Pretend the employer mandate and the individual mandate — henceforth EM and IM — are fighters.
Pretend they're in a cage match.
Which would win?
Yesterday I would have had a hard time answering that. Today, having read a letter signed by 30 economists, I'll plump for IM immediately. They practically fawn over it. EM matters little, they say; IM is the crucial third pillar. Attempts to delay IM "are really requests to gut the Affordable Care Act." IM "expresses a basic obligation of citizenship as well as an economic reality."
I can see the billboards now: "Uncle Sam wants your body (in a health insurance policy)!"
I'm not entirely kidding about that, actually. There are two major issues with the IM that this letter doesn't raise — understandably, since it's only a page long — and both of them involve concerns about whether IM's strictly economic incentives are strong enough to work. Word on some streets is that they might not be — in which case I would expect a greater good, civic responsibility campaign, a la World Wars I and II. Also as in military recruiting, the emphasis would be on young, healthy people.
The second issue is that high costs for getting coverage and low penalties for not having coverage might inspire people to go without coverage — particularly, you know, young, healthy people.
At this point I must reiterate that most of the cost numbers are not in yet, so any and all projections are subject to much change. When the final figures arrive, maybe purchasing insurance will clearly be the best economic choice even for young, healthy people.
But I definitely see the cause for concern. I was a young, healthy person — let us now pause to weep salty tears for my vanished youth — and a conscientious person and an easily scared one. I had insurance or I bought my own, even when I made very little money. That said, I last purchased my own insurance about a decade ago, when overall insurance costs were lower, and even then the price tag almost made me reconsider.
For that matter, it would be easy for me to consider the many thousands of dollars spent on my health insurance premiums as the biggest monetary forfeit in my life, because I've never come close to exceeding my deductible. My insurance did other people in my risk pool a lot of good, but in my own personal economic accounting, it was all sunk money that I would have found exceedingly useful in other applications.
There are holes in that argument, but the higher the cost of insurance, the stronger the argument's appeal.
The "get covered for society" argument, though? That wasn't part of my calculations and, honestly, right now it still wouldn't be. Its strength depends, I think, on trust in the efficacy and justice of the system. And in this maelstrom of change, I'm going to have to see some solid results, not just predictions, before I get there.
• Concerns about the strength of the individual mandate are, obviously, stronger in the beginning, when the penalties are lower. Jumping right in with stronger penalties might have alleviated some of those concerns — but then again, the shock of it could potentially have caused even bigger disruptions in the insurance market.
• Even in the first year, the penalties are probably higher than you think they are. That is, the $95 figure has been much bandied about, but the amount is actually the greater of $95 or 1 percent of household income above the tax filing threshold. For everyone making more than $19,500, it's going to be more than $95.
• However, there are a lot of exceptions.
• Reading the economists' letter, you could conceivably think that Massachusetts is now sitting pretty. It's not, precisely; according to this report, six years in, most residents were covered but per capita health spending was 15 percent higher than the national average and the state had the highest individual market premiums in the country.