As Supreme Court Weighs Individual Mandate, Experts Propose Backdoor Health Care Approaches


Supreme Court discussions last week on the individual mandate provision in the Patient Protection and Affordability Act (aka Obamacare) appear to spell trouble for the new law. (And perhaps the most important lesson from the Court’s discussion: health care = broccoli).

Justice Scalia’s attempt to equate the market for green, cabbage-like Italian vegetables with that for health care missed the point, of course. Broccoli consumption is predictable and optional, while the consumption of health care is often unpredictable and also often not really optional. Perhaps most important, an individual’s consumption of broccoli has very little impact on the market for fresh vegetables, while the consumption of health care, particularly by the growing number of persons without insurance, has a huge market effect.

While I’ll leave the constitutional law question to the justices, I won’t do the same with the policy question raised. Simply put, there is no way to have a working and efficient health care system without an individual mandate or its functional equivalent. Health care is often expensive (e.g., the most common large health care expense for young persons is trauma), and health care is often unpredictable (although it’s hard to imagine, some people believe they will never get sick or end up in the emergency room). As a result, those who don’t pay for health care often end up consuming large amounts. And the rest of us pay. 

Single payer systems (like that in Canada) provide coverage for everyone. Market-oriented systems (like the one in Switzerland) require coverage for everyone. Even Mitt Romney’s near-universal system in Massachusetts saw the requirement for an individual mandate.

If health care = broccoli, and the individual mandate at the federal level is indeed dead, we have to find a creative way to ensure that coverage (and the associated costs) are universal. That may mean individual mandates on a state-by-state basis, hardly an optimal outcome. At the other end of the spectrum, it may mean denying care in the future to those who choose not to join the system, also not an optimal outcome (and an enormous moral challenge.) More than likely, it means that we need to come up with a different (i.e., backdoor) approach to health care coverage that looks, feels, and functions like the individual mandate.