What to do about the health care invincibles?

In the heat of a softball game last spring, a runner was dashing to score. He slammed into both home plate and the catcher. The umpire called him safe.

Safe was the wrong word. Shattered was more like it. Mike's ankle had snapped, leaving his foot hanging at a right angle to his leg.

Until that day, Mike, a sturdy, vigorous 31-year-old, had been an "invincible" — part of a generation of young, healthy people with every expectation of well-being and little prospect of occupying a hospital bed.

What happened next to Mike, the son of my old college roommate, is the tale of a brand of charity that must be abandoned if the transformation of American medicine, called the Affordable Care Act, is to succeed.

After surgery and weeks of physical therapy, Mike had run up medical bills of more than $35,000. But he was lucky enough to find himself in a Raleigh, N.C., hospital that made a deal with him — a patient with two part-time jobs, no health insurance, no savings and no prospect of paying so large a bill.

Mike ended up owing less than $5,000, a third of his annual income. His parents paid that tab. The hospital wrote off the other $30,000.

With the arrival of the new year, Mike may not be so fortunate next time. And if Obamacare is to succeed, his luck should run out.

The Affordable Care Act should change the way hospitals collect from patients — imposing financial consequences not written into the law.

Mike is one of millions of young people who have made a habit of living day by day, giving no more than a passing thought to health coverage.

Republican saboteurs, trying to undercut the rollout of Obamacare, have been taking out surreal TV ads (featuring a grotesque "Uncle Sam" alternately playing gynecologist and urologist) aiming to convince young people that they don't need insurance.

They've even flitted around the country holding pizza parties to preach against what is supposed to be a conservative's North Star — personal responsibility.

In a perverse way, Mike's nearly free ride makes the right-wingers' case.

Never mind that emergency rooms don't have help for people with chronic conditions, such as diabetics in need of daily insulin shots, Parkinson's patients who depend on drugs to curb symptoms of their disease, cancer patients who require chemotherapy or any of countless other people with illnesses that are grave but don't fit the description of an emergency. And forget that the emergency room represents the highest cost of any routine health care — a cost absorbed by everyone else when the visitor to the emergency room cannot pay for the care.

Hospitals soon will have to reexamine an important question. How much care should a uninsured patient receive?

The apparent answer of Republicans, who have no health care plan to call their own, appears to be whatever it takes to fix the immediate problem. Concentrate on now, not on tomorrow.

In Mike's case, that might mean straightening the ankle and applying a cast. But surgery? Let him limp.

Most hospitals, unless they're run by free-market ideologues and are willing to risk loss of their public charters, are loathe to turn away patients.

Some hospitals, in Minnesota and elsewhere, have run into trouble after hiring bill collectors to hound patients with unpaid medical debts, no matter how unlikely payment may be.

Sometimes the billing departments of nonprofits have been aggressive chasing after former patients as well. In such cases, Congress would be wise to examine their tax-exempt status. What, after all, is the point of a nonprofit hospital if maximizing revenue is an overarching goal?

The North Carolina hospital that treated Mike was a nonprofit that merits the name. It negotiated a payment that Mike could manage, albeit with the help of his parents' checkbook.

A laudable act, but one that shouldn't be repeated in 2014 and beyond.

The hospital's charity, after all, is not charity at all. It's a health care tax on everyone else.

Republicans once acknowledged as much. Obamacare, after all, takes many of its principles from a 1989 plan promoted by the conservative think tank the Heritage Foundation.

"[A]ll households would be required to protect themselves from major medical costs by purchasing health insurance or enrolling in a prepaid plan," Heritage wrote. "The degree of financial protection can be debated, but the principle of mandatory family protection is central to a universal health care system in America."

Today, the carrot is bigger than the stick when the uninsured consider signing up for health coverage under Obamacare.

In Mike's case, his low income qualifies him for more than $2,700 a year in federal aid to pay premiums. Effectively, he would pay little or nothing for the least comprehensive coverage in North Carolina.

But the stick is hardly noticeable. In 2014, the uninsured pay only $95 for failure to sign up for Obamacare, or 1 percent of their income, whichever is greater. The penalties gradually climb to $695, or 2.5 percent of annual pay, in 2016. After that, the maximum penalties rise at the pace of inflation.

Why should hale and healthy young people, never mindful of accidents or illnesses that might befall them, worry about medical bills if they escape paying, in part or altogether?

Unpaid medical bills remain one of the chief reasons people file for bankruptcy protection. The goal of bankruptcy is to start again, with a clean slate.

So instead of letting uninsured, low-income patients walk away from their bills, Congress should encourage hospitals to avoid reaching settlements with patients who chose to sidestep health insurance.

Let the petulantly uninsured devote huge chunks of their income to paying off medical bills for years to come. After all, they passed on buying insurance.

When word spreads of friends and acquaintances being shackled with medical costs, buying health insurance may come to be considered hip.

Innovative hospital administrators, take note.

Let the hospital pick up the first $6,350 in charges for high-cost patients like my friend's son, Mike. But only if he's insured.

In the case of the fractured ankle, that would leave the hospital to collect about $29,000 from insurance — money that it formerly gave up on collecting.

The patient is rewarded for buying insurance. The hospital is recouping more of its costs. Even insurance companies benefit, in that such tales will underscore the wisdom of taking out health coverage.

Such innovations may be a while in coming. But Obamacare creates a framework for trying fresh strategies.

His father, an economist, has devised an incentive that may prove more powerful, however.

Any more trips to the hospital, Mike will be on his own. His parents have closed their checkbooks.