The Trump Administration and congressional Republicans remain stalemated over how to “repeal and replace” the 2010 Affordable Care Act (ACA). One major problem: The House approach in the American Health Care Act (AHCA) is highly unlikely to pass Congress when it increases the number of uninsured by 23 million, as estimated by the Congressional Budget Office. Real reform needs a better set of building blocks. Here I address one of those building blocks: how to replace the ACA’s individual mandate in a way that satisfies both Democratic goals for coverage and Republican concerns that government shouldn’t mandate what citizens must buy. What is the alternative? Simply make some existing government benefits, particularly tax benefits, conditional upon buying health insurance.
Such a step could also be made at least as progressive as the ACA’s mandate, which would please Democrats. And it would replace the use of a whole new penalty tax structure surrounding the ACA’s mandate, a step that should please Republicans.
Fair and efficient reform of ACA requires recognizing the logic behind individual responsibility to purchase insurance, an idea long favored by many researchers and public officials across the ideological spectrum. If government is going to support those in need, whether through Medicaid, uncompensated care, or, under some new government subsidy, how should it treat those who don’t buy health insurance even if they have the financial resources to do so? Equal justice suggests that a household making, say, $50,000 but effectively paying $10,000 to buy insurance—for instance, through lower cash compensation when receiving employer-provided insurance—shouldn’t have to subsidize other households with the same income but who don’t buy insurance.
That problem arises whenever government safety nets protect those who don’t insure against future needs but becomes particularly acute in health care when, as both Democrats and Republicans have now accepted, health insurance companies cannot exclude people with “pre-existing” conditions. Without some individual responsibility requirement, what is there to prevent people from going without insurance until they turn ill?
Democrats want to keep some requirement for individual responsibility to maintain the ACA’s coverage expansion. But why can’t Republicans find an acceptable alternative?
It’s simple math. Since adding millions to the roles of the uninsured seems politically unacceptable, the alternatives are to increase government benefits and the taxes needed to support them, or impose an even higher unfunded mandate on providers to care for the uninsured. Some commentators already believe that enactment of a House-like bill would eventually result in a universal system like Medicare for all, an unsatisfactory outcome for Republicans.
We are left with this: The federal government now spends about three-tenths of its entire non-interest budget on health care, and the share is increasing rapidly. In this expensive healthcare world, government supports should be targeted toward those who need help the most.
While the ACA’s mandate moves in the direction of establishing equal treatment of those with equal ability to buy insurance, it levies a penalty for most people that is far lower than the cost of insurance. According to a calculator provided by the Tax Policy Center, the 2016 penalty was $991 for a single person making $50,000 or $2,085 for a family of four. By contrast, the IRS indicates that an average “bronze” premium insurance policy would cost several times more: for an individual, about $2,700, and for a family of four, $10,700.
Making purchase of health insurance a condition for receiving other government benefits removes the philosophical and, for some, constitutional hang-up over whether government should mandate that we buy something. Instead, Congress could simply make health insurance a condition for opting to take some other benefits such as standard deduction, itemized deductions, or child credit. If we can get some more permanent agreement on some individual responsibility payment, the IRS can start to adjust withholding by employers for employees who don’t have employer insurance or declare otherwise that they have insurance. This would reduce end-of-the-year problems in collecting money from people who may not have any easy way to pay a penalty.
While some also suggest allowing insurance companies to charge higher premiums for those who buy insurance only when they get sick, that penalty is likely to be either too low to be effective or too high to be affordable by those who only seek insurance once sick.
In sum, any replacement structure for the ACA requires solid building blocks. Repealing and replacing the individual mandate with a conditional limit on the receipt of other government tax benefits offers one possibly bipartisan way to expand coverage, save government costs, and improve tax administration. To it, of course, must be added a subsidy system for those with too little income to afford insurance. The combination can be made as progressive or more progressive than the ACA. As noted, however, inattention to a requirement for individual responsibility will in the long run probably only add to the load that must be supported by the building block of government subsidies.
