Honest Questions about Obamacare
One of the most contentious bits regarding Obamacare is the mandate.
The contention is that without the mandate, enough young people won’t join the system for it to work, and/or free riding.
Let’s just say for a second that the first problem is not insurmountable. Assume for a second, work with me here. Let’s say the numbers bear out the supposition that sufficient people of the young and/or stupid variety can opt out without it damaging the sustainability of the system.
So the remaining contention is free riding. Once you get sick, or you need emergency care, the universal coverage part means you can walk in, and *that* is unsustainable.
So, here’s the question: why can’t those two things be coupled? Would that let us all get along?
I can think of at least two alternatives. I can think of some cases to illustrate…
One: Tommy Boy would rather buy iPads than insurance. He opts out. Tommy Boy lives to 30 in good health and realizes that he wants to get married and his wife-to-be flatly informs him that he’s getting insurance. The actuaries know how much the average person *in the pool* will cost vs. generate between 30 and death, and they can probably fix Tommy’s rate close to fair. We can have Tommy just opt-in at this point, right? Since he joined late, he’ll be paying more for insurance every year until he dies than someone who as been covered since birth, but hey, that’s okay, yes? Provided he doesn’t need a subsidy or more details, just ironing out the “do we have principled objections to this case” question.
Two: Tommy Boy would rather buy iPads than insurance. He opts out. Tommy Boy drops his motorbike on the 60 freeway and gets a metal rod through his noggin. Emergency care, physical therapy, he recovers in a year. He’s racked up $500,000 in medical bills. The hospital is forbidden to cost-shift this to other patients, they submit a bill to the Feds, the Feds pay the hospital so no other citizens are left directly holding the bag, and then the Feds (through the IRS, probably) garnish Tommy’s wages over X years, charging him interest at the Fed Window rate until he pays it off. Again, there are some heavy details to iron out, but is this a deal breaker for anybody?
If we perform an assessment on Tommy and the feds determine early on in treatment that he’d never be able to pay it off, can they refuse additional non-life sustaining treatments and Tommy has to go looking for NGO charity to get the rest of the work done? If this situation occurs, is this a deal breaker for anybody?
Three: Tommy Boy gets cancer. He’s opted out. No pre-existing condition waiver for Tommy, he can’t get insurance coverage on the normal exchanges. He can get private insurance, subsidized through his employer if he has one that provides insurance. Functionally, this is no different really than what we have now, except we offered Tommy a Golden Ticket and he ignored it, so now it’s tough on him to work it out.
If we had some system of exceptions with coverage for free riding or late opt-in, something like one or all of the above in combination, would that answer the objection to the mandate?
Wrinkle: would those people who object to the mandate, provided that they were happy with something like the above… would you accept a mandate on top of such a system if Tommy has dependents? He can opt-out for hisself, but he’s got to get coverage for minor children, plus some sort of life insurance in the event that metal rod doesn’t come out of his skull okay, just to keep his dependents off the dole. Is that okay?