I have been asked to do a presentation on the impact of health care reform on mental health practitioners to a group of local health care providers in May. So I've started analyzing this issue in more depth than I had in the recent past. My first befuddlement came rather quickly, namely my inability to understand the resistance to a legal mandate for individuals to own health insurance. Massachusetts, under the guidance of Mitt Romney, enacted the first state law that required ownership of a minimal level health insurance policy. This law subsidizes purchase of health insurance for citizens earning less than 300% above the federal poverty line. Currently for a family of four, this would be making less than $66,000 per year. The Massachusetts system offers a public option for low income families and a pool of private sector policies for those who don't qualify for the public option. They set up a state agency to enforce and administer this law. So there is at least once precedent for mandating people own a health insurance policy.
So one of the most consistent protests I hear about health care reform (which at present is really health insurance reform, we are doing nothing to change how health care is delivered), is the protest against being required to own a policy. Most states require, by law, that if you own a car you own at least a basic auto insurance policy. Home insurance, while rarely required by law, is required by almost all mortgage lien holders as a hedge against their investment. The point being that culturally we accept mandates, legal or otherwise, for for owning insurance that manages our risk when it comes to property. Also, though not required by law, almost all professionals, particularly those who have a legal license to practice their trade, own liability insurance. Again, we readily accept the sense that owning such policies, while not a mandate, is intelligent and tend to laugh heartily and the poor fools who might fore go such coverage. So, why all the hoopla over a mandate to own health insurance. The arguments I've encountered thus far seem to hinge on a) a constitutional argument that the federal government mandating such coverage is not within its federal powers, b) an argument based on the sense of unfairness that young healthy people's civil rights would be violated by making them own a policy that they do not "need", c) mandating such coverage is a boon to the insurance industry, which it certainly is; but may be the only way to get insurance companies to agree to other benefits to consumers, and d) the argument that the combination of mandating insurance coverage while not offering a public option is a recipe for disaster. Briefly the first and last criticisms hold the most water in my eyes. It seems there is little in the constitution that would grant the power to legally mandate health insurance ownership. This is a power that to me seems to clearly reside with the states. Also, the last criticism holds water as well, if I understand the nature of the bill that the senate is now putting forth, i.e. there is no public option for low income citizens. So we are potentially mandating purchase of health insurance without sufficient aid to those among the 33-45 million without insurance who do not have money to purchase it (not all of that number are simply without funds to procure insurance, many willingly fore go insurance through their jobs of state programs that they could otherwise afford).
It seems to me that the constitutional argument could be surmounted by, instead of having the federal government pass a law requiring insurance, to have the feds incentivize state government passage of such laws. This could be done as it was done with drinking age laws (for good or bad). Here the federal government (to my understanding) held federal highway dollars hostage unless state's adopted 21 as the drinking age. Louisiana famously resisted this and saw crappy infrastructure for many years because of this decision. So the feds can dangle carrots for states to pass a Massachusetts type law.
The other issue is one that is more difficult to resolve. How to ensure we aren't try to wring a dry rag, i.e. force people with no means to own any insurance policy to purchase one or face criminal penalties. This may be addressed in the current law proposed (can't find into to clarify one way or another) in that subsidies are offered so people can purchase policies even if they make too little money. Another solution is to do what Massachusetts seems to have done, i.e. expand the availability of public option insurance like Medicaid to any citizen that makes below a certain amount and offer subsidies for purchase of private sector options for those who make too much to qualify for the public option.
The above thinking about solutions ignores the likelihood that the opposition to a health insurance mandate has nothing to do with arguments over policy or funding or civil rights. It is a resistance that I think is rooted in people's attitudes about personal responsibility. People seem to hear individual mandate and immediately conceive of lazy, unhealthy citizens being "given" something by forcing young, sprightly and rugged individualist young citizens to pony up their hard earned cash. If that were the whole story this situation would certainly be an unfair and unjust mandate. To the extent that people are concerned because middle class older adults and families are going to be milked to fund insurance for the have-nots...well that may be true, but that has nothing to do with whether or not we should have an individual mandate. For those older adults in the middle class, like myself, we mostly already have insurance and the imposition of a mandate would not necessarily impose extra costs to us. Interesting, though, because we've decided to go with an insurance reform strategy, whether or not all of this adds costs to the middle class who already have insurance depends not on the government, but on the degree to which insurance companies attempt to squeeze more out of us. However, to the extent that is the underlying view, this ignores the fact that those young sprightly uninsured adults, most of whom are living on the margins, not headed towards the ranks of the college educated, and (if one looks at the typical data from research with this age group) likely to be abusing moderate levels of alcohol and recreational drugs and engaging in other risky behaviors; then one realizes that these young adults are going to be the fat, lazy unhealthy people in 10-15 years. They have just not reached a chronologically point where the scars of their youth are visible or have begun exacting a toll. Making them our noble victims of government mandates for health insurance doesn't make much sense if you consider the above. So forcing those young people into insurance might increase their contact with preventative care, and yes will bring money into either the insurance industry of public sector health care to help defray the cost of offering subsidized health insurance to older adults and their children who are living at or near the poverty level. In summary if we object to the individual mandate simply because if offends our sensibilities about youth and the sense of invulnerability that comes with it, we are biting off our nose to spite our face.
I'll post again after I've looked into the mental health practitioner end of this more, but I just had quite a few thoughts about the resistance to the mandate, a move which makes eminent sense to me.
Friday, March 19, 2010
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