Insurance Mandate May Be Health Billfs Undoing
Published: November 15, 2011 - New York Times
WASHINGTON — As Barack
Obama battled Hillary Rodham Clinton over health
care during the Democratic presidential primaries of 2008, he was adamant
about one thing: Americans, he insisted, should not be required to buy health
insurance.
gIf things were that easy,h Mr. Obama told the talk show host
Ellen DeGeneres in February of that year, gI could mandate everybody to buy a
house, and that would solve the problem of homelessness. It doesnft.h
Now President Obama may wish he had stuck to those words. On Monday, the Supreme
Court agreed to take up a constitutional challenge to his landmark health
care bill, and a decision could come in the midst of Mr. Obamafs 2012
re-election campaign.
At the heart of the challenge is gthe mandateh — a provision requiring nearly
all Americans to buy coverage or pay a penalty — that he so vigorously opposed
as a candidate. If it is struck down, much of his signature legislative
achievement could fall with it in a decision that would undoubtedly be construed
as a rebuke to the president.
Polls show the mandate is by far the most unpopular provision of the 2010
bill, and now Mr. Obama, who ultimately embraced the idea, is in the awkward
position of defending something he once rejected.
gI think his political instincts were right,h said Paul Starr, a health
policy expert at Princeton University who argues it is possible to expand
coverage by other means. gI think he saw that there could be a backlash against
a mandate and that there needed to be some other kind of approach. So in a way,
Ifm sorry he didnft stick to his original position.h
The theory behind the mandate, according to its proponents, is this:
Requiring coverage brings both sick and healthy people into the pool of those
insured, which is essential because premiums paid by the healthy offset the cost
of covering the sick. Otherwise, healthy people wait until they are ill to buy
insurance, which leads to what policy analysts call a gdeath spiralh in which
premiums skyrocket out of control.
As a candidate, Mr. Obama did favor requiring all children to have insurance.
Once he took office, his top aides began examining other options, said Ezekiel
J. Emanuel, a former health policy adviser to Mr. Obama. The aides studied
the experience of Massachusetts, which has a mandate, and health laws in other
states that do not. They considered voluntary incentives to get healthy people
to enroll.
Their internal modeling, Dr. Emanuel said, showed that a mandate would extend
coverage to 32 million uninsured people. Without such a requirement, he said,
the administration estimated it could cover 16 million people at three-fourths
the cost of covering the 32 million. Mr. Obama reversed himself.
gI donft think it was a slam-dunk,h said Dr. Emanuel, now a vice provost at
the University of Pennsylvania and a regular contributor to the New York Times
Op-Ed page. gThe president did take very seriously his reputation for following
what he said, so he was very reluctant to change his opinion unless he was very
convinced.h
Health insurers also insisted on a mandate, as did the Democrats who
controlled Congress. In July 2009, Mr. Obama told CBS
News that he was gnow in favor of some sort of individual mandate as long as
therefs a hardship exemptionh for people who truly could not afford to buy
insurance.
While the White House may have been prepared for the public unhappiness over
the provision, it appears to have been caught off guard by the constitutional
challenge — in part because Obama advisers regarded the mandate as a
conservative notion. The idea gained currency in the early 1990s, when some
Republicans proposed their own version of an gindividual mandateh as an
alternative to the gemployer mandateh in President Bill Clintonfs health plan.
Polls show the individual mandate is unpopular. The Kaiser Family
Foundation, which tracks public opinion on the health measure, reported in
March that 74 percent of Americans would keep, rather than repeal, the lawfs
provision barring insurers from discriminating against people with pre-existing
conditions. But only 27 percent would keep the mandate. (A CNN poll released
Monday found 52 percent support the mandate, up from 44 percent in June, though
unlike Kaiser CNN did not explain that failure to comply would result in a
fine.)
The Obama administration insists that if the mandate falls, so does the
provision on pre-existing conditions. gThe mandate,h said Jonathan Gruber, a
health economist at the Massachusetts Institute of Technology who has advised
the administration, gis the spinach you need to get the chocolate you want.h
Chris Jennings, a former health policy adviser to Mr. Clinton, makes much the
same point. gHealth reform without an individual requirement,h he says, gis like
driving a train without tracks; you can still move, but you canft get to your
coverage destination and it will be a rougher and far more costly trip.h
But not all economists agree. Some say the government has other ways to make
sure enough healthy people buy insurance and offset the cost of the sick. One
option is gauto enrollment,h in which the government would automatically enroll
citizens in insurance plans, but give them the chance to opt out. Mr. Starr, the
Princeton professor, who helped draft the Clinton health bill, proposes a system
of penalties and incentives to get healthy people to enroll. For instance,
people could be given a choice: Sign up now, or wait another five years.
Of the four appeals courts that have weighed the constitutionality of the Patient
Protection and Affordable Care Act, only one has struck it down. The most
recent decision, issued last week by the District of Columbia Circuit Court of
Appeals, upheld the law. The Supreme Court decision will almost certainly thrust
health care back into the public debate next year. But its effect on Mr. Obamafs
re-election campaign remains to be seen.
Professor Starr says a finding that the mandate is unconstitutional would be
ga severe blowh to the act, and the Obama presidency.
But Drew Altman, the president of the Kaiser Family Foundation, said health
policy rarely affected election outcomes. gIf any health care issue is a voting
issue,h Mr. Altman said, gitfs not health reform, itfs Medicare.h
Some experts say that if the bill had imposed a tax on Americans who did not
have insurance — rather than requiring them to buy a policy — the entire legal
fight might have been avoided.
gItfs a little bit surprising that the constitutional arguments werenft out
there sooner,h said Mark McClellan, who ran Medicare under President George W.
Bush. gThey could have written it in a way that would have better overcome the
constitutional challenges.h
That may be what the Supreme Court orders. But for Mr. Obama, it may be too
late. The Republican leaders in Congress want to repeal the bill, not rewrite
it.