The ACP Advocate Blog
by Bob Doherty
Friday, February 12, 2010
What happens if the states try to nullify an individual insurance mandate?
One issue that divides liberals and conservatives is their views on the respective roles of federal and state governments. Conservatives prefer that the states run things, liberals, the federal government. A growing number of conservatives, including columnist George Will argue that Obama's health care proposals - and in particular, a mandate that individuals buy coverage - would unconstitutionally usurp powers reserved to the states and the people by the constitution's 10th amendment.
The Commonwealth of Virginia, reports the New York Time's Katharine Seelye, is on the verge of enacting a law that would exempt state's residents from complying with an individual insurance mandate. She reports that almost two-thirds of the states have similar legislation in the works. Law professor Timothy Jost argues in the New England Journal of Medicine that such state laws are "constitutionally impossible" and that the "purpose of these laws ... is not legal but rather political" and are "part of a larger campaign to mischaracterize federal legislative efforts and stir up opposition to any federal health care reform."
It is beyond my expertise to predict how federal courts would rule on this issue. From a political standpoint, though, the individual mandate is one of the least popular features of health care reform, according to Kaiser Family Foundation's most recent tracking poll. Conservatives don't like it because they consider it a usurpation of constitutional liberties; and many liberals don't like it because it compels them to buy private health insurance, when they really would like Medicare-for-all.
The logic behind the individual mandate, though, is that if insurance companies are going to be required to accept all comers, without regard to pre-existing conditions, and would be limited in how much more they can charge them, then people need to be compelled to buy coverage when healthy. Otherwise, some would stay out of the insurance pool until they get sick - resulting in higher premiums for everyone else. This then could lead to an insurance pool "death spiral". Faced with higher premiums caused by those who didn't get coverage until they got ill, more insured people would drop coverage, since they too could just "go bare" until they get sick. Rates would go up for the remaining insured population, leading more of them to drop coverage. And so and so on until the entire system collapsed.
One way to get around this problem is to eliminate the insurance mandate altogether, and instead just enroll everyone in a government-run plan like Medicare. I doubt that this is what conservatives want, but it could end up being the simplest way of getting everyone covered, should the present approach of providing subsidies to buy coverage, combined with a ban on pre-existing condition exclusions and a requirement that individuals buy coverage, fail on either constitutional or political grounds.
Today's questions: What do you think about state laws designed to nullify a federal requirement that individuals buy coverage? And about the individual insurance mandate itself?
About the Author
Bob Doherty is Senior Vice President, American College of Physicians Government Affairs and Public Policy; Author of the ACP Advocate Blog
Email Bob Doherty: TheACPAdvocateblog@acponline.org.Follow @BobDohertyACP
- Washington, D.C. (noun): a place where nothing can...
- We're #1! We're #1!
- Health reform and the Obama budget
- Did Obama's SOTU address give enough of a lift to ...
- Which countries have the longest waits for medical...
- Dr. Seuss' Rx for Obama's health reform slump
- Will Congress throw the uninsured under the bus?
- "Dazed and Confused"
- "I'm not dead ... yet"
- Losing and winning the battle for public opinion
The Wall Street Journal's blog on health and the business of health.
Health Affairs Magazine Blog
The Policy Journal of the Health Sphere.
The Health Care Blog
Everything you always wanted to know about the Health Care system. But were afraid to ask.
Vignettes and commentaries on the medical profession.
The New Health Dialogue Blog
From the New America Foundation.
DB's Medical Rants
Contemplating medicine and the health care system
Notes From The Road
Bloggers post from medical meetings, press conferences, and policy gatherings from the U.S. and around the world, providing readers with a tasty analysis of the buzz, the people, and the stories that don't get told.
A blog dedicated to medical education, news, and policy as well as career advising.
Disease Management Care Blog
An ongoing resource for information, insights, peer-review literature and musings from the world of disease management, the medical home, the chronic care model, the patient centered medical home, informatics, pay for performance, primary care, chronic illness and health insurance.
Medical Professionalism Blog
The Medical Professionalism Blog was created by the ABIM Foundation to stimulate conversation and highlight best practices related to professionalism in medicine.