MANDATE? What Mandate?

By Steve Schulte of
Health Advocate Solutions

Please respond to (213) 999-1227

The current flap over the healthcare "mandate" (20 states and counting....) can be viewed in at least two ways.

First, some OPPOSE healthcare reform....period. They feel that we should be responsible for our OWN healthcare protection. Second, the mandate is ONE PIECE, but not the whole, of healthcare reform. Let's review both points of view.

In the first place, those who OPPOSE healthcare reform do NOT believe that each of us is entitled, by dint of citizenship, to basic healthcare coverage. Basic? Preventive, outpatient, meds, hospitalization for acute episodes of illness. No right, no quarantee.

OK. In the second place, some of us agree that the above OUGHT to be covered, but only for those of us who SEEK such care. Thus, a general MANDATE is not permissible. ONLY if we seek such coverage should we be eligible for care. (The young, etc., would not be covered and would be fully liable for their own care.....they have 'opted out'.....)

No deep analysis is required to see the difference. A mandate, which means that EVERYONE should be covered, is impermissible under this two-sided scenario. Impermissible because a) no permission was given by the citizen and b) ensuring the viability of the system overall is not a consideration.

One must understand that, from the point of view of health economists and health insurers, it matters little that the individual receives proper care. What matters is merely that the system can sustain itself. In such a care delivery system the "health of the system" is key. Therefore he mandate is an economic tool. Conclusion? Away with the mandate which ensures that everyone has to have coverage.

So, conservatives (simplistically...), who care little for universal coverage, decry the mandate. And, progressives, who care little for insurance companies, decry the mandate. Get it?

It is a small leap to see how the courts----and a Republican Congress---could take this route. Michael Moore and Ralph Nader will be cheering them on.

But, there is still hope for those who want universal coverage. Suppose the mandate fails the court test from conservatives that the Congress has the right to compel anyone to have insurance just so the system can work. What then? Well, what if we compel insurers to cover EVERYONE and make THEM figure out how to make this work financially? No need then for a mandate.....in this essentially PROGRESSIVE point of view.

From the CONSERVATIVE point of view Congress has no right to legislate the need for a commodity (health coverage).

From either point of view, healthcare reform COULD work without a mandate. On the one hand, we care little for universal coverage. If consumers could buy across state line---without defining "basic coverage"----they would find coverage they could afford.

From a VERY DIFFERENT point of view, we want universal coverage, but we put pressure on the insurers to get there rather than on the prospective insured. Rather than guarantee a windfall for corporate profits we make sure that all who wish to get "basic coverage".

Candidly, watching the current scrambling among insurers to raise rates, deny coverage and utilize other sordid tactics to wriggle out of the reach of healthcare reform it's very hard for me to be sympathetic to their entreaties. Bottom line: want universal healthcare coverage? Then find a way to enforce the rules and make it happen. Enticements be damned.

It is clearly a judicial issue whether the Congress can impel any of us to purchase a commercial product in order to make the public good of healthcare for all work. If the courts cannot find it in themselves to force this issue we must find another way to broaden access to care. (Remember: our courts say that corporations are "persons"....).

I say: healthcare is a right. Force the insurers to make it happen. Particularly if they oppose a single payer system where they would lose all independence. And, don't wait till 2014 to do so......

One more point. I am for universal coverage. I am not for a "free ride".

Those of us who support coverage for all must also support participation in making the sytem function financially. High deductibles, for example, are part of the future of any viable system that covers everyone. So is a reasonable "rating up" to cover the sickest (perhaps a ratio of 3:1 or 4:1). In this regard subsidies for the lower-income citizens makes sense as well.

So, in a way, the current fireworks over the mandate is just that: fireworks. Don't lose sight of the key issue here---how can everyone who is a citizen be guaranteed basic care? In fact, there are other ways to do just that.

Your thoughts?

Sources: NY Times, Wall Street Journal, Bloomberg Business Week, Kaiser Family Foundation


To respond to this blog, email steve6schul@yahoo.com