A modest proposal in response to eliminating the individual mandate


In 1729, a prescient Jonathan Swift wrote an essay that has a place in the health care debates of 2017. “A modest proposal for preventing the children of poor people from being a burthen to their parents or country, and for making them beneficial to the publick” reads almost like the title of a modern academic manuscript. Then, as now, it was important to look past the title before re-tweeting, though. Swift’s famous (and satirical) “modest proposal” was that those poor children should be sold as food to the upper classes.

Recently, we learned that the Senate’s tax plan proposes not just to increase taxes on many middle-class taxpayers, to decrease funding of entitlement programs, and to drive up the deficit, but to eliminate the individual mandate for health insurance.  That means that Americans will not be required to pay into health insurance risk pools. The people who don’t want to pay for health insurance are generally the young and healthy. They think they are least likely to need it, and, from an actuarial perspective, they’re right. Which means that without their contribution to the risk pool, those who do want and need health insurance will pay more for it.

The Senate proposal rests on a particular form of moral hazard that should be familiar to all health care providers: Patients who don’t have health insurance will still be able to go to the ER when they’re sick or injured. There they are assured of receiving legally-mandated care to stabilize and treat their condition. They may go on to lose their house to medical bills, and the hospital may go bankrupt under the weight of an unfunded mandate to provide care but they can reliably get emergency care — and Congress can pretend that’s an adequate protection for its citizens in this, the wealthiest nation in history.

My modest proposal is this: In the face of this plan to make health insurance more expensive for those who want it, while increasing the burden on society of those who don’t, opponents of this plan should eliminate this moral hazard. They should demand that doctors and hospitals refuse care for patients who can’t pay.  Hospitals should be permitted – no, required — to perform credit checks on uninsured patients in ER waiting rooms and on highway roadsides. Without proof that an uninsured trauma patient can cover a million-dollar bill, we should be required to wheel them to the curb and wish them luck.

We should create tiered levels of care, and provide lower quality care to patients who can’t pay for best practices.  No insurance? No MRI. Palpation will have to do. Forget chemotherapy: Have an aspirin. The American medical system provides by default some measure of universal coverage. Unfortunately, the congressional majority seems dead set against it.  We should invite the nation to experience the logical consequence of that libertarian ideal, free of the backstop of the moral imperative to care for our fellow humans, and see how they like it.

How many healthy 20-somethings with unexpected cancer diagnoses or traumatic injuries would die before we’d have universal health coverage? I like to think not many.  Because while the American people profess a belief in market-based medicine, we are at heart a charitable, humane people. We know, on some level not shared with Senate majority, that basic health care is a right.  We know that when a 25-year-old woman who didn’t think she would ever need health insurance is shot at a concert, she should get the same high-quality care as the 45-year-old mother of three who skimps and saves to pay her monthly premium.  It’s time we acknowledge that we already give people a measure of universal health care, as we should. It’s not immodest to ask everyone to pay for it, too.

Jonathan Kohler is a pediatric surgeon.and founder, RxCreative.com. He can be reached on Twitter @jekohler.

Image credit: Shutterstock.com


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