Do Not Treat? Not Gonna Work....

Floyd Norris suggests a "do not treat" list as opposed to a health insurance mandate:

At least some members of the Supreme Court seem to be persuaded by the idea that the government does not have the power to force us to buy health insurance. The whole idea seems specious and anti-free-market to me: if the government could legally enact Medicare for all, and tax all of us to pay for it, why is mandatory insurance not legal? It accomplishes the same thing, while minimizing government control of the health system....

[As an alternative, a]nyone who chose not to have health insurance, and not to indicate how they would otherwise pay, would be put on a “Do Not Treat” list. Hospitals could simply refuse to offer any treatment, respecting the person’s wish to make his or her own decisions free of an intrusive government trying to keep them alive.

The problems with that? To start with,

1. Accident victims will still get emergency care. Why? Because when the ambulance brings them in, the priority will be on stabilizing their condition and getting them treatment, not figuring out what insurance they carry, who has guaranteed their bills, or if they (or their guarantor) can pass a credit check.

2. Assuming we could screen out "do not treat" patients, people simply won't be comfortable with the idea of going back to the pre-EMTALA days when ambulances might have to go to several ER's trying to get a patient admitted before the patient perhaps dies in transit. I'm pretty sure that ambulance drivers and EMT's don't want to go back to that era, either.

3. People will still game the system. Will we also disqualify somebody from treatment for a year, a number of years or indefinitely if they contract an acute or chronic illness and can't afford to pay out-of-pocket? If so, there will be a cost to society - lost productivity, disability payments and the like, plus a potential for much higher costs when they finally qualify for Medicaid or buy insurance. If not, it's pretty safe to be a free rider.

4. It is likely to be a younger, healthier population that opts out and, although in a sense it's not fair to ask younger, healthier people to in effect subsidize the system, when lower-cost patients aren't part of the pool the cost for everybody else goes up. That could reinforce the opting out effect, which in turn would continue to cause premiums to rise... where the cycle might stop, nobody knows.

5. There are serious potential public health consequences to having people contract communicable diseases, yet not get treatment for those diseases.

6. Informed non-participation may be great for some adults, but what about their children?

Other than being more up-front about the possible consequences of not being insured, mitigated only by the extent to which insurance subsidies reduce the number of uninsured who might otherwise opt out due to cost, the net effect of any effective implementation of this proposal would be to take us back to a pre-EMTALA era. That's what universality seeks to avoid.