I’ve made no secret of the fact that I’m in support of the individual health insurance mandate that requires everyone to have coverage. From a financial perspective in terms of spreading and pooling risk (which is the purpose of any kind of insurance, including health insurance), it makes a lot of sense. When everyone is covered, the cost of caring for very sick members of the population is spread across the whole population. And no matter how healthy we may be, it’s impossible to know what tomorrow holds.
I’ve usually addressed the issue of the individual health insurance mandate in terms of how guaranteed issue health insurance would impact premiums in the absence of an individual mandate. The mandate – regardless of its popularity – just seems like the most practical way to go if we’re in agreement that individual health insurance should be guaranteed issue.
Maybe we should also be looking at the individual health insurance mandate from a more compassionate, human angle too. There has long been a bit of a harsh undertone in the healthcare reform discussions when it comes to people who are uninsured but technically able to purchase health insurance (ie, not prevented from doing so because of pre-existing conditions) if they can come up with the required premiums. There’s often an attitude of “well, what were they thinking, going without health insurance?” We expect people to take personal responsibility for a lot of things, and maintaining health insurance coverage is one of those things. But without an individual health insurance mandate that requires people to do so, there’s a not-insignificant portion of the population who will choose to forego health insurance. Maybe they could afford the premiums if they scrimped and saved or prioritized their spending differently, but for whatever reason, they don’t. It’s easy to say that they need to take responsibility for their situation if they then find themselves in need of expensive care and unable to get affordable health insurance because of a pre-existing condition. But in the words of Pulitzer Prize winning writer Nicholas D. Kristof, “that seems ineffably harsh.” Kristof is the co-author of Half The Sky, which is one of the most important books I’ve ever read. So when I saw his recent NY Times op-ed about his friend who is battling advanced prostate cancer, I read it immediately. To sum it up, his Harvard-educated friend quit his job in 2003 and has been uninsured ever since. He’s done seasonal work preparing tax returns for the last several years, but that didn’t provide health insurance and he was loathe to purchase coverage in the individual market because of the cost. Last year, he started having difficulty urinating and saw blood in his urine, but put off going to the doctor because of the high out-of-pocket costs. His cancer was diagnosed when he was sick enough to need emergency room care, and by then his PSA was 1100 (normal is below 4). Hindsight is always very clear, but it’s pretty obvious in this case that with health insurance (especially with good preventive coverage), his cancer most likely would have been detected far earlier.
Kristof and his friend Scott are quick to admit that Scott “screwed up catastrophically and may die as a result.” Kristof notes that Scott could have purchased individual health insurance and that his years in the pension industry had given him a level of expertise in actuarial statistics. He knew the risks and chose to live without health insurance anyway. And then once a problem presented itself, he chose to ignore it for too long. Neither man is trying to displace the blame for those mistakes. But Kristof points out that a mandate requiring everyone to carry health insurance is a safety net that helps to keep mistakes from turning into catastrophes. He sums it up perfectly with this:
“We all make mistakes, and a humane government tries to compensate for our misjudgments. That’s why highways have guardrails, why drivers must wear seat belts, why police officers pull over speeders, why we have fire codes. In other modern countries, Scott would have been insured, and his cancer would have been much more likely to be detected in time for effective treatment.
Is that a nanny state? No, it’s a civilized one.”
His story is one of many that have worked to put a human face on the problems created by the fact that we do not currently have an individual health insurance mandate (until 2014). And while Kristof does point out that an individual mandate is a relatively effective – if somewhat clumsy – way of preventing people from making a big mistake, he and his friend both write from a perspective of humility, without trying to minimize the error that Scott made in opting to go without health insurance. It’s hard to read it and not feel a sense that our current system has some very wide cracks through which people can fall – and sometimes die as a result. And while personal responsibility is a popular concept, it’s difficult to turn a blind eye to the places where we can make changes in our system to save people from their own mistakes.
