We Do Not Stand Alone

The Supreme Court has stepped into the health care fray and will hear a challenge to the individual mandate in the Affordable Care Act early next year. The main questions under debate are whether the federal government has the authority to require that people obtain health insurance and if they can impose a penalty for those who don’t comply.

Indeed, no one likes the government telling them what to do, especially when it comes to our bodies. It doesn’t matter that the bill grants exemptions for financial difficulty, religious reasons, low income, and temporary loss of coverage; or that the penalty is as low as $95 in 2014; or even that law enforcement would miss most offenders, just like the IRS only tracks down a tiny percentage of tax evaders. The very idea that anyone’s autonomy is compromised is repulsive to most Americans. National polls show that a clear majority views the controversial mandate unfavorably.

As this debate brews over the next months, I want to offer my vantage point for why I believe the individual mandate serves the public good.

Imagine Christy, an otherwise healthy young woman, who comes into a hospital emergency room for fever and abdominal pain. She doesn’t have insurance because she felt it was a waste of money at this stage in her life. We find that she has an infectious abscess, which requires hospitalization with intravenous antibiotics. Christy won’t sign up for Medicaid, the state-funded safety net program for low-income individuals, to get the full treatment needed because she doesn’t want to take public aid. She opts for a suboptimal choice, an oral prescription.

Chances are, if Christy had insurance, she could have seen her primary care doctor when the symptoms first started. That may have cost the system $500*. If she stayed at the hospital and used Medicaid, that may have cost $5,000*. However, by choosing an inadequate treatment, she will likely face long-term health damage, such as infertility, which will eventually cost $50,000* to manage.

Whether Christy’s health costs are $500, $5,000 or $50,000, it is uncommon that people pay 100% of the actual cost of their treatment. Even if Christy had gotten insurance along the way, it would have only accounted for a small fraction of what she required.

While our ailments and medical decisions are private, the way we tap into the health care system impacts everyone. I see cancer patients who put off chemotherapy to visit family abroad, and then come back months later with metastatic disease, necessitating more resources with decreased odds for survival. I remember a middle-aged man I met as a medical student, a cocaine addict, who showed up in the emergency room every night with chest pain and received a full cardiac work-up, warm bed, and two meals before he slipped out the next morning. He did this for months. We may get to do what we want with our bodies, but we should know that our decisions affect the whole community.

In the end, someone has to pay for the consequences of these personal choices. Health care utilization and delivery is not an individual endeavor. The costs trickle down to all of us, because only the rare patient has the money to go it alone. As much as we are repulsed by mandates, we would be more morally disgusted if we let people suffer or die on the street unattended, even if they had willfully refused to get insurance when given the opportunity. We don’t kick people out of hospitals even when we suspect they are loitering for social reasons. We’d rather err on the side of giving the sick the benefit of the doubt. So, ultimately, we all end up paying for each other’s health care.

Recent studies show that a small percentage of people expend most of the domestic health care dollars. People who are uninsured tend to cost more when they present to care. They require extensive work-ups and often more intense treatment due to worse disease. The mandate compels us to acknowledge that our fates are interconnected in health care.

In return for getting essential services when and how you need it without judgment of your preferences, you should contribute your fair share, a mere portion of what you will consume over a lifetime. The government is doing its job with the individual mandate by protecting the public good, not allowing people to take advantage of their humane, law-abiding neighbors.

I ask people like Christy to take a look at the bigger picture beyond a moment of insolvency or episode of illness to recognize the systemic ripple effect of their singular actions. This is what is means to be a responsible citizen. It’s a fallacy to think anyone stands alone.

*Note: Dollar amounts are hypothetical and meant only to illustrate a concept. It is near impossible to obtain actual costs. The complexity of health care financing is beyond the scope of this blog post.