The Case for and Against an Individual Mandate to Buy Health Insurance

A major concern with health care in the United States is that many of those who most need health care are unable to get health insurance- either because they would be charged higher premiums or not fully covered by employer plans, due to preexisting conditions. An important goal of health care reform was to make sure that all, regardless of the state of their health, could get affordable insurance coverage. Accomplishing this while maintaining some semblance of a private health insurance market is difficult.

In a free market, health insurance companies set premiums based on expected health care costs, and those costs will be much higher for people with poor health. While some employer plans continue to insure people whose health deteriorates, it is difficult for those with preexisting health problems to find a job or qualify for full health insurance coverage if they do.

If the government requires health insurance companies to cover everyone who applies without charging more for those with poor health, a problem known as adverse selection arises. Insurance companies will set a premium high enough to cover the average person who is likely to buy insurance from them. Given the choice, however, many people who are healthier than average will choose not to buy this insurance because they are unlikely to visit the doctor enough to justify the premiums they will have to pay. Almost everyone whose health is worse than average will perceive the premiums to be a bargain and will buy this insurance. The resulting below average health of those who choose to buy insurance will cause premiums to rise, making buying insurance worthwhile only for those in very poor health.

The problem described above can be overcome either by government providing health insurance for all at taxpayers’ expense or by mandating that everyone buy health insurance. The only way to sustain a private insurance market when companies are required to insure everyone without discriminating against those with preexisting health problems, is to mandate that everyone, especially those who are relatively healthy, must buy insurance.

Is it possible to have a system that does not discriminate by price based on preexisting conditions without some kind of individual mandate? The short answer is no. Hence the only way to guarantee affordable health insurance for everyone is to take away individual freedom. Although access to affordable health care may sound like a good reason for Americans to sacrifice some freedom, it is not. As I will discuss in future blogs, the argument that everyone should be able to purchase health insurance on the same terms is inherently flawed and does not hold up under careful scrutiny.