• How to teach the individual mandate, ctd.

    In August, I wrote about the difficulty of teaching the individual mandate in my Introduction to the U.S. health system course this fall at Duke because it was typically presented when discussing Republican approaches to health care reform (this is the ninth time I have taught the course, but the first time since 2008). Now it is the essence of Republican opposition to the ACA.

    This Fall I made the individual mandate the topic of the major course paper, and students had to argue whether the individual mandate was constitutional or unconstitutional, using this prompt as a jumping off point:

    Trace the history of the individual mandate as a means of expanding health insurance coverage in the U.S. When did this idea emerge? Who/what groups were the intellectual drivers of the arguments behind the individual mandate? What were the arguments in favor? In opposition? Why was the individual mandate often supported by Republicans and Conservatives in the past? Why do you think the individual mandate became a central part of the Affordable Care Act? When did the opposition to the individual mandate arise and why? From your research on the topic, are you persuaded that a federally-enforced individual mandate to purchase health insurance is acceptable under the Constitution or not? Why or why not?

    I promised in August to report what the students (undergrads, a mix of majors) concluded.

    • 3 concluded that the individual mandate is unconstitutional
    • 21 concluded that it is constitutional (7 of these profess worries about the federal government taking this step, but still felt it was constitutional)

    On the whole, the students took this assignment very seriously, and I am impressed with how deeply they delved into the relevant court cases, scholarship around the issue, as well as the historical and political aspects of the looming Supreme Court case. I think they took the question of whether an individual mandate to purchase health insurance is allowable under the Constitution far more seriously than I have.

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    • Somehow, when I read above, I was reminded of a book I recently read. You will get the connection.

      http://books.google.com/books/about/The_wisdom_of_crowds.html?id=Jrhsf5WlBxMC

      From the mouths (brains) of babes they say…

      • @Brad F
        haven’t read it, but have heard goods things about it…..Surowiecki was big man on campus at UNC when I was there though I didn’t know him.

    • Do you teach constitutional law or health economics?
      This issue is a political one dredged up as a last ditch effort to attack Obama and everything he stands for and would seem to have little to do with health economics. It will be decided by our partisan reactionary conservative supreme court based on their personal bias with a cursory reference to the constitution.
      As such, I don’t think there would be much value to your students in spending time discussing the issue. It will be decided one way or the other and everyone will then deal with the fallout… which might have been a worthy discussion topic.

      • @Mark Spohr
        Hey. It is an Intro to US Health System class…what people get sick and die from, what is insurance, difference between Medicare and Medicaid, ACA, etc. I really disagree about it not being valuable because the students have taken in very seriously, and have not only considered legal arguments (which they have), but have traced the history of the mandate and politics of switching sides. As one student put it, the individual mandate is a Republican idea that became a tool for Democrats to reach a policy goal of expanding coverage. Beyond that there are kids who argue it is constitutional, but bad policy and want to repeal it and EMTALA per their libertarian views, and one who argues it is unconstitutional yet thinks we need some sort of federally guaranteed health insurance, just implemented in a more straightforward tax mechanism. On the whole, I am very impressed by their nuance.

    • There need not be a mandate to get the same effect, designing it as a tax credit would effectively do the same thing. I think many bloggers/pundits don’t address this issue effectively: it is true that Republicans have supported a mandate in the past, and that opposition to it now is merely opposition to PPACA as a whole, especially since the mandate could be tweaked as mentioned above. But political posturing aside, it is also true (in my opinion) that forcing people to buy a product from a private company is an unprecedented and unconstitutional expansion of federal power.

      So Republican opposition to the mandate is not opposition focused on solving the problem, because that would be easy to do. Increases taxes, and give a credit for buying insurance, very simple. Add it to the long list of things we give credits for today.

      But what gets lost in that is that it really is a terrible idea to give the federal government the power to force you to buy something, regardless of whether that is the actual motivation behind the Republican opposition. And designing it that way was just as much a political ploy as the disingenuous Republican opposition, because they didn’t want to call it a tax increase, so they gambled on the constitutionality of a mandate. And now they’re in a bind because they don’t have the numbers in Congress to change the bill, so it all hinges on the Supreme Court.

      In short: Republicans are willing to let the whole thing fall apart and leave us with the terrible status quo health care system rather than make a simple tweak, and Democrats are willing to expand federal power in an unprecedented way rather than allow themselves to be accused of raising taxes. Just another example of why our political system is broken.

      • “But what gets lost in that is that it really is a terrible idea to give the federal government the power to force you to buy something…”
        Don’t know what the problem here is… the federal government already forces me to buy (from private companies)… in my car… seat belts, catalytic convertors, unleaded fuel, etc…. at work… protective clothing, ear protectors, respirators, etc…. at home … flood insurance, protective equipment, etc.
        The federal government (as well as state and local governments) already force us to buy a lot of stuff for our health and safety. I don’t see any difference for health insurance.

        • Poor analogies. Driving is a choice (it would of course be very inconvenient not to drive, but it is a choice). Things you’re required to purchase at work are a function of the occupational choice you’ve made. Your home insurance is required when you chose to purchase a home. This is a requirement to purchase something just for being alive. All of those are dependent on choices, not so of a health insurance mandate. It regulates inactivity.

          And you’ll notice I said federal. State and local government is irrelevant here (which is also why the accusations of hypocrisy from Romney are silly, state governments can do things the federal government can’t, it’s the way our political system is designed).

          Do I think this is the most egregious and appalling intrusion on liberty ever imagined? Of course not. Do I think it will lead to an immediate slippery slope such that by 2015 the federal government is requiring you to purchase broccoli? No. But I still maintain that it is an unconstitutional expansion of federal power. I’d prefer to not have PPACA, but if it’s what we’re stuck with I would not oppose a mandate set up as I described in my previous comment. But that’s not what we have. If I was confident that the Supreme Court striking down the mandate and bringing down the entire bill would lead to a better solution I would be full-bore in support of that happening, but at this point Republicans don’t have a “replace” plan, so I am rather ambivalent about the issue, other than to say that in principle I find the PPACA mandate to be fundamentally wrong.