Health Reform Without the Mandate? Yes, it’s Possible, Part 2

I made the case yesterday that an individual mandate to purchase health insurance is not an absolute imperative to meaningful health reform, nor would this week’s court ruling declaring it unconstitutional, if it were upheld by the Supreme Court, necessarily be reform's undoing.

Such a ruling would, of course, necessitate modifications to the reform law as currently written. If one simply removes the mandate without other changes, the whole system would unravel. You can’t require insurance companies to cover all-comers, regardless of pre-existing conditions, while allowing the public to forego insurance until they get sick. But you could restrict the insurer’s all-comers rule to certain blocks of time - open enrollment periods when everyone could buy insurance. The rest of the time, insurers can go back to requiring physicals, denying coverage, etc. Healthy people, then, would have a choice of whether they want to buy insurance, but that choice would come with a deadline and a risk: If you forego insurance during the open enrollment, you’d better hope you don’t need it until the next one comes around.

Today I promised some thoughts on the politics of the mandate Here's what we know: the mandate is deeply unpopular; 70 percent of Americans oppose it (most of them, bitterly). Yet their views of health reform generally are divided evenly between those opposed and those in favor. Democrats clearly lost the politics of health reform this year, and it hurt them badly in the midterm elections, but they are counting on the legislation to get more popular as the public becomes more familiar with it over time. That has not happened. However, take out the most-loathed part of reform, and suddenly it may become the winning issue Democrats need it to be.

Now consider two fact. First, who will be most severely (and negatively) impacted by the mandate? Middle class young adults, most of whom don’t make a lot of money yet don't quite qualify for federal subsidies. Few of these folks will see much benefit from having insurance since they’re mostly pretty healthy. Yet at a time when they’re beginning their careers and struggling to pay their bills and save a little to buy a house, they’ll suddenly find themselves paying thousands of a dollars a year for insurance they rarely use. Second, consider who composes President Obama’s most important political constituency. Who was it that provided the emotional energy of his campaign, who surrounded him moist-eyed during his stump speeches, who volunteered to lick stamps and knock on doors, and who came out for him in record numbers on Election Day?

Yup. Same people. So I’ve asked before, and I will ask again: What happens to the president’s chances for re-election when his most important constituency finds out that they’re the ones getting hosed by his signature domestic achievement? Nothing good, that's for sure.

The right wing of the Supreme Court could wind up giving President Obama the greatest gift he could ever hope for - a second term - by declaring the mandate void, saving him from his own overreach.