The mandate lives and conservatives weep that Americans don’t have to pay more for health coverage

The individual mandate lives! Excellent.

For uninsured Americans anyway. But for those of us who had comments ready in case it was struck down, it’s kind of inconvenient.

So, in the interest of recycling, I do want to keep something front-and-center about this particular conservative attack (opposition to the mandate) on health reform: Whatever it’s premised upon, the practical impact of opposing the mandate (and since this is true of all recent conservative ideas on health care one might be forgiven for thinking that it’s a strategy, not a quirk) is simply to make health care more expensive.

And why are conservatives dedicated to making sure Americans pay too much for health insurance? Sometimes, it’s just the price of shoveling subsidies to corporations as part of any health reform. Other times, it’s making sure that Americans don’t see government doing things too efficiently and outperforming the private sector (witness the fevered desire to “reform” Medicare by privatizing it—which will predictably make it more expensive). In the end, I guess you don’t need to believe me when I say that that’s the goal of conservative health reform; but when it’s the practical impact of everything they propose, then I think my argument is looking pretty good.

Anyway, here’s my quick primer on the mandate and why opposing it was simply another exercise in making sure Americans paid too much for health insurance.

A key barrier to individuals gaining coverage if they’re not employed by a large company (which has the clout and the legal protections to force insurance companies to cover all their employees as a group, rather than just cherry-pick the healthy ones) is insurance companies refusing to cover those with pre-existing conditions—or even just those that may become sick (and hence expensive to insure) sometime in the future. The Affordable Care Act (ACA) dealt with this by mandating insurance companies offer coverage to everybody who comes to their door (“guaranteed issue,” in the jargon of reform), and to make this a real, not just a notional “offer,” mandating that these companies charge each beneficiary the same premium (“community rating,” in the jargon, with some variation allowed by age and smoking status). These provisions, again, keep insurance companies from being able to cherry-pick just the healthy to cover.

But, if I could get insured whenever I wanted and at the same rate as everybody else, shouldn’t I just choose to not pay premiums while I’m healthy and then buy coverage after I’m already sick? This would be a big problem for insurance companies, as their pool of covered beneficiaries would be a pretty unhealthy group. And since the ACA provides subsidies to help make coverage affordable, this means that the per-beneficiary level of subsidy would be pretty high, as only unhealthy people would be receiving subsidies.

The answer to this “free-rider” problem? Make sure people carry insurance even while healthy, to make for a larger, more predictable, and healthier insurance pool to keep costs down. This is what the mandate is for.

Essentially, the ACA imposes some restrictions on insurance companies (guaranteed issue and community rating) but then gives them something in return to make sure these restrictions don’t lead to them having to cover an unhealthy pool of beneficiaries (that something in return is the mandate) and rising costs.

So the mandate makes reform more efficient. This means it must be opposed by conservatives, because they have all along been determined to make any health reform as inefficient as possible. Remember the 2006 Medicare Part D legislation that cost way too much because it barred the government from bargaining with pharmaceutical companies over drug prices? And which subsidized private HMOs to cover Medicare beneficiaries? Remember the public option, which would’ve saved the public money but was taken out of the ACA in the early stages? Remember the voucherization of Medicare called for in the Ryan budget, which would insure that Americans spend far more to cover health costs in the future?

This was no grand constitutional issue, this was just conservatives doing what they reflexively do when it comes to health reform: trying to make sure it’s as inefficient as possible.