Health Reform: The Individual Mandate, Individualism, and Collectivism

The American system of rugged individualism.

Herbert Hoover (1874-1964), Campaign Speech (1928)

No provision is currently more beleaguered than the individual mandate to obtain health insurance or pay a penalty…Ultimately, the furor over the mandate underscores the reality that solidarity remains elusive in U.S. health policy.

Jonathon Oberlander, PhD, “Under Siege – The Individual Mandate for Health Insurance and Its Alternatives,” New England Journal of Medicine, March 24, 2011

March 24, 2011 - In today’s New England Journal of Medicine Jonathon Oberlander, the health policy leader at the University of North Carolina, weighs in on the problems of the individual mandate.

The political problem for Democrats, he says, is that 76% of Americans view the individual mandate unfavorably (Kaiser Family Foundation/Harvard School of Public Health poll, January 2011).

Seventy six percent is a huge percentage. It will not be easy to overcome politically. When combined with the latest CNN poll indicating 57% oppose the law, it is clear that the individual mandate, the financial foundation for the health reform law, is mired in deep political doo-doo.

But, if the individual mandate goes down, what are the alternatives?

According to Oberlander, the alternatives are:

• A tax-financed single payer system, infeasible in the current political climate.

• Imposing heavy financial penalties on eligible people who choose to wait and buy coverage later.

• Automatically enrolling people into health insurance plans, as required for auto insurance, with a premium penalty for people who opt out but who later decide to purchase insurance.

Another alternative, which Oberlander does not mention, are Republican proposals combining universal tax credits, shopping across state lines, choice among alternative health plans as in the Federal Employee Benefit Plan, and expansion of health savings and flexible savings accounts with high deductible plans. This scenario should not be dismissed out of hand, for it likely the Republicans will win the House and the Senate in 2012 and possibly even the Presidency.

Whatever happens, the philosophical and practical arguments boil down to collectivism for the social good versus individualism for individual freedom.

Collectivists say:

• Covering everyone requires that the healthy pay for the sick.

• Social Security, Medicare, and Health Reform requires that everyone participates.

• The current health law requires the individual mandate to fund its implementation.

Individualists say:

• Our constitution does not allow government to force individuals to pay for something should they choose not to.

• The individual mandate infringes on personal liberties.

• Individual states have the right to block the mandate and to pursue their own alternatives to the mandate and to health exchanges.

In Oberlander’s words, “The mandate now confronts a legal and political backlash.” Republicans cannot overturn the law until 2013 - and then only if they make a clean sweep of the House, the Senate, and the Presidency. Until then the GOP will target the individual mandate as the best hope for crippling the health reform law.

Will the argument for collectivism - the greatest good for the greatest number at the greatest measured quality with the greatest government power – win?

Or will the American tradition of rugged individualism with its countervailing argument – too much government violating constitutional rights, infringing on individual rights, disrupting free market principles, and redistributing of wealth – prevail?

Will collectivism, as embodied in the Patient Protection and Affordable Care Act. be the remaking of American health care? Will the American tradition of rugged individualism be its undoing? If neither, what is the proper balance?

Only time, 1 year and 7 months and 8 days, from now to November 2, 2012, to be precise, will tell.