Health insurance coverage is one of the major issues at the core of initiatives to reform the United States health sector. This issue has attracted considerable attention in health reform initiatives because of the relatively high number of uninsured and underinsured people in the country. The United States has a high number of uninsured and underinsured populations despite the increased federal expenditures on health. Recent healthcare reform legislation has sought to address this issue through various ways including the introduction of the mandate to buy health insurance. The mandate is essentially an individual or employer mandate to obtain private health insurance coverage. However, the individual mandate is one of the controversial provisions of the Affordable Care Act and has been the subject of numerous lawsuits. In addition, legislation has been enacted against the mandate to buy health insurance. This paper discusses lawsuits and legislation involved against the mandate to purchase health insurance.
I. History and Background of the Issue

The individual mandate is one of the provisions of the Patient Protection and Affordable Care Act (also known as the Affordable Care Act, ACA, or Obamacare), which was enacted into law in March 2010. Based on the provisions of ACA, the individual mandate is enforceable as a tax and requires Americans to buy health insurance or face a penalty. However, low-income individuals who cannot afford to purchase health insurance are exempted from the mandate to buy insurance. Despite the enactment of the individual mandate into law in March 2010, the issue has a long tortuous history that can be traced back to 1986 when legislation by a Democrat House and Republican Senate was enacted into law (Roy, 2012). The legislation, Emergency Medical Treatment and Active Labor Act (EMTALA), which was signed by President Ronald Reagan, allowed individuals who had lost their jobs to continue purchasing health insurance using the old employer’s group plan. This regulation was the first attempt to enact the individual mandate into health care law. In 1974, President Nixon proposed replacing the single-payer model with the employer mandate. As part of the Comprehensive Health Insurance Plan, all employers would be required to provide comprehensive health insurance plans to all full-time employees. Following concerns that the employer mandate did not address health insurance for the unemployed, Bill Clinton proposed universal health care for all in 1993 based on the concept of managed competition (Roy, 2012).

The employer mandate served as the predecessor for the individual mandate because of its obvious and large problems. First, the employer mandate increased the cost of hiring new employees, which in turn discouraged new hiring and contributed to an increase in the rates of unemployment. Secondly, this mandate forced employers to pay for their employees’ health costs, which essentially increased the costs of operations that were in turn passed down to consumers in the form of high costs of products and services. Third, it failed to address the health needs and coverage of the unemployed. Fourth, it increased the cost of health insurance by insulating consumers from the value of health care, which implied that consumers had no incentive to economize. Finally, the employer mandate resulted in job lock since employees were afraid to leave their jobs because of the likelihood of higher premiums or denial of coverage because of switching plans.

The historical health reform initiatives relating to the individual mandate culminated in its inclusion and enactment into law as part of the Affordable Care Act of 2010. This represented the translation of the individual mandate theory into practice (Hackmann et al., 2015). While the individual mandate was considered necessary to help cover the costs of health care in the United States, it is one of the most politically and legally controversial provisions of Obamacare. The mandate to buy insurance has remained controversial and been the subject of legal battles. According to Hackmann et al. (2015), the individual mandate was at the center of legal challenges to the Patient Protection and Affordable Care Act. The legal challenges on this provision have been fueled by the near-unanimity that it is an egregious infringement of individual liberty (Roy, 2012). Lawsuits and legislation involved against the individual mandate have adopted a partisan approach as Democrats and Republicans argue about this provision, its effect, and legality.

On one hand, proponents of the provision (mostly Democrats) contend that this provision is necessary to cover health care costs in the country while increasing health insurance coverage to many populations of uninsured and underinsured people (Campbell & Shore-Sheppard, 2020). Additionally, these proponents have argued that this provision would help increase enrolment in the individual market and lessen health care costs on the part of the federal government. Moreover, the individual mandate would help keep a higher percentage of younger and healthier people enrolled in the individual market. Proponents of the legislation have also argued that it would help expand access to health coverage for sick people who would otherwise have been priced out of the market or denied coverage (Roy, 2012). On the other hand, many conservatives and Republicans have opposed the individual mandate on grounds that it violates individual liberty. In addition, they contend that this provision is likely to increase premiums. These opponents have increasingly coalesced around the idea of a free-market of health reform.

II. Social Issue Surrounding the Issue and Legal Dimensions

The political and legal controversial opinions regarding the individual mandate have been at the center of legal battles and legislation against the provision. These divergent opinions and arguments have made the individual mandate the least popular yet well-known provision of the Affordable Care Act. At the heart of the controversies surrounding the individual mandate are its social issues and legal dimensions or questions. The social issue surrounding the individual mandate today is the avoidable social burden brought by people who are unable to obtain health insurance coverage. Generally, the individual mandate focuses on enhancing individual responsibility with regard to health insurance coverage. According to Blake (2012), the requirements of individual responsibility that underlies this provision were considered necessary to help avoid challenges or problems associated with the free-rider.

Through enhancing individual responsibility, the individual mandate seeks to avoid the social burden brought by health insurance coverage in various ways. First, the individual mandate seeks to avoid the free-rider problem in which the health care costs for uninsured populations are paid by others. Secondly, this legislation seeks to address adverse selection, which...…the foundation for values in the health care system (Sheikh, 2007). In this case, ethics serves as the base for accountability between the public health agency and the public. Public health agencies are held accountable in their processes and activities based on the established set of values. Accountability focuses on ensuring that public health agencies carrying out their activities in a fair manner that safeguards the interests of the public and patient populations. Without ethics, it would be difficult to create a set of values to guide public health work and activities. This set of values in turn creates an atmosphere of trust between the administration and the public. Ethics also plays an important role in the public health regulatory process by promoting fairness. Ethics is essentially the premise upon which regulatory processes in the health sector are carried out with the public’s best interest at heart. Public health regulatory processes should be based on fairness and integrity, which highlight the role of ethics in these processes. For example, future regulatory measures relating to the individual mandate should be carried out with the common good in mind. This would help ensure that the legislation and policies ensure fairness by considering the interests of all stakeholders.

Ethics is also important in the administration of public health agencies and in the public health regulatory process as it promotes professionalism. Incorporating professionalism in public health practice has emerged as a critical factor in meeting the healthcare needs of the public (Slomka et al., 2008). Professionalism will continue to be a major issue in future public health practice because of the changing nature of public health delivery. Technological advancements continue to transform public health delivery processes and initiatives. As technological tools and applications are increasingly adopted in the public health sector, ensuring professionalism in healthcare delivery will continue to be a key factor for effectiveness and efficiency in public health. The need for professionalism and integrity in the administration of public health agencies and public health regulatory process is highlighted by the growing focus on population health, emerging infectious diseases, and the link between socioeconomic status and health. These issues continue to raise moral questions and demonstrate the significance of ethics. Ethics provides the foundation to address the emerging moral questions on these issues and others in public health.

In conclusion, the legal challenges facing the mandate to buy health insurance have proven challenging toward efforts to reform the U.S. health sector. In addition, some states have enacted laws that protect or oppose the mandate to buy health insurance. The lack of a mandate to buy health insurance affects efforts to increase health insurance coverage across the country as only fewer healthy people pay into the health system to counterbalance the costs of caring for the sick. Despite these lawsuits, efforts to mandate the purchase of health insurance remain critical and necessary to expand health insurance in the United States. As evident in this discussion, recent court rulings such as the decision by the United States Court of Appeals for the 5th Circuit continue to affect the individual mandate. However, states have adopted various actions and efforts to enact some form of individual mandate policies and requirements.