Why Americans should support an individual mandate.

Imagine for a moment that you work in a hospital emergency room. And just outside the door, a man has collapsed from a heart attack. Inside the facility, literally feet away from where he lies, are the equipment and knowledge to save his life. But this man doesn’t have health insurance.

Would you treat him anyway? Or let him die?

If you think the way the vast majority of Americans do, you’d choose to save the man. Whatever your political attitudes, the thought of withholding life-saving treatment from somebody because of ability to pay seems too cruel.

And that’s fine. I’d make the same decision! But if you believe that, then you should also support what remains one of the most controversial elements of health care reform, even after its enactment. That element is the individual mandate.

An individual mandate is a requirement that everybody carry health insurance. Such requirements are a feature of every universal health care system in the world. And, under the recently passed Patient Protection and Affordable Care Act, they’d be a feature of America’s health care system as well. Starting in 2014, Americans who don’t obtain coverage either through a government program, through an employer-sponsored private policy or through a plan purchased directly through the new insurance exchanges would be subject to financial penalties.

Back in 2007 and early 2008, during the campaign for the Democratic presidential nomination, the mandate became a focus of dispute between the two front-runners, Hillary Clinton and Barack Obama. Clinton supported the mandate while Obama opposed it. But after becoming president and consulting with his advisers over how best to design a plan, Obama changed his mind and indicated he would support the idea.

Obama would end up arguing for the mandate largely on the same grounds that Clinton had: It was necessary, he said, in order for the rest of the insurance system to work. A major goal of health reform is to make sure everybody, even people with pre-existing medical conditions, can get coverage. To accomplish that, you have to require that insurers offer policies to everybody, without discriminating against them based on health status. But imposing such a requirement would allow people to game the system: They could wait until they get sick and then buy coverage. The only way to avoid this problem is to make everybody carry insurance even when they are healthy.

It’s a technical argument more than a moral one. And it happens to be correct. For proof, one need look only at states that have imposed community rating (the requirement that insurers charge the same rates to people in different health conditions) and/or guaranteed issue (the requirement that insurers gives policies even to people with medical problems) without a mandate. The requirements have made coverage more available to people in poor health, but only by raising premiums substantially, as insurers anticipate healthy people will opt out of coverage until they need it.

Still, there are other reasons to support a mandate. One is explicitly about redistribution—from the medically lucky to the medically unlucky. At any one time, only a very small percentage of the population will have major health problems. The rough rule of thumb is that 20 percent of the people are responsible for about 80 percent of the costs in the system. But fortune (and misfortune) plays a huge role in determining who ends up as part of that 20 percent—all it takes is contracting a serious disease, having a debilitating accident or developing an acute condition. Rather than force this unlucky 20 percent to bear the burden of their medical expenses alone, you can ask everybody else—the people lucky enough to be in good health—to help shoulder that burden.

When you phrase it that way, the argument for a mandate sounds awfully liberal. But there is a third argument for the mandate—related, but from a different philosophical point of view. That’s where the dying man outside the emergency room comes in.

The fact is that, even before the Affordable Care Act passed, the U.S. guaranteed health care in life-threatening situations. Under the Emergency Medical Treatment and Active Labor Act, which the Democratic Congress passed and President Ronald Reagan signed in 1986, providers of medical care must give stabilizing care to people who need it, regardless of ability to pay.

The law is hardly a substitute for universal coverage: It doesn’t require that providers offer preventive or follow-up treatment and it allows them to collect huge bills afterwards. But, in practice, many doctors and hospitals will end up providing quite a lot of charity care. And while they can pay for at least some of that out of their own revenues, they inevitably pass a portion of those bills onto everybody else, in the form of higher insurance premiums and higher taxes.

But some uninsured people who end up getting charity care could afford to pay for insurance premiums—or, at least, pay some portion of them. It might not be enough to offset the entire cost, but it’d be enough that they were making a reasonable contribution to the cost of their own care. And there’s no reason they shouldn’t. As one mandate supporter explained a few years ago, “for people who can afford to buy insurance, it's time for them to step up to the plate and buy that insurance.”

Does that sound like a conservative argument? That’s because it is. The quote is from a Fox News interview with former Massachusetts Governor Mitt Romney, in 2006, not long after he signed into law that state’s universal coverage scheme. Romney, of course, is a Republican. The Massachusetts system closely resembles the one the U.S. will get under the Affordable Care Act, complete with an individual mandate.

Today, Romney denounces the Affordable Care Act as an unconscionable government takeover of health care. And he is just one of many conservatives who supported the individual mandate before it became part of “Obamacare.” But don’t be fooled. If Romney and fellow Republicans weren’t so determined to tarnish the Affordable Care Act politically, they’d acknowledge what they said before: The individual mandate makes perfect sense.

Jonathan Cohn is a senior editor of The New Republic. This column is a collaboration between TNR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization, which is not affiliated with Kaiser Permanente.

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