The recent freezing, nasty winter weather isn’t the only snow job to blanket most of the country. With the Florida court decision declaring the federal health care reform act unconstitutional, you’d think reform was dead. But as only a Monty Python character could voice…it’s not dead yet. Clear away the competing court decisions and nothing much has changed. The only decision that matters is the U.S. Supreme Court opinion that will eventually come. That Supreme Court battle was preordained the minute the reform law was passed.

What gets lost in the white out of shouting by supporters and opponents is the simple truth that the individual mandate is simply a method to replace what health insurance has always been – financing of health care. Everyone who gets care has to pay; no free riders. Reform must eliminate both uncompensated care and disproportionate distribution of risk. Put simply, doctors have to get paid and a few plans can’t wind up with the sickest patients and the least amount of money.

First, let me please beg the proponents of health care reform and the individual mandate to stop comparing the health insurance mandate to auto insurance. “Well, we mandate the purchase of auto insurance don’t we?” Yes, we do.

Most states (not Congress) mandate the purchase of liability insurance to ensure that drivers are financially responsible for the mayhem caused by accidents. Health plan coverage is first party coverage; auto liability insurance is third party coverage – big difference. A Congressional act mandating that people take care of themselves and a state statute mandating that people take responsibility for the injuries they inflict are not the same.

Moreover, states can do what Congress can’t. The tenth amendment to the U.S. Constitution provides:

The powers not delegated to the United States by the Constitution, nor prohibited by it to the States, are reserved to the States respectively, or to the people. 

Why bother making weak arguments to support an individual mandate? Let’s be honest; reform needs a way for everyone to contribute to the cost of their own health care. We would also appreciate if those who are healthy and those who have the most money pay for the poorest and the sickest. Any other explanations for health care coverage mandates are simply dishonest and the dishonesty stands in the way a problem solving.

Let me repeat myself.  Health Care = $$$. No matter how you analyze health care reform, you end up with a discussion of who pays for health care. You can use a social model like Medicare that does not price coverage based upon individual risk or an actuarial model like auto insurance that attempts to calculate each person’s risk and charge for coverage accordingly.

As a country and as individual states, we have always tinkered with and taken away tools for risk pricing. A federal example would be GINA which bans the use of genetic information in pricing health plans. It seems the better we get at predicting risk, the more we want to limit the information. A state example would be Washington’s longstanding prohibitions on pricing on the basis of “race, creed, color, national origin, religion, or ability to read, write, or speak the English language.” Yes, the overwhelming majority of us object to this type of discrimination however much an underwriter could draw a correlation between these differences and health risk.

The question is not whether our cause is just or reasons for banning a particular rate making practice are noble. The question is whether we believe in risk pricing or not. The clear proof is that we don’t. Well, we sort of don’t. The only question that remains to debate is how far we are willing to go in limiting factors to be considered in pricing health care coverage.

Both state and federal governments have been moving away from risk based financing and toward a social insurance model for decades. Many states have community rating laws that strictly limit both the type of factors to be used in setting prices and the weight to be given these factors. At some point, the system will simply calculate the cost of care for a population and then calculate the amount of money to charge for that care. Once calculated, the debate over how to get the money into the system begins.

The point of an individual mandate is to ensure that those who would otherwise choose not to contribute are forced to contribute anyway. Somehow a mandate to buy insurance seems better than a tax collected to pay for it. Even then, we squirm when service is denied to those who don’t pay – we watch a home burn to ground because of unpaid fees.

Cut down all the mandates to buy coverage and you leave insurance companies with buyers who know they need coverage. Limit the price for coverage, restrict the factors to weigh in setting the price and then require companies to sell coverage to the sick and what do you have? No insurers.

Is our national debate over reform a debate over whether we need health care? Isn’t the debate over how we are going to pay for care? Are those who oppose mandates upset with methodology? Would they prefer a tax? Employer mandates only? No care or treatment for those who refuse to buy coverage? No discharge of health care debt in bankruptcy? No care for the unemployed? An expansion of the Medicare program? Parking meters on hospital beds?

Let me repeat myself again, “Health care = $$$.” If we want the freedom to buy insurance ourselves from the companies we choose, then we have to figure out a way to solve that fundamental equation – mandate or not.

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