syke files - march 2013

7/29/2019 Syke Files - March 2013

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MARCH 2013

RESOLVED: THE UNITED STATES SHOULD NOT REQUIRE ITS CITIZENS TO HAVE HEALTH

INSURANCE

VOLUME 3, ISSUE 7


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SYKE FILES MARCH 2013THEUNITEDSTATESSHOULDNOTREQUIREITSCITIZENSTOHAVEHEALTHINSURANCE

1

PRO:FRAMEWORK:

DEFINITIONOFREQUIREDTOHAVEINSURANCE..............................................................................................8

MANDATEINOBAMACAREISRESOLUTIONAL:......................................................................................................9

ADVERSESELECTION:.......................................................................................................................................................10

MANDATEISARESULTOFLOBBYING,GIFTTOINSURANCECOMPANIES:..................... ..................... ....11

ALTERNATIVES:

EMPLOYERMANDATEISBADTOO:............................................................................................................................12

JUSTTAXPEOPLE:...............................................................................................................................................................13

LETSTATESFIGUREITOUT:..........................................................................................................................................14

REMOVE MANDATES:.......................................................................................................................................................15

SUBSIDIZE:..............................................................................................................................................................................16

MANDATEONLYWORKSASACOMPLEMENTTOACOMPLETEOVERHAUL:.................... ...................... 17

COMPLIANCE:

PEOPLEWONTCOMPLYWITHILLEGITIMATE,UNENFORCABLELAWS:.................................................18AUTO INSURANCE PROVES COMPLIANCE IS EMPIRICALLY LOW:...........................................................19

CONSTITUTION:

ORIGINALISMDICTATESINSURANCEISNOTCOMMERCE:..........................................................................20

CONGRESSHASNOCOMMERCEGROUNDSONWHICHTOTOUCHINSURANCE:...............................21

MANDATEISUNCONSTITUTIONALINDEPENDENTOFCOMMERCECLAUSE:............................. ...........22

MANDATE ISNT A TAX:..................................................................................................................................................23

DANGERS OF ACCEPTING MANDATE AS A TAX:................................................................................................24

ONLYACCEPTABLEMANDATESARETHOSENECESSARYTOTHEEXISTENCEOFGOVERNMENT:

.......................................................................................................................................................................................................25

NEITHER NECESSARY NOR PROPER, EXPLODES LIMITS ON POWERS:................................................26

COSTS:

MANDATEDOESNTREDUCEPREMIUMSOFTHEINSURED:..........................................................................27

UNINSUREDARETHATWAYDUETOCOSTS,NOTCHEATING:......................................................................28

MANDATE DOES NOTHING TO MAKE CARE MORE AFFORDABLE:.................... ..................... .................29


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2

HIGHCOSTSKEYTOCONTROLLINGOVERSPENDINGBYPATIENTS:................... ..................... ..................30

PATIENTSFEELINGCOSTSKEYTOREFORMINGHEALTHCARE,MANDATESHIELDS:................... ....31

MANDATES INCREASE PREMIUMS:..........................................................................................................................32

MIDDLE-CLASSFAMILIESCANTAFFORDINSURANCE:....................................................................................33

UNINSUREDWOULDUSEANADDITIONAL$69BILLIONINCARE:..............................................................34

ONLY 20% OF CURRENTLY UNINSURED CAN AFFORD TO BUY INSURANCE:...................................35

UNINSUREDSSPENDINGWOULDSHIFTTOTHEGOVERNMENT:................................................................36

WOULDHAVETOCOVERTHECOSTSOFCURRENTLYUNCOMPENSATEDCARE:...................... ...........37

FREE RIDERS:

HAVING INSURANCE DOESNT SOLVE FREE RIDING:......................................................................................38

UNINSUREDPAYFORALOTOFTHEIRCARE:........................................................................................................39

FREERIDINGISONLYWORTH3%OFHEALTHCAREEXPENDITURES:...................... ...................... ..........40

INNOVATION:

MANDATESUBJECTTOINTENSEREGULATION:...................................................................................................41

OVERREGULATION DUE TO MANDATE CUTS OFF HEALTHCARE INNOVATION AT THE KNEES:

.......................................................................................................................................................................................................42

OVERREGULATIONINCREASESCOSTS,IMPACTISLESSACCESS:.................... .................... ..................... ....43MANDATEASLIPPERYSLOPETOOVERREGULATION:......................................................................................44

INSURANCEJOBLOCKSTIFLESENTREPRENEURSHIP(REQUIRINGINSURANCEMAKESTHIS

WORSE?):..................................................................................................................................................................................45

MEDICARE/MEDICAID:

MEDICAID CANT HANDLE THE INCREASED LOAD:................... ...................... .................... ..................... .......46

PUBLIC INSURANCE ASSOCIATED WITH NEGATIVE HEALTH OUTCOMES:........................................47

PUBLICINSURANCEUSESINEFFECTIVEMEASURES,LEADINGTOBADHEALTHOUTCOMES:......48

MINIMUM BENEFITS:

LOBBYING WILL EXPLODE THE MINIMUM BENEFITS, RAISING PRICES:............................................49

MASSIVE INCREASE IN MANDATED BENEFITS INEVITABLE:.....................................................................50

STATESEMPIRICALLYPROVETHATMANDATEDBENEFITSWILLEXPLODE:................................ .......51

MEDICALGROUPSWILLLOBBYTHEGOVT.FORINCLUSIONINTHEMANDATEDPACKAGE:.........52

MEDICAREPROVESLOBBYINGINCREASESMANDATEDBENEFITS:..................... ..................... .................53

INCREASING MANDATED BENEFITS INCREASES PREMIUMS 20 TO 50 PERCENT:........................54


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THE IMPACT TO INCREASED MINIMUM MANDATED BENEFITS IS LESS PEOPLE GET CARE:..55

LIVES:

GAINING INSURANCE DOESNT HAVE A SIGNIFICANT EFFECT ON SAVING LIVES:.........................56

POLSKYSTUDYONMEDICARETRANSLATESTOAGENERALVIEWOFPROVIDINGINSURANCETO

UNINSURED:............................................................................................................................................................................57

MULTIPLESTUDIESHAVESHOWNTHATPROVIDINGINSURANCEDOESNTIMPROVEHEALTH

OUTCOMES:.................... ..................... .................... ...................... .................... ...................... ..................... ..................... .......58

UNINSURED ACTUALLY REPORT HIGHER HEALTH THAN THOSE COVERED BY MEDICARE OR

MEDICAID, AND EQUAL HEALTH TO PRIVATELY INSURED:.......................................................................59

UNINSUREDAREBETTEROFFTHANMEDICARE/MEDICAID,EQUALTOPRIVATELYINSURED,

WHENMEASUREDBYCHRONICCONDITIONS:.......................................................................................................60

DEFENDINGROSSSTUDY,CAUSATIONISCLEAR,VARIABLESARECONTROLLEDFOR,

METHODOLOGYISSOUND:.................... ..................... ...................... .................... ..................... ...................... .................61

EVEN PRIVATE INSURANCE DOESNT IMPROVE HEALTH OUTCOMES SIGNIFICANTLY:.............62

INSURANCEISPOSITIVELYCORRELATEDTOOBESITY:...................................................................................63

OVERUTILIZATION:

CHANGESMIGHTLEADTOINCREASEDHEALTHCAREUSEAMONGALREADY-INSURED:..............64

THOSEONPUBLICINSURANCEUSESIGNIFCANTLYMORERESOURCESTHANUNINSURED:.........65SLPPERY SLOPE:

BROCCOLIARGUMENT:.....................................................................................................................................................66

LEGAL SLIPPERY SLOPES EXIST, NOT A FALLACY:..........................................................................................67

MANDATEISACLEARLOGICALSLIPPERYSLOPE:..............................................................................................68

CONGRESS WILL ABUSE ITS NEW POWERS:........................................................................................................69

STRIKINGDOWNMANDATEDOESNTCREATEASLIPPERYSLOPE:...........................................................70

ANSWERS-TO:

A/TMANDATEKEYTOUNIVERSALCOVERAGE:..................................................................................................71

GRUBER/CBOINDICT:.......................................................................................................................................................72

A/TMASSACHUSSETTSASANEXAMPLE:................................................................................................................73

A/TFREERIDERSJACKUPEVERYONEELSESPREMIUMS:.............................................................................74

A/TNEEDMANDATETOSOLVEDISCRIM/ADVERSESELECTION:...............................................................75

A/TSTATESWITHCOMMUNITYRATINGHAVEHIGHPREMIUMS:.................... ..................... ..................... 76

A/TUNINSUREDBANKRUPTCIES:...............................................................................................................................77


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A/T HAVING INSURANCE WILL SOLVE FOR BANKRUPTCIES:................... ..................... ..................... .......78

A/TMCWILLIAMSSTUDY:...............................................................................................................................................79

A/TREDUCESRACIALDISPARITIES:..........................................................................................................................80


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5

CON:

FRAMEWORK:

DEFINITIONOFREQUIREDTOHAVEINSURANCE............................................................................................81

MANDATEINOBAMACAREISRESOLUTIONAL:....................................................................................................82

ADVERSESELECTION:.......................................................................................................................................................83

57% UNINSURED USE MEDICAL SERVICES ANNUALLY, ALMOST ALL DO WITHIN FIVE YEARS:

.......................................................................................................................................................................................................84

NOIMPACTTOAUTONOMY,MANDATEDOESNOTREQUIREUNDERGOINGHEALTHCARE:...........85

UNIVERSAL COVERAGE:

W/OMANDATE,NUMBERUNINSUREDSKYROCKETS:......................................................................................86

UNIVERSALCOVERAGEIMPOSSIBLEWITHOUTMANDATE:...........................................................................87

CONSTITUTION:

MANDATEPERFECTLYACCEPTABLEUNDERCOMMERCECLAUSE:...........................................................88

COMMERCECLAUSEAPPLIESEVENWITHINDIRECTINFLUENCEONCOMMERCE:..................... .......89

COMMERCECLAUSEDOESNTMATTER,NECESSARYANDPROPERWORKS:.........................................90

JUSTICEBLACK:INSURANCEISJUSTANOTHERBUSINESS,BURDENISONPRO:.................... ..............91

CONGRESSCANREGULATENON-COMMERCIALACTIVITYANDCOMMERCIALINACTIVITY:..........92

FRAMERS UPHELD MULTIPLE MANDATES, INCLUDING ONE TO BUY INSURANCE:......................93

MANDATEOKAYUNDERTAXINGPOWER:..............................................................................................................94

MANDATENECESSARYANDPROPERTOUPHOLDINGRESTOFBILL:....................................................95

MULTIPLE FOUNDING FATHERS PASSED A HEALTH INSURANCE MANDATE:.................................96

NOHISTORICALEVIDENCETHATFRAMERSCONSIDEREDMANDATESUNCONSTITUTIONAL:.....97

FRAMERSMANDATESWEREMOREONEROUSTHANHEALTHINSURAN CE ONE:........................98

FRAMERSMANDATESPROVEMANDATESAREPROPER:............................................................................99ADVERSE SELECTION:

WITHOUTMANDATEADVERSESELECTIONRAISESPREMIUMS:..............................................................100

MASSACHUSETTS PROVE MANDATE SOLVES ADVERSE SELECTION:.................................................101

MANDATEWILLBEEVENMOREEFFECTIVENATIONALLYTHANINMASSACHUSETTS:..............102

ALTERNATIVES:

MANDATEISBIPARTISAN:...........................................................................................................................................103

MANDATEKEYFORPRIVATE-SECTORBASEDREFORM:...............................................................................104


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PREFERMANDATEDBENEFITSOVERUNIVERSALCARE:.............................................................................105

MANDATESHAVELESSDEADWEIGHTLOSSTHANUNIVERSALCAREPAIDBYTAXES:.................106

COSTS:

UNINSUREDPASSTHEIRCOSTSON:..................... ..................... ...................... .................... ..................... ...............107

UNINSUREDUSEEMERGENCYROOMASSOURCEOFCARE:........................................................................108

INDIVIDUALSUNDERESTIMATEECONOMICVALUEOFINSURANCE:......................................................109

POSITIVE EXTERNALITIES DEMAND MANDATED INSURANCE:............................................................110

UNINSUREDUSEOFE.R.COSTSBILLIONSANNUALLY:..................................................................................111

UNINSURANCE=LONG-TERMDEVELOPMENTALLOSSESFORCHILDREN:.........................................112

UNINSURED LACK OF PARTICIPATION IN WORKFORCE COSTS 130 BIL ANNUALLY:...............113

UNINSURED DRAIN 60% OF EMPLOYER-PROVIDED HEALTH INSURANCE:...................................114

NOEVIDENCEINMASSACHUSETTSTHATMANDATEINCREASEDCOSTOFHOSPITALCARE:....115

MASSACHUSETTSSHOWSMANDATELOWERSCOSTSFOREVERYONE:................................................116

EMPLOYERSCANTCOVEREMPLOYEESANYMORE:........................................................................................117

ACCESS:

INSURANCEINCREASESACCESSANDREDUCESCOSTS:................................................................................118

MANDATEDECREASESUNINSURANCE:.................................................................................................................119

INCREASED INSURANCE = INCREASED MEDICAL CARE:............................................................................120

MORALITY:

MANDATEKEYTOSTOPPINGDISCRIMINATION:..............................................................................................121

MANDATEKEYTOPERSONALRESPONSIBILITY:..............................................................................................122

ACCESS TO HEALTHCARE KEY TO OPPORTUNITY AND THEREFORE JUSTICE:............................123

UNIVERSALACCESSTOINSURANCEKEYTOJUSTICE:....................................................................................124

INCREASINGINSURANCEDECREASESHEALTHDISPARITIES:....................................................................125MANDATE REDUCES RACIAL DISPARITIES IN ACCESS TO HEALTH CARE:......................................126

LIVES:

UNINSUREDLESSLIKELYTOBEABLETOFULFILLPRESCRIPTIONS:.....................................................127

UNINSUREDPOSTPONEORDONTGETCARE:...................... ...................... .................... ..................... ...............128

UNINSUREDMORELIKELYTOGETLATEDIAGNOSESFORCANCER:......................................................129

UNINSUREDARE50%LESSLIKELYTOGETPREVENTATIVECARE:........................................................130


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UNINSUREDLESSLIKELYTOGETGOODCAREFORCHRONICDISEASESLIKELIVERDISEASEOR

DIABETES:.............................................................................................................................................................................131

BEING UNINSURED IS AS DEADLY AS DIABETES, STROKES, HIV, AND HOMICIDES:..................132

275,000LIVESLOSTINTHENEXTDECADEDUETONOINSURANCE:.....................................................133

UNINSUREDINCREASEDISEASEBURDENAMONGCOMMUNITIES:.........................................................134

68 TO 84 DEATHS DAILY DUE TO UNINSURANCE:........................................................................................135

WARRANTLEADINGFROMUNINSURNACETODEATH:.................................................................................136

CHILDRENWITHOUTINSURANCE60%MORELIKELYTODIE:..................................................................137

300,000 HAVE DIED DUE TO NO INSURANCE SINCE 1995:......................................................................138

STUDYSAYING68DEATHSDAILYISLIKELYCONSERVATIVE:...................................................................139GETTINGINSURANCE=HEALTHGAINS:...............................................................................................................140

STUDIESTHATAREDESIGNEDWELLSHOWBENEFITSOFINSURANCE:..............................................141

MCWILLIAMSLITERATUREREVIEWISOF42STUDIES:................................................................................142

REVIEW OF 42 STUDIES FINDS CONSISTENT POSITIVE EFFECTS OF INSURANCE ON HEALTH:

....................................................................................................................................................................................................143

HEALTHINSURANCESHOWNTOBEGOODFORARANGEOFDISEASES:..............................................144

HEALTHINSURANCEPOSITIVELYCORRELLATEDWITHPREVENTATIVECARE:...................... ........145

ANSWERS-TO:

A/TOVERUTILIZATION:................................................................................................................................................146

A/TOVERUTILIZATION/MORALHAZARD:...........................................................................................................147

A/TEVERYONEWILLGOONTOPUBLICINSURANCE:.....................................................................................148

A/TMANDATEINCREASESHEALTHCAREOVERUTILIZATION:.................................................................149

A/TSLIPPERYSLOPE:.....................................................................................................................................................150

A/TLEGALSLIPPERYSLOPEISDANGEROUS:.....................................................................................................151

A/TGUNMANDATEWASUNDERMILITIAPOWER:.........................................................................................152A/TUNCONSTITUTIONALBECAUSEITSAPRIVATEPURCHASE:................... ..................... ..................... .153

A/TINSURERSLOBBYINGPUTTHEMANDATEINTOTHELAW:................................................................154

A/TINACTIVITYCANTBEREGULATED:...............................................................................................................155

A/TVERYSMALLHEALTHINSURANCEACTIVITY:...........................................................................................156


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8

PRO

FRAMEWORK

DEFINITIONOFREQUIREDTOHAVEINSURANCETherecentMassachusettshealthinsurancelegislation,knownasChapter58,includedseveral

features,themostsalientofwhichwasamandateforindividualstoobtainhealthinsurance

coverageorpayataxpenalty.Allindividualswererequiredtoobtaincoverage,withtheexception

ofindividualswithreligiousobjectionsandindividualswhoseincomesweretoohightoqualifyfor

statehealthinsurancesubsidiesbuttoolowforhealthinsurancetobe affordable as determinedbytheMassachusettsHealthInsuranceConnectorAuthority.

KOLSTAD AND KOWALSKI IN 2010

JONATHANKOLSTAD,UNIVERSITYOFPENNSYLVANIA,ANDAMANDAKOWALSKI,YALE

UNIVERSITYANDNATIONALBUREAUOFECONOMICRESEARCH.JUNE3,2010.THE IMPACT OF

ANINDIVIDUALHEALTHINSURANCEMANDATEONHOSPITALANDPREVENTIVECARE:

EVIDENCE FROM MASSACHUSETTS.

http://www.hec.unil.ch/documents/seminars/iems/319.pdf

ACCESSED:MARCH3,2013


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9

MANDATEINOBAMACAREISRESOLUTIONAL:

The national health reform legislation passed in March 2010 shares many features of theMassachusetts reform, including an individual mandate to obtain health insurance coverage,

newrequirementsforemployers,expansionsinsubsidizedcare,state-levelhealthinsurance

marketplacesmodeledontheMassachusettsConnector,andnewrequirementsforinsurersto

coverdependentstoage26,tonameafew.

KOLSTAD AND KOWALSKI IN 2010

JONATHANKOLSTAD,UNIVERSITYOFPENNSYLVANIA,ANDAMANDAKOWALSKI,YALE

UNIVERSITYANDNATIONALBUREAUOFECONOMICRESEARCH.JUNE3,2010.THEIMPACTOF

ANINDIVIDUALHEALTHINSURANCEMANDATEONHOSPITALANDPREVENTIVECARE:

EVIDENCEFROMMASSACHUSETTS.http://www.hec.unil.ch/documents/seminars/iems/319.pdf



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ADVERSESELECTION:

Adverseselectionoccurswhenalargerfractionofrelativelyunhealthypeoplethanhealthypeoplepurchasehealthinsurance.Itisanalogoustothepurchaseofcarinsuranceonlybyhigh-riskdrivers

(orworse,onlybydriverswhohavejusthadanaccident).

CHANDRA ET AL IN 2011

AMITABHCHANDRA,JONATHANGRUBERANDROBINMCNIGHT,PhDs.NEWENGLANDJOURNAL

OFMEDICINE.JANUARY27,2011.THEIMPORTANCEOFTHEINDIVIDUALMANDATE

EVIDENCEFROMMASSACHUSETTS.

http://phes.co/Newengland/Ahmed/The%20Importance%20of%20the%20Individual%20Mandat

e%20%E2%80%94%20Evidence%20from%20Massachusetts.pdf

ACCESSED:FEBRUARY25,2013


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MANDATEISARESULTOFLOBBYING,GIFTTO

INSURANCECOMPANIES:ThedebateswithClintonduringtheprimariesforcedObamatobecomebetterversedinhealth

policy,andtheymayhaveevenhadsomeinfluenceonhisthinkingaboutthemandate.Theposition

oftheinsuranceindustrymayalsohaveencouragedObamatochangehisposition.Notlongafter

Obamalockedupthenomination,KarenIgnagni,presidentofAmericasHealthInsurancePlans

themainlobbyistfortheinsurancecompaniesflewtoObamascampaignheadquartersinChicago

tosaythattheindustrywouldacceptareformplanthatincludedtheguaranteedissueofpolicies

withnopreexisting-conditionexclusionsifthelegislationalsoincludedamandatethateveryonebe

covered.Inotherwords,themandatewasthepricefortheindustryscooperation.

STARR IN 2011

DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.

DECEMBER14,2011.THEMANDATEMISCALCULATION.

http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-

care-act#



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ALTERNATIVES

EMPLOYERMANDATEISBADTOO:GovernorSchwarzenegger'sproposal,meanwhile,couplesanindividualmandatewithanemployer

mandate:anyemployerwith10ormoreemployeeswouldhavetoprovidehealthcoverageorpay

anadditionalpayrolltax.Thisregulationwouldconstituteadirecttaxonemployment,as

businesseswillfinditintheirinteresttohirefeweremployees(possiblycompensatingwithmore

hoursperworker)tominimizehealthinsurancecosts.Meanwhile,businesseswithfewerthan10

employeeswillhaveastrongincentivenottoexpand,asdoingsocouldexposethemtothe

mandate.

WHITMAN IN 2007

GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.

THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH

CAREMANDATE.

http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-

mandate



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JUSTTAXPEOPLE:

Inonealternative,forexample,thelawcouldhaveimposedataxtopayforhealthcare,whileprovidinganoffsettingcredittothosewithinsurance.Theeffectwouldhavebeenidenticaltothe

mandate.

STARR IN 2011




care-act#



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LETSTATESFIGUREITOUT:

OrtheAffordableCareActcouldhavedelegatedtheresponsibilityofcurbingfreeridingtothestatesgivingthemanopen-endedmenuofpoliciestochoosefrom,whichmighthaveincludedthe

mandateaswellastheseotheroptions.AstatethatfollowedtheexampleofMassachusettsand

enactedamandatewouldthendosounderstatelaw,eliminatinganyconstitutionalchallengethat

couldbebroughtinfederalcourt.Theotheradvantageofthisapproachisthatthestatescould

experimentwithdifferentpolicies,andthenationcouldlearnfromtheirresults.

STARR IN 2011


DECEMBER 14, 2011. THE MANDATE MISCALCULATION.

http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-care-act#



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REMOVEMANDATES:Abetterapproachtohealthreformwouldfocusonremoving,ormitigatingtheeffectof,existing

mandatesthatdriveupinsurancepremiums.Statesthatgenuinelywanttohelptheuninsured

oughttorepealsomeoralloftheirmandatedbenefitlaws,allowingfirmstoofferlow-priced

catastrophiccarepoliciestotheircustomers.Ifspecial-interestpressureshamperthissolution,the

federalgovernmentcouldassistbyusingitspowerundertheConstitution'sinterstatecommerce

clausetoguaranteecustomerstherighttobuyinsurancepoliciesofferedinanystate,notjust

theirown.Thatwouldenablepatientstopatronizefirmsinstateswithfewercostlymandates.As

anaddedbonus,statelegislaturesmightfeelpressuretoeaseregulationstoattractmoreinsurance

businessfromout-of-statecustomers.Removingmandateswoulddofarmoretoexpandhealthcarecoveragethanaddingnewmandatesevercould.

WHITMAN IN 2007


THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUALHEALTH

CARE MANDATE.


mandate



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SUBSIDIZE:

Somecriticssimplycomplainthatthemandateisbadpolicy.Ihavetoagree;indeed,likepresidentialcandidateBarackObama,Iopposedthemandate.Therearetwowaystokeephealthy

peopleintheinsurancepool:mandatesandsubsidies.Subsidieswouldhavebeennotonlymore

politicallypalatable,butalsolessregressivebecausetheywouldrelyonournormaltaxsystem.

Moreover,ourcurrenthealthcaresystemissoinefficientthatIwouldnothavemandatedthe

purchaseofinsurancewithoutstrongerreformstoincreaseitsefficiency.Ialsohatebroccoli.But

thereisadifferencebetweenthepoliciesonedisfavorsandwhattheConstitutionprohibits.

ELHAUGE IN 2012

EINERELHAUGE,J.D.THENEWENGLANDJOURNALOFMEDICINE,JANUARY5,2012.THE

IRRELEVANCEOFTHEBROCCOLIARGUMENTAGAINSTTHEINSURANCEMANDATE.http://www.nejm.org/doi/full/10.1056/NEJMp1113618



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MANDATEONLYWORKSASACOMPLEMENTTOA

COMPLETEOVERHAUL:Intheabsenceofanexpansioninpubliccoverage,healthinsurancemarketreforms,purchasing

pools,orhigh-riskpools,orsomecombination,mightbeneededtobringthecostofcoverage

availabletothisgroupintotheaffordablerange.Suchreformscouldalsoreducetheincome-related

subsidiesthatwouldberequiredtomakecoverageaffordable.Itmightalsobenecessaryto

mandatethatpeopleobtaincoverageonceincome-relatedfinancialsupportisavailable,ashas

beenrecentlyenactedinMassachusetts.

DUBAY ET AL IN 2006

LISADUBAY,JOHNHOLAHANANDALLISONCOOK.MARKETWATCH,THEPEOPLETOPEOPLEHEALTHFOUNDATION.NOVEMBER30,2006.THEUNINSUREDANDTHEAFFORDABILITYOF

HEALTHINSURANCECOVERAGE.

http://www.dev.mdvinteractive.com/ccf/wp-content/uploads/2012/03/The-uninsured-and-the-

affordability-of-health-care.pdf



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COMPLIANCE

PEOPLEWONTCOMPLYWITHILLEGITIMATE,

UNENFORCABLELAWS:EventhoughSenateDemocratschickenedoutfromframingthepenaltyasatax,theCBOdecided

nonethelessthatpeoplewouldrespondtoitasataxandthat,evenwithoutanymajorsanctions,the

lawwouldestablishanewsocialnormleadingmillionsofmostlylow-incomepeopletopayfor

healthinsurance.Themandateultimatelyrestsonlittlemorethanahopethatindividualswill

complywiththelawbecauselaw-abidingcitizensgenerallydocomplywithlawsandperhaps

becauseofanillusionthatfailingtopaythepenaltieswouldbringthesameenforcementmeasures

asfailingtopaytaxes.Butamandatethatiswidelyseenasillegitimateisunlikelytocreatethesocialpressuresonwhichtheseestimatesarecounting.Anditwillnottakelongforpeopleto

discoverthattheycandefythemandatewithimpunity.

STARR IN 2011




care-act#



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AUTOINSURANCEPROVESCOMPLIANCEIS

EMPIRICALLYLOW:Forty-sevenstatescurrentlyrequiredriverstopurchaseliabilityautoinsurance.Do100percentof

driversinthosestateshaveinsurance?No.Forstateswithanautoinsurancemandate,themedian

percentageofdriverswhoareuninsuredis12percent.Insomestates,thefigureismuchhigher.

Forexample,inCalifornia,whereautoinsuranceismandatory,25percentofdriversareuninsured

morethanthepercentageofCalifornianswholackhealthinsurance.

WHITMAN IN 2007


THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH

CARE MANDATE.


mandate



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CONSTITUTION

ORIGINALISMDICTATESINSURANCEISNOT

COMMERCE:Under the original meaning of commerce, insurance contracts did not qualify. Such contracts are

merepromisestopaymoneyupontheoccurrenceofspecifiedconditions,anddonotinvolvethe

conveyanceofgoodsorotheritemsfromonestatetoanother.AndsotheSupremeCourtheldinthe

1869 case of Paul v. Virginia that issuing a policy of insurance is not a transaction of commerce.

BARNETT IN 2010

RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY

JOURNALOFLAW AND LIBERTY. COMMANDEERING THE PEOPLE: WHY THE INDIVIDUAL

HEALTH INSURANCE MANDATE IS UNCONSTITUTIONAL.

http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-

redir=1



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CONGRESSHASNOCOMMERCEGROUNDSONWHICHTO

TOUCHINSURANCE:Thus,undertheoriginalmeaningoftheCommerceClause,asaffirmedbytheCourt,Congresslacks

anypoweroverthehealthinsurancebusiness.

BARNETT IN 2010


JOURNAL OF LAW AND LIBERTY. COMMANDEERING THE PEOPLE: WHY THE INDIVIDUAL

HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.


redir=1ACCESSED:FEBRUARY14,2013


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MANDATEISUNCONSTITUTIONALINDEPENDENTOF

COMMERCECLAUSE:Existingdoctrinerevealstheindividualmandateisunconstitutionalevenifweassumethat

CongresshasthepowertoregulatetheinsurancebusinessthattheNewDealSupremeCourtgaveit

inSouthEastern Underwriters.

BARNETT IN 2010


JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUAL


http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-redir=1



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MANDATEISNTATAX:Consideredapartfromthepenalty,itisobviousthattheindividualinsurancemandatecannothave

beenimposedtoraiserevenueandthereforebejustifiedunderthepowerofCongresstotax.The

mandateraisesnorevenueforthegovernmentwhatsoever.Tothecontrary,itcommandsthat

citizensproviderevenuetoprivateinsurancecompanies.

BARNETT IN 2010




http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-redir=1



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DANGERSOFACCEPTINGMANDATEASATAX:ButthegovernmentstaxpowertheoryisfarmoreradicalthantheCommerceandNecessaryand

ProperClausetheorypreciselybecausetheSupremeCourthasgenerallydeferredtoanyinvocation

ofthetaxpowertoraiserevenuetospendforthegeneralwelfare.Thisnormaldeferenceiswhythe

mandatesdefendersshiftedtheargumentfromtheCommerceClausetothetaxpower.Yetifits

theoryisaccepted,Congresswouldbeabletopenalizeormandateanyactivitybyanyoneinthe

country,provideditlimitedthesanctiontoafineenforcedbytheInternalRevenueService.

BARNETT IN 2010


JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUALHEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.


redir=1



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ONLYACCEPTABLEMANDATESARETHOSENECESSARY

TOTHEEXISTENCEOFGOVERNMENT:Toseewhy,considerthedutiesthefederalgovernmentdoesimposeonthepeople:registerforthe

draftandserveifcalled,sitonajury,filloutacensusform,andfileataxreturn.Noneofthese

dutiesareimposedviaCongressspowertoregulateeconomicbehavior.Instead,allhave

traditionallybeenconsideredfundamentaldutiesthateachpersonowestothegovernmentby

virtueofAmericancitizenshiporresidency.Eachofthesedutiescanbeconsideredessentialtothe

veryexistenceofthegovernment,notmerelyconvenienttotheregulationofcommerce.

BARNETT IN 2010

RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITYJOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUAL



redir=1



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NEITHERNECESSARYNORPROPER,EXPLODES

LIMITSONPOWERS:Eitherthenationalgovernmenthasunlimitedpoweroverthepeopleoritspowersarelimited.If

thelatter,theremustbesomelimittotheNecessaryandProperClause.Courtscouldlimititsscope

byexaminingthesubstanceofeachlawtoseeifitistrulynecessary,butthistheyhavedeclinedto

do.Instead,theCourthasdevelopedformaldoctrinestoidentifywhenanexerciseofpoweris

incidentaltotheregulationofcommerce,andwhenitisremoteandunnecessary.If,however,

Congressisallowedtoregulateanydecisionthathasaneconomiceffect,orthatCongressdeems

essentialtoitsregulatoryambitions,thentheschemeoflimitedandenumeratedpowerswouldbe

atanend.Becauseitisbothunnecessaryunderexistingdoctrineandalsoimproper,theindividual

healthinsurancemandateisunconstitutional.

BARNETT IN 2010





redir=1



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27

COSTS:

MANDATEDOESNTREDUCEPREMIUMSOFTHE

INSURED:Withautoinsurance,atleastthereisareasonableargumentthatawell-enforcedmandatecould

reduceinsurancepremiums.Whenmanymotoristsareuninsured,thosewhodobuyinsurance

need,andaresometimesrequired,tobuycoveragefordamagedonetotheirvehiclesbythe

uninsured.Sowhentheuninsuredbecomeinsured,others'premiumscouldfall.Butthisargument

simplydoesn'tflyinthecaseofhealthinsurance,because(asalreadynoted)uncompensatedcareis

suchasmallfractionofoverallhealthspending.

WHITMAN IN 2007



CARE MANDATE.


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UNINSUREDARETHATWAYDUETOCOSTS,NOT

CHEATING:Notallfreeridersaretryingtotakeadvantageoftheirfellowcitizens.Formany,healthinsurance

premiumsarejusttoohigh.

WHITMAN IN 2007



CAREMANDATE.


mandateACCESSED:FEBRUARY11,2013


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MANDATEDOESNOTHINGTOMAKECAREMORE

AFFORDABLE:Yettheindividualmandatedoesnothingtomakeinsurancemoreaffordable.Theredoexist

regulatoryreformsthatcouldmakeitmoreaffordable,butthosereformsaredesirable

independentoftheindividualmandate.Themandateseekstocommandabetteroutcomemore

insuredpeoplewhiledoingnothingtomakeithappen.Youcan'tgetbloodfromastone.

WHITMAN IN 2007



CARE MANDATE.


mandate



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30

HIGHCOSTSKEYTOCONTROLLINGOVERSPENDING BY

PATIENTS:InafamousRANDstudy,patientswithfirstdollarinsurancecoverageconsumed43percentmore

healthcarethanpatientswhohadtopayalargedeductible,andyetthetwogroupsexperienced

indistinguishablehealthoutcomes.Theobviousconclusionisthatmanyhealthserviceshave

negligiblebenefits,butpatientswillgetthemanywayunlesstheyfaceatleastsomeportionofthe

costs.

WHITMAN IN 2007


THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTHCAREMANDATE.


mandate



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PATIENTSFEELINGCOSTSKEYTOREFORMING

HEALTHCARE, MANDATESHIELDS:Effectivehealthcarereformwouldinvolvemakingcustomersmorecost-conscious.Theindividual

mandate,sadly,willtendtoshieldcustomersfromcostsandimpedeinnovationsthatcouldpush

costsdown.

WHITMAN IN 2007



CAREMANDATE.

http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-mandate



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MANDATESINCREASEPREMIUMS:Usingafixedeffectsmodel,Ifindthattheaveragemandateincreasespremiumsby0.44-1.11%

annually.Thisimpliesthatnewmandateswereresponsiblefor9-23%ofallpremiumincreases

overthe1996-2011period.

BAILEY IN 2012

JAMESBAILEY,DEPARTMENTOFECONOMICS,TEMPLEUNIVERSITY.OCTOBER29,2012.THE

EFFECTOFHEALTHINSURANCEBENEFITMANDATESONPREMIUMS.

http://papers.ssrn.com/sol3/papers.cfm?abstract_id=2107945



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MIDDLE-CLASSFAMILIESCANTAFFORDINSURANCE:

Overthelastfewdecades,theUnitedStateshaswitnessedskyrocketinghealthcarecosts.Healthinsurancepremiumshavebeenrisingonaveragebydouble-digitpercentagepointsoverthepast

fiveyears,arateofincreasethatis2-3timestherateofinflation.1Becauseoftheseout-of-control

healthcarecosts,therehasbeenasteepriseinthenumberofuninsuredAmericans.Currently,

morethan45millionAmericanslackanyformofhealthinsurance,andmillionsmoreare

underinsured theyhaveinsurancebutlackadequatefinancialprotectionfromhealthcarecosts.

Whilethisproblemwasformerlyaproblemconfinedtolow-incomeAmericans,moreandmore

middle-classcitizensarebecomingdirectlyaffectedbytheproblem.

CHUA AND CASOY IN 2008

KAO-PINGCHUAANDFLAVIOCASOY,AMERICANMEDICALSTUDENTASSOCIATION.NODATE.

THE CASE FOR UNIVERSAL HEALTHCARE.

http://www.amsa.org/AMSA/Libraries/Committee_Docs/CaseForUHC.sflb.ashx



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UNINSUREDWOULDUSEANADDITIONAL$69BILLIONIN

CARE:Theadditionalhealthcarethatwouldbeusedbytheuninsurediftheyhadinsurance:

TheInstituteofMedicineestimatedthatthiswouldamountto$34-$69billionperyear,depending

onwhetherthebenefitspackageofferedtotheuninsuredofferedpublicinsurance-levelbenefits

(e.g.MedicaidorS-CHIP)orprivateinsurance-levelbenefits.Notethatthisnumberassumesno

structuralchangesinthesystemsofhealthcarefinancingordelivery,averagescopeofbenefits,or

providerpayment.



THECASEFORUNIVERSALHEALTHCARE.




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ONLY20%OFCURRENTLYUNINSUREDCANAFFORD

TOBUYINSURANCE:The2005CurrentPopulationSurvey(CPS)isusedtoestimatewhatshareofuninsuredAmericans

areeligibleforcoveragethroughMedicaidortheStateChildrensHealthInsuranceProgram

(SCHIP),needfinancialassistancetopurchasehealthinsurance,andarelikelyabletoafford

insurance.Twenty-fivepercentareeligibleforpubliccoverage,56percentneedassistance,and20

percentcanaffordcoverage.

DUBAY ET AL IN 2006

LISADUBAY,JOHNHOLAHANANDALLISONCOOK.MARKETWATCH,THEPEOPLETOPEOPLE

HEALTHFOUNDATION.NOVEMBER30,2006.THEUNINSUREDANDTHEAFFORDABILITYOF

HEALTHINSURANCECOVERAGE.

http://www.dev.mdvinteractive.com/ccf/wp-content/uploads/2012/03/The-uninsured-and-the-

affordability-of-health-care.pdf



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36

UNINSUREDSSPENDINGWOULDSHIFTTOTHE

GOVERNMENT:Thecostofcoveringtheout-of-pocketcoststheuninsuredcurrentlypay:

Theuninsuredpay35%ofhealthcarecostsout-of-pocket,comparedto20%fortheinsured(8).It

isestimatedthatofthe$100billionincaretheuninsureduseperyear,26%waspaidout-of-pocket

by the uninsured, or $26 billion. As Uwe Reinhardt wrote, If the purpose of public policy in this

areaweretoprotectAmericanfamiliesfromfinancialdistress,thenpresumablysomeofthisout-

of-pocket spending by the uninsured would be shifted from the uninsured to the governments

budget.9 The cost of covering these out-of-pocketcostswoulddependonthegenerosityofthe

benefitsofferedtotheuninsured.







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WOULDHAVETOCOVERTHECOSTSOFCURRENTLY

UNCOMPENSATED CARE:Thecostofcoveringuncompensatedcarecostsprovidedbyhospitals,physicians,andother

providerstotheuninsured:

Currently,$34.5billionayearisspentonuncompensatedcarecosts,whichincludesfreecare,

discountedcare,andbaddebtthatiswrittenoffbytheprovideriftheuninsuredpersoncannot

pay.8Asystemthatcoveredtheuninsuredwouldlikelycoversomeoralloftheseuncompensated

costs;theexactamountwoulddependonthespecificsolutioninquestion.







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FREERIDERS:

HAVINGINSURANCEDOESNTSOLVEFREERIDING:First,weshouldnotethatnotallfreeridersareuninsured.Infact,peoplewithinsuranceconsume

almostathirdofuncompensatedcare.

WHITMAN IN 2007



CARE MANDATE.http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-

mandate

ACCESSED: FEBRUARY 11, 2013


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UNINSUREDPAYFORALOTOFTHEIRCARE:

Second,notallcarereceivedbytheuninsuredispaidforbyothers.AnalystsattheUrbanInstitutefoundthattheuninsuredpaymorethan25percentoftheirhealthexpendituresoutofpocket.

WHITMAN IN 2007



CAREMANDATE.


mandate



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FREERIDINGISONLYWORTH3%OFHEALTHCARE

EXPENDITURES:Sohowmuchuncompensatedcareisreceivedbytheuninsured?Thesamestudyputsthenumber

atabout$35billionayearin2001,oronly2.8percentoftotalhealthcareexpendituresforthat

year.Inotherwords,eveniftheindividualmandateworksexactlyasplanned,itwillaffectatbesta

mere3percentofhealthcareexpenditures.

WHITMAN IN 2007



CAREMANDATE.http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-

mandate



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INNOVATION:

MANDATESUBJECTTOINTENSEREGULATION:Inadditiontodefiningaminimumbenefitspackage,anindividualmandatemustalsospecifyother

featuresofqualifyinginsurancepoliciessuchastheirmaximumpayouts,deductibles,and

copayments.Thesamepoliticalpressuresthataffectthebenefitspackagewillalsoaffectthese

othercharacteristics.Healthcareprovidershaveastrongfinancialincentivetoassurethatpatients

havelowdeductiblesandcopaymentssothattheywillconsumemoreservices.

InMassachusetts,nohealthinsurancepolicywithadeductiblegreaterthan$2,000foranindividual

or$4,000forafamilywillsatisfythemandate.Inaddition,qualifyingpoliciesmaynothaveany

maximumannualorper-conditionpayout.Andthisismerelytheregulatorystartingpointforalaw

thathasnotyetgoneintofulleffect(someaspectsoftheplanwon'tkickinuntil2009).Weshould

expectfurtherregulationstoaccumulatewiththepassageoftime.

WHITMAN IN 2007



CARE MANDATE.


mandate



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OVERREGULATIONDUETOMANDATECUTSOFF

HEALTHCARE INNOVATIONATTHEKNEES:Consequently,theindividualmandatewillhaveadeleteriousimpactontheflexibilityofhealth

plans.Healthcarebuyersandinsurersneedtheopportunitytoexperimentwithdifferenttypesof

coverage.Higherdeductiblesandcopayments,forexample,givepatientsanincentivetoweighthe

potentialbenefitsofhealthservicesagainsttheircostsakeycomponentofanyeffectiveplanto

controlhealthcarecosts.(HealthSavingsAccounts,orHSAs,couldallowpeopletosavetax-free

dollarsforout-of-pockethealthexpenses,withunuseddollarsrollingovertotheirretirement

accounts.)Insurersmightalsowanttoexperimentwithotherpolicies,suchasplansthatofferfull

coverageforonlycertaintreatmentsforparticularconditions,whilerequiringpatientstocoverthe

differenceinpricebetweencoveredtreatmentsandmoreexpensiveones.Buttheindividualmandate'sone-size-fitsallapproachcutsoffsuchinnovationattheknees.

WHITMAN IN 2007



CARE MANDATE.


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OVERREGULATIONINCREASESCOSTS,IMPACTISLESS

ACCESS:Moreimportant,healthinsuranceplanswithlowerdeductiblesandcopaymentsaremore

expensive.Regulationsthatmandatemoregenerousplansdriveuppremiums,therebypricing

somepeopleoutofthemarket.Theresultismoreuninsuredpeople,morepeopleinsuredonlyvia

publicsubsidy,orboth.

WHITMAN IN 2007




mandate



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MANDATEASLIPPERYSLOPETOOVERREGULATION:

Risinginsurancepremiums,asaresultofagrowingmandatedbenefitspackage,willfuelgreaterpublicdissatisfactionwiththehealthcaresystem.Furtherregulationsthathitchhikeonthe

individualmandatewillonlymakemattersworse.Ironically,freemarketsratherthangovernment

willlikelycatchtheblame,thusfuelingdemandformoreintrusiveinterventionsintothehealth

caremarket.

WHITMAN IN 2007



CAREMANDATE.

http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-mandate



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45

INSURANCEJOBLOCKSTIFLESENTREPRENEURSHIP

(REQUIRING INSURANCEMAKESTHISWORSE?):Joblockreferstotheideathatpeoplestaywiththeirjobswhentheywouldratherworkelsewhere

becausetheircurrentjoboffershealthinsurance.Forexample,manyindividualsopttostaywith

theirjobinsteadofstartingtheirownbusinessbecausetheyareunsureofwhethertheycanget

healthinsuranceontheindividualmarket,whichhashigherpremiumsandoftendeniespeople

withpre-existingconditions.Althoughthenumberofpeoplewhowouldbeself-employedifthere

wereuniversalhealthcareiscontroversial,onestudyfrom2001putthenumberat3.8million

Americans.14Thislossofentrepreneurshipisarealeconomiccostinasocietythatisrelyingon

start-upstooffsetthelossofjobsthataremovingoffshore.







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MEDICARE/MEDICAID

MEDICAIDCANTHANDLETHEINCREASEDLOAD:Theerosionofemployer-basedcoveragehasbeenpartiallyoffsetbyincreasedenrollmentin

Medicaid,whichisdesignedtoprovideasafety-netforthelowestincomeAmericans.However,

Medicaidhasrecentlybeenthesubjectofrelentlessfundingcutsbycash-strappedstatesand

Congressionalrepresentativeswhoareideologicallyopposedtowelfareprograms.Astheprogram

continuestobeslashed,itiscertainthatMedicaidwillnotbeabletooffsetthelossesinemployer-

basedinsurance,resultinginmoreandmoreuninsuredindividuals.







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PUBLICINSURANCEASSOCIATEDWITHNEGATIVE

HEALTHOUTCOMES:Publicinsuranceisnotassociatedwithgoodhealthoutcomes.Infact, for two out of three health

measures, persons on Medicaid and Medicare alone are significantly less healthy than

persons with no insuranceNeitherresultcanbeattributedtoinitialhealth,age,race,gender,

maritalstatus,education,employmentstatus,income,oreconomichardship,ortosampleselection.

Thus, thehealthcommodityhypothesis that medical insurance is associated with good

health outcomes is not supported, butthereasonsfortheassociationbetweenpublicinsurance

andworsehealthneverthelessremainunclear. Medicare and Medicaid were enacted on the

premise that public insurance for the elderly and poor would help protect the health of

vulnerable groups, not make it worse.Itseemsunlikelythatpublicinsurancecouldworsenhealth,yetcomprehensiveadjustmentsforinitialhealthandsocioeconomicanddemographic

characteristicsraisethequestionofwhyhavingpublicinsuranceisassociatedwithworsehealth,

notbetter,thanbeinguninsured.

ROSS AND MIROWSKY IN 2000

CATHERINEROSSANDJOHNMIROWSKY,THEOHIOSTATEUNIVERSITY.THE MILBANK

QUARTERLY, VOLUME8NUMBER2.2000.DOESMEDICALINSURANCECONTRIBUTETO

SOCIOECONOMICDIFFERENTIALSINHEALTH?

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751153/pdf/milq_171.pdf



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PUBLICINSURANCEUSESINEFFECTIVEMEASURES,

LEADINGTOBADHEALTHOUTCOMES:GivenourresultsthatMedicaidpatientsvisitthedoctormoreandreceivemoredrugsthanthe

uninsured,butthattheiroverallhealthworsensovertimeratherthanimproving,itseemspossible

thattreatingpoor,publiclyuninsuredpatientswithdrugsisalesseffectivewayofproducinghealth

thanalternativesthataddressrootcauses.Prescriptiondrugsareexpensive,andtheiruseisaway

forthemedicalprofessiontokeepcontroloverpoorpeopleshealth.



QUARTERLY, VOLUME8NUMBER2.2000.DOESMEDICALINSURANCECONTRIBUTETOSOCIOECONOMICDIFFERENTIALSINHEALTH?




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MINIMUMBENEFITS

LOBBYINGWILLEXPLODETHEMINIMUMBENEFITS,

RAISINGPRICES:Ifyou'regoingtomandatesomething,youhavetodefineit.Underanindividualmandate,

legislatorsandbureaucratswillneedtospecifyaminimumbenefitspackagethatapolicymust

coverinordertoqualify.It'snotplausibletobelievethispackagecanbedefinedinanapolitical

way.Eachmedicalspecialty,fromoncologytoacupuncture,willpressurethelegislaturetoinclude

theirservicesinthepackage.Andasthebenefitspackagegrows,sowillthepremiums.

WHITMAN IN 2007



CAREMANDATE.


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MASSIVEINCREASEINMANDATEDBENEFITS

INEVITABLE:The"basic"packagemightinitiallybeminimal,butovertimeitwillsuccumbtothesamespecial-

interestlobbyingthataffectseveryotherareaofpublicpolicy.Ifpsychotherapyisnotinitially

includedinthepackage,eventuallyitwillbe,oncethepsychotherapists'lobbyhasitsway.And

likewiseforcontraception,dentalcare,chiropractic,acupuncture,invitrofertilization,hair

transplants,adinfinitum.

WHITMAN IN 2007



CAREMANDATE.


mandate



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STATESEMPIRICALLYPROVETHATMANDATED

BENEFITSWILLEXPLODE:Thisisnotmerespeculation.Evennow,everystateintheunionhasalistofmandatedbenefitsthat

anyhealthinsurancepolicymustcover.Mandatedbenefitshaveincludedalloftheserviceslisted

aboveyes,evenhairtransplantsinsomestates.Allstatestogetherhavecreatednearly1900

mandatedbenefits.

WHITMAN IN 2007


THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDS OF THE INDIVIDUAL HEALTH

CARE MANDATE.http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-

mandate



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MEDICALGROUPSWILLLOBBYTHEGOVT.FOR

INCLUSIONINTHEMANDATEDPACKAGE:Giventhatmedicalinterestgroupshavefounditworththeirtimeandmoneytolobby50state

legislaturesforlawsaffectingonlyvoluntarilypurchasedinsurancepolicies,mandatoryinsurance

willonlyexacerbatetheproblem.Ifthebenefitspackageisestablishedatthefederallevel,the

incentivetolobbywillbethatmuchgreater.

WHITMAN IN 2007




mandate



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MEDICAREPROVESLOBBYINGINCREASESMANDATED

BENEFITS:MedicareandMedicaidprovidefurtherevidence.Giventhemassivefundsatstakeinthose

programs,itshouldcomeasnosurprisethatlobbyinghasaffectedthelistofcoveredbenefits.A

publicoutcrypreventedViagrafrombeingcoveredbyMedicareandMedicaid,butotherdrugsand

serviceshavenotattractedthatkindofscrutiny.In2004,afterheavylobbyingbypharmaceutical

companiesthatmakeantiobesitydrugs,Medicarereclassifiedobesityasanillness(orrather,

removedlanguagesayingitwasnotanillness),therebyclearingthewayforcoverageofobesity

treatmentsincludingdietpills,weight-lossprograms,andbariatricsurgery.Althoughbylaw

Medicarecanpayonlyfor"medicallynecessary"services,theobesitystoryaptlydemonstratesthe

subjectiveandultimatelypoliticalmeaningofthatterm.

WHITMAN IN 2007



CAREMANDATE.


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INCREASING MANDATEDBENEFITSINCREASES

PREMIUMS20TO50PERCENT:Mandatedbenefitsdriveupinsurancepremiums;afterall,insurancecompaniescan'tmakemore

payoutswithouthigherrevenues.Existingmandateshaveincreasedpremiumsbyanestimated20

to50percent,dependingonthestate.Thereiseveryreasontobelievethesameprocesswillaffect

theminimumbenefitspackageunderanindividualmandate.

WHITMAN IN 2007



CAREMANDATE.


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THEIMPACTTOINCREASEDMINIMUMMANDATED

BENEFITSISLESSPEOPLEGETCARE:Mandatedbenefitsdriveupinsurancepremiums;afterall,insurancecompaniescan'tmakemore

payoutswithouthigherrevenues.Existingmandateshaveincreasedpremiumsbyanestimated20

to50percent,dependingonthestate.Thereiseveryreasontobelievethesameprocesswillaffect

theminimumbenefitspackageunderanindividualmandate.Asaresult,evenmorepeoplewillfind

themselvesunabletobuyinsuranceanddecidenottocomply.Otherswillbuytheinsurance,but

onlybyrelyingonpublicsubsidies.Ahealthpolicyintendedtoreininfreeridingandcostshifting

willtendtoencouragemoreofthesame.

WHITMAN IN 2007



CAREMANDATE.


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LIVES:

GAININGINSURANCEDOESNTHAVEASIGNIFICANT

EFFECTONSAVINGLIVES:StudyDesign

Weuseaquasi-experimentalapproachtocomparethehealtheffectsofinsuranceforthenear-

elderlyuninsuredwithpreviouslyinsuredcontemporaneouscontrols.Theprimaryoutcome

measureisoverallself-reportedhealthstatuscombinedwithmortality(i.e.,excellenttoverygood,

good,fairtopoor,dead).

Results

Thechangeinthetrajectoryofoverallhealthstatusforthepreviouslyuninsuredthatcanbe

attributedtoMedicareissmallandnotstatisticallysignificant.Forevery100personsinthe

previouslyuninsuredgroup,joiningMedicareisassociatedwith0.6fewerinexcellentorverygood

health(95percent CI: 4.8, 3.3), 0.3 more in good health (95 percent CI: 3.8, 4.1), 2.5 fewer in fair

or poor health (95 percent CI: 7.4, 2.3), and 2.8 more dead (4.0, 10.0) by age 73. The health

trajectorypatternsfromphysicianobjectivehealthmeasuresaresimilarlysmallandnot

statisticallysignificant.

Conclusions

Medicarecoverageatage65forthepreviouslyuninsuredisnotlinkedtoimprovementsinoverall

healthstatus.

POLSKY ET AL IN 2009

DANIELPOLSKYANDMANYOTHERS,HEALTH SERVICES RESEARCHVOLUME44,NUMBER3.

PAGES926-945. JUNE 2009. THE HEALTH EFFECTS OF MEDICARE FOR THE NEAR-ELDERLY

UNINSURED.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699915/ACCESSED:MARCH2,2013


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POLSKYSTUDYONMEDICARETRANSLATESTOA

GENERALVIEWOFPROVIDINGINSURANCETOUNINSURED:ByusingMedicareasaquasi-experiment,wehaveexploredwhethertheindirecthealth

consequencesoflackinghealthinsurancecouldbearrestedbyprovidinghealthinsurancetothe

uninsured.



PAGES926-945.JUNE2009.THEHEALTHEFFECTSOFMEDICAREFORTHENEAR-ELDERLY

UNINSURED.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699915/



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MULTIPLESTUDIESHAVESHOWNTHATPROVIDING

INSURANCEDOESNTIMPROVEHEALTHOUTCOMES:Forbothsubjectiveandobjectivehealthstatusmeasures,wedidnotdetectarelativeslowingof

healthdeclineforthepreviouslyuninsuredbetweenages65and73whencomparedwiththe

previouslyinsured.

OurevidencethatMedicaredoesnotimprovethephysicalhealthstatusoftheuninsuredrelativeto

theinsuredisconsistentwiththelackofdetectiblehealtheffectsfromthemoregenerouscoverage

groupsintheRANDHIE(Manningetal.1987).TheRANDHIE,theonlyrandomizedtrialtolookat

thequestionofwhethergenerosityofbenefitdesigninplans(withacatastrophiccaponout-of-

pocketexpenditures)affectshealth,foundthatwhilepeoplereceivingfreecareusedmoreservices,

theydidnothavebetterhealthoutcomesamongabroadarrayofhealthmeasuresthanthosewithlessgenerouscoverage.



PAGES926-945.JUNE2009.THEHEALTHEFFECTSOFMEDICAREFORTHENEAR-ELDERLY

UNINSURED.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2699915/



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UNINSUREDACTUALLYREPORTHIGHERHEALTH

THANTHOSECOVEREDBYMEDICAREORMEDICAID,AND

EQUALHEALTHTOPRIVATELYINSURED:Table1showstheeffectofinsuranceonhealthoutcomes,withadjustmentforinitialhealth,

socioeconomicanddemographiccharacteristics,andthehazardofattrition(seethefirstcolumn

foreachhealthoutcome).Comparedwiththeuninsured,personscoveredbyMedicaidand

Medicarereportworsehealth,whereastheprivatelyinsuredarenotsignificantlydifferentfromthe

uninsuredintheirreportsofhealth.








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UNINSUREDAREBETTEROFFTHAN

MEDICARE/MEDICAID,EQUALTOPRIVATELYINSURED,WHENMEASUREDBYCHRONICCONDITIONS:ChronicconditionsaresignificantlymoreprevalentamongpersonsonMedicaidandMedicarethan

amongtheuninsured.Theprivatelyinsureddonotdiffersignificantlyfromtheuninsured.








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DEFENDINGROSSSTUDY,CAUSATIONISCLEAR,

VARIABLESARECONTROLLEDFOR,METHODOLOGYISSOUND:Theseassociationsandnonassociationsbetweenmedicalinsuranceandhealtharenotduetoinitial

healthstatus,socioeconomicanddemographiccharacteristics,orsampleselection.Weadjustfor

baselinehealth,thehazardofattrition,gender,race,age,maritalstatus,changeinmaritalstatus

overtime,education,employmentstatus,changeinemploymentstatus,householdincome,change

inhouseholdincome,economichardship,andchangeineconomichardship.Thus,allmodels

includecomprehensiveadjustmentsforhealthandsocialcharacteristics.






ACCESSED: MARCH 1, 2013


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EVENPRIVATEINSURANCEDOESNTIMPROVE

HEALTHOUTCOMESSIGNIFICANTLY:In sum, persons with private insurance do not differ significantly from the uninsured in their

self-reported health, physical functioning, or number of chronic conditions,whereaspersons

withpublicinsurancereportworsehealthandmorechronicconditionsthantheuninsured.

Insurance is not associated with better health outcomes in any case.



QUARTERLY, VOLUME8NUMBER2.2000. DOES MEDICAL INSURANCE CONTRIBUTE TO

SOCIOECONOMIC DIFFERENTIALS IN HEALTH?




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INSURANCEISPOSITIVELYCORRELATED TOOBESITY:

Astudyreleasedlastsummerfoundthatpeoplewhohadhealthinsuranceweremorelikelytogainweightthanpeoplewholackedit.Theauthors,fromStanford,RAND,andUniversityCollege

London,foundthathealthinsuranceincreasedbodymassindexby1.3to2.1points.

NOAH IN 2010

TIMOTHYNOAH,STAFFER,SLATEMAGAZINE.FEBRUARY3,2010.HEALTHREFORMAND

MORALHAZARD.

http://www.slate.com/articles/news_and_politics/prescriptions/2010/02/health_reform_and_mo

ral_hazard.html



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OVERUTILIZATION:

CHANGESMIGHTLEADTOINCREASEDHEALTHCAREUSE

AMONGALREADY-INSURED:Finally,dependingonthesolutionchosen,thosewhoarecurrentlyprivatelyinsuredmayalsouse

morehealthcare(e.g.ifhealthcareweremadeavailableforallwithnoorminimalcost-sharing,

theremightbeincreasedusageofhealthcareacrosstheboard).Furthermore,thereisthe

possibilitythatcoveringtheuninsuredthroughapublicinsuranceprogrammaytemptemployers

todropcoverageandpushtheiremployeesontothepublicinsuranceprogram(crowd-out);the

exact magnitude of this additional cost would depend on the solution chosen.


KAO-PING CHUA AND FLAVIO CASOY, AMERICAN MEDICAL STUDENT ASSOCIATION. NO DATE.





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THOSEONPUBLICINSURANCEUSESIGNIFCANTLYMORE

RESOURCESTHANUNINSURED:PersonsonMedicaidvisitthedoctorsignificantlymoreoftenthantheuninsured.Adjustmentfor

healthincolumn2showsthatthisisbecausetheirbaselinehealthispoorerMedicaiddoesseem

toprovideaccesstocare.PersonsonMedicaidalsoreceivemoremedicaltreatment,asindicated

bythenumberofprescriptiondrugstheyaretakingMedicaidrecipientstakesignificantlymore

prescriptiondrugsthanothers,evenwithadjustmentfortheirpoorerhealth.



QUARTERLY, VOLUME8NUMBER2.2000.DOESMEDICALINSURANCECONTRIBUTETOSOCIOECONOMICDIFFERENTIALSINHEALTH?




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SLIPPERYSLOPE:

BROCCOLIARGUMENT:OpponentsofthemandatearguethatadecisionupholdingitwouldgiveCongressunlimitedpower

toimposemandatesofanykind.Thatincludesthemuch-discussedbroccolipurchasemandate

postulatedbyFederalDistrictJudgeRogerVinson,theauthorofoneofthethreedistrictcourt

opinionsstrikingdownthemandate.Ifthemandatewereupheld,heexplains,Congresscould

requirethatpeoplebuyandconsumebroccoliatregularintervals,notonlybecausetherequired

purchaseswillpositivelyimpactinterstatecommerce,butalsobecausepeoplewhoeathealthier

tendtobehealthier,and...putlessofastrainonthehealthcaresystem.Suchslipperyslope

concernshavebeenprominentlyemphasizedinthreeofthefourfederalcourtdecisionsstriking

downthelaw.

SOMIN IN 2012

ILYASOMIN,ASSOCIATEPROFESSORATGEORGEMASONUNIVERSITYSCHOOLOFLAW.LAW

AND CONTEMPORARY PROBLEMS,VOLUME75,P.75.AMANDATEFORMANDATES:ISTHE

INDIVIDUALHEALTHINSURANCECASEASLIPPERYSLOPE?

http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1678&context=lcp&



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LEGALSLIPPERYSLOPESEXIST,NOTAFALLACY:Alegalslipperyslopeargumenthastwodistinctcomponents:logicalandempirical.Alogical

slipperyslopeoccursifjudgescannotcoherentlydistinguishAfromBforexample,ahealth

insurancepurchasemandatefromanyothermandatethatCongressmightenact.Itshouldbenoted

thatalogicalslipperyslopeargumentneednotconcedethatAisjustifiableinandofitselfandis

onlyconstitutionallysuspectbecauseitleadstoB.Rather,theconstitutionalityofAisdependenton

thequalityofthereasoningjustifyingit.Iftheonlyavailableargumentinitsfavorisdefective

becauseitinevitablyalsojustifiessomethingclearlyunconstitutional,suchasB,thenAis

impermissibleinitsownrightforlackofasoundargumentinitsfavor.

SOMIN IN 2012







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MANDATEISACLEARLOGICALSLIPPERYSLOPE:

Fromthestandpointoflogic,Iconcludethatthefederalgovernmentsargumentsreallydoleadtoanunlimitedcongressionalpowertoimposevirtuallyanymandate,saveafewthatareprecluded

bytheindividualrightsprovisionsoftheConstitution.Thesameresultoccursunderallthreeofthe

governmentsmajorargumentsfortheconstitutionalityofthemandate:claimsthatthemandateis

authorizedbytheCommerceClause,theTaxClause,andtheNecessaryandProperClause.

SOMIN IN 2012




http://scholarship.law.duke.edu/cgi/viewcontent.cgi?article=1678&context=lcp&ACCESSED:MARCH3,2013


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CONGRESSWILLABUSEITSNEWPOWERS:Theempiricalaspectoftheissueismoredifficulttoassess.Itdependsinpartonfuturepolitical

dynamicsthatarehardtopredict.Nevertheless,thereisasubstantiallikelihoodthatCongresswill

takeadvantageofanunconstrainedpowertoimposemandatesforthepurposeofbenefiting

favoredinterestgroups.Suchmandatescouldbemademorepalatabletothepublicbyposingthem

aspublichealthmeasuresoreffortstostrengthentheeconomy.Mandatescouldalsobepromoted

byclassicBaptistBootleggercoalitions,whichcombinepublichealthadvocatesandindustry

interestgroups.Suchcoalitionscaneffectivelyportrayanefforttobenefitaninfluentialinterest

groupasameasurepromotingthepublicgood.

SOMIN IN 2012







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STRIKINGDOWNMANDATEDOESNTCREATEASLIPPERY

SLOPE:Fromalogicalpointofview,thevalidityofthesefearsdependsonthereasoningadoptedbythe

SupremeCourtinafuturedecisionstrikingdownthemandate.Intheory,theCourtcoulddosoina

decisionthatalsooverrulesorseverelylimitsimportantprecedents.However,suchlogical

implicationsdonotarisefromthemostlikelypathbywhichtheCourtmightstrikedownthe

mandate:holdingthatCongresscannotusetheCommerceClauseandNecessaryandProperClause

to regulate inactivitydefined as imposing mandates merely on the basis of ones presence in the

UnitedStates.Suchadecisionwouldleaveintactallexistingprecedentsandmajorgovernment

programs.ItwouldnotevencomeclosetorestoringLochner,whichrestrictedawiderrangeof

regulatorylegislationandaffectedstatelawsaswellasfederalones.Itisalsounlikelytoseriously

impedefuturefederaleffortstocombatepidemicsorotheremergencies.

SOMIN IN 2012







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ANSWERS-TO:

A/TMANDATEKEYTOUNIVERSALCOVERAGE:Manyliberalsassumethatuniversalhealthcarerequiresanindividualmandate;butthereare

arguablybetteralternatives.Infact,asthelawstands,themandatemaysimplynotworkbecauseit

lacksadequatemeansofenforcement.

ForDemocrats,then,savingtheAffordableCareActlegally,politically,andpracticallycould

verywellmeangettingridofthemandate.

STARR IN 2011




care-act#



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GRUBER/CBOINDICT:

Buttheseestimatesarehighlyspeculativeforonekeyreason:Theyassumesubstantialcompliancewithamandatethathasnoenforcementbehindit.Thosewhodonotsignupforinsuranceare

supposedtofaceafine;but,iftheydontpayit,thegovernmentcannotimposeanycriminal

sanctions,liensonproperty,orleviesonincome.TheIRSonlyhasoneclearmethodofcollection:

withholdingataxrefund.AsJudgeLaurenceSilbermanoftheD.C.CourtofAppealswroteinhis

decisionupholdingthemandate,[T]hisprovisionssuccessdepends...onvoluntarycompliance.

Theindividualmandate,inshort,isamandateonlyinthesensethatatoygunisagun.Thereisno

waytofireit,thoughsomepeoplewillblinkifitispointedatthem.

STARR IN 2011

DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.DECEMBER14,2011.THEMANDATEMISCALCULATION.


care-act#



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A/TMASSACHUSSETTS ASANEXAMPLE:

Theonestatewithamandatehardlyoffersmuchguidance.Massachusettsnowhasnear-universalcoverage,but,evenbeforeitsrecentreforms,onlyabout10percentofitspopulationwas

uninsured.RomneysprogrampassedwithoverwhelmingsupportfrombothRepublicansand

Democratsinthestatelegislature.Business,labor,andthehealthcareindustryallbackedthelaw.

And,whenthemandatewentintoeffect,theagencyinchargeoftheprogramranTVadswithstars

fromtheBostonRedSoxsayingitwastimetogethealthinsurance.Insomestatestoday,by

contrast,theuninsuredrepresent20percentormoreofthepopulation,and,insteadofelite-led

supportforthehealthcarelegislation,thereiselite-ledopposition.Underthoseconditions,open

defianceofthemandatewillberespectable,andcompliancewiththemandatemaybemuchlower

thantheofficialestimatesassume.

STARR IN 2011



http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable

syke files - march 2013

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