By Dr. Brian C. Joondeph

Donald Trump, at a recent CNN town hall event, told Anderson Cooper, “I like the mandate.” He was referring of course to the Obamacare individual mandate, a cornerstone of the Affordable Care Act, requiring all Americans to either purchase health insurance or pay a penalty.

He justified his support of the mandate by saying, “I don’t want people dying in the streets.” Are people really dying in the streets due to not having health insurance?

The Emergency Medical Treatment and Labor Act, passed in 1986, ensures pubic access to emergency services at hospitals regardless of ability to pay. This certainly prevents people with acute illnesses or injuries from “dying in the streets.”

But what about chronic illnesses such as heart disease or diabetes that eventually kill people if untreated? Treatment of these illnesses would be covered under traditional health insurance. And under the individual mandate, everyone has insurance. Or do they?

Despite the Obamacare individual mandate being in place, 33 million Americans are still without health insurance, more than 10 percent of the population. Some mandate. It’s more like a suggestion.

Donald Trump predictably walked back, or clarified his remarks, saying he wants to repeal all of Obamacare, including the individual mandate, and “replace it with something much better.” That’s fine, but there still remains the problem of the uninsured, either by choice or circumstance. And that number is “yuge,” to borrow a Trumpism.

Americans are divided equally on the issue of whether or not it is the responsibility of the federal government to make sure all Americans have health-care coverage. Is health care a right or a privilege? Leaving the philosophical argument aside, there remains the problem of paying the bill after medical care is rendered.

Hospitals, and their physicians, are required by law to render emergency care. That means someone who shows up in the emergency room with a life-threatening injury or illness will be treated whether or not they have insurance. What happens if the patient has neither insurance nor money to pay the bill? Sure, the hospital can send the patient to collections, but good luck collecting a $50,000 bill from someone with $50 in their checking account. It’s not a realistic business model, as those costs need to somehow be recouped. Typically they are recovered by charging insurance companies $1.50 for a Tylenol tablet, a 10,000 percent markup.

Enter Medicaid, health insurance for the poor, specifically those with incomes up to 133 percent of the federal poverty level, or about $30,000 per year for a family of four. Suppose a scaled-down version of Medicaid, basically catastrophic coverage, was provided to all American citizens.

Wait! Another budget busting entitlement? Not really. Look at current insurance coverage. Half the population is already covered under employer-based private insurance. Twenty percent are now on Medicaid and 13 percent on Medicare. This really applies to the 10 percent currently uninsured, those Donald Trump worries might be “dying in the streets.”

Those with private commercial insurance provided through their work are unlikely to give it up for a bare-bones Medicaid policy. It’s the same for those on Medicare. It really comes down to just the uninsured benefiting from this new entitlement, not everyone, and paid for by the savings from repealing Obamacare – assuming such a plan is part of a replacement for Obamacare, not just another add-on program.

A “Medicaid-For-All” plan would be a bare-bones insurance plan, without the bells and whistles of the Obamacare essential benefits. Oregon created such a plan in the mid-1990s, essentially “rationing” health-care services. Rationing is a dirty word, conjuring up visions of the British NHS system, with long waitlists and people dying waiting for treatment. Yet some form of rationing is necessary to distribute any commodity of finite supply and potentially infinite demand.

Oregon created a list of medical services and ranked them based on community meetings, public opinion surveys, quality of life preferences, cost-benefit analysis and medical outcomes research. Everyone had input into the process of ranking procedures in terms of importance. Based on available funding, a line was drawn. Everything above the line was funded and everything below the line was not. The list is subject to reassessment and change each year, meaning a new ranking of services and a line drawn somewhere else.

It’s not a perfect system. There are some winners and some losers based on individual circumstances. But at least it’s a safety net to assuage Donald’s concern of “people dying in the streets” and a reasonable component of a market-based system if Obamacare is ever repealed and replaced. Finally, this would take the politically thorny issue of the uninsured off the table.

Such a plan would be moot for the vast majority of Americans already with commercial insurance or Medicare, or those already on Medicaid. And it would be without the exercise in folly of forcing people to buy something they don’t believe they need.


Dr. Brian C. Joondeph is a retina surgeon at Colorado Retina Associates and serves on the faculty of Rocky Vista University School of Medicine. Twitter @retinaldoctor.

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