It's worth noting, too, that while the goal of the mandate is crucial to reform, the mandate isn't the only way to achieve that goal. For universal coverage to work, healthy people have to be brought into the insurance pool; if mostly the sick and old sign up, insurance will become more and more expensive, further driving away the healthy. The mandate, with an accompanying fine, is one approach to avoid such a spiral. Another, as Paul Starr of the American Prospect has pointed out, would allow individuals to opt out of the system but would force them to wait five years before opting in again and becoming eligible for subsidies. If they get sick in the meantime, they must either pay for treatment on their own or find an insurer willing to take them on, presumably at inflated rates.A few more details from Mr. Starr,
Which would work better? The truth is that we don't know.
In other words, instead of paying a fine, they would forgo a potential benefit. For five years they would become ineligible for federal subsidies for health insurance and, if they did buy coverage, no insurer would have to cover a pre-existing condition of theirs.We've already made the decision not to let the uninsured die in the streets, and that will continue. We're not going to start turning people away from emergency rooms, let alone turning away their dependent children who had no say in the matter, merely because we've legislated away their ability to insure themselves for what is now a pre-existing condition and they cannot otherwise afford care. Their unpaid bills would burden the budgets of hospitals with emergency departments nd public hospitals, and eat up the charity care budgets of nonprofit providers.
It's not even a close call.
I'm not going to pretend to like the mandate. It's a clumsy tool, and stands to be extremely unpopular if people are forced to buy substandard insurance. Easier and better alternatives could be fashioned, but they would constitute "new taxes" on the middle class - something that was deemed out of the question for this reform bill - and would be attacked from the right as part of a "government takeover". For example, a payroll tax could be implemented, either with the collected taxes directed to the employees' insurance providers or with employers exempted from the tax if they documented that their employees were enrolled in adequate health insurance. Increase that tax over time to the point that it is sufficient to cover the worker's share of a full insurance premium, and you could even provide to automatically enroll people who failed to sign up on their own in the cheapest plan available through their exchange.
With all of the right-wing flip-flopping attacks on the mandate, who knows? Maybe a court will rule against the mandate and we'll get a more sensible approach to the issue that the Republicans will like even less but that will be more easily enforced and sustained. But let's not pretend that perpetuating the problem of uninsured patients at emergency rooms is a good alternative approach.