More on individual mandate and the options

Mark Hall with a very nice, succinct piece in the New England Journal of Medicine addressing the constitutionality of the individual mandate. He does a good job of addressing the legal/constitutional, political and health policy dimensions to this question.

Universal coverage or something close is a necessary, but not sufficient condition to deal with our health care cost problem. There are three basic ways to expand insurance coverage toward anything resembling universal from our current point of 50 Millionish uninsured.

• Government insurance, such as Medicare, Medicaid or a new plan in which government acts as the insurer. Such government insurance needn't be expansive, it could be catastrophic like what I wrote here.
  
• Employer mandate, in which employers are compelled to provide insurance or pay a tax to support such coverage if they do not. Hawaii has had one for 30 years and has the second highest rate of insurance (after Massachuetts, that has an individual mandate).
  
• Individual mandate, which is what the Affordable Care Act proposes.
  

A fourth option is direct government provision of care, like in the Veterans Administration in the U.S., or the National Health Service in the U.K. This would be an actual takeover of the health care system, and I list it as a possibility in the interest of completeness since some of my students read this blog.

If the Supremes rule that the individual mandate is unconstitutional, then I see only two other options left. If there are other ways to move toward universal coverage, which is a necessary but not sufficient condition to addressing costs, we need to see this laid out in a bill that is marked up in a House committee, scored by the CBO and subjected to the debate and discussion that was afforded the ACA. There are some good ideas hidden amidst GOP talking points on health policy, but they have to come together in a piece of legislation for the Republicans to be taken seriously on the health policy front.