How Much Does the Mandate Matter, Anyway?

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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 MotherJones.com,
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,
MotherJones.com,
Utne.com.

Image by DonkeyHotey,
licensed under Creative
Commons
.

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