Jonathan Cohn

Who Doesn't Want Health Insurance?

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The individual mandate continues to be health care reform's most controversial element, both in the courts and on the campaign trail. And many of the mandate's critics see this as a matter of principle. Requiring people to carry health insurance, they say, compromises individual freedom. I don't agree with that argument, but I understand it.

What I don't understand is why the requirement scares people without such strong libertarian instincts.

The vast majority of Americans have health insurance right now. What they want is a promise that the insurance will always be there, even if they lose their jobs, see their incomes fall, or develop serious medical conditions. And the same goes for many, quite probably most, people who don't have insurance. They, too, would like to have the financial protection against illness. They would like to know they can get medical care and not just the urgent kind. But they can't get health benefits right now because they don't have enough money or because they have pre-existing conditions. 

There are obviously some people who don't have health insurance and, furthermore, don't want to have health insurance. They'd rather take their chances and pay out of pocket. But I think that's an awfully small group of people and, quite honestly, I don't think they have the right to make that choice--unless they feel like relinquishing their right, under the Emergency Medical Treatment and Active Labor Act (EMTALA), to stabilizing or life-saving care in case of an emergency. This is the essence of the constitutional case for the mandate.

It's true that the Affordable Care Act does more than require people to get insurance. It sets minimum standards for what that insurance covers and requires community rating, under which insurers can't vary premiums based on an individual's propensity to get sick. This means that some people--mostly young, healthy men with cheap, bare-bones policies--may have to pay more to keep their benefits than they would otherwise pay. But plenty of these people are older and/or sicker, which means they should benefit from the new regulations. And that's not to mention the fact that, between subsidies and reforms designed to reduce the cost of care, many of these people will end up paying less for their insurance anyway. 

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