Health Care Reform: The Individual Mandate


Yeah. So. Health care reform. Deeeeep breath…

I have refrained from talking 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 reccission, 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 aboveboard.  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 fuck? 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. 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.

Note: If you hate everything about the Affordable Care Act and have spent this post mentally composing the comment that will knock me off my socialist high horse, you can save the keystrokes. I’ve already heard it. Yelling at me in the comment section won’t change my mind on this, just do you know.

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15 comments for “Health Care Reform: The Individual Mandate

  1. August 18, 2011 at 6:49 am

    Don’t get me started on insurance. Last night I got home from work only to find a notice that J’s health insurance was being canceled. No, strike that, that it WAS canceled on August 5th. In a panic, I called. I’ve never received a notice. I’ve never received a bill.

    And they politely told me that it will cost me $1100 to reinstate his coverage and that he will cost $500 a month to insure.

    He weighs 35 pounds.

    He’s basically healthy with no major problems.

    The reason? He had to go to the ER twice last year… once b/c I was panicked over his breathing, when he turned out fine and once for the broken arm.

    I now have to pay $500 a month, plus a $2500 deductible and a $35 copay. Which basically means that at the end of the year, I will have easily paid more than my insurance company for J’s health care.

    Insurance companies are running a racket and it HAS TO STOP.

  2. amy
    August 18, 2011 at 6:54 am

    Thank you again for putting this into language everyone can understand. I also have gripes about the very profitable insurance companies and also the pharmecutical companies that charge over $300 for prescritptions that the insurance companies will not pay for. Yeah, my answer is to yank all the advertising that pharm companies pay for and then we should prices coming down. In a fairytale.

  3. August 18, 2011 at 9:04 am

    I have two points regarding this.

    One: I, too, wept at its passing. I am the proud mother of a little girl born with Down syndrome (which is NOT a disease, yet falls into the “pre-existing condition category) and who underwent open heart surgery to repair a congenital heart defect when she was seven months old. I’ve watched my friends’ children with Ds have their coverage cancelled, or their premiums significantly raised. It sickens me. So I was ecstatic that no insurance company could ever again declare my daughter not worthy of their coverage.

    Two: For all the people who throw their hands up in the air about how “their” tax dollars will have to pay for the uninsured of our nation…and automatically assume that those uninsured are unemployed, parasitic ne’ever-do-wells…let me tell you something. Some of the folks that need that protection are people like my mother: a breast cancer survivor whose small company did not offer a group plan to their full-time employees. The generalization is false, so please get off your “us” versus “them” soapbox. A lack of insurance knows no employment status.

    Three: (OK I lied, but I forgot this part) There are other insurances that we must, by law, carry–whether we want to or not. Namely, auto insurance. Yet no one is contesting the constitutionality of that. My husband loathes paying for auto insurance. But we do it, because we never want to be holding the bill for an uninsured accident.

    Thanks, Rebekah, for such a great post.

  4. August 18, 2011 at 9:50 am

    Muttering Mama – You compared being required to have health insurance to being required to have auto insurance. To that I respond, THANK YOU for that comparison! This whole time I’ve been thinking that it’s completely ridiculous that those who CHOOSE not to have health insurance be fined for their choice. But I never questioned why we are required to have auto insurance or be fined.

    It makes sense, why would someone not question insurance their car but fight for their health to be uninsured?

    I never thought of it that way, so thank you for that comparison!

  5. August 18, 2011 at 9:57 am

    THANK YOU. THANK YOU! For taking on this topic. As the mother of a chronically ill child (read 20ish ER visits, 2 surgery’s, 6ish different specialists during his short 5 years) I LOVE THIS LAW! I have what would have to be classified as GREAT insurance and have come to believe that anyone who says they are happy with their insurance and doesn’t believe their is a healthcare crisis in this nation simply hasn’t been put in a position to test the coverage they really have…. PLEASE PLEASE PLEASE Supreme Court rule in favor! This law needs to stay on the books.

  6. Rebekah @ mom-in-a-million
    August 18, 2011 at 11:41 am

    I don’t bring up auto insurance because it’s not a perfect analogy. While being insured is a condition of car ownership, car ownership itself is voluntary. Owning a body is, well, not. So this is really the first time the government is saying consumers must buy something just for being alive.

  7. August 18, 2011 at 1:51 pm

    I guess I never understood people’s issue with this. People get their panties in a bunch because they’re being forced to carry health insurance?

    The only way for this health reform to work is to force EVERYONE to have health insurance, the sick and the healthy. That way you create a large enough pool of people so that, while you’re insuring this person with a cancer-ridden body, you’re also insuring 3 people that aren’t costing you anything. That’s the WHOLE point of insurance.

    And, you know what, so what if it doesn’t work? You tried at least. And then scrap it and try something else. It’s not going to destroy the world if we do something, it doesn’t work, and you have to try something else. But the intentions are good. Something NEEDS to be done.

    I have a friend that got HIV, not from sex, but because a fucking crazed nurse stuck herself with a needle (she had HIV) and stuck him with it when he was at the hospital for surgery. Totally not at fault, but uninsurable. People like him need to be able to get coverage. And, you know what, if I have to insure myself to get people like him coverage, then so fucking be it.

    And hospitals write off MILLIONS of dollars a year for ER visits that they don’t get paid for. That’s why medical costs are SOOO fucking high! They have to account that they won’t get paid half of the time so they have to raise their rates astronomically, which in turn makes our health insurance raise….it’s such a vicious circle. Something needs done and I’m glad that they’re at least trying to do something about it.

  8. Katy
    August 18, 2011 at 4:20 pm

    When my sister was 6 years old she had a seizure, and continued to have roughly 2 or 3 a year for several years after that. The doctors tried everything but could never figure out why it was happening. Otherwise, she was a solid, healthy child. Meanwhile all the insurance companies claimed that she “was born that way” and the seizures were, therefore, a pre existing condition so she was denied coverage.

    This went on for about 10 years. Meanwhile, my parents worked themselves to the bone trying to pay the bills and find the cause of the seizures before one of them caused irreperable brain damage. As a result, my 3 siblings and I became the token latch key kids who always needed rides to ball games and swim meets because our parents were always at work.
    My sister ended up trying to kill herself at the age of 8 and then again at 12. My brothers developed serious drinking problems in high school. My sister eventually outgrew her seizures and is a perfectly healthy grown woman now. But the financial and emotional stress of that time still affects my family and our relationships to this day.

    Now I’m on Medicare and the state and tax payers pay for my therapy as I try to work out why I’m so resentful at having to help raise 3 siblings and how having no life of my own left me an emotionally and socially stunted 37 year old who can’t function without anxiety meds or hold down a job. My meds are covered by the state too.

    Long story short? I think all this could have been avoided.

  9. anthrogrrl
    August 18, 2011 at 9:00 pm

    I have two part-time jobs, and no health insurance right now. When I was laid off, we couldn’t afford either COBRA or to put me on my husband’s insurance. I could get a private policy, but the only condition I hope to need medical care for in the near future is pregnancy, and NO PRIVATE PLANS cover maternity care anymore. Some of them claim to, but they all have a separate, ridiculously high deductible for maternity care. And children are not covered until they are born. So I have chosen to wait until next March, when the open enrollment for my husband’s insurance rolls around again, to get coverage and to start trying to get pregnant. And that is simply ridiculous, IMHO.

  10. Karen Moeller
    August 26, 2011 at 4:37 pm

    I think ACA is a step in the right direction and I, too, cried at its passage. It meant my soon-to-be college graduate without a job could stay on our insurance.

    Still, I must say I’m disappointed. I was hoping for the single payer option as put forth by Physicians for a National Health Program. Far too many of our medical dollars do not go for medical care. I think this will eventually come about in this country, but probably not in my lifetime.

    It’s ironic that what we celebrate is something that our friends in Europe still feel is far below what the richest nation should have.

  11. September 4, 2011 at 3:39 pm

    Bravo, my friend, bravo. SOOO well written and it’s amazing to know someone who was involved with this and explain it so clearly!

  12. Kristi Simpson
    November 6, 2013 at 12:57 pm

    I, too, support the ACA but am having a hard time finding an answer to my question. Maybe you could help or at least point me in the right direction. I am a stay at home mom with five kids. They are all eligible and enrolled in CHIPS. My husband has great insurance through his company (his yearly income is $50,000). Before the law I had a $75 limited benefit fixed-indemnity plan. I did find out that the children are still eligible for CHIPS, but if I am required to buy through my husband’s employer insurance I would now pay $422 a month. Can I buy an individual insurance plan even though my husband’s plan is available?

  13. November 22, 2013 at 7:28 pm

    Thanks a lot! This is definitely an superb web page!

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