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An individual

Introduction

The Case for a Mandate

mandate, if

Roughly 46 million Americans are cur-

Some observers have seen an individual

federal, would be

rently uninsured.1 That has sparked a nation-

mandate as an achievable step on the road to

an unprecedented

universal coverage. Having long equated

al debate over how to expand coverage, with

insurance coverage with access to health care

many people setting a goal of "universal cov-

expansion of

and access to better health, they see an indi-

erage," that is, every American would have

government

vidual mandate as producing better health

some form of health insurance. Some people

outcomes. They argue, for example, that peo-

have advocated a single-payer system under

power.

ple will receive more preventive care if they are

which the government would administer a

covered by insurance. In reality, however, the

taxpayer-financed system. Others have called

experience of rationing under national health

for an employer mandate, requiring employ-

insurance schemes in other countries shows

ers to provide their workers with insurance.

that insurance coverage and access to care are

Both of those approaches have obvious prob-

entirely different things.8 Moreover, evidence

lems that have prevented them from gaining

much public support.

that insurance coverage or access leads to bet-

ter health outcomes is uncertain at best.9

As a result, a third approach to universal

coverage is now getting serious attention--an

Other observers, including economists of

individual mandate, a legal requirement that

all stripes, have tended to embrace individual

every American obtain adequate private health

mandates for another reason. When an indi-

insurance coverage. People who don't receive

vidual without health insurance becomes sick

such coverage through their employer or some

or injured, he or she still receives medical treat-

other group would be required to purchase

ment. In fact, hospitals are legally required to

individual coverage.

provide care regardless of ability to pay.

Such a mandate, if federal, would be an

Physicians do not face the same legal require-

unprecedented expansion of government

ment, but few are willing to deny treatment

power. As the Congressional Budget Office

because a patient lacks insurance.

noted in 1994, "The government has never

However, such treatment is not free. The

required people to buy any good or service as

cost is simply shifted to others--those with

a condition of lawful residence in the United

insurance or, more often, taxpayers. In fact,

States."2

uncompensated care costs an estimated

$40.7 billion per year, with 85 percent of that

Despite that, proposals for an individual

cost borne by federal, state, and local govern-

mandate have drawn a surprising degree of

ments.10 Thus, to a large degree individuals

support from conservatives. The Heritage

Foundation has supported such a mandate

without health insurance are "free riding" on

for more than a decade.3 Senate Majority

the rest of us.

In addition, those most likely to go without

Leader Bill Frist (R-TN) has expressed gener-

al support for the idea.4 Articles favoring an

health insurance are the young and relatively

healthy. For example, although 18 to 24 year

individual mandate have been featured in the

Weekly Standard.5 Ron Bailey endorsed the

olds are only 10 percent of the U.S. popula-

tion, they are 21 percent of the long-term

concept on the libertarian website, Reason.

com.6 Perhaps the latest such proposal comes

uninsured.11 For these young, healthy individ-

from Gov. Mitt Romney of Massachusetts, an

uals, going without health insurance is often a

expected Republican candidate for president

logical decision. However, this becomes a form

in 2008.7

of adverse selection. Removing the young and

healthy from the insurance pool means that

An individual mandate is an attempt to

those remaining in the pool will be older and

address real problems in the American health

sicker. That results in higher insurance premi-

care system. But there is ample reason to be

ums for those who are insured.12

skeptical of that approach.

2