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REHABILITATING HEALTHCARE : One nation, insured : Some states, such as Arizona, are considering ways to opt out of a national plan. That's foolish.

November 16, 2009

As healthcare reform legislation advances in Congress, more state lawmakers are looking for ways to limit its effects on their constituents. At the front of the pack is the Arizona Legislature, which agreed to put a constitutional amendment on next year's ballot that would provide three new rights to its citizenry: to obtain coverage from a private insurer, to buy healthcare services with their own funds directly from doctors and hospitals, and to be free not to buy insurance or participate in a particular healthcare plan. That last right would run counter to the comprehensive reform bills moving through Congress, which would require everyone to obtain at least a minimum level of coverage -- with subsidies, if necessary. Spurred by a conservative advocacy group called the American Legislative Exchange Council, lawmakers in nearly 20 other states have either introduced or announced plans to introduce proposals similar to Arizona's "healthcare freedom act."

Although proponents of these measures say states can go further than the federal government to protect their residents, it's not clear whether a state constitution can trump a federal healthcare mandate. Nevertheless, the resistance in Arizona epitomizes a central problem for proponents of reform: Many Americans look at a federal overhaul of healthcare as a threat, and don't see how they will benefit from covering millions of uninsured people at taxpayer expense.

Arizona went through this exercise last year too, when voters narrowly defeated a ballot measure with most of the same features as the current edition. Dr. Eric Novack, the Phoenix orthopedic surgeon leading the effort to adopt the amendment, said one of the problems for consumers today is that there's nothing in the Bill of Rights to protect an individual's control over his or her healthcare. It's an issue on both sides of the debate -- there's no right to obtain health insurance or to see a doctor when you're sick either. And without such basic assurances, the public is left to trust policymakers to do the right thing as they address one of the most pressing problems with the current system, which is an unsustainable increase in costs.

That's asking a lot, to put it mildly. Yet Arizona's initiative, despite some sensible elements, goes too far. It's reasonable to demand that Congress allow people to buy whatever healthcare services they can afford out of their own pockets. That's how the law stands today, with some limits in the Medicare program to guard against fraud, and the comprehensive reform bill passed by the House wouldn't change it. Allowing people to ignore a national mandate to buy insurance, however, would encourage them to carry policies only when they need treatment. Instead of having a broad customer base to spread costs across, insurers would mainly serve those who rack up high medical bills, sending premiums even higher than they're going today. Theoretically, Congress could avoid this problem by allowing insurers in states that opt out of the mandate to deny coverage for preexisting conditions and charge people higher rates after they fall ill. But that would just preserve within those states the worst features of the current system.

Implicit in proposals such as Arizona's is an every-man-for-himself vision of society. Why shouldn't the healthy be able to refuse to pay for insurance they're confident they won't use? Because they have a stake in making healthcare affordable for those who need it. The healthier the public is as a whole, the more productive it is and the faster the economy can grow. And most important, bringing everyone under the insurance umbrella will make it easier to achieve the changes in how healthcare is demanded, delivered and paid for that are essential to curbing costs over the long term. When it comes to the public health, there should be no opting out.

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