There Is No Such Thing As Universal

Ezra Klein asks an odd question.


Lots of folks claim they don’t. They’re untested, or unimportant, or whatever else. So the Urban Institute, as august and respected a think tank as DC’s got, decided to run the numbers.

But I wonder: who claims that individual mandates don’t matter? If an individual mandate “didn’t matter,” surely there’d be no point in opposing an individual mandate? Actually, it seems pretty clear to me that individual mandates matter a great deal. I used to be in favor of them and I now oppose them. Why? Well, I used to think individual mandates didn’t matter that much — the administrative costs would be relatively low, they’d be easy to enforce, uncompensated care was a crucially important issue, the affluent uninsured were a serious burden on the healthcare system — and I’ve since concluded that most of these claims are in fact way off base. The administrative costs would be high, a mandate would be extremely difficult to enforce, uncompensated care represents a tiny slice of health expenditures, and the affluent uninsured are a minor problem. The real problem, unsurprisingly, is the large number of poor and working class people who can’t afford healthcare. That is a problem worth tackling. In fact, I could even be persuaded to support a larger public system modeled on the Veterans Health Administration. It is entirely possible to address these pressing problems without a mandate.

Now, as to the notion that achieving universal coverage is impossible without a mandate, that is of course true. It is so obviously true as to be trivial: if it is illegal for anyone to be uninsured, the uninsured will be criminals. Voting is compulsory in Australia and turnout is, er, pretty high. (There are many spoiled ballots, but that is a separate issue.) To be sure, there will still be “uninsured” individuals, including illegal migrants, etc. But these are legal nonpersons. Some of us, myself included, find the idea of criminalizing life choices to be deeply unattractive — so unattractive that it should only be done when absolutely necessary. Does the cause of guaranteeing that every American has health insurance coverage merit this kind of coercion? Again, please note that I believe that everyone who wants coverage and doesn’t have the means to pay for it should have some public alternative available. That involves spending far more money than we do at present, I’m guessing, or at least shifting tax subsidies in a more constructive direction. I’m really asking about the affluent uninsured.

Urban takes a stab at this question, rather misleadingly in my view.

The report is summarized as follows.

In this brief we conclude that, absent a single payer system, it is not possible to achieve universal coverage without an individual mandate.

Tautology. What is the alternative case — that everyone living within the borders of the United States voluntarily decides to purchase health coverage? Not a tough straw man to knock down.

The evidence is strong that voluntary measures alone would leave large numbers of people uninsured.

Again, obviously true. Uninsured — but what would be the social composition of this uninsured population? That is the essential question. The Obama approach, for example, seeks to guarantee that no one falls in the “wants coverage but can’t afford it” camp, which is the right goal.

Voluntary measures would tend to enroll disproportionate numbers of individuals with higher cost health problems, creating high premiums and instability in the insurance pools in which they are enrolled, unless further significant government subsidization is provided.

The devil is in the details. How many of the healthy, affluent uninsured will choose to remain uninsured if the cost of private coverage is sharply reduced thanks to expanded public programs, including federal reinsurance? The instability issue is real, and it will exist under any system that emphasizes choice of insurance provider. This is why large-scale public providers and opt-out systems are attractive. But is this a reason to criminalize the decision to remain uninsured? How far are we willing to go in punishing those who make that choice?

The government would also have difficulty redirecting current spending on the uninsured to offset some of the cost associated with a new program without universal coverage.

Again, we completely ignore the “difficulty” the government would have in enforcing this quixotic measure.

Some say, “we do it with car insurance!” Regulating automobiles, which involve a dense web of surveillance, regular registration, etc., is a piece of cake in comparison. Your right to drive can be revoked. What do you do to an incorrigible skinflint who refuses to buy health insurance?

The ongoing revolution in the biosciences makes these questions mostly moot. We are arguing about building a coercive apparatus to solve a social problem that won’t exist in the same form for very long. But of course that coercive apparatus will never go away.