An individual mandate would be an unprece-
Insurers unable to charge more for an
dented expansion of government power and
increasingly expensive product can be expected
intrusion into the American health care system.
to trim costs by cutting back on their reim-
As the CBO puts it:
bursement rates to hospitals and physicians.
The result will ultimately be rationing and a
An individual mandate has two fea-
lack of available health care goods and services.
tures that, in combination, make it
An individual mandate, therefore, should
unique. First, it would impose a duty
not be seen in a vacuum. It is more akin to
on individuals as members of society.
the first in a series of dominoes. By distorting
Second, it would require people to pur-
the health care marketplace, an individual
chase a specific service that would have to
mandate would set in place a cascading series
be heavily regulated by the federal gov-
of additional mandates and regulations
ernment (emphasis added).52
resulting, ultimately, in a government-run
health care system.
On a practical level, such a mandate is likely
to prove unenforceable. More important, an
Conclusion
individual mandate will almost certainly lead to
By distorting
a cascading series of additional mandates and
the health care
regulations resulting in a government-run
There is no easy answer to the free-rider
health care system. However we ultimately deal
problem. Human nature being what it is, as
marketplace,
with the uninsured and the free-rider problem,
long as we make the decision to help those who
an individual
we should bear in mind the Hippocratic Oath:
cannot (or will not) pay for their own health
mandate would
"First do no harm." An individual mandate,
care, we will provide an incentive for people to
then, is clearly not the way to go.
take advantage of society's generosity.
set in place a
On a fundamental level we must shift the
Although universal coverage schemes sound
cascading series
health care debate away from its single-mind-
desirable in theory, in practice none is likely to
ed focus on expanding coverage to the bigger
reach every American, and all carry significant
of additional
question of how to reduce costs and improve
price tags, both in terms of dollars and in terms
mandates and
quality. That will require the introduction of
of unintended consequences for the health
regulations
market mechanisms to give consumers more
care system as a whole. On the other hand,
control over and responsibility for their health
being a compassionate society, we are unlikely
resulting,
care decisions.
to refuse health care to those without insur-
ultimately, in a
In doing so, we can actually increase cover-
ance (or other resources with which to pay for
government-run
age and reduce the free-rider problem. In par-
it) as punishment for their lack of foresight.
ticular, if young, healthy people are able to pur-
This conundrum, how to provide care to
health care
chase low-cost catastrophic insurance, they are
those who truly need help while discouraging
system.
more likely to see becoming insured as in their
free riding, must be dealt with whether the deci-
self-interest. And, to the degree that health care
sion to provide for the needy is made by gov-
and health insurance become less expensive,
ernment or civil society (although government
more low-income people can be brought into
complicates the issue when it mandates that
the system.
providers provide uncompensated care thereby
That would be a better, more realistic, and
preempting experimentation with ways to dis-
far less risky approach than individual man-
courage free riding). Rather than let one gov-
dates.
ernment mandate spawn another (and another,
and another . . . ), the best, although admittedly
imperfect, answer might be to make existing
Notes
government mandates more flexible as a way to
encourage more innovative approaches to deal-
1. Carmen DeNavas-Walt, Bernadette Proctor, and
ing with the free-rider problem.
Cheryl Hill Lee, "Income, Poverty, and Health
9