Will Americans Support the Individual Mandate?
by Tara Sussman, Robert J. Blendon, and Andrea Louise Campbell
Health Affairs
April 21, 2009
Survey questions
A random half of the sample was asked about a “stand-alone individual mandate.” The survey set the context as follows: “This proposal would require all Americans to have insurance. Most people would still get insurance through their work. People who don’t get insurance from work would have to buy it themselves, or pay a fine if they don’t. People with lower incomes would get help from the government paying the cost of health insurance.”
The other half of the sample was asked about a “shared-responsibility” plan. The context here was as follows: “This proposal would place requirements on individuals, employers, the government, and insurance companies so that everyone shares in the responsibility. Individuals who don’t already have insurance would be required to buy it or pay a fine, with financial help from the government for people with lower incomes. Employers would be required to cover their workers, or pay money into a pool that helps people buy insurance. Government health insurance programs would be expanded. Insurance plans would be required to take anyone who applies, even if they have a prior illness.”
How does support for shared responsibility compare to that for a stand-alone mandate?
A shared-responsibility plan was more popular than the stand-alone mandate in 2008. Fifty-nine percent of the public supported it, compared to the 48 percent who supported the stand-alone mandate.
Do Republicans and Democrats have different reasons for their opinions on mandate-based reform?
Respondents who supported the stand-alone individual mandate plan or the shared-responsibility plan were asked to select from a list their major reasons for support. The most popular reasons were “making sure everyone has health insurance is the right thing to do”; “people with health insurance will get preventive and more continuous care”; and “by requiring the uninsured to get insurance, people won’t face higher health care costs to cover the unpaid medical bills of those who don’t have insurance.” A substantial majority of both Democrats and Republicans offered each of these reasons, but more Democrats than Republicans agreed with the first, principle-based reasoning. Also, more Democrats than Republicans related their support to redistributing the costs of the sick: “to get everyone into the same insurance pool, so we can spread the costs of sick and healthy people over the whole population.”
Similarly, reform opponents were asked to select major reasons for their opposition. Republicans’ and Democrats’ responses reveal their fundamental disagreements on government’s role in health care. Among those who did not support either mandate plan, many more Republicans than Democrats said that the reform would lead to government-run health care or higher taxes, or both. The Democrats who opposed the plans were significantly more likely than the Republicans to say that these reform options were the wrong approach because a single government health plan was needed. Republicans and Democrats also disagreed on the issue of the individual mandate itself. A higher percentage of Republican opponents than Democratic opponents disagreed with the principle of government requiring people to buy insurance. More Democrats than Republicans opposed mandates because they thought that people might not be able to afford the insurance they were being required to purchase.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w501
If this article gains traction, the conclusion that likely will be reported is that Americans support an individual mandate to purchase insurance as long as it incorporates “shared responsibility.”
This interpretation would certainly please insurance industry executives since they have said that they can agree to sell insurance to anyone regardless of preexisting conditions (guaranteed issue), but only if everyone is required to have insurance (individual mandate). The insurance industry would be willing to share the responsibility with individuals, employers and the government.
But what is shared responsibility? The responsibility of the individual is to pay his/her portion of the premium plus all out-of-pocket expenses, including cost sharing and costs of products and services not covered by the insurance plan. The responsibility of the employer is to pay a portion of the employee’s insurance premium, but economists agree that it is really the individual’s forgone wage increases that pays the premium. The government’s responsibility is to pay for part or all of the care provided to individuals who do not have the funds to pay for care, but it is really ultimately individuals who are paying the taxes that fund the government programs. And the responsibility of the private insurance industry? They don’t pay into the system; they take a large amount of funds out of the system – funds that again are ultimately paid by individuals.
So “shared responsibility” is not a sharing of responsibility; all of the responsibility falls on individuals. “Shared responsibility” is merely a rhetorical framing that advances the interests of some of the stakeholders, especially the private insurance industry.
Even if the respondents to the survey accepted the concept of shared responsibility, it would be a real stretch to conclude that a 48 percent support of a stand-alone mandate means that the public is opposed, whereas a 59 percent support of a mandate with shared responsibility is a solid public endorsement (11 percent difference). This is not a ringing endorsement of a concept that is more of a marketing slogan than a genuine policy proposal.
That said, there is an important take-home message from this survey. Those opposed seemed to understand the policy principles involved. Republicans were opposed because of higher taxes and greater government involvement. Democrats were opposed because a single government health program was needed instead of a mandate to purchase private plans that might not be affordable.
Pretending that the marketing ploy of shared responsibility will bring us bipartisan consensus on reform will only reinforce the process that we are about to see. The Republicans have already gained the greatest concession – single payer is off the table – and they will continue to use the process to gain further concessions that will destroy any semblance of health care equity, and then they will vote against the final bill anyway.
