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PPACA: A Choice, Not a Mandate?

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As the Supreme Court hears six hours of oral arguments over three days this week on whether the “individual mandate” in the PPACA is unconstitutional, I find myself thinking about some comments I heard last week from longtime universal health care advocate Paul Starr.

Starr, author of the 2011 book Remedy and Reaction: The Peculiar American Struggle over Health Care Reform,” (Yale University Press) is professor of sociology and public affairs at Princeton University. If Obamacare ends up moving forward after the Supreme Court tackles it, this guy’s ideas about the individual mandate – which I became aware of via a report on NPR on March 23, I find intriguing.

Starr proposes having limited open enrollment periods like employers offer. “There would be a time once a year to have open enrollment, instead of allowing people at any time to sign up for coverage and then to stop paying for coverage,” Starr was quoted as saying in the NPR report. This would prevent people from signing up for coverage only when they’re sick.

But it was the next idea he mentioned that really caught my attention. Instead of having a mandate, make it a choice in this way: allow people to opt out of the law’s requirement to have health insurance for a period of five years at a time, but in doing so they would also completely opt out of the law’s benefits.

“That means that you wouldn’t be eligible for the subsidies, or use the insurance exchanges, you wouldn’t be guaranteed a policy with no pre-existing conditions,” Starr told NPR. “Are you in or are you out? And I think it would allow people to opt out without any penalty, but it would also nudge a great many people to take part. And I think it would deal with both the constitutional issues and a lot of the political opposition to the mandate.”

No mandate, just a choice. Of course, if this were to become policy in place of the individual mandate, many will make the wrong choice and inevitably show up at hospitals with ailments and no means – or intention – of paying for care. But this already happens, and insured Americans foot the bill. In 2008, millions of uninsured people who received health services racked up $43 billion in uncompensated costs. The average U.S. family and their employers paid an extra $1,017 in health care premiums in 2008 to compensate for the nearly 50 million uninsured, according to a study by Families USA.

If PPACA were to be repealed, the Congressional Budget Office forecast earlier in March that the number of Americans with no health insurance would rise to 60 million by 2020. This would inevitably increase premiums for the insured as health care providers raise prices to offset the cost of uncompensated care provided to those without insurance.

Whatever happens with the PPACA, the problem of having a significant percentage of uninsured people in this country figures to persist. While I like the concept of allowing people a “choice” to opt out, it will not prevent those who do from showing up at a hospital who will treat them.

LifeHealthPro has editorial staffers on the ground in Washington D.C. this week, covering the Supreme Court hearings. You can stay up to the minute by visiting


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