November 8, 2017

Individual Mandate Squeamishness Bodes Ill for Single-Payer

Robert Graboyes

Senior Research Fellow

The Republican tax bill released on November 2 doesn’t touch the individual mandate of the Affordable Care Act (“Obamacare”). Perhaps rationally, Republicans are squeamish about tampering with entitlements—even ones they despise. In 2010, Democrats, with a filibuster-proof Senate majority, were similarly squeamish when they softened the individual mandate from a fire alarm to a whispered suggestion to taxpayers.

This squeamishness bodes ill for those who imagine a single-payer system would rein in America’s health care costs. Such measures are only as potent as the officials who create them. (Caveat: Recent reports suggest President Trump may eviscerate the individual mandate by executive order, and House Republicans are rethinking its omission from the tax bill.)

The mandate imposes financial penalties on those who don’t sign up for insurance. In 2009, strong mandates were floated, but Democrats watered them down: Smaller penalties. No wage garnishment. The government could only penalize shirkers by reducing income tax refunds—useless against those who expect no refunds. Congress exempted numerous groups from the mandate. A strong mandate, in 2010, appeared politically toxic.

Today, Republicans balk at repealing the individual mandate because the Congressional Budget Office (CBO) estimates that repeal would lead to 15 million fewer people with insurance. Given the flimsy mandate, the CBO’s estimate is likely way overblown, but Republicans fear being labelled “the people who took care away from millions”—even though repeal wouldn’t actually take anything away from anyone. Repeal, in 2017, appears politically toxic.

Individual mandates can and do work elsewhere. Switzerland and the Netherlands both have private insurance systems with near-universal compliance for two reasons: First, Swiss and Dutch people tend to bend willingly to government edicts and social pressures. Second, these countries’ mandates have sharp teeth. Earlier this year, National Review writer Kevin Williamson wrote: “If you fail to comply with the mandate, the Swiss government will garnish your wages and charge you a penalty equivalent to the cost of the premiums plus up to 50 percent, and, if you persist, the government will sign you up for an insurance policy and allow the provider to sue you for back premiums covering the period during which you were uninsured.” The problem with current U.S. health care policy, Williamson opined, is that: “Policymakers in both parties are trying to replicate Swiss policies in a country that isn’t Swiss.”

Single-payer advocates note that single-payer countries spend less on health care per person than America does. But most of that difference results from the fact that Americans have become spendthrifts in general, and health care simply follows general behavioral patterns. But, in fairness, European/Canadian single-payer systems do take many actions to hold down spending. Let’s examine just one example:

In the United Kingdom, health authorities in one region are planning to save money by refusing non-emergency surgical procedures to smokers or obese people. Show up with nicotine in your bloodstream or a bit too much weight on the scale, and the government will indefinitely deny access to surgery until you first quit smoking and/or lose as much weight as the government orders you to.

Try that in America, where we resent heavy-handed authority and where, given the demographics of smoking and obesity, wealthy white people would tend to receive surgery quickly, with ethnic minorities and poorer whites denied care on government whim. While this is merely one vivid case, single-payer systems are loaded with strictures that pliant Europeans and Canadians dutifully obey but which would elicit pitchforks in America. Tell Americans to wait a month for a biopsy after a suspicious mammogram, as happens in Europe in Canada. Deny them the latest drugs or new technologies.

But, you might ask, can’t a single-payer system simply force spending down by fiat? Well, we have a single-payer system in America—Medicare. In 1997, Congress voted to limit Medicare spending and then, for nearly two decades, delayed implementation. In 2015, the limits were repealed. You can’t replicate European or Canadian policies in a country that isn’t European or Canadian.

Ultimately, a government’s austerity measures are only as strong as its population’s willingness to endure them. Americans show little such inclination in that direction. Nor should they.