed to a local fire service, usually as part of their contents and buildings fire insurance. You attached the emblem plate of your fire service provider to you house. When there was a fire, your provider could see from the plate that you had subscribed to the service. This was an inefficient system and municipal fire brigades replaced private providers.
Like the bygone providers of private fire services, the USA continues to insist upon maintaining an antiquated system of sickness insurance when sickness care is a public good that should be provided to all for free at the point of delivery, just like in the event of a fire.
In principle, sickness care could be funded locally like schools, police and fire brigades. It should no more be provided via insurance than these essential services.
32
Colenso: It is not just "sickness" care. Most people see their doctor for "well visits" to improve their health, in addition to "sick visits" to obtain treatment for illnesses. Those well visits help prevent illnesses that cost the public more money in the long run.
4
Healthy people need "health" care to stay healthy. (If you can figure out how to get a mammogram in the ER, please do let us know.)
Perhaps we should note that the US is the only developed country that does not insist that all citizens are covered, and all that have an income pat in. WE are the odd ones out and it has cost us dearly in poor overall health and higher costs.
Other developed countries spend 40-60% less than we do and achieve similar or better results with patients polling happier, and even though different countries have different approaches ensuring all are covered is one of the consistent traits
41
We made choices, about 50 years ago, that were not that illogical in their era -- but which have proven disastrous long term.
In the 60s, most employers provided insurance -- most people were covered -- and health care was vastly more affordable. A hospital visit was a few hundred dollars -- not $4000 a day.
We made a noble start with Medicare, but never expanded it to younger people. Our Medicare is just like Canadian single payer which started in the 60s --- only they covered everyone and we only covered the aged.
BUT...Canada was then a very small, all-white middle class nation with little diversity. Most of the population was concentrated on the US border (meaning they could piggy back on our more advanced hospitals).
NO nation with universal care has the US's size or diversity -- the huge underclass of poverty (30% of the population) with huge health needs but no ability to pay at all -- the massive immigration, let alone ILLEGAL immigration.
And no other nation has the entrenched medical establishment, where doctors and nurses and hospital administrators all expect earn high salaries and benefits -- 2-3 times what they earn in other nations.
To have universal or single payer care....we'd have to convince all those medical professionals to take a 50% pay cut. If you can do that -- we can have single payer TOMORROW.
1
States have tried to fix health insurance without a mandate, and that has failed.
There needs to be at least a requirement for people to have catastrophic health insurance, so if they get sick, they don't go to the ER for a non-emergency, or go bankrupt because of medical bills.
For a homeless person, a $1000 medical bill would be catastrophic. For a rich person, maybe a $50,000 medical bill would be catastrophic.
Since the mandate is so unpopular, maybe catastrophic insurance (with a deductible based on the person's income) should be paid for with a tax instead.
The tax would pay for government-provided insurance; or people could opt out and buy private insurance, subsidized by the tax.
The catastrophic insurance should also include preventative care such as vaccinations and screenings. That would encourage people to get the preventative care and save money in the long term.
9
If it provides coverage for preventative care, is it really catastrophic coverage? I absolutely think that everyone needs some form of health insurance. Illness happens when we least expect it and is costly. No one wants to pay for healthcare, but everyone wants the latest electronic device. Health insurance may not be a tangible asset, but without it one may be not be able to get the best and latest care. Many people don’t really think ahead and plan for the unexpected.
16
Really vaccinations should be free to all regardless of anything else. The feds or states should at least do that much in the direction of universal coverage since the return on vaccinations is huge and the cost is pretty trivial.
6
For a homeless person, a $1,000 bill is not catastrophic - it gets paid by everybody else, in the form of higher costs across the board, as the hospital tries to keep revenue in line with expenses. (I'd like to see an ER visit billed at a mere thousand dollars.)
The very rich, whose interests the GOP is entirely focused on, have no need for insurance: a $100,000 bill is peanuts, the cost of a single automobile. That's why their perspective on the ACA is, "I don't care, so long as I don't have to pay for it."
10
So we should keep the mandate that I need to subsidize your insurance premiums so that I can get cheaper insurance premiums? No thanks... you don't get efficient markets by mandating consumption. I'd like to see more Americans insured (thru employer sponsored plans for anyone over 30hrs/wk) but this mandate thing was junk from the start. No American wants to be ordered to prioritize X over Y in their household budget.
4
What about people who are self-employed or not working? The trouble with not having a mandate is that individual health insurance becomes too expensive - because healthy people don't buy it.
And it costs everyone when those healthy people do get sick. They go to the ER, or they go bankrupt from big medical bills.
Insurance could be paid for with a tax, rather than having a mandate. The tax would pay for a "public option" - government-provided health insurance; or people could opt out of that and buy private insurance, subsidized by the government.
27
You misunderstand: you (and the rest of society) need to subsidize "my" premium so that you (and the rest of society) don't have to pay for "my" catastrophic healthcare cost when it strikes and I'm not insured.
And think about it: there is a mandate to have car insurance (everywhere except NH), there is a mandate to have workers compensation insurance (everywhere)... There's also a mandate to pay taxes, by the way. There's a reason these mandates exist. Healthcare isn't just "a market" because you can't opt out of treating another human being who needs it - or at least any developed, wealthy nation can't opt out to take care of its sick. So everyone needs to be insured, period.
43
Actually, Nic, you misunderstand. I currently subsidize "your" Starbuck's coffee, either way. Your coffee is produced without adequate cost basis to provide for health insurance. I'd rather see the price of Starbuck's coffee go higher so you can decide if it has real economic value to you. There's the answer. When all service industries (for eg) demonstrate adequate cost basis and the market selects valuable participants employer sponsored health insurance can be increased to the levels currently subsidized by the mandate. Come back to the US, Nic. Pay your taxes.
2
The GOP and Trump seem committed to creating a health care train wreck and it looks like they are on the right track for one through successive Trumpian moves.
First, he killed off the cost sharing subsidies after a long period of suspense. But insurers by law still have to provide them under the Silver Plan, so they jacked up Silver Plan rates to cover the cost. Now subsidized clients can obtain Gold or Bronze coverage for free in many areas, at taxpayer expense. Brilliant!
Now the Individual Mandate might go away and Trump has extended the term of short term plans (which exclude pre-existing conditions) to one year renewable. Non-subsidized healthy customers will flock to these plans whose premiums are less than half a comparable ACA plan, with the ability to jump back to an ACA plan if they develop a disqualifying condition. That will cause ACA rates to soar as their population becomes more unhealthy.
But this seems to be the plan to kill Obamacare, leaving millions of tax paying middle class families without affordable insurance or a deduction for medical expenses, while lower income families get their insurance for free.
As I recall, that is exactly what Trump supporters hated most about the ACA.
17
We need Universal Healthcare. I read about a voucher plan espoused by Pres Nixon in the 1970's...It is good for Business and mobility of the work force to cover citizens for healthcare.
It is the right thing to do. A voucher would be subsidized for the poor but first dollar costs would belong to the patient 10% of outpatient and 5% of inpatient costs up to a certain amount. Doctors who accept patients in this plan will be rewarded with a tax benefit.
There would be a business tax based on revenues as well as a per capita assessment from the state to support this, We would get rid of Medicaid, a state expense.
This is a very complex issue but doable to provide healthcare to all citizens.
7
As a PhD health economist, my job is to advise governments across developed and developing countries on how to improve their health care systems. All of the former, and a growing number of the latter, have insurance manadates (The ACA’s mandate is actually much weaker than those imposed by other countries). They are critical for stabilizing health insurance markets and achieving universal health coverage. There is no true substitute, assuming the objective is to provide more people with health insurance and keep premiums in check. The CBO acknowledged this in their scoring of the House and Senate bills. Gutting only the mandate would be like taking painkillers to treat one's ruptured appendix; without addressing the underlying illness, one will likely die.
38
They have mandates, but they also offer people fair, low cost insurance with NO DEDUCTIBLES. And premiums that are priced on a sliding scale according to income.
So the comparison is totally false.
12
Apparently Matt K, your tuition was wasted. Mandating consumption is no way to create an efficient market. It's nothing more than a price support. True economic gain is only achieved by expansion of employer sponsored health insurance, and commensurate price increases for goods & services. The market selects which of those goods/services are then supportable and economically worthless enterprises are allowed to fail.
1
Concerned Citizen: I'm not sure who "they" refers to, but countries' health financing systems are extremely diverse. Despite this diversity, it is absolutely possible to draw lessons from different countries. In fact, evidence gained across populations, contexts, and time only strengthens our understanding of issues. For sake of argument let's only consider systems upon which the ACA marketplaces were designed - Switzerland and the Netherlands being two. A vast body of evidence shows that mandates are necessary but insufficient conditions for private health insurance markets to thrive (again, assuming the objective is to cover the population and keep premiums in check). Put another way, there may be problems aside from the mandate that must be addressed to fix the marketplaces. But the mandate is still essential.
Joey: I'm quite certain Kenneth Arrow - one of the world's great health economists - and most others in my profession would disagree.
Set your tax withholding to the point that you owe the IRS at the end of the year, there is no mechanism to collect the individual mandate at that point.
In Australia all international students require health insurance as terms of the student visa. How does the government ensure nearly complete compliance with this law from a relatively young and healthy population. Easy. The insurance plan is $350USD (per year!) for great quality care with no deductible and low out of pocket limits. That’s because their health provider costs are mandated by the government and their healthcare system isn’t a basket case.
How does the USA ensure noncompliance by the young and healthy. Provide a bronze plan that’s $380 per month with a $4000 deductible and $7000 out of pocket plan. You don’t have to be a math PhD to realize those are bad odds. Especially when they can’t deny you for preexisting conditions if you ever do get sick.
8
You've roughly described my own lousy, worthless Obamacare policy.
I would NEVER have bought this on my own. Though I badly want good health insurance....there is none to be had from Obamacare, which is ALL high deductible, lousy plans.
If I could decline my Obamacare...I would do it tomorrow. And I could then use the $315 each month I basically throw in the toilet and pay for at least SOME basic care -- a few doctor visits, a few prescriptions.
Right now, I do not DARE enter a doctor's office! If I did -- say, for a bad sinus infection -- they would want to do a blood panel. The last blood panel I had was $2500 before insurance (80%, so I still had to pay $500 out of pocket!). No way can I afford that AND my high premiums. Plus the Dr. visit itself, and any meds or tests. Likely to get a few antibiotics for that sinus infection, I would end up with $3000-$3500 bill. NO WAY JOSE.
So I suffer.
THANKS OBAMA!
Hope analyst will also include the increased cost for Medicare that occurs when more people reach the age of eligibility with more severe chronic conditions because of failure to have diagnosis or disease management early on.
26
Due to my lousy, worthless Obamacare policy that I was FORCED BY PAY due to the Individual Mandate....I cannot get ANY medical care whatsoever, so I am putting off 100% of it until I turn 65 in a few years.
Then I assure you, I will be all over that Medicare like white on rice, because I will need all kinds of expensive procedures.
THANKS OBAMA!
First of all, it was Richard Nixon that suggests a single payer health care program, but the idea was quickly put down by the AMA(American Medical Association) that at the time had the political power. The very fact that we have not had one single program, which would be a sliding fee schedule for everyone done similarly to Switzerland, has created the departure in the last 40 years of businesses, first to Mexico, then to Asia because the cost of companies paying all of the health care premiums was said to be half of the price of an auto(which also included their pension benefits) when it rolled off the assembly line. Having 8 separate health care systems in this country where two of them are in danger of running out of money within 10 year because Medicaid is free, and Part A hospital for Medicare is free, then there is Veterans which is also free, as is Native American, Federal Prisons, ACA is heavily subsidized, and then current military and federal government employees are mostly subsidized, and so most of those above aren't contributing to the cost of a very unhealthy population. We don't need tax cuts, as we are collecting 30% less this year from what we are taking in, and pay only interest on the $21 trillion in debt we owe, so do we really call any of what has gone on for the last 60 years, good citizenry or good government? Absolutely not, as we have a citizenry that has been asleep at the switch, and a Congress incompetent, at best!
27
I meant to say that we are taking in 30% less this year that what our government is spending. Thanks!
Kind of hard to believe the GOP didn't do this right out of the chute. The mandate was unpopular, and Chief Justice Roberts had to really pretzel to call the mandate penalty a "tax." Congress never would have passed it as a tax increase. Now Congress is doing what the Supreme Court probably should have done in the first place under the law. Scalia was right, that time. He'd approve of how it is being handled now. And he'd approve if it didn't get through the Congress, either. He'd say that is what legislatures are for.
2
"...the law’s requirement that Americans either obtain insurance or pay a fine was coercive and unfair."
I feel the same about mandatory car insurance,mandatory FICA withholding from my paycheck, "sin taxes" on my beer,and Federal gas taxes.
Hell,I'm opposed to everything I don't like!
Great article!
67
You don't have to drive. You don't have to drink. But you kind of need health care. Fining people because they can't afford to pay for a for profit product that offers no value is ridiculous. I just had to drop my ACA coverage after seeing premiums rise 20%/year. And the deductible was so high I couldn't see a doctor or have my labs run the whole time I was covered under ACA. Most people who support it are either really sick or really poor and getting nearly free coverage, or they have never had to deal with it. It's flawed, it's failing, and we need to move on toward the revised, expanded MedicareForAll we deserve.
6
Very good point.
A similar thing exists in Australia - but its an increased levy toward public health if you can't demonstrate you have private health insurance.
Its normal all round the world.
5
I have an objection to many things but not to compelling everyone to do what is best for everyone. The car insurance model should be applied to HealthCare, firearms, vaccinations, and voting. The USA needs to use our smartest ideas and citizens not nonsense dreamed up by dolts working for the 1%.
5
let's get this straight. Previously, the GOP has tried to repeal/replace Obamacare and hoped to be able to claim that no-one would loose insurance.
Now they want to repeal Obamacare BECAUSE they want people to loose insurance?
What kind of sick minds to GOPers have?
68
I bought individual insurance before Obamacare. I could do so because I live in a state that required insurers to sell me insurance. Because my state had no individual mandate, few people bought it. As a healthy male in my 50's, my insurance cost about 25,000 annually, and was going up significantly every year. Under the ACA, I got more protections against dishonest insurers, lower out-of-pocket costs, and pay less than a third as much in premiums.
The fact that you're still trying to explain the rationale of the individual mandate to people is a damning indictment of the news media.
61
I also live in NY State, and I'm in my 50's. I was uninsured before the ACA because I couldn't afford individual health insurance.
16
Go figure. I live in a state that didn't require insurers to sell everyone insurance.
After the ACA, my premiums are 3x what they were before for worse coverage. The ACA was a net negative for our family.
Your mileage will vary
3
Repealing the mandate for healthy people is a bit like allowing people to sign up for health care after they have developed a life-threatening illness, or allowing people to buy life insurance after they are dead.
40
Medicare does not have a mandate.
You don't need a mandate to get people to sign up for a fair deal -- good coverage -- reasonable rates and NO HIGH DEDUCTIBLES.
13
But Medicare services older people, who know that if they are not sick now, they will be soon. Its population is not healthy young people who think they are invincible. And many of these healthy young people, especially on modest incomes, will do the statistics if they can, and decide to do without insurance, until one day when they realize they need help paying their medical bills. Every medical insurance that works enrolls everyone, and charges them proportionally to their income.
15
The thing is if insurance is priced appropriately then "doing the statistics" should lead most people to buy it. That it doesn't is a sign that profits are too high somewhere.
9
When the GOP and their ulema at the Heritage Foundation realized President Obama would happily take the mandate they favored if it got ACA to pass, they both abandoned the idea.
They saw Obama dusted the spite attempt off his shoulder, and decided to tape their nose back on upside-down to re-spite him.
7
Insurer profits have skyrocketed since Obamacare. The idea that they need the mandate to keep prices down is a joke.
10
Do you have some evidence for that claim?
Many insurance companies have left the ACA marketplaces because they were losing money there.
Also, the profits of insurance companies are limited by the ACA. I actually got a refund check when my insurance company didn't spend 80% of the premiums on medical care or quality improvement.
7
Look at the insurer's stock prices - all exponentially higher than before Obamacare.
Claims of insufficient profits in select markets are used to condition the politicians and media to say that only massive profits are acceptable.
The 20 percent profit limit is very easy for them to manipulate. If you were one of the few who got a refund check, that means they were making so much excess profit in your market that even the shadiest accountants in the world couldn't make it look like it was close to 20 percent.
2
Agreed.
The ACA was a GIFT to the insurance companies altho its not clear to me that they realized it at first.
Imagine: a mandate. People have to buy health insurance just like they have to buy car insurance.
What hypocrisy this is. What blind and unyielding hatred and bitterness is this that even our courts twist themselves in knots to come up with legal reasoning to negate or minimize something that has been a given in our society for SO LONG: that to follow the constitutional imperative to promote and even provide (thats what the Social Security Act says) for the general welfare, people can be mandated to do a thing for that welfare that they might not ordinarily do absent some a priori legal requirement.
Ignoring the premium hike argument for now, let's call this what it really is.
Huge tax break for 1%ers and booming corporations by eliminating insurance for 13 million Americans.
That is all there is to it.
58
Simple solution: no insurance, no service. There could be a reality TV show following the dying as they are turned away from the emergency rooms. Bread and circuses.
I don't understand why all discussions of 'insurance' are always so void of any understanding of how insurance functions. Insurance does not function if the only buyers are the ones that are going to file claims. It can be priced so it can function like that, but the price would essentially be equal to the cost of the services provided which is the problem in the first place. That price is too high for almost everyone. This is why everyone needs to buy into the same pool of insurance so there will be payers that do not have claims. This is how car, fire, house, and all ordinary insurance functions.
There is one critical difference in the discussion of healthcare insurance. We do not turn people away from emergency rooms. Almost everyone agrees that is immoral. Therefore, everyone is going to have some kind of healthcare cost. It is the rare individual who makes it from cradle to grave without some kind of medical intervention at some point. Especially with today's technology which steps in near the end of everyone's life and spends gigantic amounts of money to extend that life by some amount of time.
OK then, everyone has too pay something, however we have a lot of poor people at the bottom end of the economy who have no resources available at all for even a small payment of any sort.
81
I appreciate your post - may I add what I think is a new development in this ongoing tragedy - Anthem Insurance recently began denying coverage if you go to an emergency room but it is not (by their definition) an emergency. Others will folow shortly if they have not already. Example given: a woman with a ruptured ovarian cyst was billed for the ER visit after Anthem denied it - Of course, she could not possibly have known that it was not an emergency by Anthem's definition - and of course a ruptured cyst is an emergency - nor did she have another choice anyway. A weekend and no urgent care close by. I practiced medicine for almost 40 years and have watched it slowly deteriorate into something that I never dreamed could happened and that is, frankly, immoral. As fourth year medical students we were picketing for Universal Health Care. We have waited far too long ...
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Kind of like how even though it's supposed to be against the law, insurance companies don't cover colonoscopies, or only partially cover them -- if something abnormal is found.
As though all patients receiving screening colonoscopies know they have an issue and want to cheat the insurance companies.
Since the rules allow the medical insurance companies to charge huge prices AND blatantly deny what is supposed to be required coverage -- the ACA is NOT working.
Thus, letting people opt out and choose other options like catastrophic coverage (assuming they have the means to pay the large deductible) should be allowed.
And if this makes rates more untenable than they already are -- good -- then perhaps the Beltway clowns can actually get around to passing a Medicare for All program with some clarity, decide how to pay for it, and let people worry about something more productive than the arbitrary mess that the currently mandatory ACA is.
It's not as new as you think. I've been denied ER coverage several times, including once when I had a horrible agonizing sinus infection while out of town on vacation. The urgent care facility doctor told me it was a BRAIN TUMOR (!!!!) despite the fact I recognized it was a sinus infection -- and would not give me any antibiotics for it -- but sent me ASAP to the nearest hospital ER -- where I had to wait in agony for 7 hours to be seen by an intern -- who told me "Lady, you have a sinus infection" and laughed at the idea it was a brain tumor.
They gave me IV antibiotics, a prescription and sent me home at 2AM, after a total of 11 hours trying to get medical care.
My health insurance at the time rejected the claim, as I obviously had no brain tumor and said "it was not an emergency" even though A DOCTOR HAD SENT ME THERE. I had to pay 100% of the cost -- about $1400 back then (it would be much more today) out of pocket.
Sanger-Katz explains what will happen but not why ? "Without the mandate, economic studies have suggested, fewer healthy people would buy health insurance. Their exit from the market would raise insurance prices."
But there are many examples of insurance in which the only buyers are high risk buyers - e.g. American General insures mainly high risk drivers, FEMA provides flood insurance only for those in flood zones, etc.
High risk insurance is certainly viable. Like all insurance, it simply requires the insured to pay the expected outflows from the policy. If you lose $6 when a coin lands on tails, you expect to pay $3. But if you lose $6 in the less likely case when a dice lands on 6, you only expect to pay $1 (or 1/6 of $6). There's no need to rely on one group to offset the other.
What makes Obamacare different is that it relies on Community Rating. That's a fancy way of saying that that low risk consumers are expected to pay MORE than their expected outflow to offset high risk consumers paying less. In the example above, both the coin and the dice would pay $2. But the problem is that the coin sees this as a great deal while the dice does not. So you tend to end up with more coins (high risk consumers) and insurer losses and price hikes. And that's exactly what we've seen. That's why liberals argue you need the mandate. But we should keep in mind that the mandate is simply coercion to force the healthy to do what is not in their interest.
6
“High risk insurance is certainly viable. Like all insurance, it simply requires the insured to pay the expected outflows from the policy. “
Simple as that ! The whole mandate -thing logic is just like a Business School exercise! Therefore, the “low-risk,” healthy individual who considers health insurance to be an undue burden propping up the sick, pesky masses not like their own , alpha male selves should refrain from ever using such health care related services when falling ill or requiring them to pay for the birth of his children should he decide to realize the American Dream and venture out on his own by, say, creating his own business. Let someone else pay for my needs, only when I need them! Does that accurately sum up the Conservative view of what’s in “their interest?”
Yes, because those "dice" will be coins in the future.
Also because uninsured people go bankrupt, hurting others, not just themselves.
And they burden ER's with non-emergency visits.
1
But in medical care, no one really knows what will be in their interest tomorrow or next year. Will they fall off the roof cleaning a gutter tomorrow? Get cancer next year? This is why insurance must already be in place for everyone, and not seen as paying someone else's expenses this year while I'm still healthy.
3
This analysis is really short-sighted. You cannot look at the financial implications without considering the fact that the uninsured still run up healthcare costs but often have no ability to pay these costs. The system still eats these costs. Repealing the mandate may reduce government subsidies, but likely increases the total cost of healthcare. Apparently the Republicans and the author don't understand how insurance works.
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However, it would let responsible people choose insurance which works best for them.
If we want socialized medicine, then we should adopt that, such as a "Medicare for All" program, pay for it with taxes (though we'd no doubt pay for it with more borrowing), and be done with it.
However, since we have this mess which greatly restricts choice, has terribly narrow provider networks, etc. -- better that competent, responsible people be able to, for example, purchase catastrophic coverage and take care of their health, instead of being reamed by the insurance industry every year (at a rapidly escalating rate, BTW), mandated by our government to take care of the inept and irresponsible with the giant MESS that is the ACA.
I spent more than 30 years in the Insurance industry. Regarding group health insurance, there is one dictum: you will always enroll everyone who is sick; the key is to enroll enough healthy ones to pay the claims. So it is with the Afordable Care Act: if ther are to be no restriction on enrollment, and no exclusion for pre-existing conditions, then the premium base must be as broad as possible. If not, the entire thing will be economically unsustainable.
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If you want to know how much just look at New York, the state with the most expensive health insurance in the country with average rates triple those of California. Why? They're one of the few states that mandate coverage of pre-existing conditions. This mandate, without a corresponding coverage mandate leads to incredibly high premiums, even for "emergency-only" coverage and drives up the uninsured rate substantially as the young and healthy opt to risk it. As New York has shown it's not sustainable to have a pre-existing condition mandate without a coverage mandate, a concept that should be obvious to anyone with a basic understanding of economics.
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"They're one of the few states that mandate coverage of pre-existing conditions. " In fact the ACA itself mandates coverage or pre-existing conditions. Moreover what you say about rates is also not true. Rates in NYC are about twice rates in Los Angeles -- because health care charges in NYC are much higher than in Los Angeles.
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NY State has "community rating", meaning the insurance companies have to charge everyone the same, regardless of age or their preexisting conditions.
So the individual market had a "death spiral" before the ACA, where individual insurance was incredibly expensive.
If they allowed insurance companies to charge more based on age, it would encourage young, healthy people to buy insurance. But a mandate would likely still be necessary.
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Congress not Obama put it in, and if you have to punish people to get them to have insurance it probably is not a good idea. There are other bad parts of this bill that make it not insurance, like how much you can charge. It needs to be eliminated and replaced with something that gives states opportunity (block grants), something that helps those with severe issues they can't afford, and focused on improving health and medical process.
2
No one is exempt from ever needed health care. People without insurance are not turned away from hospital emergency rooms, even if they can't pay out of pocket for needed, often life saving, care. Those of us with health insurance wind up paying the cost.
We require drivers to have liability insurance. Health insurance is no different in this respect. The risk is not zero. The mandate should be strengthened. And yes, the three legged stool of the ACA demands it.
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There are plenty differences between car insurance and health “insurance”. When you buy liability insurance for you car, you pay according to your risk profile (young males are high risk and pay more). And if you have a bad driving record (one too many speeding tickets), you pay a higher price. And you can live your life and never use it. And if you do not want to pay it, don’t drive. Even with the liability insurance mandate, I pay more for uninsured and underinsured drivers insurance than my own liability insurance because I guess a lot of drivers in my area either don’t have liability insurance or they do not have enough coverage. So the liability insurance mandate does not seem to work in my state.
2
Maybe emergency rooms should stop treating patients who cannot pay.
EMTALA essentially provides catastrophic health insurance (see no one turned away at Emergency Dept). People will still get sick, break something, etc. and present at hospitals regardless of insurance. Hospitals hold empty bag. Cost shifting.
Ask your average politician or consumer about EMTALA and they haven't a clue. A need for the mandate should be discussed while referencing EMTALA as it frames the discussion.