May 26, 2018
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Health care mandates everlasting

By Dr. Erik Steele

Having happily snoozed through constitutional law classes in college, I am now conditioned to do likewise whenever the words “Constitution” and “law” appear in the same sentence. That makes it tough for me to stay awake long enough to contemplate recent news that 25 American states are suing the federal government on the grounds that the new health care reform law is unconstitutional.
Most of these lawsuits challenge the right of the federal government to require people to buy health insurance or pay a penalty tax, which the Affordable Care Act does starting in 2014. The suits claim this provision violates something called the Commerce Clause of the Constitution (poking your tongue with a sharp pencil can restore alertness here).
Leaving that question of constitutionality to sharper and dustier brains than mine, it’s worth reviewing mandates that already exist in health care and health insurance, and understanding they are required to make the system work.
As far as I know (I may have slept through this, too), no one has sued to relieve me of the first two mandates: getting older and sharing each other’s health care costs. As we age, we usually develop illnesses and get very expensive. When that happens, what we cost to care for often exceeds what we pay into the system in premiums, mandating that money we put into the system earlier when we were healthier, and other Americans help pay the costs of our care.
The entire system works on the mandate that we pay more when we are healthy — and don’t use much care — so the system has the money to pay for us when we are sick and costly.
It’s just like mandatory car insurance, a system in which we all pay some money each year so there is plenty of money to pay for the night a moose tries to join us in the front seat of the car.
The next mandate is economic: You are going to pay for health care and health insurance regardless of whether you buy health insurance. You can escape a health insurance premium, but you cannot escape the mandates of the health care market to pay for your care some other way (unless you can mandate perfect health forever — let me know if that works out for you).
If you have no health insurance and get a compound fracture snowmobiling under the influence of Schlitz Malt Liquor, you are going to get a medical bill big enough knock you on your economic can. Enough mandates to rattle your addled brain will follow. Paying the bill mandates a big hit on your life savings. Walking away from it means frequent supper-time telephone discussions with bill collectors about your mandate to pay what you owe.
You can declare bankruptcy, which many do; half of all personal bankruptcies in America are due to the havoc health care costs wreak on personal finances. You might get your hospital to write your bill off as free care, but as with the bankruptcy option, then some other poor slob just gets your mandate to pay passed on to them in the form of higher hospital charges and health insurance premiums for their care. Your freedom not to have health insurance is then my mandate to help pay for your health care.
Finally, the mandate for all of us to be insured or pay a tax helps pay for the mandate that the Affordable Care Act imposed on health insurance companies to pay for pre-existing medical conditions. That, in turn, lifted the mandate that serious illness exposes us to possible financial ruin just because we changed insurance companies. The requirement that insurance companies now pay for pre-existing conditions has been tremendously popular, which in that regard makes suing to overturn the mandatory insurance provision tantamount to “suing ourselves in the foot.”
The Midas muffler guy always said, “You can pay me now or pay me later.” Mandates in health care are similar; we can sue and overturn one, and the mandate to pay for our care some other way will simply come back to us in another form.
The idea that a health care system can function without mandates is a sweet dream.
Erik Steele, D.O., a physician in Bangor, is chief medical officer of Eastern Maine Healthcare Systems.

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