What Changed My Mind on the Individual Mandate

March 26, 2017

The death of the GOP’s quixotic attempt at an Obamacare replacement is surely cause for some relief, not only for Democrats but, more importantly, for all those whose health care would have been genuinely at risk, as well as the growing number of professional organizations publicly expressing alarm at a bill that seemed designed to gut the parts of the Affordable Care Act that were actually doing some good rather than amending its flaws.  Indeed, the very idea that the ACA needs amending has long been buried beneath the polemic between those seeking to either repeal or defend it at all costs.  Now that it remains in place “for the foreseeable future,” the tone of the polemic appears to be shifting only slightly, with defenders still blindly refusing to admit to any problems with it, and detractors hoping to wait out (and urge on) its self-destruction just for the chance to say “told you so.”

With a view to reviving nonpartisan examination of what is both right and wrong with the ACA, I offer here my own critical reflection on one aspect of it that I myself have come to rethink – not from the perspective of a policy wonk or an insurance expert, of which I am neither, but that of a language service provider who has had occasion to witness a sampling of particular situations in which the positive and negative effects of the ACA are manifest.  Working as a telephonic interpreter, I have gone through countless applications to the federal health insurance Marketplace, as well as phone calls to various insurance companies from US nationals (naturalized citizens and green card holders in this context) with limited English proficiency.  In a health care system that can be difficult to navigate even in one’s native language and culture, the need to do so with the help of interpreters and translated materials only adds to the complications that many have faced when trying to sign up for – or keep – health insurance.

One of the ACA’s more controversial points has been its “individual mandate” requiring individuals to purchase health insurance or pay a penalty on their tax returns.  Defenders of the mandate argue that those with the health and financial means to have less immediate need of health care have a responsibility to pay into the insurance market in order to keep the cost affordable for those who need it most.  I’ve generally found this point persuasive, and I cannot agree with objections based merely on personal choice, as if anyone’s choice were worth more than anyone’s life.  At the same time, lost in the debate between individual choice and the common good are the many people who fall through the cracks within a deeply flawed system.  Having been largely convinced of the merits of the mandate as a step toward universal health care, observing multiple instances of people being failed by the system has given me pause. 

Many cases I’ve heard confirm the reports of skyrocketing costs.  In some of these cases it is the insurance companies raising premiums, sometimes without warning, which can be devastating for someone living paycheck to paycheck.  But the premiums themselves are not the only culprit.  Often, people may unexpectedly lose the tax credits they had received through ACA subsidies, for a number of reasons.  One of the most frequent reasons is documents not ending up in the right place, which happens disturbingly easily if any detail is off, as I’ve heard in a surprising number of conversations about documents being resent and re-requested multiple times. 

In other cases, people may experience what in Obamacare’s parlance is termed a “qualifying life event” – for example, a change in one’s state of residence, income, family size, or marital status, which would qualify them for a special enrollment period to purchase insurance outside of the designated “open enrollment” – without knowing that they have a limited time frame after the change occurs in which to do so.  Some people have simply made do with hospital sliding-scale payment systems, which allow them to get the care they need, only to discover that they still don’t meet the insurance requirement.  In the above situations, the lack of adequate and timely information, including frequent lapses in communication and responsibility between the Marketplace and insurance companies, appears to be a widespread problem in general, which of course is only exacerbated when there is a language barrier.

Still others simply find themselves in an awkward gap in which, between their actual incomes and living expenses, rising premiums, and the mysterious machinations of the Marketplace’s tax credit calculus, they still end up without any insurance options they can actually afford – and are penalized for it.  The system ends up being especially punitive toward people who are legally married but separated from their spouses, whether due to estrangement or practical necessity.  People in these situations often find themselves in a double bind, since they are disqualified from receiving a tax credit if they don’t file taxes jointly but may still qualify to purchase insurance they can’t afford, leaving them fined as well as uninsured.

To complicate matters further, in states where legislators have chosen not to expand Medicare and Medicaid services, people who qualify for low-cost insurance they can’t receive are exempt from the fine, but still left without insurance.  This latter situation is of course the fault of state-level politics rather than the individual mandate, which only further demonstrates the very concrete ramifications of the political tug-of-war that health care in America has become.

The real problem with the individual mandate is not that it “forces” health insurance on those in a position to choose not to buy it, but that it too easily ends up hurting those who have difficulty affording insurance – the very people the mandate was supposedly meant to protect.

—Julia Smucker

Julia Smucker writes for Vox Nova.