The Supreme Court’s Affordable Care Act hearings last month renewed debate over the individual mandate within the single-payer movement. As expected, there are a wide variety of views on this issue. It’s important to take some time to reflect on some of the arguments made about the mandate. This is by no means comprehensive, but a sampling of some of the various positions we’ve heard. We think it’s important to keep the discussion going, and learn from each other and this political moment.
The mandate can be traced back to at least 1989 with a proposal by conservative think tank The Heritage Foundation. The proposal draws a comparison between car owners being required to have auto insurance, and recommends such a requirement for “all households to protect themselves from the potentially catastrophic costs of a serious accident or illness.”
Proponents of the mandate explain its need the same way we explain the necessity for universal coverage: bringing everyone into the pool – both healthy and sick – lowers costs because you need the money paid by the healthy to offset the costs of the sick. Dr. Ezekiel J. Emanuel, a former health policy adviser to Obama, said “[the Obama administration’s] internal modeling showed that a mandate would extend coverage to 32 million uninsured people. Without such a requirement the administration estimated it could cover 16 million people at three-fourths the cost of covering the 32 million.”
Before the ACA was even passed in late March 2010, there was opposition to the mandate from the single-payer movement.
In 2006, Physicians for a National Health Program (PNHP) said, “individual mandates do nothing to control the rising cost of care, continuing to funnel health dollars though wasteful private insurers and hospitals. Instead, they mandate that cost of covering the uninsured should be incurred by the uninsured themselves.”
In 2009, PNHP released a press release highlighting that Massachusetts – Massachusetts health reform being the model on which the ACA is based – actually had a slight increase in uninsured residents after state health reform, including a mandate, was implemented.
PNHP-New York Metro Chapter released talking points on the mandate prior to the passage of the ACA, including, “The plan is completely inadequate in expanding coverage and controlling costs. It is essentially an insurance industry bailout.”
The California Nurses Association/National Nurses United (CNA/NNU) released a statement early in March 2010 listing ten significant problems with the legislation – number one being “The individual mandate forcing all those without coverage to buy private insurance, with insufficient cost controls on skyrocketing premiums and other insurance costs.”
Single-payer supporters’ perspectives on the mandate haven’t changed since the ACA became law.
Single Payer Action, It’s Our Economy, and 50 doctors filed an amicus – or friend-of-the-court – brief with the Supreme Court arguing that the individual mandate is unconstitutional with the argument, “The failure of Americans to purchase health insurance from private insurance companies does not in any way obstruct the power of Congress to regulate the national healthcare market. As Medicare and the VHA demonstrate, Congress is capable of regulating healthcare markets effectively… by implementing single payer systems.” This, however, was just one of more than 100 amicus briefs – one of the largest number filed for a case in history – by both people in support of and against the ACA.
Healthcare-NOW! released an action entitled Never Mind the Mandate encouraging our members to send emails to Congress and the President with the message, “No matter the outcome of the Supreme Court hearings, we still need single-payer healthcare.” Nearly 3,000 members participated in this action.
The debate generated by this court hearing, and the political implications of its decision, will have far reaching effects. What follows is a sampling of arguments made, both for and against, the individual mandate by single-payer supporters. Comments are from Healthcare-NOW!’s website, individual emails, blog-postings and articles, and from our April 1, 2012 Activist Conference Call.
Ricardo (Comment on www.Healthcare-NOW.org): Without the individual mandate, people will wait until they need healthcare and then sign up for health insurance. The individual mandate increases the number of healthy people in the insurance pool and will lower cost… To oppose the Individual Mandate is to play into the hands of the right wingers who oppose the ACA and a single payer system. Opposing the individual mandate is a step backwards not forwards.
Daniel (Comment on www.Healthcare-NOW.org): In a free enterprise system competition serves to keep prices low. Because of this, most businesses try to set their prices lower than the competition to attract customers. At the same time, they try to offer more, or better, services than the competition to attract more customers. The mandate REMOVES this important economic driving force!
Dianne (Comment on www.Healthcare-NOW.org): The mandate must be repealed if for no other reason than the adverse effects that this scheme will have on the working class and poor. Basically, the way the MA plan and Obamacare works is the people who the politicians claim will be helped become the funding mechanism for this scheme. The tax credits (subsidies) go to the insurers – your tax dollars at work. And when more money is needed by the gov’t, the Exchanges (high-flying salaries and bennies for many tied to the industry) and the insurers, up go the premiums including those in the subsidized plans.
Kevin (Comment made during HCN’s April 1 Activist Conference Call.): I also wanted to talk about how being forced to buy insurance is an outrage. We’ve been hearing how bad a job the Obama industry has been doing selling the mandate. But every single American family and business has felt insurance abuse. And so Obama’s marketing team – who are great at marketing – couldn’t sell it because they are trying to sell something no one really wants.
Kevin Zeese, Co-Director of It’s Our Economy (Presenter on HCN’s April 1 Activist Conference Call): We decided to file the amicus brief with the Supreme Court to get out the single-payer position on this debate. We felt very strongly that the mandate – forcing people to buy health insurance – was the exact opposite of what single-payer advocates would want. Single-payer wants to remove the insurance industry, and the mandate further entrenches the private health insurance industry – we don’t see the ACA as a step in the right direction, but rather getting us further away from it. I was very disappointed HCN and PNHP didn’t join in the amicus brief. I know Healthcare-NOW!’s board was divided on that.
Sandy, RN (Comment emailed in response to “The Supreme Court, Health Care and the Current Political Moment”): From developments in Massachusetts and subsequently at the national level, it is clear that the Democratic Party is as addicted to commercial health insurance money as the Republican Party is to pharmaceutical money. Just as single payer was ruled off the table at the beginning of the process that lead to the adoption of the Massachusetts plan in 2006, so too did the Obama administration and the leadership of both houses of Congress rule single payer (and shortly thereafter the so-called public option) off the table right at the beginning of the federal discussion in January 2009.
A couple of months ago, two of us from the Massachusetts Nurses Association approached our first-term representative in Congress to try to convince him to sign on to the Sanders/McDermott single-payer bill, the one that had been endorsed by the AFL-CIO. He proceeded to speak in glowing terms of all that PPACA would do. When I pointed out that all of that was put at risk by the deficit-reduction deal that he had voted for on August 1st, the conversation abruptly ended.
There will be no policy discord among main-stream Democratic incumbents or candidates. Politics trumps policy. After all, this is an election year.
Helen (Comment made during HCN’s April 1 Activist Conference Call): I think the mass media isn’t covering us because the single-payer community hasn’t come out and taken a really clear position on striking down the mandate. I think it starts with Healthcare-NOW! who had a campaign saying “Never Mind the Mandate,” and I think it was a mistake to pitch it that way. I think we should have come out really really clearly against the mandate. And other single-payer groups – NNU – is saying, “Well. Let’s see what happens.” And I think that’s dodging. I think people were afraid to say so because they want to get Obama reelected.
Ken (Comment made during HCN’s April 1 Activist Conference Call): As a healthcare professional as well, I agree totally that the mandate is putting more power in the insurance industry and not where we want to go. But I agree that to some extent that argument doesn’t get us where we want to go. And there’s some people in the single-payer movement even who see real human beings being helped by parts of the ACA, and it’s hard to say we want those benefits to go away. I agree, we didn’t need the mandate to get those benefits, but that’s where we are.
Don (Comment made during HCN’s April 1 Activist Conference Call): The task is to build a mass movement, and in my 19 years of trying to build one, it’s much easier to have a discussion with a human being when you have a piece of legislation then when you don’t. It’s much easier than saying “we have this thing we want” [single-payer healthcare] and talking in the abstract. We do have visits, we do demonstrate in the state capitol, we do ask people to write letters. Because when people start making commitments to do something, the more they do.
Bob (Comment made during HCN’s April 1 Activist Conference Call): In regards to the mandate and this whole bill and why there’s so much antipathy toward this mandate is because this imposes a tremendous burden on the poor and will be a tremendous revenue stream for the insurance industry. Yes, there are good things in this bill, but those good things don’t come close to what this bill is going to do in terms of pumping up the insurance industry.
Francesca (Comment made during HCN’s April 1 Activist Conference Call): I think what this comes down to is a difference in organizing tactics. It’s not just that a lot of people are supporting the Democrats, but that people believe there are different ways that social change happens. Some believe voting and lobbying are the ways to make change while others believe in civil disobedience and direct action. I think that’s where the discrepancy comes in – that we weren’t unified in how to portray a message as opposed to not being able to unite on a message.
This is only a summary of various arguments we’ve heard made about the future of the individual mandate and its impact on the single-payer movement. We are eager to keep this conversation going, and to continue to learn from each other’s experiences on how best to respond to this issue. Please continue to email us your thoughts or comment below.
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