Health care reform forces you to buy health insurance. That's fair. Here's why.

Critics say health insurance shouldn't be mandatory because health care is not a right. But it is a right in emergency rooms.

Seth Wenig/AP
People walk out of the emergency room of Jamaica Hospital in New York. Conservatives argue that government can't force people to buy health insurance because health care is not a right. But federal law guarantees health care in emergency rooms around the country.

One day soon, I would like to walk into my neighborhood supermarket, load up my cart with goodies and walk out the door. When I’m confronted by security about the matter of paying for the stuff, I’ll just tell them to make everyone else in the store pick up the tab. If I lived in Virginia, I’d tell ‘em to go see Attorney General Ken Cuccinelli, who says I don’t have to pay.

Well, that's not exactly what he says, but bear with me. Cuccinelli is one of 11 GOP state attorneys general arguing that it is unconstitutional for the federal government to require everyone to buy health insurance (as the new health law does). Virginia, indeed, has gone a step further and made it illegal to require anyone to buy health insurance.

I won’t get into the constitutional issues (they are way beyond my pay grade), but the economics is worthy of note. And my crude grocery store example gets to the core of the debate over whether the government can “make” us buy health insurance by taxing us if we don’t.

Conservatives like to argue that health care is not a right. But, in fact, it is. For years, federal law has required most hospitals to accept patients into their emergency rooms whether or not the sick and injured have the means to pay. If you run your car off the road and break your leg, the EMTs don’t demand to see your insurance card or ask, “credit or debit?” They trundle you off to the nearest hospital--which must fix you up.

This care is, of course, not free. Those of us who are insured pay for it. Indeed, the medical business survives on the black art of cost-shifting—that is to say, spreading the costs of those who can’t (or won’t) pay to those who can.

Thus, a modest proposal: Virginia and other states that ban the individual mandate should also exempt hospitals and physicians from any obligation to treat the uninsured. EMTs should demand upfront cash before scraping you off the road. You pays your money, as they say, and you takes your choice.

Keep in mind the rest of us are taxed by Mr. Cuccinelli’s unwillingness to buy insurance in other ways as well. For instance, if the young and healthy refuse to purchase coverage until they need care, premium prices for the rest of us rise. In that world, I will, in fact, be paying a tax on your refusal to buy insurance. Under the new law, you pay the tax. That, it seems to me, is how the incentive ought to work.

Finally, I can’t help but wonder if states barring the mandate could find themselves with no insurance coverage at all. Here’s why: Insurers would still be required to sell to all comers and still could not underwrite for health status (another key provision of the new health law). If they must sell to all, but only the sick buy, the insurance market will fall into what is happily called the death spiral. Premiums will keep rising as only those most in need of insurance buy, until coverage becomes unaffordable for nearly everyone and insurers finally abandon the market. Remember, in the health debate it was the insurance industry, not those wacky Democrats, that demanded tough penalties for non-buyers.

Lots to chew over here. Meanwhile, I’m off to the grocery store.

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