Universal Coverage: A Suggestion

As I understand it, the argument in the big lawsuit being brought against the President's health care plan is this: Under the Commerce Clause (in Art. I, Sec 8 of the U.S. Constitution), the federal government has the right to regulate commerce among the states.

This has been interpreted very broadly, to reach almost all economic activity that occurs within the U.S.

The lawsuit, however, argues that this rule provides only the power to regulate commercial activity that is taking place, or might take place; there is no power to compel that any particular activity be undertaken by anyone.

Example: You can be forced, if you, say, sell beef at wholesale, to abide by various federal restrictions on how beef cattle are slaughtered, packaged, graded for quality, and so forth. But if you grow vegetables, or just have some idle acreage, you cannot be compelled to begin raising and selling beef cattle.

To a layman, this argument makes some sense. Of course, the government has the power to tax; but by definition, taxes apply to economic activity, not inactivity. [this may need a separate examination]

It would be unfortunate, from my perspective, if this argument were to prevail. The individual mandate is key to the Affordable Care Act, for well-rehearsed reasons that go like this:

1. The system will depend on the availability of private insurance for everyone not covered by Medicare, Medicaid, or similar government programs; and the lack of a "public option" means that tens of millions will not be so covered, and so will have to seek private insurance.
2. Private insurers are required to offer coverage to all comers, on substantially comparable terms, so that everyone will have access to coverage.
3. To avoid "adverse selection" --a situation in which healthy people stay away because of the cost of insurance-- everyone not only can, but must, buy insurance. Subsidies exist to support those who may not be able to pay for the coverage.

This third point needs elaborating: If the cost of insurance is high, and I am healthy, why not just forego the insurance? After all, because of item #2, I can always buy in if I get sick, or start to age, and so forth. The result, of course, would be that (1) only the sick would sign up, (2) this would drive costs up, and so (3) even more people would begin to drop their insurance.

They key point in all this is that you can sign up whenever you want to. And this is a mistake. First of all, it's not true now even for Medicare participation: if you don't sign up within a specified time after you become eligible, you will be charged more to join; and if you miss the window for signing up, it will remain closed for a time.

This could easily be applied to private insurance under the Affordable Care Act:

• Everyone is allowed, but not required, to sign up for health insurance;
• If you fail to sign up, any insurer with whom you subsequently sign up can charge you a premium based on how long you went without coverage.

But there's more: If you don't sign up, you won't have another opportunity to sign up for five years. And, when you do apply, your application cannot be approved prior to the date that is 12 months after your application is received. So, if you don't sign up when the program is first available, you are guaranteed to be uninsured for a long time.

There are details to be ironed out, including notification, what to do with people who don't sign up but then join a company that provides coverage, and so forth. These are, I think, administrative matters that can be resolved fairly easily.

What's the catch? It's a big one: What do we, as a society, do with the person who fails to sign up, and then has a catastrophic accident, or a stroke, or gets cancer?

I'm sorry; but I suggest that we have to be harsh here: these people are on their own.

No, we won't leave them to die in the alley outside the ER entrance. But they will receive maintenance care ("palliative care") only, unless they pay, in advance, for any extensive treatment, curative or otherwise. And they (or their estates) will be billed for that care.

So, you don't have to have health insurance. But you do have to face the consequences, just as those who now rail against this requirement would presumably prefer.