The Debate Over Mandatory Health Insurance

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Guests:

Julie Rovner, NPR health policy correspondent
Stuart Altman, Professor of National Health Policy at the Heller School for Social Policy and Management, Brandeis University

The proposal to require people to have health insurance is one of the most controversial aspects of the health care overhaul bill, which is currently in the Senate Finance Committee. Right now, Massachusetts is the only state with a mandatory health care requirement. Guests evaluate how it could play out on a national scale.

NEAL CONAN, host:

This is TALK OF THE NATION. I'm Neal Conan in Washington. The Baucus Bill continues to make slow progress in the Senate Finance Committee. This version of health care overhaul is given the best chance to eventually become law, and while it's a long way from finished, it shares one crucial and controversial element with all the other proposals in Congress. If it's approved, it would require everyone to have health insurance.

Most Americans are covered under employer plans. Approximately 46 million people are currently uninsured. Under this individual mandate, they would have to buy health coverage or pay a fine. The size of that penalty and the levels of subsidies for the poor are still a matter for debate.

If you're among the uninsured, what would this mean for you? Give us a call. We also want to hear from listeners in Massachusetts, which has required all of its citizens to have health insurance for three years now. How's that working for you? 800-989-8255 is the phone number. Email us, talk@npr.org. You can also join the conversation on our Web site. That's at npr.org. Click on TALK OF THE NATION.

Later in the program, Orson Scott Card joins us to talk about the comic book adaptations of his two best-known sci-fi novels, but first, the individual mandate. NPR health policy correspondent Julie Rovner joins us here in Studio 3A. Always nice to have you on the program.

JULIE ROVNER: Always nice to be here.

CONAN: Now, this individual mandate is in the Senate Finance Committee bill. It's in all the other bills that have gone through Congress, as well. Why is it in all of them?

ROVNER: Well, you know, one of the most popular elements of all of these bills, popular on a bipartisan basis, is the idea of what we call the insurance reforms, to make it harder for insurers to turn people down if they have pre-existing conditions, particularly.

What the insurers will say, and with good reason, is that if they have to sell to everybody, they don't want people to be able to wait until they're sick to buy insurance.

So the idea is that the need to have everybody in the insurance pool, the sick and the healthy, and also the people can't wait until they're sick to get insurance. Hence, you get this individual mandate - so that everybody will have to have insurance, it will be easier for the insurers to spread that risk so that they can afford to sell to everybody who's sick or not. That's where you get the idea of this individual mandate.

Now, I should point out the original idea of this, there would also be an employer mandate, that employers would have to help to pay the costs for their workers. There is a lack of an employer mandate in the Senate Finance Committee Bill. There is an employer mandate in most of the other bills. So that little piece is missing.

What happens, though, about people who come and say, you know, can't we do this in little pieces, can't we just have the insurance changes? As I mentioned, it's hard to have the insurance changes without having some kind of mandate for everybody to be covered. You can't really have the mandate unless you have some help with poorer people to afford it. You can't have the subsidies without a way to pay for them, and then you end up with these big, behemoth bills.

CONAN: But just basically, you're describing a bit of a quid pro quo. The insurance companies, all right, if we have to cover everybody, if we can't deny people on the basis of - you've already been diagnosed with cancer, I'm sorry you can't buy insurance anymore - then if we're going to accept that risk, we have to get that new pool of customers. They have to buy insurance.

ROVNER: That's right. They want to have the healthy as well as the sick so they can spread those costs among everybody. Right now, the largest group of people without insurance are young people, age 18 to 24. The census numbers that came out just last week said that 29 percent of people between 18 and 24 don't have insurance. They'd like to get those people, who are largely healthy, into the pool and paying premiums so they can afford to cover the people who are sick.

CONAN: This, however, raises questions about forcing people to buy insurance or pay a penalty. What's the penalty?

ROVNER: Well, the penalty varies. And the penalty, I should point out, has been taken down since the bill was first introduced. Right now under the Senate Finance Committee Bill, the penalty would be, let's see, up to $950 a year for individuals, up to $1,900 a year for families. So it's a pretty big penalty. That's an excise tax.

In the House, there's also a penalty. It's up to 2.5 percent of your adjusted gross income, up to the cost of the actual average premium. So there are penalties in all of the bills if you don't buy these policies.

CONAN: And this is likely to be one of those things that keeps moving. This target is going to keep moving as the bill goes through various iterations and goes down to - well then finally - if it ever is - reconciled between the House version and the Senate version before it ends up on President Obama's desk, if it ever does.

ROVNER: Yes, it does. And you know, it's funny. If you look at the polls, there's a lot of resistance to this individual mandate, but of course, there's no resistance - the insurance changes are very popular. Having employers help provide insurance is very popular. The one piece of this, of course, that makes it all work is that everybody has to buy insurance or has to have insurance is the part that's not so popular, and yet that's the part that ties it all together.

CONAN: And we want to hear from those of you who do not have health insurance right now in this program. We also want to hear from those of you in Massachusetts, where this has been the law for three years. How's it working out? 800-989-8255. Email talk@npr.org, and Chip is on the line with us from Tulsa.

CHIP (Caller): Yeah, hi. I've actually tried, on a couple different occasions, to get insurance either through, Blue Cross and Blue Shield or the National Association of the Self-Employed or whatever, and the insurance is just so extremely expensive that it's just not - it's cost prohibitive. I can't make enough money being self-employed to afford it.

CONAN: And that's, Julie, the first thing that a lot of people are going to say.

ROVNER: That's right, and that's one of the things that would change under these bills, that there would be limits. You couldn't charge people who have these pre-existing conditions more, people…

CHIP: It's not that I have a pre-existing condition. I have two kids, and in order to get insurance for the two kids and myself through Blue Cross and Blue Shield, it was over $600 a month, and we had to make an appointment to get sick.

(Soundbite of laughter)

CHIP: And then when I went to go to work, when I became self-employed and tried to get insurance just for myself at the National Association of the Self-Employed, I was paying $480 a month, and none of the doctors that I normally would see were allowed or covered, and…

CONAN: They weren't part of the plan. So you weren't allowed to see them if you wanted to get health insurance coverage. So Julie, What would these bills do for Chip, if anything?

ROVNER: Well, the idea is that when they create these health insurance exchanges that there will be plans that are supposed to be affordable. Now, of course, affordable is in the eye of the beholder. The idea is depending on your income, there will be help on a sliding scale, but you could have to pay up to, depending on your income, 12 percent of your income just for premiums.

CHIP: You know, honestly what I would like to see, and I know this is just a pie-in-the-sky idea, but I would love to see the legislatures go, like, undercover and just go out into the workforce with assumed IDs and try to buy insurance on the open market so they could actually appreciate the struggle that we as citizens have to get decent insurance with affordable rates and not crazy deductibles or co-pays or anything. If there were some way to orchestrate that, just to allow them to actually see and experience the frustration that I have every day, whenever I'm trying to mess with the insurance companies, I think that would be way cool.

CONAN: Chip, I'm not sure that they would share your definition of way cool, but it sure would be interesting. Thank you very much for the phone call.

CHIP: Thank you.

ROVNER: It's definitely not easy out there, and that is definitely one of the things that these bills are trying to go after. There is, you know, obviously less expensive insurance, but you may have $10 or $15 or $20 thousand deductibles.

So the idea is to have comprehensive insurance that's affordable, but again what people describe, one person's affordable is another person's out of reach.

CONAN: Well, let's bring another voice into the conversation, Stuart Altman, a professor of national health policy at the Heller School for Social Policy and Management. That's at Brandeis University in Waltham, Massachusetts. He joins us from the studios of member station of WLIU in Southampton, New York, and nice of you to be with us today.

Professor STUART ALTMAN (Professor of National Health Policy, Heller School for Social Policy and Management, Brandeis University): Well, thank you, Neal, it's a pleasure.

CONAN: Now, this requirement has been, well, required in Massachusetts for three years now. How is working out there?

Prof. ALTMAN: Well, it's working pretty well. Obviously, there are people in Massachusetts that find that the current plan really hurts them. There are people who really had less expensive insurance before and now find they can't buy it. Because the way the system works in Massachusetts, the Connector, which is our insurance exchange, establishes what is considered to be an acceptable policy, and these policies do have restrictions on how high the deductible can be.

They require prescription drugs and other services that have to be covered. So there are people who are now required to buy it that find that it's more expensive, but as Julie pointed out, this individual mandate is the key to all health care insurance reform.

If you pull this piece out of it, the whole thing falls apart. And it falls apart, as Julie pointed out, because insurance companies would find they need to continue to medically underwrite. It also falls apart because these individuals, yes some of them are healthy, but some of them are sick, and the experience so far in Massachusetts has been that the insurance companies are getting a mix of both healthy and sick people.

CONAN: So among the uninsured in Massachusetts, that percentage of the 46 million that they had before, you'd think a lot of them are young and relatively healthy, but they're about the same as the regular population?

Prof. ALTMAN: Well, they're probably - over time, I think they will be healthier, but you know, those of us who argued we needed to have the uninsured covered argued that the uninsured weren't getting as much health care as they needed. And you know what? They weren't. And so a lot of our physician groups and hospitals are finding that people who are newly insured are asking for more health care.

CONAN: Well, because they can pay for it.

Prof. ALTMAN: That's exactly right, and the important thing that I did not even realize, and I've been studying this for a very long time, is that the - it turns out that the individual mandate is far more important than the employer mandate.

Almost - over 40 percent of those that are newly insured are people who previously were covered by their employer but chose not to get the coverage. And so they are now asking the employer to have coverage under an existing policy, partially paid for by the employer.

CONAN: Has this achieved, very broadly, the goals of first of all getting everybody or almost everybody health insurance coverage, and has it brought down costs?

Prof. ALTMAN: Well, actually, it - just before the economic meltdown, Massachusetts had reached a level of only two-and-a-half percent uninsured, which, compared to the national average of 15 percent, is incredibly low. So we had really reached almost universal coverage.

With respect to health insurance premiums, though, that's another story. The latest estimates are that insurance premiums for the fully insured, not the people who are being subsidized, is going up at about 10 percent, which is a very high number. So we're continuing to see a substantial amount of growth in our health care costs.

CONAN: All right, stay with us, if you would, Stuart Altman. Also, Julie Rovner will be with us. We'll talk more about mandatory health insurance in a moment, what it would mean to you and how people would pay for it. If you're in Massachusetts, how is this working out for you? 800-989-8255, or zap us an email. The address is talk@npr.org. Stay with us. I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

(Soundbite of music)

CONAN: This is TALK OF THE NATION. I'm Neal Conan in Washington. If a health bill passes, chances are you'll be required to have insurance, either through an employer or purchased on your own. If you're not covered now, you'd be fined. It's one of the more controversial proposals in the massive overhaul of the health care system and our focus today.

NPR health policy correspondent Julie is here with us in the studio. Stuart Altman, a health economist at the Heller School for Social Policy and Management at Brandeis University is with us from a studio on Long Island.

If you're uninsured, what would this mean for you? If you live in Massachusetts, the only state that requires all of its citizens to have health insurance, well, how's that working out for you? 800-989-8255. Email us, talk@npr.org. You can also join the conversation on our Web site. Go to npr.org, and click on TALK OF THE NATION.

Here's an email from Elizabeth in South Deerfield, Massachusetts. I have the Massachusetts coverage. As a self-employed person, it made getting insurance easier and less expensive, but the big problem of fighting insurance companies about what is covered, etcetera, remains. The good doctors are leaving private, primary-care practice, and the last thing anyone needs when sick is to have to fight an enormous bureaucracy about whether they will cover what you've been paying them premiums to cover. And Julie, would this new health care proposal - now, it's unfinished, we don't know exactly what the bill is going to be - but would it propose to answer this situation?

ROVNER: Well, certainly the idea of having these health insurance exchanges, there would be a goal of trying to deal with that also, I think, at least under most of the bills - the idea that there would be a centralize place to go to complain about problems with your plan, in addition.

I don't believe that the Connector in Massachusetts has that level of, you know, customer service in addition. I think their - the job that they do, and I think Stuart can answer this a little bit better than I, is to simply coordinate the plans that are available.

So I think that would be one thing that there would be an effort in some of these bills in Congress to address.

CONAN: To address. Stuart Altman?

Prof. ALTMAN: Well, I'd need to know more from that caller or emailer because the Connector does more than just be like a Travelocity. It really does negotiate with the insurance companies, makes sure that the coverage is what it says.

I suspect what's happening to her is a problem. It's not a problem unique to Massachusetts, it's just that we just don't have enough primary-care physicians. She is finding it difficult. Many primary care physicians are going into what we call concierge medicine and saying, you know, in addition, if you want to be seen by me, you have to pay an additional amount of money, and that is not covered by the insurance companies.

CONAN: A retainer, yeah. All right, let's get another caller on the line. This is Dick(ph), Dick in Raleigh.

DICK (Caller): Yes, thanks for taking my call. I've got a couple of points here. One of them is I personally do not want insurance companies influencing my medical care as they are now. I principally am a - I practice alternative care.

I try and stay away from drugs. I try and stay away from X-rays, from doctors because what they're doing is they're just administering policy of insurance companies, and insurance companies to me are at the heart of the cost problem.

I didn't need them before. They don't need to be between me and my doctor or me and my hospital or me and anything. If they're not there, I can deal with it. I can actually understand the cost. I don't understand a single thing about insurance and what they care to give me, what they want to give me. It's deceptive. You know, they're talking about giving me 80 percent. Eighty percent of what? Eighty percent of what I've got coming from particular care.

So anyway, the alternative-care issue, the issue about insurance being between me and my medicine, and I don't believe in somebody…

CONAN: You're going back over earlier points, Dick. Is there a question here?

DICK: No, I wanted to make those points.

CONAN: Okay, thanks very much for the call, appreciate it. Alternative providers, would they be insured, would they be repaid, Julie?

ROVNER: Many private health insurers do cover alternative practitioners, and no reason to believe they would stop. I also think - I'm pretty sure that under these bills that there would be - the way it works is that these plans would have to have actuarial equivalence, is what it's called. So I'm sure that there would be plans that would still allow people to buy coverage that would have, for instance, you know, a large deductible. So if this caller wanted to buy a plan with a big deductible and not that much coverage up front, and he wanted to get his alternative care, and then perhaps he'd only have catastrophic coverage if, you know, he was run over by a bus, he could probably do that.

CONAN: There is an analogy that many people make, saying: what is the difference between requiring people to have health care coverage and requiring everybody who owns a car to have car insurance? And we have an email question on that point from Dorothy in St. Louis: This drives me crazy. Can no one understand the distinction, she writes? You're only required to have car insurance for damage you might do to another's automobile. You're not required to insure your own car. Your lien holder, if you have one, will require you to have insurance on your car, but if your car is paid off, it can be left uninsured - I'm not sure that's right.

Anyway, requiring health insurance would be like a requirement to have insurance to fix your own car. I will not buy health insurance. I cannot afford it, and I cannot afford any amount in payment. Luckily, I'm almost 61 years old, so I have only four more years until Medicare.

But this analogy that we keep hearing, what's the difference between…

Prof. ALTMAN: It is…

CONAN: Go ahead Stuart, I'm sorry.

Prof. ALTMAN: I'm sorry, Neal. Well, I'm sorry. Your caller is not right in the following sense. Hundreds, if not thousands, of people every day wind up in emergency departments and hospitals that are uninsured, and as a result, these hospitals, doctors and the health care system really provides hundreds of millions of dollars of free care every year.

This free care is ultimately paid for by those who have insurance. That caller or emailer would, in a very real sense, similar to car insurance, be a potential risk, and the people like me and you, who are insured, would wind up paying the bill, and we call them free riders, and the system has to change.

Employers, particularly large employers, find that they're paying three times. They're paying for their workers, they're paying for their workers' families, and they're paying for the uninsured. So she's not right.

CONAN: There's another problem with the analogy, though, Julie. You don't have to have a car.

ROVNER: That's right, and actually…

Prof. ALTMAN: That's a very good point.

ROVNER: I heard a libertarian make the argument last week who said that, you know, that the differences with car insurance, you can get by without a car, but with health insurance, it's pretty hard these days to get by without a body.

(Soundbite of laughter)

CONAN: Let's get another caller on the line. This is Sandy(ph), Sandy with us from Denver.

SANDY (Caller): Hello.

CONAN: Hi, Sandy, go ahead, please.

SANDY: Hi, thank you so much for taking my call. I just drove through a dead spot. I am a 58-year-old, unemployed, diabetic cancer survivor. I'm presently on COBRA. I am absolutely flabbergasted at what could happen to me once my COBRA runs out, and I understand that, you know, 20-year-olds probably don't think they need to have health insurance, but on the other hand, I am looking at having had health insurance for various employers for about 35 years, and now all of a sudden I am about to be just kind of cut adrift.

CONAN: And so if - when your COBRA runs out, you're afraid you won't be able to get coverage because will have the cancer as a pre-condition?

SANDY: Exactly. I mean, I may be able to get coverage, but who knows what it's going to cost.

CONAN: Julie?

ROVNER: That's correct. Actually, under a law passed in 1996, when your COBRA expires, they are required to offer you a continuation policy, but under that same law, they're not required to offer it to you in any way that you might be able to afford.

CONAN: And how would that change under the proposed legislation, again not finished.

ROVNER: Again not finished, but again, that's exactly the type of thing that's being talked about, that things like these pre-existing conditions would not be taken into account.

On the other hand, there are age-rating restrictions that they are talking about so that someone who is in their 50s could be charged considerably more than someone who is in their 20s. That's a big fight that they're looking at. In the House bill, someone, you know, in their 50s could only be charged twice as much as someone in their 20s. In the Senate bill, they could be charged four times as much.

So it's still going to be expensive, but at least, you know, this woman is probably going to - it would be considerably cheaper than what she's probably looking at for when she runs out of her COBRA.

CONAN: Sandy, good luck.

SANDY: Thank you so much.

CONAN: Email, this from Dan(ph) in Tulsa. What's going to happen to those people such as veterans who don't have insurance but are basically covered by the VA benefits? I work but don't buy health insurance through my employer, the federal government, because the VA treats any medical issue I may have, even those not related to my disabilities. Would I be forced to buy insurance under this plan if it becomes law. Stuart Altman, do you know about that?

Prof. ALTMAN: My sense is that if you have coverage that is equivalent, you would be covered, but Julie may have a better sense of what's in the federal law.

CONAN: Julie?

ROVNER: Yeah, I believe that people who have VA coverage would not be affected. That would be considered…

CONAN: That's what I thought, as well.

ROVNER: Yeah, you would be covered.

CONAN: Let's go to Kyle(ph), Kyle with us from Lewisburg in Kansas.

KYLE (Caller): Hi, how's it going?

CONAN: Pretty well.

KYLE: Good. I'm glad you guys are talking about this. I've been waiting for this issue to come up on your show.

CONAN: Go ahead.

KYLE: Well, I'm 22. I'm from Kansas, and I voted for Obama, but now I'm kind of having some regrets because I do feel like this has kind of taken away some freedom by making us buy insurance, and I'd rather save my money and pay cash or get a payment plan if I go to the doctors.

CONAN: And if this is passed, and you did that, you'd have to pay a fine when you file your income tax.

KYLE: I know. And I don't know. It doesn't seem right to me. And I'd just like it to be an option, just like the WIC program is or FAJ loans. It's - you know, it's an option that you can do or you can choose not to. And like you say, you can own a car and not own a car, but if you want - you know, what I mean?

Prof. ALTMAN: Well, that's…

KYLE: I just want to have the freedom over safety and security.

CONAN: And Julie, that - Kyle's point is something that a lot of people bring up. The government is forcing you to have health insurance.

ROVNER: Yes, indeed it is. That's why this is a very touchy subject. This was a big deal when it went through in Massachusetts. They tried to do it in California, and they could not get it through because a lot of people objected. And it was not just Republicans. There were a lot of Democrats who would have rather had a single-payer system like Canada's, who didn't like the idea of having an individual mandate. They were concerned about people being required to pay, perhaps, more than they could afford.

But there also is this libertarian streak in the American psyche that people don't want to be required to spend money. You know, whether or not it's a tax -and that's a fight amongst itself - people don't like to be told what they have to do with their money. And that's exactly what this is.

CONAN: Stuart Altman, I wonder, where there constitutional challenges in Massachusetts? People saying, wait a minute, the government can't force me to do this?

Prof. ALTMAN: Not that I know of. There - obviously, we have the same kind of people as everybody else, and this was not uniformly supported. But it's surprising how little opposition we're getting. There - as I pointed out in the beginning, there are individuals who do voice their concerns, but it is not a major issue. You'd be surprised in a positive way how little opposition we've had to our - when you go outside of Massachusetts, you read stories about the system failing. But you come to Massachusetts, you don't see it very much at all.

CONAN: And Kyle, I wonder if you'd feel the same way if you suddenly got into an accident.

KYLE: Well, yeah. And I would be paying for that paying for that for a long time, but I would not just be a freeloader and say, oops, sorry. You know, I would stick to it. And I think that a lot of young people, you know, are very freedom-minded right now, you know, maybe not as they get older, like you say, and have more health problems.

CONAN: Julie?

ROVNER: You know, I have a chance to go…

KYLE: (unintelligible)

ROVNER: …to Switzerland last year, which has an individual mandate, much as is being discussed, and not, you know, not an employer mandate. People have to buy themselves - and actually insurance is very expensive in Switzerland. And there is some help, but not a lot. People pay a lot. And I was really shocked at how people were completely blase about the whole thing. They were - you know, the idea that, of course we're required to buy health insurance. Why wouldn't be -we be required to buy health insurance? They were just - they were very proud of their system. They were completely - it just - it seemed so ingrained in the culture. And I thought, boy, it would just seem so odd to have this conversation in America.

But, you know, everybody, everybody I talked to - of course, it was the first question I asked everyone. And they were like, oh, yeah. We think it's just -it's fine. It's great. Nobody minded the money that they paid. They loved the idea of having health insurance and the idea that it was universal, and the idea that they had to pay this money every month - no problem.

CONAN: Thanks very much, Kyle.

Prof. ALTMAN: Neal?

CONAN: Very quickly, if you would.

Prof. ALTMAN: I appreciate what this caller said about he'd pay his bills. But he should realize that his bills would be three times higher for the same service if he was uninsured. And while I know he would try, the reality is that very few people pay their bills who are uninsured.

CONAN: We're talking about mandatory health coverage. And you're listening to TALK OF THE NATION from NPR News.

And the gentleman you just heard is Stuart Altman, professor of national health policy at the Heller School for Social Policy and Management at Brandeis University in Massachusetts. Julie Rovner is also with us, NPR's health policy correspondent.

Just to follow up on Stuart Altman's point, this email from Tara: I'm a self-employed photographer living in Boston. The mandatory health insurance in our state has been almost too good to be true. Because I didn't make much money my first two years in business, my health care was completely free. I made more money last year, and my monthly payment went up to $77, which is completely comfortable for me.

I have a $15 co-pay for a physician visit, $15 for prescriptions, and I was able to choose between four different companies for coverage. I love my doctor. I haven't had a single problem. I used to think Martha's Vineyard was the best thing ever happened to Massachusetts. Now I think it's mandatory health care. I hope the rest of our country can enjoy the same peace of mind and pride in their health as I'm doing here in Massachusetts.

Let's see if we can go to another caller - David with us from Cornwall in Connecticut.

DAVID (Caller): I guess - hello. I guess - I wanted to express the idea that I don't have health insurance now, so I'm instead putting the amount I would have paid for health insurance into my own account. But I wouldn't object at all to a mandate for individual insurance if it was in support of a government option. But I do object to the individual mandate if it has to go to insurance companies who have all that excessive overhead.

CONAN: Well, there might be other options, at least in the Baucus bill - these co-ops that we're talking about, Julie?

ROVNER: That's right. There would be, you know, member-owned and member-run co-ops that would not be, technically, private insurance. It would also not be government-run. So, there could be something that's at least envisioned to be in between.

DAVID: Well, I just heard someone on the radio a couple of hours ago who seemed well-informed on the subject who said that overhead in Medicare, for instance, is between three and $.06 on the dollar.

CONAN: Four percent, yes. Yeah.

DAVID: And that overhead in the best of the nonprofit HMOs was about $.13 on the dollar.

CONAN: Is he right, Julie?

ROVNER: Yeah, that's about right.

DAVID: And indeed, the worst of the HMOs was about $.37 on the dollar. And so, I'm just - I would much rather have a mandate in the direction of supporting something that had overhead of between of three and $.06 on a dollar.

CONAN: Well…

ROVNER: Neal…

CONAN: Very quickly, if you would. We're running out of time. Thank you for the call, David.

Prof. ALTMAN: Okay. Just - I want to make one point to play that up: You can't use the Medicare analogy when it comes to - even a government insurance. Medicare has everyone immediately covered, and it - so it doesn't have to sell. You go - if you set up these private plans that have to sell to individuals, while they may not be as high as insurance companies, they're not going to look anywhere like Medicare, those numbers make no sense.

CONAN: And one quick email question from Amy - this to you, Julie: I'm a nurse and we treat many Amish families who do not believe in insurance. Would they be exempt?

ROVNER: Yes, they would.

CONAN: All right. Thank you. It was one quick answer we can give you. Thank you both for your time. NPR health policy correspondent Julie Rovner, here with us in the studio. And Stuart Altman at the Brandeis University in Waltham, Massachusetts, joined us today from member station WLIU in South Hampton, New York. Appreciate your time today.

ROVNER: Sure.

Prof. ALTMAN: Well, thank you.

CONAN: And when we come back, we're going to be talking about comic books. With the adaptations of two science fiction classics by Orson Scott Card: "Ender's Game" and "Ender's Shadow." The professor of writing and literature at Southern Virginia University will join us. Stay with us.

I'm Neal Conan. It's the TALK OF THE NATION from NPR News.

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