The Mandate and Its Enemies

On the coattails of its second anniversary, the Supreme Court is hearing arguments regarding the constitutionality of the Affordable Care Act (ACA).

The question at hand is the legality of the "health insurance mandate." Requiring citizens to purchase health insurance on the private market, it stands as the first leg of the "three-legged stool" of health care reform -- the others being subsidies to help poor Americans pay for now-required health insurance, and laws forbidding health insurers from discriminating based on pre-existing conditions.
 
Such a moment occasions a peer back into the history of health reform to ask: Why the mandate in the first place?
 
There are two answers: the political answer, and then the technical answer.
 
First, the political answer: Because the multibillion-dollar health insurance industry had a lot to lose in health reform.
 
Stalwarts on the left have understood health reform to mean a complete reconstruction of the health system -- a move to the single-payer or single-provider system that have worked so well in other high-income countries.
 
Our health system has been a (pseudo-)market system for decades, and the industry that had the most to lose was the health insurance industry -- proud owners of a market that would no longer exist if the government was to take on health care. Unwilling to tolerate reforms that would destroy its market, the health insurance industry and its partners dumped billions of dollars into lobbying, especially among its natural market-friendly allies on the right, against any reform plan that wouldn't leave room for health insurance. As money tends to in Washington, it won.
 
The watered-down health insurance we got was one that secured the financial future for the health insurance industry.
 
Which leads to the technical answer: Because that health insurance market health reform ultimately secured is really quirky.