For the moment, Republicans are setting aside their seven-year effort to repeal and replace the Affordable Care Act. A slew of bills failed in the Senate, and now President Trump and the Republican majority in Congress plan on turning to tax reform. But doubtless, before long we’ll be hearing about the Affordable Care Act again. Not only do conservatives despise it, but even Democrats think it needs work. What I’d most like conservatives to rethink, during this interim peace, is their opposition to the individual mandate.
This is the part of Obamacare that requires most citizens to have health insurance or else pay a fine. It’s essential to the affordability of the insurance plans offered by the exchanges. When younger, healthier people buy health insurance, those funds becomes available to pay for health care for older, sicker people, so those who are most likely to use their policies don’t have to be charged unaffordable premiums.
Republicans haven’t always hated the individual mandate—in fact, they were for it long before they were against it, as an illuminating New Yorker article shows. However, once the Affordable Care Act started to be seen as Barack Obama’s signature achievement, conservatives began to focus their ire (inexplicably) on the individual mandate. It infuriated them, or at least they said it infuriated them, for young, healthy people to be required by law to buy policies they didn’t want. This was the “Nanny State” at its worst.
Liberals like me who want to see Obamacare continue and thrive are strongly inclined to make a liberal case for the individual mandate: thirty-five-year-old Mary ought to have to pay for insurance, so that seventy-year old Bob, who has diabetes, clogged arteries and cataracts, can get the care he needs. Perhaps we liberals are in favor of everyone having health insurance because we want to live in a compassionate society, or we believe in a right to health care, or we think an egalitarian society must provide equal access to basic health care. But conservatives aren’t going to be convinced by liberal arguments. What’s needed is a conservative case for the individual mandate.
In fact, there is a strong conservative case for it. Having to buy health insurance is quite different from having to buy other things conservatives don’t want everyone to have to buy. If Mary hates opera, I can understand why conservatives wouldn’t want her to have to chip in so Bob-the-opera-lover can have it. But what Mary funds, in having to buy health insurance, at least might be her own care.
About 20 years ago I knew a “Mary” who elected not to purchase health insurance. At her age, she was unlikely to have any sort of unaffordable health problem, she figured, but then suddenly she had one—or rather, two. First she had cancer, and then she developed a heart problem. Had Mary been required to buy health insurance, it wouldn’t simply have funded the health care that Bob needed, it would have helped pay for Mary’s own healthcare.
But Mary wanted to take her chances! Why not let her? This is a coherent conservative response, if conservatives are willing to follow through. Just as someone must go without a car if they don’t save money for a car, it’s conceivable that they should have to go without expensive medical care, if they don’t buy themselves health insurance. But that would mean giving Mary no access to treatment for her cancer and her heart problem, instead of treatment at a hospital that takes non-paying patients. And the problem is that conservatives aren’t quite that hard-hearted.
Mary did receive the care she needed, thanks to the 1986 law that requires most hospitals to admit and treat people who have an urgent need for medical care. Conservatives would say, I’m pretty sure, that this was well and good. I don’t hear anyone saying that Mary should have had to die in agony, since she didn’t have the private funds to cover her staggering medical bills. Nobody’s calling for the repeal of the 1986 law.
But here’s the thing. If Mary didn’t purchase health insurance before she needed expensive medical care, but later used the healthcare system funded by others, she was… well, no offense to Mary, but she was a freeloader—a kind of cheater. And conservatives are against freeloading and cheating. So you don’t have to be for compassion to embrace the individual mandate. You just have to be against freeloading and cheating, assuming that you don’t in fact wish to see the uninsured suffer and die because they can’t pay for medical care.
I don’t think there’s a single Republican congressman or senator who would admit to supporting the individual mandate. It was seen by conservatives as a stunning betrayal when, in 2012, Chief Justice Roberts sided with the liberal wing of the Supreme Court and opined that the individual mandate was constitutional. But it ought to be perfectly respectable to be for it, even in conservative circles. Unless you want to see the uninsured suffer and die for lack of funds to purchase their healthcare on an as-needed basis, you are aiding and abetting freeloaders if you don’t support the individual mandate. And that’s embarrassing, if you’re a conservative.
Personally, I’d much rather argue for the Affordable Care Act based on compassion or rights or egalitarianism, but this is a case of many roads to the same summit. If indignation about freeloading will get Republicans there, then let there be more indignation.