The Individual Mandate

Ryan F. Holmes is the assistant director of health care ethics at the Markkula Center for Applied Ethics.  Views are his own.

President Donald Trump issued an executive order last month directing government agencies to relax or refrain from implementing aspects of the Affordable Care Act (ACA) “to the maximum extent permitted by law.” This was an effort to fulfill a campaign promise to repeal and replace the now seven-year-old law. While the ACA has improved healthcare delivery for millions of Americans, it has also created burdens on individuals and families, particularly by requiring individuals to submit proof of health insurance or face a financial penalty, also known as the individual mandate. This is the aspect of the law requires government agencies to impose a fine on any individual that cannot prove he or she is covered by an existing health insurance plan. While no clear plan exists to repeal or replace the current law, the executive action offers the opportunity to reflect on the principles at play as we reflect on the healthcare system and consider how to move forward.

Trump’s executive order offers no specifics about how to limit enforcement of the ACA, but not enforcing the individual mandate could fall into that category. This mandate has been controversial, as it requires individuals to purchase something. It limits the individual’s freedom to free association and enterprise, which are central in a liberal democracy such as ours. Indeed, opponents have argued that this mandate places limits on individual’s that are beyond our traditional values. With the executive order, Trump has moved to limit what some call an unjustified imposition on personal freedom.

When considering the idea of freedom, though, we might also consider what values are at stake as we review the impact of the ACA, particularly the value of the common good. The ACA was designed and implemented to offer access and affordability to many, including those who have suffered from an illness that might recur, otherwise known as a preexisting condition. Preexisting conditions occur in millions of Americans. Considering the rates of obesity and cancer survivorship, many individuals would qualify with a preexisting condition. Prior to the ACA, this meant individuals would have to pay excessive rates, some prohibitively high, in order to obtain coverage.

In order to allow for these rates to decrease, others must shoulder some of the costs. The rates of other plans must increase some.  More importantly, nearly everyone needs to participate because healthy insurees use fewer services and so subsidize those who need more care. The individual mandate, then, serves as motivation towards the common good, helping to ease the burdens of many.

We can surely argue about whether particular fees, tax incentives, or proposed healthcare saving accounts will meet the objectives we intend. But it is equally important to consider what values and principles are most important and what trade-offs we will make by supporting one value or principle over another. Valuing individual freedom by allowing individuals to walk away from the health insurance market will inevitably mean that the common good will lose out and others will go back to suffering without affordable healthcare.  In order to achieve the best policy, it seems that we ought to also consider the principles at stake and what is most important to us all.

Photos: (AP Photo/Damian Dovarganes)  (AP Photo/J. Scott Applewhite)