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Many, many years ago, I don't remember when, in advance of a presidential election, I don't remember which, I had a conversation with a friend of mine in which he stated his intention to vote for the Republican candidate. When I asked him why, he said he did not want to pay extra taxes for the universal public health insurance program that the Democratic candidate was sure to put in place were he to win the election.

It occurred to me at that point to ask, before the conversation could go any further, "Do you actually believe that the fact that we don't have universal health coverage in this country, doesn't cost you money?"

As I recall he didn't have a definitive answer. He might have muttered something about how having universal coverage would probably cost more anyway, but I don't remember.  The sense I got was that he, like so many others, had never really thought about what it costs to not have universal medical coverage in a country like this.

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Most people I encounter who oppose universal health care in principle, irrespective of what they know and don't know about the Affordable Care Act, oppose it for a simple reason: They don't want to pay for other people's health care. Granted, "conservative" politics these days is driven primarily by self-congratulation and resentment, and their policy ideas are mainly grounded in selfishness and cruelty; to wit:

I'm the guy that faces the facts and takes care of myself. ... I pay higher insurance rates for the uninsured or I pay higher taxes to help buy them a policy. Lose, lose for the millions like me. Win, win for the lazy. ... I'm not talking about old people, the disabled or those that really can't take care of themselves. I'm talking about the lazy good for nothing people that want everything that I have but don't want to earn it.
This person, of course, fails to realize that all the self-congratulation and resentment in the world won't prevent his "lazy good for nothing" strawman from ever getting sick or injured, or from seeking medical help when he does; neither will it prevent any medical provider from treating him and building the cost into what he charges everyone else. EMTALA or no EMTALA, people who can't pay will still seek, and receive, medical treatment, and people who can pay will foot the bill. There is absolutely no way, in any modern society, to avoid spreading, shifting, sharing and subsidizing the cost of medical care. No way, no how, not possible, can't be done, don't look for it, never gonna happen. The only sane question to ask is how to do it, not whether to do it or not.

As it is, we have tens of millions of people walking around with tens of billions of dollars worth of uninsured medical risk. The cost of all that uninsured medical risk is built into the cost of medical care, and medical insurance, the cost of which is in turn built into the cost of everything we buy. When you buy a Pepsi at the 7-11, you're paying for the health insurance of 7-11 employees, Pepsi employees, employees of the trucking company that delivered the soda to the store, the plastics company that made the bottle, the ad agencies that market the drink, and on down the line. Whether my friend or the above commenter is aware of it or not, not having universal health care in the U.S. does cost money. A lot of money, in fact.

Yet the anti-universal-healthcare cohort still clings to the notion that they can actually live in a world where everyone pays only for their own medical needs, and for those who can't pay, it's their problem and no one else's. It's simple and clear and easy to understand. What's also clear is that they really haven't given much thought to how we might go about actually making that happen, or what making that happen would cost.

I've written at length in the past about all the measures that would have to be taken in order to ensure that those who can't pay for medical care don't ever get it, and that no one ever has to contribute financially to anyone else's health. How could we accomplish this through the law, through federal legislation? In addition to repealing EMTALA, we'd have to, at a minimum, pass legislation that would:

1. Make it a federal crime to call 911 or go to a hospital if you don't have insurance and/or can't afford treatment.

2. Make it a federal crime for any medical provider to treat any patient who is uninsured and/or can't pay, or who the provider reasonably believes is uninsured and/or can't pay.

3. Require 911 operators to ascertain, and set up a system that enables them to ascertain, the insurance and financial status of the caller and/or the patient, and/or take a monetary deposit over the phone, before dispatching EMT.

4. Set up gatekeepers in every hospital to ascertain, and set up a system that enables them to ascertain, the insurance and financial status of the patient and/or take a monetary deposit, before allowing the patient to enter the ER.

5. Place law-enforcement officers in every hospital to enforce (4), block entry to or eject people from the hospital if they can't pay or try to enter before their insurance/financial status is established.

6. Prosecute any patient who uses or attempts to use medical services without insurance or adequate financial assets, under theft-of-services statutes.

7. Limit or abrogate liability of providers for negative medical outcomes (including death) caused by errors or delays in ascertaining the insurance/financial status of any patient.

Now, granted, some of this probably can't be achieved at the federal level and would be better left to the states. But that's not really the point. What these measures have in common, obviously, is the theme that every person should have to prove, in every situation including emergencies, and to the satisfaction of the medical provider or gatekeeper, that he can afford and pay for medical care before receiving it. The point is that we would have to take numerous extraordinary, draconian and very expensive steps to put up enough roadblocks to keep the uninsured and the poor out of emergency rooms and prevent them from ever calling 911, and we'd also have to stop hospitals and doctors from accepting patients who can't pay and redistributing the cost to everyone else. (Even if EMTALA is repealed, providers can still do that on their own if they so choose.) What's outlined here is just the tip of the iceberg. What's more, there's little doubt that people would still fall through the cracks and/or abuse the system, such as by defrauding their way past the gatekeepers and into the ER.

But a system like this would also create the added risk -- and cost -- of keeping people who should have access to health care out of it, whether as a result of error, negligence or malfeasance in determining their insurance/financial status.  Those who generally oppose participation in civilization and consider it an affront to their own personal autonomy, such as by equating taxes and public services with "theft," &c., often fail to realize that what you do to/for one you must do to/for all. You can't keep the uninsured out of the system without setting up roadblocks, viz., some way to make sure a patient can pay before he gets in the proverbial door. And that means everyone has to get through those roadblocks, which means everyone has to be blocked. There has to be a presumption in place, that everyone has to overcome, that everyone is uninsured and/or unable to pay until proven otherwise.

Which brings us to the $40 billion elephant in the room, viz., how much would all this cost? How much would it cost taxpayers to set up all these roadblocks? How much would it cost providers to set them up and put them into use? How much would it cost insurers and individuals to guard against being mistakenly or wrongfully denied treatment? And that's not even taking into account the costs, public and private, that everyone would have to bear that arise from living in a country filled with millions of people walking around with untreated disease and disability.

At what point, then, do we realize that it is cheaper for all of us, collectively and individually, to just provide health care to those who need it? You can't stop people from getting sick or injured, or from seeking medical help when they do; you can either pay for their treatment, or you can pay for the mechanisms that will prevent them from being treated. To put it another way, when the above commenter's "lazy good for nothing" strawman breaks his arm and goes to the ER, the commenter can either (a.) pay a doctor to treat him, or (b.) pay a gatekeeper to check his finances, pay another gatekeeper to kick him out, pay a cop to arrest him, pay a D.A. to prosecute him for theft of services, and pay the Department of Corrections to put him in jail for a year or two (where, naturally, he will get treatment for his broken arm).

Thom Hartmann made a similar point on his show recently, in the context of welfare/public assistance. We know that there are people who abuse the system, who get benefits when they shouldn't, but eventually it costs us more to prevent such people from getting undeserved benefits than it would cost to just give them the benefits. The same applies in the health-care context, which every other nation in the world has figured out.

Why the anti-civilization cohort in this country has not figured this out yet, I don't know.  Maybe they'd rather pay more to make sure unworthy people are made to suffer, or maybe they're OK with paying for that regardless of the cost. Maybe they'd rather just feel aggrieved than come up with an actual solution to their own grievance. As I mentioned above, they tend to be motivated by self-congratulation and resentment. Maybe the grievance is an end in itself; since the world without social obligation that they envision can never and will never exist, the perpetual grievance is enough to sustain and validate them. Who knows.

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