Risk Insider: Noah Skillin

Do I Have a Right to Be Uninsured?

By: | May 2, 2017 • 3 min read
Noah Skillin is the COO and a founder of Risk Cooperative. His focus is on leading the marketing, compliance, systems and IT for a global risk and insurance advisory firm based in Washington, DC. He is an experienced risk management practitioner holding PMP and CRM designations.

With the ongoing attempts to repeal the Affordable Care Act, one key argument against the ACA is that the mandate for all individuals to have health insurance coverage strips Americans of their right to make a personal decision. But is it only personal? Should individuals have the right to refuse coverage and go uninsured?


On paper in a zero-sum world, the answer to this question is easy. If you want to take the risk of not having health insurance, who is to stop you? Presumably individuals can weigh the cost of having coverage against the chance of needing medical attention and determine if they wish to forego coverage.

However, it’s not that simple. When others go without insurance, it not only comes at a cost to society, but also to the individuals who have elected to pay for insurance, as well as the businesses that provide it to employees.

When the number of individuals experiencing serious medical conditions is higher, it can also lead to full hospital and emergency room beds and increased waiting times for ambulances and treatment, impacting both insured and uninsured individuals alike.

Many argue that the lower-cost options under the ACA come with high deductibles that require patients to pay significant fees out of pocket. While it is true that there are high-deductible plans, it is important to note that a primary feature of the ACA was to ensure that preventative care is available to all Americans without being subject to any deductible.

In other words, any insured person can seek treatment for preventative or wellness benefits, such as annual physicals. These visits often uncover issues early on, when they are more easily and affordably treated. However, when an individual is uninsured, they are unlikely to seek treatment for seemingly minor issues. Often, these issues are exacerbated if they are not treated early.

The end result may be much more serious and costly emergency medical visits. In addition, with the rise of vector-borne diseases, such as Zika and others, when the uninsured do not seek treatment early it can lead to more rapid spread of the disease throughout society.

When the number of individuals experiencing serious medical conditions is higher, it can also lead to full hospital and emergency room beds and increased waiting times for ambulances and treatment, impacting both insured and uninsured individuals alike.

A healthier community is important for the economy. If workers are sick, they either miss work or work while impaired, decreasing their productivity. The healthier they are, the more productive and thus the stronger the economy.

There are also real costs that may be passed on to insured individuals. Since the passing of the Emergency Medical Treatment and Labor Act in 1986, emergency departments are federally mandated to treat patients regardless of insurance or ability to pay for treatment. When an uninsured patient comes to an emergency room, he or she receives the same treatment as an insured patient — and these are often the costliest as they are, by their nature, serious events.


When the patient is unable to pay after the fact, there is little recourse for the hospitals to recuperate funds for the treatment provided. This in turn can lead to higher fees and increased insurance costs for those who are insured, in addition to taxpayers funding this through Medicare and Medicaid programs.

Patients without insurance cost the health care system billions each year. The American Hospital Association estimated that hospitals in 2015 provided more than $35 billion worth of uncompensated care.

While it may seem like a personal decision to buy insurance or not, the reality is the choice has serious consequences on others, including those who cannot afford insurance and others who are insured. The impacts can range from worse care, to increased spread of diseases, to a less productive workforce.

More from Risk & Insurance

More from Risk & Insurance

Risk Management

The Profession

Janet Sheiner, VP of risk management and real estate at AMN Healthcare Services Inc., sees innovation as an answer to fast-evolving and emerging risks.
By: | March 5, 2018 • 4 min read

R&I: What was your first job?

As a kid, bagging groceries. My first job out of school, part-time temp secretary.

R&I: How did you come to work in risk management?

Risk management picks you; you don’t necessarily pick it. I came into it from a regulatory compliance angle. There’s a natural evolution because a lot of your compliance activities also have the effect of managing your risk.

R&I: What is the risk management community doing right?


There’s much benefit to grounding strategic planning in an ERM framework. That’s a great innovation in the industry, to have more emphasis on ERM. I also think that risk management thought leaders are casting themselves more as enablers of business, not deterrents, a move in the right direction.

R&I: What could the risk management community be doing a better job of?

Justified or not, risk management functions are often viewed as the “Department of No.” We’ve worked hard to cultivate a reputation as the “Department of Maybe,” so partners across the organization see us as business enablers. That reputation has meant entertaining some pretty crazy ideas, but our willingness to try and find a way to “yes” tempered with good risk management has made all the difference.

Janet Sheiner, VP, Risk Management & Real Estate, AMN Healthcare Services Inc.

R&I: What was the best location and year for the RIMS conference and why?

San Diego, of course!  America’s Finest City has the infrastructure, Convention Center, hotels, airport and public transportation — plus you can’t beat our great weather! The restaurant scene is great, not to mention those beautiful coastal views.

R&I: What’s been the biggest change in the risk management and insurance industry since you’ve been in it?

The emergence of risk management as a distinct profession, with four-year degree programs and specific academic curriculum. Now I have people on my team who say their goal is to be a risk manager. I said before that risk management picks you, but we’re getting to a point where people pick it.

R&I: What emerging commercial risk most concerns you?


The commercial insurance market’s ability to innovate to meet customer demand. Businesses need to innovate to stay relevant, and the commercial market needs to innovate with us.  Carriers have to be willing to take on more risk and potentially take a loss to meet the unique and evolving risks companies are facing.

R&I: Of which insurance carrier do you have the highest opinion?

Beazley. They have been an outstanding partner to AMN. They are responsive, flexible and reasonable.  They have evolved with us. They have an appreciation for risk management practices we’ve organically woven into our business, and by extension, this makes them more comfortable with taking on new risks with us.

R&I: Are you optimistic or pessimistic about the U.S. health care industry and why?

I am very optimistic about the health care industry. We have an aging population with burgeoning health care needs, coupled with a decreasing supply of health care providers — that means we have to get smarter about how we manage health care. There’s a lot of opportunity for thought leaders to fill that gap.

R&I: Who is your mentor and why?

Professionally, AMN Healthcare General Counsel, Denise Jackson, has enabled me to do the best work I’ve ever done, and better than I thought I could do.  Personally, my husband Andrew, a second-grade teacher, who has a way of putting things into a human perspective.

R&I: What have you accomplished that you are proudest of?

In my early 20s, I set a goal for the “corner office.” I achieved that when I became vice president.  I received a ‘Values in Practice’ award for trust at AMN. The nomination came from team members I work with every day, and I was incredibly humbled and honored.

R&I: What is your favorite book or movie?

The noir genre, so anything by Raymond Chandler in books. For movies,  “Double Indemnity,” the 1944 Billy Wilder classic, with insurance at the heart of it!

R&I: What is your favorite drink?


Clean water. Check out Water.org for how to help people enjoy clean, safe water.

R&I: What’s the best restaurant at which you’ve eaten?

Liqun Roast Duck Restaurant in Beijing.

R&I: What is the most unusual/interesting place you have ever visited?

China. See favorite restaurant above. This restaurant had been open for 100 years in that location. It didn’t exactly have an “A” rating, and it was probably not a place most risk managers would go to.

R&I: What is the riskiest activity you ever engaged in?

Eating that duck at Liqun!

R&I: If the world has a modern hero, who is it and why?

Dr. Seuss who, in response to a 1954 report in Life magazine, worked to reduce illiteracy among school children by making children’s books more interesting. His work continues to educate and entertain children worldwide.

R&I: What do your friends and family think you do?

They’re not really sure!

Katie Dwyer is an associate editor at Risk & Insurance®. She can be reached at [email protected]