I believe that individual mandates are highly advantageous, for the following reasons:
Universality
If one of the goals of health reform is to ensure universal health coverage, then why abandon that goal before you even start? It is sometimes argued that individual mandates won't ensure universality, pointing to the examples of mandated auto insurance. This, however, is a faulty comparison: auto insurance is not sold on a sliding scale basis. Both the Edwards plan and the Clinton plan suggest tax credits that would in effect make health insurance less expensive for people with lower income. Besides, the question that should be asked is not "do individual mandates guarantee 100% coverage" but rather "do individual mandates guarantee substantially higher coverage than lack of such mandates". I don't think you could argue in good faith that substantially higher coverage couldn't occur.
People also question how individual mandates might be enforced. A commenter at Bleeding Heartland suggests that this could easily be tied to the income tax structure, as is done in Canada:
| One way on how it could be done is if you have purchased a plan it shows up on the income tax form, if not, then you pay for a public plan. If your income is at a certain level you get subsidies or you don't pay. There are a number of ways to deal with it without it becoming an enforcement nightmare. |
(Of course even Obama's plan will have to address the issue of enforcement, as it too includes a mandate, but only for children. Nevertheless there would need to be some way to enforce that.)
Others have pointed out that any universal health plan includes an individual mandate, whether paid to an insurance company or through taxes. While discussing plans debated in California, Ezra Klein addresses the issues of universality thusly,
| I'm hearing a lot of hating on the individual mandate* -- and I don't get it. Some are complaining that the mandate "criminalizes the uninsured," others are saying "The uninsured shouldn’t have a financial penalty onto top of the health and financial consequences of being uninsured." So let me try and say this clearly: Single-payer health care is an individual mandate. The enforcement mechanism, in that case, is taxation. If you don't pay your taxes, you're breaking the law. If you decide to withhold the portion of your taxes that go towards health care, you're a criminal. In fact, there is absolutely no universal health care system that wouldn't include a mandate of some kind -- that's how you make it universal. |
Some plans put forth by Republicans that include individual mandates have failed to provide enough relief to low-income families. However, if such relief is offered, individual mandates are both fair and important toward achieving universality and affordability.
Affordability
A major challenge for any health reform is making coverage more affordable. This becomes much more difficult if you allow the young and healthy to opt out. Again, I defer to Ezra Klein's simple explanation of the matter:
| Indeed, without a mandate, you can't have a decent health system: If the healthy can opt-out until they get sick, coverage will be unaffordable for everyone. For a risk pool to work, it needs members at low risk. |
The same principle would be at play in a single payer system. People would have to support the system through their taxes even if they are young and healthy. It is this principle of mandatory inclusion of all, both the healthy and the unhealthy, that makes universal health insurance affordable.
Getting a Plan Through
Of course the most important element of any plan is getting it passed. Some might think that Obama's plan would be easier to achieve because it is less ambitious. But, ironically, in this case it would likely be easier to get the more ambitious Edwards and Clinton plans through. Why? Because the high demands they make on the insurance companies (i.e., that they guarantee a certain level of coverage to everyone, no matter what there pre-existing conditions) are offset by a benefit to insurance companies (a much larger pool of insured, due to individual mandates). If you remove this "carrot" of a much larger pool, you will have insurance companies fighting this tooth and nail, and it will be much more difficult to get up to 60 votes in the Senate without otherwise further weakening the program. Interestingly, though, as pointed out above, this is not just a benefit to the insurance companies, but it is an overall advantage to the program as it helps bring us closer to universality and brings down costs for everyone.
Experts Speak Out
Numerous health care experts have spoken out about the need for an individual mandate. Here are just a few excerpts:
Kaiser Family Foundation's Diane Rowland: 'An individual mandate is the only alternative to government provision of coverage if you hope to achieve universal healthcare.'
Urban Institute's John Holahan: 'Implementing universal coverage requires an individual mandate.'
New American Foundations' Len Nichols: ‘Programs that do not require participation will never approach universality.’
United Hospital Fund: 'An individual mandate is required to achieve universal coverage.'
California Medical Association: ‘There will be no significant improvement in health care coverage without some type of mandate.'
Summary
In summary, individual mandates are a win-win situation. When accompanied by tax credits to individuals to make health insurance affordable (as the Edwards and Clinton plans do), the main opposition to them comes from right-wing groups such as CATO, which view them as a "slippery slope to national health care." That's hardly a reason for progressives to oppose them.
People can judge for themselves whether this is an important enough issue to sway their support for a candidate. And, left unsaid in this diary are the somewhat smaller differences between the Edwards and Clinton plan (are the differences between all three of these plans and Kucinich's single player plan). Those will have to be discussed elsewhere.
I look forward to your comments.
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