by Joost Steffensen

Created on: June 11, 2009   Last Updated: June 14, 2009

The way the current Health care debate is going, the most likely outcome seems to be neither Universal Health care nor a more regulated version of the present system. Instead it is likely to be a system under which a public plan competes with private insurance under a new set of rules the most important of which being that health insurance providers can no longer turn people away because they have preexisting conditions. However it seems unlikely that buying health care will be mandated.

I've been breaking my head over the question how such a system would end up covering all Americans, because I suspect a lot of young and healthy or extremely strapped people will simply not opt in. I've come up with a couple of ways to make it happen.

A universal mandate seems politically unacceptable. However I can envision a situation in which a limited mandate might work. I think most people would find it acceptable that people be obliged to sign up for the public plan if they have no insurance if:

They show up at an emergency room.

They apply for any kind of government assistance.

They ask for a tax rebate.

They sign up for college.

They apply for a credit card.

They sign up their kids for school

They apply for a job.

This could be done in a number of ways. The easiest would be to attach health insurance information to social security numbers. Then you pass a law saying all of the above are only possible if you have or are willing to sign up for the public plan (or private health care). Then if say you apply for a job your potential employer would have to check if you have insurance and if not either sign you up or not hire you.

These measures should ensure most people enrolling in a health care plan eventually.

The second question then is how do you ensure that people don't dump their insurance at the first opportunity. I think the answer is making it illegal to do so. You should be allowed to switch to a different plan, but not to opt out once signed in.

Which brings me to the third question, how do you get young people to sign in as early as possible. I think this can be solved by making the policy more expensive for those who sign up at a later age and also by automatically signing those up who were insured under their parents insurance as soon as they hit 18.

As for children being insured, they should be automatically insured with their parents as soon as a parent signs up (same for spouses and domestic partners).

In many ways a system like this comes very close to but is not quite a universal mandate. That leaves space for those who prefer to live of the grid to treat themselves with snake oil and bowie knives when the shit hits the fan.

For those of us who like being part of a caring thoughtful well-organized society it provides the opportunity to bring down and spread costs for something most of us will most likely need eventually.

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