How to Teach the Individual Mandate

I am teaching Public Policy 111 (Intro to the U.S. Health System)  for the ninth time this fall at Duke University. I love teaching this class of Freshman and Sophomores, and it is why I am a college professor. However, it has been hard to prepare for it this Summer because so much has changed since I last taught it in the Fall of 2008.  I didn’t even have a blog then!

However, the hardest part of preparing has been figuring out what to say about the individual mandate. I have always taught it in this course, and it was prominent in the “Republican health reform alternatives” section.  Some years I have had students read Responsible National Health Insurance by Mark Pauly, Patricia Danzon, Paul Feldstein, and John Hoff, the intellectual background behind why the mandate was the preferred Conservative approach. We talk about the Chaffee bill which was the Republican alternative to the Clinton plan in 1993-94 that contained an individual mandate to purchase coverage and set up state based insurance markets in which individuals could buy policies with income based subsidies. Wait…

Even as late as June 14, 2009, Senator Charles Grassley (R-IA) the ranking Republican on the Senate finance committee and member of the “gang of six” was saying on Fox News that the individual mandate was a bipartisan way to achieve health reform and he talked about the themes of responsibility and reducing cost shifting that have typically been the hallmark of Republican support. By the fall of 2009 he and most other Republicans had decided that an individual mandate was unconstitutional. I find the argument that “we were for it the past 18 years we just didn’t realize its passage would violate the Constitution” to be absurd. However, I don’t want to just get up and vent my spleen to the kids about this. So, I have decided to ask them. Each semester we have one long paper due at the end, and this year the topic will be as follows:

  • 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 will write about their answers in December.



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