Individual Mandate Flies Under the Radar

Looking back at the August town hall protests, the issues that burned the brightest were frequently not real issues at all. Angry demonstrators railed against Canadian-style, single-payer socialized medicine, which has not been proposed; "death panels" that would pull the plug on Granny, which aren't happening; and illegal immigrants receiving health benefits, which is specifically prohibited in all of the legislation that has been proposed.


But left nearly unexplored by angry activists was a measure of sweeping consequence that is almost guaranteed to become law if Democrats pass even a scaled-back version of health care reform: a requirement that every American carry an approved form of health insurance by 2013 or pay a penalty to the IRS.

Committees in both the House and Senate have voted in favor of the proposal, known as an individual mandate, and the Senate Finance Committee will likely support the measure when it meets again in the fall. Although President Obama opposed mandates during the 2008 campaign, he says he now supports them because of exemptions for people living near the poverty line, along with subsidies for other Americans who still can't afford coverage.

Conservative critics contend that such a mandate would be a federal power grab exponentially larger than the concept of a public option, which will drive health care costs up under the guise of cost containment. The issue itself lies at the Republican fault lines of individual responsibility and individual freedom, pitting pro-business pragmatists against movement activists.

Dennis Smith, of the Heritage Foundation, a conservative think tank, calls the individual mandate "an earth-shaking" issue. "My objections are the unprecedented power of the federal government over the individual," he said. "They're basically saying, 'No matter what else is going on in your life, we're here from the government and you are going to do this.' "

Michael Cannon, of the libertarian Cato Institute, calls the mandate "the most sweeping provision of the Obama health plan" and argues that giving the government the power to mandate coverage would effectively nationalize private health coverage. "When the government requires everybody to buy health insurance, it has the power to dictate every heath insurance policy in the country," he said "That then gives the government power over every aspect of health insurance and every aspect of care."

Although a handful of congressional Republicans have objected to individual mandates, the earliest backers of the concept were influential Republican leaders and lawmakers, including the late Sen. John Chaffee (R-R.I.), a moderate who proposed it in 1993.

Then-Gov. Mitt Romney, took up the cause for individual mandates as he pushed for universal health care in Massachusetts. Romney claimed victory in a 2006 Wall Street Journal op-ed titled "Health care for everyone? We found a way." In that essay, Romney noted proudly -- and accurately -- that he had proposed the individual mandate in his state, calling it a "personal responsibility principle," and had shepherded the measure through a Democratic legislature. "A free ride on government is not libertarian," Romney wrote. Now a possible favorite for the 2012 presidential nomination, Romney has since distanced himself from the Massachusetts approach, apparently in efforts to court his party's conservative base.

And as recently as this month, Sen. Charles Grassley (R-Iowa) told PBS that the way to get universal coverage is "through an individual mandate and that's individual responsibility and even Republicans believe in individual responsibility."

Cato's Cannon says that the mandate was "baked into the cake" of this year's health care reform proposals by the "raw self-interest" and early lobbying of the Obama administration by the health insurers, who want the government to expand their customer base. "They would love the government to put a gun to your head and say, 'Buy insurance,' " Cannon said.

Health insurance executives hardly hide this motivation. The last person to deny the industry's involvement in the mandate would be Karen Ignagni, the president of America's Health Insurance Plans, who has argued vocally for an individual mandate for years. Ignagni testified before the Senate Health committee in June and participated in the White House Health Care summit in March.

Ignagni told legislators that an individual mandate is essential to offsetting the cost of expanding health care coverage. "We are proposing to combine guarantee-issue coverage with an enforceable individual health insurance requirement and premium assistance to make coverage affordable, while eliminating preexisting condition exclusions and eliminating rating based on health status in the individual market," she said in June.

In other words, in order to pay for the coverage that Congress wants to guarantee to Americans, such as covering preventative care, eliminating lifetime caps and requiring coverage for people with pre-existing conditions, the pool of insured individuals has to include millions of the young, healthy, uninsured Americans who simply opt out of health care insurance pools. They do so either because they feel invincible as a function of their age, or because they believe that the premiums they would have to pay would be better spent on other, more pressing, financial needs. The Kaiser Family Foundation estimates that one-third of the uninsured in the United States are between 19 and 29 years old.

Although Ignani, President Obama and other mandate backers contend that expanding the pool will bring down costs, if it happens that way it will probably take time: A report by the Commonwealth Fund released last week showed that Massachusetts, with its individual mandate, has the most expensive health insurance premiums in the country. Dennis Smith at the Heritage Foundation said the individual mandate drives up the costs of premiums because service providers lobby the government to have their services mandated, which drives "the advocacy groups to say now you have to raise the level of subsidies."

In terms of a "minimum" level of coverage, the House bill already requires plans to include primary care and hospital services, as well as coverage for prescription drugs, rehabilitative services, mental health and substance abuse disorder services, preventive care, and oral health, vision, and hearing services for children under 21 years of age.

Public support of the individual mandate is strong, until coercive measures are mentioned. A July Pew poll found that 65 percent of Americans supported requiring everyone to have health insurance, but that support plummeted to 34 percent when NBC asked if people should pay a penalty if they did not have insurance.

So the question remains, why, with so much opposition in August to phantom proposals, was there relatively little opposition to one that undoubtedly will affect every American? Conservative activists involved in the tea party movement told Politics Daily they are still making their way through all of the parts of health care reform they find offensive, including the public option, the costs of reform, tax increases and specific measures like comparative effectiveness research.

Cato's Cannon countered, "There are Republicans who just don't get how sweeping a provision it is."

Outside of Washington, some states have already moved to nullify any mandates that Congress passes this year. The Arizona legislature recently approved a ballot measure for 2010 that will give Arizona voters the choice to exempt themselves from any individual health care mandates. On Saturday, David Rivkin and Lee Casey wrote an op-ed in The Washington Post questioning the legality and constitutionality of an individual mandate.

Adam Brandon, the Vice President for Communications of FreedomWorks, a group led by former Republican Majority Leader Dick Armey, said his organization focused its early resources on opposing the public option and kept its talking points general as long as President Obama stuck to generalities as well. "But as you see us come out of this, you'll see us taking more about the individual mandate," Brandon said. "We will vociferously fight that."

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