The Washington PostDemocracy Dies in Darkness

The Health 202: A eulogy for the individual mandate

with Paulina Firozi


Farewell, individual mandate. May you rest in peace.

Republicans have ensured the Affordable Care Act’s requirement to buy health coverage – viewed by many as the key to making the entire, sweeping 2010 health-care law work in concert – will never reach its ninth birthday. With a stroke of his pen (likely in early January for technical reasons), President Trump will enact a major tax overhaul that effectively closes the case on the individual mandate by slashing its accompanying tax penalty starting in 2019.

During a cabinet meeting, President Trump lauded the passing of the GOP tax plan. (Video: The Washington Post)

“In this bill, not only do we have massive tax cuts and tax reform, we have essentially repealed Obamacare, and we’ll come up with something that will be much better,” Trump said yesterday at the White House, as he proclaimed victory on the tax effort. “Obamacare has been repealed in this bill.”

Let’s pause right here and clarify something: The ACA as a whole is still very much alive. Americans can still access its insurance subsidies and expanded Medicaid program and buy plans in compliance with its insurer mandates. That’s unlikely to change in 2018, as Doug Jones's recent win in Alabama just about guarantees Republicans just won’t have enough Senate votes to repeal and replace the law.

Conservative health wonk Chris Jacobs:

CNN's Jim Acosta:

The senior vice president at the Kaiser Family Foundation:

But the individual mandate’s death is still noteworthy, both practically and politically. Independent analysts have estimated that without it, anywhere from 3 million to 13 million fewer Americans will have health coverage a decade from now. It’s been viewed as necessary for motivating healthy people to buy coverage so it’s not just the sick entering the individual market risk pools.

Over the years, the GOP-led House has repeatedly tried to shoot holes in the mandate, and not just by voting to repeal it. In July 2013 and again the following March, the House passed measures to delay the mandate for one year. A few weeks later, the chamber approved another bill to delay the mandate for five years.

Every single health-care bill Republicans have introduced over the past few years, including all the various House and Senate measures last spring and summer, has proposed repealing the mandate. And don’t forget the infamous 2012 Supreme Court case where the constitutionality of the mandate – and thus of the whole law – was challenged (but ultimately upheld).

The mandate has long symbolized much of what Republicans hated about the ACA – the idea the government can hand down more rules about who buys coverage and what that coverage looks like (even though let’s recall it was the conservative Heritage Foundation that was an initial proponent of the idea).

Senate Finance Committee Chairman Orrin Hatch (R-Utah):

Sen. Tom Cotton (R-Ark.):

Director of Progressive Programming at Sirius XM Radio:

So it’s not shocking that’s the part of Obamacare they chose to target in their tax overhaul, especially since their chance at a health-care bill seems to have passed. Democrats and advocates for the ACA have known for a while this was likely coming down the pipeline – and there was not much they could do to stop it.

Yet Republicans have talked for so long about repealing the mandate, election cycle after election cycle, it’s still hard to believe we’re actually standing here.

The Health 202 asked leading health-care wonks -- on the right as well as the left – to offer some parting comments. Let’s call a eulogy of sorts.

--Andy Slavitt, former Centers for Medicare and Medicaid Services administrator under Obama: “The main effect of Republicans’ action today is to raise the cost of insurance for middle class families. The law has proven to be highly resilient and actions against it look increasingly petty. As a larger matter, to Republicans’ chagrin, they have now removed the only unpopular feature of the ACA. The rest of it enjoys overwhelming popular bipartisan support and will be much harder to remove.”

--Chris Jennings, former health-policy advisor to Obama: “Not overly original, but true: You break it, you own it and all the associated increases in premiums, out-of-pocket costs and uninsured Americans. Congratulations.”

--Jim Capretta, former Office of Management and Budget health-care director under George W. Bush: “There’s some exaggeration on both sides of the debate about the individual mandate. Advocates of the mandate say that its repeal will devastate the individual market. There’s not much evidence for this view. On the other hand, opponents of the mandate sometimes say its repeal will have no effect at all.  That’s also not true. 

“The individual market under the ACA is already somewhat unstable, and is suffering from an elevated level of adverse selection. The repeal of the mandate is going to make this not-so-great situation slightly worse. But the market is unlikely to collapse, as the ACA subsidies are sufficient to induce significant enrollment even without the mandate.

“Republicans now have some responsibility for the functioning of the marketplaces. Unfortunately, it does not seem like GOP leaders in Congress or the Trump administration have a clear idea of what they would like to do once the mandate is repealed.”

--Tom Scully, CMS administrator under George W. Bush: “I don t think the mandate ‘repeal’ will make a big difference. A Trump IRS was not going to enforce the penalties anyway. I am sure that insurers would prefer that it stay in place, but I bet he real behavioral impact will be minimal.”

--Newt Gingrich, former GOP House speaker (who once supported the idea of an insurance mandate): “A bad idea passed in a bad way and repealed in a classic American model of clumsy but correct.”

--John McDonough, Harvard health-policy professor: “As Mark Twain is reported to have said on May 31, 1897, ‘the report of my death was an exaggeration.’ The legislation reduces the penalty for non-compliance with the mandate to zero. The legal requirement remains intact.

“This is not trivial. It will not take long for the damage from the zeroing out of the ACA penalty to become clear. Because Massachusetts still has an enforceable mandate -- and penalty -- on its books, we will have speedy evidence of the impact of this policy change. 

“In 2019 or 2021, a future Congress that cares about the stability and workability of the nation's individual health insurance market, unlike the current Congress, will revisit this policy and likely re-establish a workable new policy.”


--Okay, so taxes are done. What happens next? Congressional leaders are now considering another short-term spending bill, after talks aimed at passing more-ambitious legislation appeared to collapse as Friday's government shutdown deadline nears, our colleagues Mike DeBonis and Erica Werner report.

"Republicans have pushed for increased military funding and disaster aid for hurricane-ravaged communities in the South. Democrats, meanwhile, want a boost to domestic programs and a solution for young immigrants brought to the United States illegally as children," Mike and Erica write. "But with a midnight-Friday shutdown deadline looming, not to mention the coming holidays, GOP leaders in the House and Senate indicated that lawmakers were likely to do the bare minimum — passing another short-term spending bill to keep the government open and then revisiting everything in January."

“There’s a whole bunch of stuff that’s got to get wrapped up and loose threads out there that have to be tied together at some point, and if we end up having to do that all in the first two weeks of January, I guess that’s what we’ll end up doing,” No. 3 Senate Republican John Thune told reporters yesterday.

--Lawmakers did defuse one potential landmine yesterday, when Sen. Susan Collins (R-Maine) -- who had conditioned her vote for the tax overhaul on the separate passage of two market stabilization bills — agreed to withdraw her demand the health-care provisions get attached to the year-end spending legislation. There was a growing resistance among House Republicans, whose most conservative members refused to vote on legislation they saw as improving the Obamacare marketplaces.

“Rather than considering a broad year-end funding agreement as we expected, it has become clear that Congress will only be able to pass another short-term extension to prevent a government shutdown and to continue a few essential programs,” Collins said in a joint statement with Sen. Lamar Alexander (R-Tenn.). Both are sponsoring separate bills to make so-called cost-sharing reduction payments and reinsurance payments to marketplace plans.

Boston Globe's Victoria McGrane:

--President Trump is eager to sign both marketplace stabilization bills in January, the White House told Politico yesterday. “We believe that we will work with the House to get those passed,” a senior White House official said. “We think that we will be in a more comfortable place in January to get that passed.”

--Basically, Republicans are pushing off nearly every troublesome political issue until next year. That includes a five-year reauthorization of funding for the Children's Health Insurance Program, the popular and bipartisan safety-net program that covers 9 million low-income kids and pregnant women. The latest plan is to temporarily extend CHIP funding through March (the year's first quarter) in the short-bill funding bill the House plans to vote on today to keep the government open through Jan. 19.

Did we use the words "popular" and "bipartisan" to describe a program Congress hasn't seemed able to fund for more than 80 days now? Yes, yes we did. The present gridlock is befuddling parents around the country whose kids are dependent on CHIP. The short-term funding will help some states, but it won't completely solve the long-term uncertainty that's really starting to cripple them as they try to plan their programs for next year.

My colleague Robert Samuels visited a Utah family facing some hard-to-make decisions about their 2018 coverage, as they wait to see what Congress will do. Ashlee and Levi Smith have relied on CHIP to cover their boys, ages 3 years and 3 months, but now they're torn between optimism and anxiety as they consider whether to stretch their finances to buy a private plan or wait for Congress to fund the program.

"For the Smiths, who are Republicans, the congressional stalemate over the $15.6 billion program is bigger than a question how to pay. It is also a question of who — or what — to believe," Robert writes.

"Over the course of the year, their faith in the GOP-led Congress has eroded. Their general disenchantment became more pronounced when lawmakers, including even their home-state senator, Orrin G. Hatch, an architect of the CHIP program, failed to secure the funding. The Smiths have watched their GOP representatives in Washington focus on pushing politically difficult initiatives — from seeking to rescind the Affordable Care Act to enacting a sweeping tax overhaul."

“Jesus, bless them,” said Ashlee Smith, holding her son Aiden in her hands. “I am not being very nice to my government, and I have faith that one day there will be good leaders who can put all the fighting aside. But they’ve put themselves in such a corner that none of them can work together even when they agree.”


AHH: The Trump administration is waging a linguistic battle across official Washington, seeking to shift public perception of key policies by changing the way the federal government talks about climate change, scientific evidence and disadvantaged communities, The Post's Juliet Eilperin and Lena H. Sun report.

"The push drew fresh attention after employees at the Department of Health and Human Services were told to avoid certain words — including 'vulnerable,' 'entitlement' and 'diversity' — when preparing requests for next year’s budget," Juliet and Lena write. 

A recent example: In late summer, the Office of Juvenile Justice and Delinquency Prevention issued a document to employees and contractors bearing a column of words and phrases to be avoided, alongside a column of acceptable alternatives. The one-page document obtained by The Post recommends using “all youth” instead of “underserved youth" and referring to crime as a “public issue/public concern” rather than a “public health issue/public health concern." The document also says to avoid “substance abuse disorder” in favor of “substance abuse issue" -- even though experts are trying to raise awareness that substance abuse is a disease.

OOF: Today the CDC reports that U.S. life expectancy declined for the second consecutive year in 2016, fueled by a staggering 21 percent rise in the death rate from drug overdoses. The nation hadn't seen two consecutive years of declining life expectancy since 1962 and 1963, when when influenza caused an inordinate number of deaths, The Post's Lenny Bernstein and Christopher Ingraham write.

“I think we should take it very seriously,” said Bob Anderson, chief of the Mortality Statistics Branch at the CDC's National Center for Health Statistics. “If you look at the other developed countries in the world, they’re not seeing this kind of thing. Life expectancy is going up.”

"The development is a dismal sign for the United States, which boasts some of the world’s highest spending on medical care, and more evidence of the toll the nation’s opioid crisis is exacting on younger and middle-aged Americans," Lenny and Christopher write. "More than 42,000 Americans died of opioid overdoses alone in 2016, a 28 percent increase over 2015. When deaths from drugs such as cocaine, methamphetamine and benzodiazepines are included, the overall increase was 21 percent.

OUCH: As allegations of sexual misconduct, harassment and assault have been pouring in from countless women, the reports have sparked the question: What makes some men sexual harassers? The Post’s William Wan reports that social scientists and psychologists have struggled with that question in recent years. He breaks down their research, and some findings, by answering five main questions:

What causes some men to harass and not others?

John Pryor, one of the early pioneers to study sexual harassment, invented a test in 1987 to measure a man's tendency to harass. Called the 'Likelihood to Sexually Harass' scale, Pryor’s test has become a cornerstone for research today on sexual harassers. Over time, the test has identified these factors as the most distinctive in harassers: a lack of empathy, a belief in traditional gender sex roles and a tendency toward dominance/authoritarianism.

Why are people in positions of power so often doing the harassing?

One of  Berkeley professor Dacher Keltner's experiments found that people who see themselves as wealthier were more likely to cut pedestrians off on a crosswalk. Another study found that those who felt powerful were even more likely to take candy from children. Other experiments have shown that powerful people become more focused on themselves, more likely to objectify others and more likely to overestimate how much others like them.

What makes these men think women want to see all that?

One of the most puzzling and icky details from the recent string of high-profile cases is this signature move of several powerful men: Exposing themselves to women, apparently with the expectation that those women are attracted to them or will be once they see their bodies. There is, surprisingly, a scientific explanation for this. A particularly eye-opening 2011 study found that people in leadership often pick up phantom sexual signals from subordinates that aren’t really there.

So what are these men really after? Sex or dominance?

"The hackneyed phrase everyone always says about sexual harassment is that it’s not really about sex, it’s about power," Pryor told William. "But that’s not really true. It’s about both."

 Why is it almost always men doing the harassing?

There’s a statistical answer for this: The way our society stands now, with all its flaws, discriminatory biases, and historical and cultural baggage, there remain many more men in leadership positions than women. There’s also a feminist structural reading of such harassment: that harassment often serves as a vehicle to exert dominance and put women in their place.

--A few more select reads from The Post and elsewhere:


Major initiative seeks to combat U.S. soldiers’ weight problems and injuries (Vicky Hallett)

How Racism May Cause Black Mothers To Suffer The Death Of Their Infants (NPR)

Can a Cup of Hot Tea a Day Help Preserve Eyesight? (New York Times)


When Nursing Homes Push Out Poor And Disabled Patients (Kaiser Health News)

Envision Healthcare pays $31 million to settle ER fraud claims (Axios)


Judge: Plastic Surgery Was Wrongly Denied for 3 HIV Patients (Associated Press)


Hickenlooper makes emergency plea for lawmakers to extend children’s health insurance program (Denver Post)

Coming Up
  • The American Enterprise Institute holds an event on “New thinking about poverty and economic mobility” on Jan. 18. 

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