One of the strongest driving forces behind officeholders resorting to the individual mandate is the desire to substitute “off-budget” mandated private funds in place of more visible taxes that they would otherwise find hard to impose to meet their insurance coverage goals and finance additional health care spending. Making the full costs of mandatory coverage more transparent reduces popular support for the latter. The hope instead is that an individual mandate can obscure the full sticker-price shock to taxpayers because mandated private spending is not officially treated as part of the federal budget. Instead, employers and insurers are enlisted as surrogate “tax collectors” through less transparent and politically accountable means.
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[A]n individual mandate often promises, but never manages, to pay for itself. In order to get lower-income individuals to comply with a mandate to purchase more insurance than they can afford, or want, to purchase, substantial taxpayer subsidies are used to fill some of the affordability gap. Insurance mandates create a perpetual conflict between their escalating costs, limited public and private resources to pay for them, and the false guarantees of richer coverage ahead. The imbalances may be financed through various combinations of higher taxes, reduced benefits, higher premiums, lower take-home pay, fewer economic opportunities, and less insurance coverage for everyone else. Doing so also reduces portions of any projected increases in new premium “revenue” expected by insurers and health care providers from expanded coverage. Eventually, some of those less-visible costs are reimposed on the initially more “fortunate” newly insured.
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The penalties for failing to comply with the mandate also are rather modest in proportion to the likely average premium cost of required coverage. The predictable result was that millions of individuals calculated that it is much less expensive to pay the penalty than to purchase mandatory insurance. The law’s guaranteed-issue incentives for potential purchasers, coupled with loose enforcement of eligibility for special enrollment periods between annual open season windows, encouraged individuals to enroll “just in time” when sick and “go bare” when healthy (and pay less in penalties than in total premiums), further ensuring limited and erratic mandate compliance.An argument I often encounter is that we've got to have the individual mandate because we have EMTALA, so uninsured people will get free (to them) but expensive (to us) emergency room care when we might have treated them more cheaply with preventive care at clinics. Setting aside whether preventive care really is cheaper, I remain skeptical whether you really can force people to pay in advance for their uncertain future health benefits when (1) they don't or can't afford to plan ahead effectively otherwise, and (2) it's fairly clear they'll have acceptable options if they roll the dice instead. This is why I say that solving the healthcare cost problem for some people is always going to be an issue of charity, whether we face it or not. If we're going to do it, let's do it, not pretend we can make them pay for their own charity.
And so we're left with people like me, who are absolutely by-golly going to be insured one way or another--but in a delusory quest to force it on people who resist it, we have to take my own insurance away and make it inhumanly difficult to replace. But if I refuse to vote for Clinton I'm a racist misogynist who doesn't care about the poor.