Star Tribune

Those attacking the individual mandate to buy health insurance -- a critical but increasingly controversial component of the 2010 Affordable Care Act (ACA) -- ought to scrutinize their own paychecks.

There, in all the fine print detailing withholding, is proof that this is hardly a radical new concept.

The nation already has a mandate to purchase health insurance. It's called the Medicare payroll tax.

Those who work help buy health insurance for America's elderly by paying into the funding stream earmarked for the popular Medicare program.

That the nation has had a mandate in place for decades hasn't deterred partisan legal challenges to this integral part of the federal health care overhaul, with the ultimate goal of blocking its implementation.

There are now more than 20 federal lawsuits contesting the individual mandate on constitutional grounds. While courts in two states have upheld its constitutionality, a federal court in Virginia earlier this month reached a different conclusion.

It's widely expected that a divided-along-political-lines U.S. Supreme Court eventually will rule on the issue. Whether the mandate survives the legal fight is unclear.

That should concern anyone interested in fairness and health care affordability.

Far from being an attack on personal liberty, as it has been disingenuously portrayed as being, the mandate helps ensure that people take responsibility for their health care costs. Those who choose not to pay for health care simply cannot continue to pass their costs onto everyone else.

In many ways, the Medicare payroll tax is just one of a number of "mandated" health care purchases by taxpayers and health care consumers in the United States. Each year, the uninsured rack up about $56 billion in uncompensated care.

According to the Kaiser Commission on Medicaid and the Uninsured, federal and state governments -- in other words, tax dollars -- pay for at least 75 percent of these costs.

For example, Medicare and the joint federal-state Medicaid program for the poor make extra payments to hospitals deemed to pick up a disproportionate share of care for those without insurance.

Some of the remaining costs likely get shifted along to the privately insured, potentially resulting in higher premiums. Responsible consumers have little choice but to pay.

According to the White House, insured families on average pay $1,000 more a year to cover those without insurance.

A new report this week detailed the sobering consequences of stripping the mandate from the newly passed ACA -- a grim but real possibility.

Without the mandate, taxpayers and health consumers would continue footing the bill for the uninsured, concluded researchers in a paper from the respected Robert Wood Johnson Foundation and the Urban Institute.

With a mandate, uncompensated care would decline by $42.4 billion under the ACA, but only by $14.7 billion without one. The number of uninsured would decline by 27.8 million if the mandate stays in place, but by only 10.1 million if it disappears.

"The finding that uncompensated care costs are much higher without the mandate suggests that individuals who would be uninsured without the mandate are essentially free riders shifting the costs of their care on to the rest of society,'' the researchers concluded.

Some who go without insurance truly can't afford it; the ACA mandate will help get them into the system and learn about their eligibility for new subsidies or an expanded Medicaid program.

The mandate, even the ACA's weak one, is also the best mechanism to force the "Evel Knievels" of the health care world, as experts call those whose can afford to pay for some or all of their insurance but go without, to mend their reckless ways.