The Individual Mandate: Health Care Reform in Context

via iStock Photo/Christopher Futcher

I have been reluctant to write about health care reform and the Affordable Care Act up until now because I was professionally involved in lobbying for its passage. People I worked with were involved in the discussions of what the bill should and should not include. Seeing this bill written and passed was one of the pinnacles of my time at my old job: this was a once in a lifetime opportunity for anyone involved in public health advocacy and I’m not ashamed to say I wept when it passed.

The law is not perfect, but it has some provisions that will greatly improve the medical landscape of America. The main provision that mattered to me was the one that prevents insurance companies from denying coverage for pre-existing conditions or committing rescission, revoking coverage for allegedly undisclosed pre-existing conditions.

We all heard the story of the woman who got a cancer diagnosis and her insurance company combed through her entire medical past and decided that  treatment for acne, which she had failed to share with them because hello!? — it was treatment for acne, was an excludable condition and yanked her coverage. They didn’t give her any of her premiums back: they just cut her off. And it was totally legal and above board.

Seeing insurance companies have to stop discriminating based on medical history is a victory for patients. It’s a victory for me personally, actually. I am uninsurable on the individual market. I’m golden as long as I’m part of a group plan, such as one offered through an employer, but if I were to knock on an insurance company’s door asking for a policy, they’d take one look at the c-section I had in 2008, the benign breast cyst I had in 2009 and my history of cervical abnormalities and they’d laugh in my face before slamming the door. But in 2014, they have to stop laughing and take my money if I want an insurance plan. And they had to stopping pulling that kind of shit on kids in 2010. And for that I say “Thank you former Speaker Pelosi, President Obama, and the late Senator Kennedy as well as all the experts and advocates who worked to make that happen.”

Now, the regulation of insurance companies and the ending of industry-wide medical discrimination is actually something that polled pretty well on the ACA. What bothers people about the bill is the flip side of the insurance equation: the individual insurance mandate. That’s the part of the law that says everyone has to have insurance or pay a fine. The law gets pretty labyrinthine on that aspect and there are all kinds of details about how people can get insurance once they are required to do so: through employers, through state-run insurance marketplaces called exchanges, through just buying a plan from a company. Different sized businesses have different requirements for what they have to do to help their employees get insurance. Individuals can be eligible for subsidies to help pay for their coverage. It’s a MASSIVE policy network and I don’t understand it all. But at the end of the day, you will need to get insurance if you don’t already have it,  give it to your employees if you run a business of a certain size, or pay an penalty tax for not doing so.

The question this raises is “What the f^&%? How can the government tell me to go out and buy something if I don’t want to?.”

I say, “Why don’t you want insurance? You’re really into gambling on your bank account being sufficient to safeguard your health?” I also say “Read up on EMTALA.”

EMTALA is the Emergency Medical Treatment and Active Labor Act of 1986. This is the law that basically states that if you show up at an emergency room with a medical emergency – or a condition that is not immediately visible but that you self-identify as an emergency – the emergency room has to examine you, stabilize you, and provide in-patient follow-up care for you until you can be released or transferred regardless of your ability to pay. You can walk into an emergency room, knowing you’re broke and uninsured, tell them you are sick and require evaluation on an emergency basis, and they must see you. They may decide you’re not that sick and send you home but they have to evaluate you. They might decide you’re sick as hell and admit you for further treatment and keep you there until you’re well enough to go home. At no time can your ability to pay factor into your treatment plan. And when you can’t pay the bill, they can’t sue you. They can send it to collections and it will appear as a black mark on your credit report but they can’t take you to court for payment. They’re just shit out of luck for the cost of your care.

How much does mandated care of the medically indigent cost? In 2003, hospitals provided about $40.7 billion in uncompensated care, much of it attributable to emergency room care.

How does this relate to the individual insurance mandate? Because EMTALA is a mandate that requires providers to provide service to those who cannot pay for it. In essence, EMTALA has turned emergency rooms into a public service on par with police or fire services only no tax is levied to pay for it. The individual mandate in the Affordable Care Act becomes that tax, paid to insurers rather than to the federal government.Yes, you may be paying for a service you never need but that is the case with taxes you pay for the fire department, too. And yes, you may end up paying for someone else’s care, but, again, that’s the case with taxes for the fire department, too. Meanwhile, having insurance means you have better access to health care and a likelihood of better outcomes if you gt sick so you win on many counts.

Right now, the question of the Constitutionality of the individuate mandate is wending its way through the courts. I’m not keeping an accurate score but I think decisions have been pretty even so far on whether or not the individual mandate can stand. The Supreme Court is expected to render a final decision on whether the individual mandate violates the Commerce Clause of the Constitution in their next session. I think (hope) they will rule in favor of it, in light of the settled law of EMTALA. If they don’t, the rest of the ACA crumbles. That would be a pity, because, imperfect as it is, the law is already saving lives and could save many more if it’s allowed to stand.

Rebekah is a DC-area mom with an over-developed sense of irreverence, socialist tendencies, ADD, and a blog.  She recently quit her non-profit sector job to pursue her dream of not working. She now spends her time answering her 3-year-old son’s questions and ranting at her blog Mom-in-a-Million, musing on being a mom in today’s world in her column So Here’s the Thing at the Washington Times Communities and talking about life as a DC Mom at TheDCMoms.

This post originally appeared on her blog Mom-in-a-Million.

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