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Opinion: Risk management and the use of force

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During a conference at the L.A. Chamber of Commerce today, Gov. Schwarzenegger made the pitch for his health care reform package. It’s an impressive plan that draws on a premise—mandatory health insurance for all—that some great minds support. Like Columbo, though, I’ve been scratching my head and thinking about something that’s still puzzling me. To make the numbers work (i.e., to make it cost-effective for providers to offer insurance to everybody regardless of pre-existing conditions and the like), the plan relies on getting the Golden State’s 6.5 million uninsured residents into the system. It’s especially attractive to mandate that young and healthy people pay for insurance, since they’ll help fund the system without, in most cases, burdening services.

My question: What will be the mechanism for compelling these people to buy insurance? Not everybody who is currently uninsured is unable to pay for it. How do you force a person who just doesn’t want to buy insurance to buy insurance?

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So I asked the governor. His response was that it would be like auto insurance: You have to have auto insurance to drive. I questioned the comparability of the two cases: In the case of auto insurance, there’s a privilege the state can deny you if you don’t comply. If you don’t buy liability insurance, you can’t drive legally. What privilege can the state take away if you refuse to buy health insurance, since denying emergency room care is not an option?

To this, Daniel Zingale, the governor’s senior policy advisor, replied that there will be many places to ‘reach out’ to the currently uninsured, specifically naming schools and the tax system. (In Massachusetts, the insurance mandate is covered in state income tax forms, which require filers to specify that they are insured.)

The governor then said that what his plan really aims for is to ‘change the mentality of people.’ He mentioned his own experience as a young immigrant accustomed to the situation in Austria, where everybody had health coverage, and bewildered by the challenges of getting covered in the U.S. The mentality change, he added, is part of establishing a ‘culture of coverage.’ He and Zingale both said that the currently uninsured do want to be covered.

I’m all for changing the mentality of people, but I still think there’s an issue here: If people don’t want to come to the ball park, nothing’s gonna stop them, and if they don’t want to buy insurance, at some point you’ll have to force them. I don’t know that that’s a showstopper, and there appear to be many ways of addressing the problem. But the end point I keep seeing is the use of force to get that healthy 25-year-old freelancer doing something he or she just may not want to do. Compulsion is not an issue anybody wants to talk about this early in the proposal, but it’s a real issue nonetheless.

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