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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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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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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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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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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
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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
ACCESSED:MARCH3,2013
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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#
ACCESSED:FEBRUARY12,2013
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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
DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.
DECEMBER14,2011.THEMANDATEMISCALCULATION.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-
care-act#
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LETSTATESFIGUREITOUT:
OrtheAffordableCareActcouldhavedelegatedtheresponsibilityofcurbingfreeridingtothestatesgivingthemanopen-endedmenuofpoliciestochoosefrom,whichmighthaveincludedthe
mandateaswellastheseotheroptions.AstatethatfollowedtheexampleofMassachusettsand
enactedamandatewouldthendosounderstatelaw,eliminatinganyconstitutionalchallengethat
couldbebroughtinfederalcourt.Theotheradvantageofthisapproachisthatthestatescould
experimentwithdifferentpolicies,andthenationcouldlearnfromtheirresults.
STARR IN 2011
DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.
DECEMBER 14, 2011. THE MANDATE MISCALCULATION.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-care-act#
ACCESSED:FEBRUARY12,2013
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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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUALHEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
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
ACCESSED:FEBRUARY17,2013
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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
DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.
DECEMBER 14, 2011. THE MANDATE MISCALCULATION.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-
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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
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
RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY
JOURNAL OF LAW AND LIBERTY. COMMANDEERING THE PEOPLE: WHY THE INDIVIDUAL
HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-
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MANDATEISUNCONSTITUTIONALINDEPENDENTOF
COMMERCECLAUSE:Existingdoctrinerevealstheindividualmandateisunconstitutionalevenifweassumethat
CongresshasthepowertoregulatetheinsurancebusinessthattheNewDealSupremeCourtgaveit
inSouthEastern Underwriters.
BARNETT IN 2010
RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY
JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUAL
HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
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
RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY
JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUAL
HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
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
RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY
JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUALHEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-
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
HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-
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
RANDYE.BARNETT,GEORGETOWNUNIVERSITYLAWCENTER.NEWYORKUNIVERSITY
JOURNALOFLAWANDLIBERTY.COMMANDEERINGTHEPEOPLE:WHYTHEINDIVIDUAL
HEALTHINSURANCEMANDATEISUNCONSTITUTIONAL.
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=1433&context=facpub&sei-
redir=1
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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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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UNINSUREDARETHATWAYDUETOCOSTS,NOT
CHEATING:Notallfreeridersaretryingtotakeadvantageoftheirfellowcitizens.Formany,healthinsurance
premiumsarejusttoohigh.
WHITMAN IN 2007
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH
CAREMANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
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MANDATEDOESNOTHINGTOMAKECAREMORE
AFFORDABLE:Yettheindividualmandatedoesnothingtomakeinsurancemoreaffordable.Theredoexist
regulatoryreformsthatcouldmakeitmoreaffordable,butthosereformsaredesirable
independentoftheindividualmandate.Themandateseekstocommandabetteroutcomemore
insuredpeoplewhiledoingnothingtomakeithappen.Youcan'tgetbloodfromastone.
WHITMAN IN 2007
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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HIGHCOSTSKEYTOCONTROLLINGOVERSPENDING BY
PATIENTS:InafamousRANDstudy,patientswithfirstdollarinsurancecoverageconsumed43percentmore
healthcarethanpatientswhohadtopayalargedeductible,andyetthetwogroupsexperienced
indistinguishablehealthoutcomes.Theobviousconclusionisthatmanyhealthserviceshave
negligiblebenefits,butpatientswillgetthemanywayunlesstheyfaceatleastsomeportionofthe
costs.
WHITMAN IN 2007
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTHCAREMANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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PATIENTSFEELINGCOSTSKEYTOREFORMING
HEALTHCARE, MANDATESHIELDS:Effectivehealthcarereformwouldinvolvemakingcustomersmorecost-conscious.Theindividual
mandate,sadly,willtendtoshieldcustomersfromcostsandimpedeinnovationsthatcouldpush
costsdown.
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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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.
CHUA AND CASOY IN 2008
KAO-PINGCHUAANDFLAVIOCASOY,AMERICANMEDICALSTUDENTASSOCIATION.NODATE.
THECASEFORUNIVERSALHEALTHCARE.
http://www.amsa.org/AMSA/Libraries/Committee_Docs/CaseForUHC.sflb.ashx
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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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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.
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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WOULDHAVETOCOVERTHECOSTSOFCURRENTLY
UNCOMPENSATED CARE:Thecostofcoveringuncompensatedcarecostsprovidedbyhospitals,physicians,andother
providerstotheuninsured:
Currently,$34.5billionayearisspentonuncompensatedcarecosts,whichincludesfreecare,
discountedcare,andbaddebtthatiswrittenoffbytheprovideriftheuninsuredpersoncannot
pay.8Asystemthatcoveredtheuninsuredwouldlikelycoversomeoralloftheseuncompensated
costs;theexactamountwoulddependonthespecificsolutioninquestion.
CHUA AND CASOY IN 2008
KAO-PINGCHUAANDFLAVIOCASOY,AMERICANMEDICALSTUDENTASSOCIATION.NODATE.
THECASEFORUNIVERSALHEALTHCARE.
http://www.amsa.org/AMSA/Libraries/Committee_Docs/CaseForUHC.sflb.ashx
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FREERIDERS:
HAVINGINSURANCEDOESNTSOLVEFREERIDING:First,weshouldnotethatnotallfreeridersareuninsured.Infact,peoplewithinsuranceconsume
almostathirdofuncompensatedcare.
WHITMAN IN 2007
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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UNINSUREDPAYFORALOTOFTHEIRCARE:
Second,notallcarereceivedbytheuninsuredispaidforbyothers.AnalystsattheUrbanInstitutefoundthattheuninsuredpaymorethan25percentoftheirhealthexpendituresoutofpocket.
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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FREERIDINGISONLYWORTH3%OFHEALTHCARE
EXPENDITURES:Sohowmuchuncompensatedcareisreceivedbytheuninsured?Thesamestudyputsthenumber
atabout$35billionayearin2001,oronly2.8percentoftotalhealthcareexpendituresforthat
year.Inotherwords,eveniftheindividualmandateworksexactlyasplanned,itwillaffectatbesta
mere3percentofhealthcareexpenditures.
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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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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THE CATO INSTITUTE. SEPTEMBER/OCTOBER 2007. HAZARDS OF THE INDIVIDUAL HEALTH
CARE MANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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OVERREGULATIONINCREASESCOSTS,IMPACTISLESS
ACCESS:Moreimportant,healthinsuranceplanswithlowerdeductiblesandcopaymentsaremore
expensive.Regulationsthatmandatemoregenerousplansdriveuppremiums,therebypricing
somepeopleoutofthemarket.Theresultismoreuninsuredpeople,morepeopleinsuredonlyvia
publicsubsidy,orboth.
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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MANDATEASLIPPERYSLOPETOOVERREGULATION:
Risinginsurancepremiums,asaresultofagrowingmandatedbenefitspackage,willfuelgreaterpublicdissatisfactionwiththehealthcaresystem.Furtherregulationsthathitchhikeonthe
individualmandatewillonlymakemattersworse.Ironically,freemarketsratherthangovernment
willlikelycatchtheblame,thusfuelingdemandformoreintrusiveinterventionsintothehealth
caremarket.
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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INSURANCEJOBLOCKSTIFLESENTREPRENEURSHIP
(REQUIRING INSURANCEMAKESTHISWORSE?):Joblockreferstotheideathatpeoplestaywiththeirjobswhentheywouldratherworkelsewhere
becausetheircurrentjoboffershealthinsurance.Forexample,manyindividualsopttostaywith
theirjobinsteadofstartingtheirownbusinessbecausetheyareunsureofwhethertheycanget
healthinsuranceontheindividualmarket,whichhashigherpremiumsandoftendeniespeople
withpre-existingconditions.Althoughthenumberofpeoplewhowouldbeself-employedifthere
wereuniversalhealthcareiscontroversial,onestudyfrom2001putthenumberat3.8million
Americans.14Thislossofentrepreneurshipisarealeconomiccostinasocietythatisrelyingon
start-upstooffsetthelossofjobsthataremovingoffshore.
CHUA AND CASOY IN 2008
KAO-PINGCHUAANDFLAVIOCASOY,AMERICANMEDICALSTUDENTASSOCIATION.NODATE.
THECASEFORUNIVERSALHEALTHCARE.
http://www.amsa.org/AMSA/Libraries/Committee_Docs/CaseForUHC.sflb.ashx
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MEDICARE/MEDICAID
MEDICAIDCANTHANDLETHEINCREASEDLOAD:Theerosionofemployer-basedcoveragehasbeenpartiallyoffsetbyincreasedenrollmentin
Medicaid,whichisdesignedtoprovideasafety-netforthelowestincomeAmericans.However,
Medicaidhasrecentlybeenthesubjectofrelentlessfundingcutsbycash-strappedstatesand
Congressionalrepresentativeswhoareideologicallyopposedtowelfareprograms.Astheprogram
continuestobeslashed,itiscertainthatMedicaidwillnotbeabletooffsetthelossesinemployer-
basedinsurance,resultinginmoreandmoreuninsuredindividuals.
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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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.
ROSS AND MIROWSKY IN 2000
CATHERINEROSSANDJOHNMIROWSKY,THEOHIOSTATEUNIVERSITY.THE MILBANK
QUARTERLY, VOLUME8NUMBER2.2000.DOESMEDICALINSURANCECONTRIBUTETOSOCIOECONOMICDIFFERENTIALSINHEALTH?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751153/pdf/milq_171.pdf
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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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH
CAREMANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH
CAREMANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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STATESEMPIRICALLYPROVETHATMANDATED
BENEFITSWILLEXPLODE:Thisisnotmerespeculation.Evennow,everystateintheunionhasalistofmandatedbenefitsthat
anyhealthinsurancepolicymustcover.Mandatedbenefitshaveincludedalloftheserviceslisted
aboveyes,evenhairtransplantsinsomestates.Allstatestogetherhavecreatednearly1900
mandatedbenefits.
WHITMAN IN 2007
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH
CAREMANDATE.http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
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
GLENWHITMAN,ASSOCIATEPROFESSOROFECONOMICSATCALIFORNIASTATENORTHRIDGE.
THECATOINSTITUTE.SEPTEMBER/OCTOBER2007.HAZARDSOFTHEINDIVIDUALHEALTH
CAREMANDATE.
http://www.cato.org/policy-report/septemberoctober-2007/hazards-individual-health-care-
mandate
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INCREASING MANDATEDBENEFITSINCREASES
PREMIUMS20TO50PERCENT:Mandatedbenefitsdriveupinsurancepremiums;afterall,insurancecompaniescan'tmakemore
payoutswithouthigherrevenues.Existingmandateshaveincreasedpremiumsbyanestimated20
to50percent,dependingonthestate.Thereiseveryreasontobelievethesameprocesswillaffect
theminimumbenefitspackageunderanindividualmandate.
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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THEIMPACTTOINCREASEDMINIMUMMANDATED
BENEFITSISLESSPEOPLEGETCARE:Mandatedbenefitsdriveupinsurancepremiums;afterall,insurancecompaniescan'tmakemore
payoutswithouthigherrevenues.Existingmandateshaveincreasedpremiumsbyanestimated20
to50percent,dependingonthestate.Thereiseveryreasontobelievethesameprocesswillaffect
theminimumbenefitspackageunderanindividualmandate.Asaresult,evenmorepeoplewillfind
themselvesunabletobuyinsuranceanddecidenottocomply.Otherswillbuytheinsurance,but
onlybyrelyingonpublicsubsidies.Ahealthpolicyintendedtoreininfreeridingandcostshifting
willtendtoencouragemoreofthesame.
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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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.
POLSKY ET AL IN 2009
DANIELPOLSKYANDMANYOTHERS,HEALTH SERVICES RESEARCHVOLUME44,NUMBER3.
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.
POLSKY ET AL IN 2009
DANIELPOLSKYANDMANYOTHERS,HEALTH SERVICES RESEARCHVOLUME44,NUMBER3.
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.
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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UNINSUREDAREBETTEROFFTHAN
MEDICARE/MEDICAID,EQUALTOPRIVATELYINSURED,WHENMEASUREDBYCHRONICCONDITIONS:ChronicconditionsaresignificantlymoreprevalentamongpersonsonMedicaidandMedicarethan
amongtheuninsured.Theprivatelyinsureddonotdiffersignificantlyfromtheuninsured.
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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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.
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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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.
ROSS AND MIROWSKY IN 2000
CATHERINEROSSANDJOHNMIROWSKY,THEOHIOSTATEUNIVERSITY.THE MILBANK
QUARTERLY, VOLUME8NUMBER2.2000. DOES MEDICAL INSURANCE CONTRIBUTE TO
SOCIOECONOMIC DIFFERENTIALS IN HEALTH?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751153/pdf/milq_171.pdf
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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.
CHUA AND CASOY IN 2008
KAO-PING CHUA AND FLAVIO CASOY, AMERICAN MEDICAL STUDENT ASSOCIATION. NO DATE.
THECASEFORUNIVERSALHEALTHCARE.
http://www.amsa.org/AMSA/Libraries/Committee_Docs/CaseForUHC.sflb.ashx
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THOSEONPUBLICINSURANCEUSESIGNIFCANTLYMORE
RESOURCESTHANUNINSURED:PersonsonMedicaidvisitthedoctorsignificantlymoreoftenthantheuninsured.Adjustmentfor
healthincolumn2showsthatthisisbecausetheirbaselinehealthispoorerMedicaiddoesseem
toprovideaccesstocare.PersonsonMedicaidalsoreceivemoremedicaltreatment,asindicated
bythenumberofprescriptiondrugstheyaretakingMedicaidrecipientstakesignificantlymore
prescriptiondrugsthanothers,evenwithadjustmentfortheirpoorerhealth.
ROSS AND MIROWSKY IN 2000
CATHERINEROSSANDJOHNMIROWSKY,THEOHIOSTATEUNIVERSITY.THE MILBANK
QUARTERLY, VOLUME8NUMBER2.2000.DOESMEDICALINSURANCECONTRIBUTETOSOCIOECONOMICDIFFERENTIALSINHEALTH?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2751153/pdf/milq_171.pdf
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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?
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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
ILYASOMIN,ASSOCIATEPROFESSORATGEORGEMASONUNIVERSITYSCHOOLOFLAW.LAW
AND CONTEMPORARY PROBLEMS,VOLUME75,P.75.AMANDATEFORMANDATES:ISTHE
INDIVIDUALHEALTHINSURANCECASEASLIPPERYSLOPE?
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MANDATEISACLEARLOGICALSLIPPERYSLOPE:
Fromthestandpointoflogic,Iconcludethatthefederalgovernmentsargumentsreallydoleadtoanunlimitedcongressionalpowertoimposevirtuallyanymandate,saveafewthatareprecluded
bytheindividualrightsprovisionsoftheConstitution.Thesameresultoccursunderallthreeofthe
governmentsmajorargumentsfortheconstitutionalityofthemandate:claimsthatthemandateis
authorizedbytheCommerceClause,theTaxClause,andtheNecessaryandProperClause.
SOMIN IN 2012
ILYASOMIN,ASSOCIATEPROFESSORATGEORGEMASONUNIVERSITYSCHOOLOFLAW.LAW
AND CONTEMPORARY PROBLEMS,VOLUME75,P.75.AMANDATEFORMANDATES:ISTHE
INDIVIDUALHEALTHINSURANCECASEASLIPPERYSLOPE?
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CONGRESSWILLABUSEITSNEWPOWERS:Theempiricalaspectoftheissueismoredifficulttoassess.Itdependsinpartonfuturepolitical
dynamicsthatarehardtopredict.Nevertheless,thereisasubstantiallikelihoodthatCongresswill
takeadvantageofanunconstrainedpowertoimposemandatesforthepurposeofbenefiting
favoredinterestgroups.Suchmandatescouldbemademorepalatabletothepublicbyposingthem
aspublichealthmeasuresoreffortstostrengthentheeconomy.Mandatescouldalsobepromoted
byclassicBaptistBootleggercoalitions,whichcombinepublichealthadvocatesandindustry
interestgroups.Suchcoalitionscaneffectivelyportrayanefforttobenefitaninfluentialinterest
groupasameasurepromotingthepublicgood.
SOMIN IN 2012
ILYASOMIN,ASSOCIATEPROFESSORATGEORGEMASONUNIVERSITYSCHOOLOFLAW.LAW
AND CONTEMPORARY PROBLEMS,VOLUME75,P.75.AMANDATEFORMANDATES:ISTHE
INDIVIDUALHEALTHINSURANCECASEASLIPPERYSLOPE?
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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
ILYASOMIN,ASSOCIATEPROFESSORATGEORGEMASONUNIVERSITYSCHOOLOFLAW.LAW
AND CONTEMPORARY PROBLEMS,VOLUME75,P.75.AMANDATEFORMANDATES:ISTHE
INDIVIDUALHEALTHINSURANCECASEASLIPPERYSLOPE?
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ANSWERS-TO:
A/TMANDATEKEYTOUNIVERSALCOVERAGE:Manyliberalsassumethatuniversalhealthcarerequiresanindividualmandate;butthereare
arguablybetteralternatives.Infact,asthelawstands,themandatemaysimplynotworkbecauseit
lacksadequatemeansofenforcement.
ForDemocrats,then,savingtheAffordableCareActlegally,politically,andpracticallycould
verywellmeangettingridofthemandate.
STARR IN 2011
DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.
DECEMBER 14, 2011. THE MANDATE MISCALCULATION.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-
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.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable-
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
DR.PAULSTARR,PROFESSOROFSOCIOLOGYATPRINCETONUNIVERSITY.THENEWREPUBLIC.
DECEMBER14,2011.THEMANDATEMISCALCULATION.
http://www.newrepublic.com/article/politics/magazine/98554/individual-mandate-affordable