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How Much Does the Mandate Matter, Anyway?

6/22/2012 3:52:57 PM

Tags: Affordable Care Act, Individual Mandate, Barack Obama, Health Care Reform, Supreme Court, Anthony Kennedy, Medicaid, Sam Ross-Brown.

Supreme Court Cartoon

A lot of Americans have been bracing for bad news from the Supreme Court this week. No one knows how the Court will decide on the Affordable Care Act (ACA), but it doesn’t look good for the law’s supporters. In particular, Anthony Kennedy’s tough questions for Obama’s solicitor general during last March's hearings don’t bode well. If Kennedy turns out to be the bench’s swing vote, his dead-set passion for individual liberty may spell big trouble for the law's insurance mandate.

But how important is the mandate? Actually, for most Americans, not that much, says the Nation’s George Zornick. While the mandate does make getting individual insurance mandatory, the vast majority of Americans are either insured already, qualify for assistance, or are exempt. That’s according to a recent Urban Institute study that Zornick cites, which puts the ongoing debate into a little bit of context. For starters, about a third of nonelderly Americans (88m) don’t have to worry about the mandate at all. The list of official exemptions is a long one, and includes Native Americans, those with religious objections, the very poor, prisoners, and others. And most of these people (63m) already have some kind of insurance anyway.

And if you’re not exempt, chances are you already have insurance, or you qualify for assistance. According to the Urban Institute, 26 million now-uninsured Americans would need to buy into a plan, but most (19m) would qualify for free coverage through Medicaid or CHIP, or receive subsidies for private plans. It’s the remaining 7 million that much of the controversy is about. And because eligibility for Medicaid and other assistance is mostly based on income, there’s much less of a chance that the mandate would punish the people who can’t afford coverage in the first place.   

All told, if the entire ACA went into effect today, about 98 percent of Americans would comply with the mandate, or qualify for assistance. That means that the number of Americans who oppose the ACA (47 percent) is more than 20 times the number who would personally be affected by the mandate. As long as the safety-net parts of the ACA remain intact, most people probably wouldn’t notice if we lost the mandate.    

So who should really be biting their nails right now? Insurance companies, says Kevin Drum. Writing on, Drum points out that the mandate is really set up to benefit them. This was the Obamacare argument all along: without a mandate, healthy people won’t buy in. Insurers would then have to pick up the tab for millions of Americans who until now couldn’t get coverage because they were too sick—not to mention the healthy people once they finally get sick themselves.

But if the Court does strike down the mandate, says Drum, all is not lost. We won’t see most of these problems for at least a few years, and by that time, the ACA will be hard to completely reverse. The only option then is making it work in the long-term, which may mean “Congress passes a constitutionally approved version of the mandate (for example, by making it a tax credit) or else nationalizes health care even further.” Meanwhile, the subsidies will kick in much sooner. Whatever the Court decides, there’s nothing saying this is the end of the debate.

That’s exactly what Utne assistant editor Suzanne Lindgren pointed out a couple of months ago, and it seems even truer now. Most Americans still want major health care reform, and a shakeup over the mandate would only reopen the discussion. Strong majorities still favor single-payer, she found, and if the Supreme Court strikes down all or part of the ACA, we may begin to move in that direction. Whatever the Court decides, there are still a lot of options on the table.

Sources: New York Times, The Nation, Urban Institute, Gallup,,  

 Image by DonkeyHotey, licensed under Creative Commons.  


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