I began thinking about the mandate again after reading an article on the Affordable Care Act from the Roosevelt Institute's Next New Deal blog last month. The author looked at how low-wage workers, such as fast food workers, may fare poorly under the ACA's provisions because the deductibles of their new employer-provided health care will be more expensive than the penalty for no coverage. As the full scale of Affordable Care Act unfurls, we'll get to see more about how well it accomplishes the goals implicit in its name. Hopefully, it will.
However, the case above underscores the counter-intuitive contours of the debate around the individual mandate. The individual mandate is a conservative policy that can only be championed through conservative rhetoric. Befitting a conservative policy--especially one originating at the Heritage Foundation--it penalizes those on the lower end of the income scale for being on the lower end of the income scale. No one actively does not want to have health insurance; the uninsured are those whose job will not cover their insurance or who simply cannot afford to purchase insurance on their own.
Arguing for the individual mandate requires a rhetoric of "individual responsibility," a frame that makes use of the image of "freeloaders" who take advantage of mandatory hospital care (a policy from Reagan). These "freeloaders" who are "shirking" their personal responsibility sound a lot like the "moochers" of the right-wing imagination. The language that supports the individual mandate counters the (liberal) idea that health care is a fundamental human right.
If viewed as a tax instead, it is regressive, and it taxes people while not directly providing services. In a single payer system like Canada's or a multi-payer system like Germany's, individuals are taxed to pay for their health insurance. However, those who would be taxed under this system are not benefiting in such regard.
I know I've used the car insurance analogy to justify the individual mandate on legal grounds in discussions before, but the analogy is rather weak. You can choose not to have a car, and you can choose to sell your car if you want. A health insurance mandate applies to your very person.
A more appropriate comparison would be the other main mandate that we have for the individual as individual: our education mandate. In the U.S., we have compulsory attendance for primary and secondary school, and each state has a similar requirement, mandating a certain minimum number of years of attendance. These laws arose at the state level (rather than the federal level like the ACA), but the mandate that they contain is attached to the individual, not to a physical object the individual can choose to own.
I have always thought that education and health were both similar because of their integral role in the concept of the public welfare. Unlike what many on the right would like to believe, the Constitution does assert the government's role in promoting the "general Welfare." It also asserts the government's role in securing "the Blessings of Liberty." Here, I think, it would be important to underscore the role of education and health care to the concept of positive liberty. Conservatives often speak in terms of negative liberty, freedom from external restraint (at least, when it doesn't come to reproductive issues, for one). However, positive liberty--the possession of the power and resources to fulfill one's potential--is essential to liberalism. The Standford Encyclopedia of Philosophy explains positive liberty in the following way:
Put in the simplest terms, one might say that a democratic society is a free society because it is a self-determined society, and that a member of that society is free to the extent that he or she participates in its democratic process. But there are also individualist applications of the concept of positive freedom. For example, it is sometimes said that a government should aim actively to create the conditions necessary for individuals to be self-sufficient or to achieve self-realizationEducation and health care---the culture of the mind and the health of the body--enable individuals to be engaged citizens and to pursue meaningful work; they provide the conditions necessary for individuals to realize their potential.
Returning to the prior discussion of mandates, you might note that there is a key difference in how we implement education and health care policy. With education, there is a clear mandate, but the government finances and administers schools to help people to comply. The government says, "You must attend school from age x to age y, and we will make schools available for you to do so. You can opt for private school if you wish--on your own money, but we will make sure that you have a solid option paid for and administered by the collective purse."
But if the education mandate were like the health care mandate, the government would run no schools. The government would be the single payer of pre-K or kindergarten (an equivalent for Medicare here). The government would pay your full school costs (or most of them, at least) if you fall below a certain income. If you make more than that and don't already send your children to school, the government might organize you and other parents in a pool for greater efficiency and give you some start-up capital and subsidies. The government would make sure that the schools that exist cannot deny students because of learning disabilities or any other issues. However, the government would run no schools.
Now, to reverse that comparison, how would the health care system look if we designed it based on the principles by which we have designed the education system? First of all, everyone would have a publicly-administered and publicy-financed primary care practice in his or her neighborhood. You would have to register with your local practice. If you choose not to enroll there, you still have the option of going to a private practice (a mandate of coverage would hold), but the government will not pay for you to do so; it is your own choice. Primary care is something that everyone needs, and the local demand for primary care is in direct correlation with population.
However, what about hospitals and the various specialists that reside there? A comparison to higher ed works to some degree here. Each locality would certainly need access to a hospital with various specialists; however, the demand is not as directly tied to population as the demand for primary care is. It might not be advisable for the number of each type of specialist to be determined by a centralized agency. Consequently, you would have less of a public monopoly but still a strong public presence in the market. The state would administer and finance a number of hospitals, employing a number of different specialists, to ensure broad access; however, many would exist in the private sector as well. The state-administered hospitals might not have the most expensive technologies or snazzy interior design; however, they will offer a robust array of services.
However, with the rising costs of higher ed and growing student debt (like health care debt), our current financing arrangement is certainly not perfect, and the comparison I've drawn would need to be further worked out and perfected. Perhaps the state would pay for the full costs at the universally accessible institutions that it administers and would subsidize the costs of individuals who choose to go to the private hospitals (paying only to the level of cost of the public hospitals). We would also need to have the efforts of cost-control so badly needed in higher ed right now.