Can Barack Obama make you buy health insurance?

How to fix health policy.
Aug. 4 2009 6:59 PM

Can Obama Make You Buy Health Insurance?

An inquiry into health reform's constitutionality.

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Illustration by Robert Neubecker. Click image to expand.

Barack Obama spent much of the 2008 presidential-primary season arguing with Hillary Clinton about whether health reform should include a so-called "individual mandate" requiring all Americans to purchase health insurance. Clinton argued that it should. Obama argued that it shouldn't (even though his own plan called for a more limited individual mandate requiring parents to purchase health insurance for their children). One of Obama's central arguments was that enforcing such a mandate would be impractical. "You can mandate it," Obama said, "but there still will be people who can't afford it. And if they can't afford it, what are you going to fine them?"

At the time I thought Obama had the better argument, not just on practicality but also with respect to the Constitution. "If you want to drive a car," I wrote,

it's accepted that you have to buy private auto insurance. But that's conditional on enjoying the societal privilege of driving a car; you can avoid the requirement by choosing not to drive one. A mandate to buy private health insurance, however, would be conditional on … being alive. I can't think of another instance in which the government says outright, "You must buy this or that," independent of any special privilege or subsidy it may bestow on you.

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Nearly two years later, Obama has made peace with the individual mandate, which is included in the bills that cleared three House committees and one Senate committee. The House bill imposes on anyone who neglects to purchase health insurance for himself or his family a 2.5 percent tax on modified adjusted gross income. The Senate health committee bill imposes a minimum penalty of $750. (We're still waiting to hear from the Senate finance committee.) Yet I've continued to wonder whether the individual mandate is constitutional.

Should health reform pass, it seems a dead certainty that conservatives will go to court to challenge the individual mandate. A preview of their arguments can be found on the Web site of the conservative Federalist Society in the paper, "Constitutional Implications of an 'Individual Mandate' in Health Care Reform" by Peter Urbanowicz, a former deputy general counsel at the Health and Human Services department, and Dennis Smith, a former director of HHS's Center for Medicaid and State Operations. One of these turns out to resemble my earlier argument:

Nearly every state now has a law mandating auto insurance for all drivers. But the primary purpose of the auto insurance mandate was to provide financial protection for people that a driver may harm, and not necessarily for the driver himself. And the auto insurance mandate is a quid pro quo for having the state issuing a privilege: in this case a driver's license.

Since I first wrote about this, it's been pointed out to me that the comparison with auto insurance is not a legal argument at all. (I am not a lawyer.) The legal question isn't whether it would be unusual for the government to compel people to buy health insurance. It's whether it would square with the Constitution. Mark Hall, a professor of law at Wake Forest University, argues that it would, in part based on the commerce clause, which since the New Deal has permitted the federal government to expand its power in various ways by defining various activities as "interstate commerce." Although health delivery is often local, Hall writes, "most medical supplies, drugs and equipment are shipped in interstate commerce." More to the point, "most health insurance is sold through interstate companies."

Yes, counter Urbanowicz and Smith, but "it is a different matter to find a basis for imposing Commerce Clause related regulation on an individual who chooses not to undertake a commercial transaction." Does the commerce clause cover your refusal to engage in interstate commerce?

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