This has been on my mind for a while and this is the first time I’ve seen it in print, by Jonathan Oberlander in NEJM:
[O]ne alternative [to the mandate] is to limit enrollment in the exchanges to a fixed period each year and impose premium penalties for eligible people who choose to wait and buy coverage later — and to make the penalty apply not just the first time they purchase insurance, but across their lifetimes. This model is employed by the Medicare Part D program for prescription-drug coverage, which the Bush administration and many Congressional Republicans supported.
However, to induce healthy uninsured people to sign up, the late penalty might have to be substantial, in which case this arrangement would be operating similarly to the mandate. As the health care economist Len Nichols points out, if we don’t have the political will to impose a strong penalty in conjunction with an individual mandate, we probably wouldn’t have the will to impose one as part of a fixed enrollment system. Furthermore, it’s not clear how a lifetime late penalty would work when people’s insurance coverage could shift over time among private plans in the exchange, private plans outside the exchange, Medicaid, employer-based coverage, and eventually, Medicare. [Bold mine.]
Elsewhere in the piece, Oberlander expresses skepticism that ACA opponents will be satisfied if the mandate is replaced with something else. I agree. The mandate is not the issue. If it were, there would be broad, bipartisan efforts to craft and pass an alternative. There isn’t.
Only by contorted logic can one support the law and not the mandate. For this health reform law, a mandate or something very similar is necessary. Those fully engaged on either side know it. They also know that the real options in the 111th Congress were this law or no effective, comprehensive reform that achieves near-universal coverage. At a national level, those are the same options today. That’s just political reality, backed up by decades of history of failed reform attempts.
For everyone engaged in the debate, the mandate is just a means to an end. With it, the law has a chance of fulfilling the goals that motivated its passage. Without it, it does not.