Tag Archives: Individual Mandate

It’s a Penalty! It’s a Tax! It’s Unprecedented!

I have been bemused–and occasionally amused–by all the posturing over the provision in the Affordable Care Act requiring people to purchase health insurance.

How dare they!!

If you listen to the right-wing blogs and talking heads, you’ll come away believing that such a mandate is unprecedented. The government has never required us to do something, or penalized us for failing to do something.It’s unAmerican to penalize inaction. That evil Obama  is introducing an entirely foreign element into American law. (The fact that Romney did exactly the same thing in Massachusetts is obviously different….)

Of course, this line of attack is entirely fanciful.

As a legal scholar recently noted, the very same week it upheld the ACA, the Supreme Court affirmed a law requiring sex offenders to register their whereabouts, employment and appearance with local authorities. If they fail to do so, the law in question imposes a penalty of ten years in prison–a bit more draconian than the ACA’s fine. The Court made it clear that this mandatory registration was not punishment for a crime –the individuals subject to the requirement have already paid their debt to society for those transgressions (a contrary construction would run afoul of the Ex Post Facto prohibition).

Courts upholding this particular type of mandate–and there have been several–have explicitly said that the only conduct being punished was the “inactivity” of failing to register.

There are many other examples–so many that a Professor at John Marshall Law School has actually written an essay on “The Incredible Ordinariness of Federal Penalties for Inactivity.”

As I have repeatedly noted, there is nothing wrong with faulting provisions of this particular approach to healthcare reform. What I find absolutely astonishing, however, are the  logical contortions opponents will go through in order to attack the legitimacy of any attempt to  extend access to healthcare. I have been absolutely stunned by opponents’ self-righteous denunciations of such efforts, and by their evident willingness to simply let the uninsured suffer and die.

A recent editorial in the Journal of the American Medical Association is worth quoting.

That editorial began “Physicians and hospitals have a moral duty to provide acute care and emergency care to those who need it.” Proceeding from that expressly moral premise, the editorial concluded that individuals “have an enforceable moral duty to buy sufficient health insurance to cover the costs of acute and emergency care…requiring individuals to buy health insurance is consistent with respect for  individual liberty because individuals have a duty to mitigate the burdens they impose on others.”

We don’t talk much about the morality of policy. We should.

Yesterday, every single House Republican voted to take away health coverage for young adults staying on their family plans, raise prescription drug prices for seniors, end protections for those with pre-existing conditions, reinstate lifetime insurance caps, scrap tax breaks for small businesses, raise the deficit, and take benefits away from 30 million Americans. Pundits reporting the vote generally noted that it was one of a series of such votes, and that it stood no chance of ultimate passage. They spent a lot of time analyzing the politics of the GOPs message and speculating on its electoral effect.

To the best of my knowledge, none of them pointed out how utterly immoral it was.

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Is the Individual Mandate Constitutional?

The most controversial provision of the Affordable Care Act  is undoubtedly the individual mandate–the requirement that almost everyone carry health insurance.

Why a mandate? As the LA times said, “A mandate is key for reducing the ranks of the uninsured, who often turn to emergency rooms for care, driving up everyone’s costs. Spreading the costs—among healthy and sick—is also the only way to make the reforms work.” Health economists agree–in order for this reform to work, it has to include the mandate. So—It’s necessary, but is it constitutional?

According to most constitutional scholars, yes. Here’s the analysis:

Congress has authority both to regulate commerce among the several states, and to “lay and collect taxes to provide for the general welfare.” The Senate bill requires that citizens purchase qualifying health coverage; if they don’t, they pay a tax penalty. Exemptions are granted for religious objections, financial hardship and a variety of other reasons. The House bill didn’t impose a “mandate” per se, but amended the Internal Revenue Code to levy a “tax on individuals without acceptable health coverage.” Functionally, the two provisions are essentially the same. (Interestingly, opponents concede that Congress could lawfully establish single-payer (Medicare for All, say), and tax us to pay for it.)

In 1944, Supreme Court established that insurance is an economic activity that falls within Congress’ regulatory power. More recently, the Lopez and Gonzales cases clarified how the Court understands “economic” and “non-economic” activities within the context of Commerce Clause. In Lopez, Court held that Congress exceeded its authority by legislating against guns near schools; in Gonzales, it ruled that the act of growing marijuana at home could be regulated by the federal government even though the conduct was not itself economic, because the larger interstate “regulatory scheme would be undercut unless the intrastate activity were regulated.” As one scholar has summarized, “ If health insurance is itself an ‘ingredient’ of interstate commerce and ‘self-evidently’ within Congress’ Commerce Clause authority, the statutory goals for broadening, making more efficient and less costly, and otherwise improving health insurance coverage, fit equally within that authority.

Further, the individual mandate requirement easily qualifies as a ‘necessary and proper’ means of achieving those goals, under the standard first articulated by Chief Justice Marshall [in 1819] and adhered to since: “Let the end be legitimate, let it be within the scope of the constitution, and all means which are appropriate, which are plainly adapted to that end, which are not prohibited, but consist with the letter and spirit of the constitution, are constitutional.”

The Federalist Society and other opponents of the mandate have argued that refusal to purchase insurance is inactivity, and thus not subject to regulation. How, they ask, can government regulate a decision not to act?  But as judges have noted who upheld the mandate, people who refuse to buy insurance are not doing “nothing.” They are gambling that they won’t need coverage, or they are deciding to self-insure. In either case, they are also deciding to game the system, making the overall program unworkable.

Refusal to purchase health insurance would be analogous to refusal to pay social security and Medicare taxes or, at the state level, refusal to purchase auto insurance.

Most constitutional scholars believe the mandate will be upheld; others–noting the ideological tilt of several of the Justices–are less certain, although they agree that precedents would ordinarily require such a result.

Ironically, since opponents of the mandate are making the case that ONLY a single-payer system is constitutional, a victory for opponents might actually result in the enactment of a single-payer system, since the multiple markets we’ve been operating under are simply not sustainable.

Works for me.

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