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The Individual Mandate Is Obamacare’s Linchpin
It makes little sense to strike the mandate down while leaving the rest of the law intact.


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Marc Siegel

Last week, when the Eleventh Circuit Court of Appeals ruled that Obamacare’s mandate that everyone buy health insurance is unconstitutional, it paved the way for a showdown in the U.S. Supreme Court. For the first time, the mandate was struck down separately from the rest of the health-reform law, raising the possibility that we could be left with the behemoth but without its controversial head.

It is clear to me that the individual mandate is unconstitutional. But removing it while leaving the rest of the law intact would make things much worse for doctors, patients, and insurance companies alike.

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Proponents of the law have always referred to the mandate as the linchpin, because compelling everyone to have health insurance of some kind is the only way for the federal government to ensure compliance across the board with its new policies and mandates — including coverage of everyone, regardless of preexisting conditions. In fact, the biggest reason for making insurance involuntary is to avoid the so-called “insurance death spiral,” where without an individual mandate, healthy people will wait to get insurance until they get sick, which drives up prices. Further, insurance companies and drug companies decided to play ball with the president only because of the guarantee of millions more customers many of whom are still healthy.

So what will happen to my patients if the court’s decision stands?

First, insurance premiums will continue to rise. They are rising already, and the new Obamacare regulations will cause them to rise further. Whether you believe that Obamacare should mandate insurers to cover birth-control pills, sterilization procedures, morning-after pills, breast pumps, and domestic-violence screens without a co-pay, one thing’s for sure: Doing so will put financial pressure on insurers. The draft regulations of the health-reform law, instituted last year, are pushing insurers in the direction of lower co-pays and deductibles, which will also result in higher premiums as insurers struggle to preserve profits. And without the individual mandate, private insurers will have fewer customers than anticipated, amidst all this governmental pressure. Add to that the costs of covering everyone, regardless of preexisting conditions, at relatively the same price, and premiums will soar.

Second, employers, who currently provide health insurance to over 160 million workers, will see the rising premiums and decide to dump their employees onto the new state health-insurance exchanges beginning in 2014. A recent report by the consulting firm McKinsey predicts that at least 30 percent of employers will consider this move. But without the individual mandate, these employees may decide that it isn’t worth it for them to buy insurance on the exchanges, and go without it altogether.

Third, with Medicaid expanding to cover families with up to $60,000 in income in many cases, expect enrollments to swell well beyond the 16 million additional beneficiaries now anticipated. Patients dumped by employers but no longer faced with a penalty for not buying insurance will quickly apply for Medicaid if they qualify. When you add this tremendous expense to the government subsidies for the low-income patients who use the exchanges, you can see that the burden to the federal and state governments, and ultimately to the taxpayer, will be enormous.

As I’ve said many times, the last thing we doctors need is more insurance, and more government regulation of that insurance, interfering with our one-on-one practice of medicine. With the individual mandate, Obamacare is very problematic for both doctors and patients. Without the mandate, Obamacare will be the perfect storm.

— Marc Siegel, M.D., is an associate professor of medicine and medical director of Doctor Radio at NYU Langone Medical Center. He is a Fox News medical contributor and author of The Inner Pulse: Unlocking the Secret Code of Sickness and Health.



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