Kenen explains why the mandate matters

Joanne Kenen

About Joanne Kenen

Joanne Kenen, (@JoanneKenen) the health editor at Politico, is AHCJ’s topic leader on health reform and curates related material at She welcomes questions and suggestions on health reform resources and tip sheets at Follow her on Facebook.

Usually I blog about topics that that lend themselves to local coverage, that explain health reform in the context of a state or community. But I think it’s worth taking a quick look at the individual mandate, or “shared responsibility,” because it’s so important – as politics and as policy. It’s back in the news after the Aug. 12 ruling. We won’t know its fate until the Supreme Court tells us, but it’s worth noting now:

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Joanne KenenJoanne Kenen is AHCJ’s health reform topic leader. She is writing blog posts, tip sheets, articles and gathering resources to help our members cover the complex implementation of health reform. If you have questions or suggestions for future resources on the topic, please send them to

  • Courts have been divided and, on the appeals court level, it hasn’t been all partisan. One Democratic-appointed judge ruled against the mandate as written, and one Republican-appointed judge ruled for it.
  • The federal health reform law doesn’t go away if the mandate is struck. But it will look different.
  • Even with a mandate, the Affordable Care Act by 2019 would cover about 32 million people – and still leave 23 million uncovered. (That’s the CBO estimate from 2009.)
  • The insurance industry’s [reluctant?] support for the Affordable Care Act was contingent on having the mandate. States that have changed the insurance rules – requiring plans to accept people with pre-existing conditions, etc. – without a mandate have seen costs skyrocket, which in turn means fewer, not more, people end up covered.
  • There’s a lot of speculation about when the Supreme Court will rule – the timing could affect the presidential elections – but that’s speculation at this point. “If the court upholds the law, the Republican base gets energized four months before the election,” Bradley Joondeph, a Santa Clara University law professor, told the Wall Street Journal. “If it gets struck down, well, there go the guts of the centerpiece of Obama’s domestic agenda.”

I’m going to give you some links that will help follow the legal case, (AKA are we all wheat farmers?) and then highlight articles that have outlined some of the policy alternatives to the mandate – other steps that would encourage, although not require, more people to get covered. Of course, getting any changes through the Republican-controlled House is daunting, but not impossible if it were part of a larger “must-pass” or compromise legislation.

Legal issues

  • Health Affairs/RWJF did a recent issue brief.
  • The SCOTUS (Supreme Court of the United States) blog – which I suspect most of us health policy types have heard of but don’t actually read – is mandate madness. Seems to be rivaled only by same-sex marriage as the topic of choice.
  • Linda Greenhouse (from last December) had an online ‘Opinionator” piece in The New York Times.

Policy Alternatives

  • Austin Frakes, of the Incidental Economist blog (a good blog, by the way), recapped some of the main policy alternatives and I looked at a few approaches here for Kaiser Health News. (I don’t usually link to my own work on this blog, but am making an exception today.)
  • Paul Starr has been worried about the mandate all along (here and here).
  • Julie Rovner of NPR (among others) reported on the history of the mandate, which is generally regarded as a Republican idea when it emerged during the first President Bush’s administration. Republicans now generally oppose it, as this essay at the Heritage Foundation makes clear.

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