The ACA won't work without the individual mandate, we must keep it

 The ACA won't work without the individual mandate, we must keep it
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As a physician, I see firsthand how the health care individual mandate the requirement that everyone carry health coverage — has a particularly bad reputation in the public eye. Though many Americans rally behind the idea of protecting individuals with pre-existing conditions, the idea of requiring people to purchase health insurance is less popular.  

Perhaps this is due to skepticism around government transparency, or because we bristle at the idea of being forced into a decision, even one to buy health insurance. Whatever the cause, we are suddenly facing a far larger health care crisis, but one that can be shifted by looking to how we’ve historically helped get essential health care into American communities.

Despite multiple attempts, Congress has failed to repeal the Affordable Care Act (ACA). We are now in the critical time period in which millions of Americans can sign up for health insurance during open enrollment. However, damage from the battle over the last year is palpable as confusion reigns that could prove detrimental to the entire system itself.


The Trump administration continues to attempt to sabotage the ACA as funding has been cut for advertising and navigators who help answer questions about enrollment. In fact, only 15 percent of the uninsured and 40 percent of marketplace enrollees are aware that open enrollment has even begun.

And now, Congress is trying one more time to undermine the ACA by using the tax bill talks as a means to repeal the individual mandate. These challenges continue despite the fact that the Supreme Court already ruled in 2012 that the individual health insurance mandate is constitutional.

The individual mandate requires everyone must purchase health insurance that meets minimum standards or pay a penalty. Though the link between the tax bill and individual mandate might appear murky, the tax bill serves as a way for Congress to push through a measure that will destroy the underpinnings of the ACA. Simply put, without having the individual mandate as a key requirement of the ACA, fewer may buy policies, and thus, insurance companies will have no choice but to increase rates to close the gap. Prices increase and the system falls apart.

There’s a way out here, one that involves reframing the lens through which we view the system, and our responsibility to each other, and one we can find in historical health care narratives. The majority of advances in health care over the last 100 years have resulted from controlling of infectious disease. As a pediatric cardiologist who works in a children’s hospital, it is rare for me to see a child die from an infectious disease. Compare this to the early 1900s, when 30.4 percent of all deaths occurred in children less than 5 years of age.

Much of the decrease in mortality is due to introduction of vaccines with implementation of universal vaccination programs. Vaccination protects the person who gets the vaccine certainly, but also has the potential to protect everyone in the community as long as a critical portion of the community is vaccinated (usually about 80-90 percent). The infectious disease has a lower chance of actually being present or being transmitted and leads to the concept of community-wide or “herd immunity.”

We must shift our thinking of required health-care coverage to the way we approach community vaccination. Just as vaccinations need a critical number of people to be vaccinated to reach community immunity, the ACA needs a critical number of people to participate if the system is to function.

The truth is that the ACA would not be sustainable without of the individual mandate. Costs to individuals would be substantially higher, as the health-care market needs both sick and well people to purchase insurance so the market can support everyone in need of care. Without the requirement to purchase insurance and the option for a majority of American to opt-out of participation, the system falls apart.

To be sure, we must be honest about what Americans want from their health care system. Despite what we may hear anecdotally from Washington D.C., majority of Americans want a bipartisan solution that improves the ACA instead of repealing it.

Further, the individual mandate surfaces very real concerns including the fact that a certain part of the population is not eligible for government subsidies and simply cannot afford the premiums. However, that’s all the more reason to not simply let the health-care system implode, but rather to find solutions that helps bring all citizens into the system.

So, as Congress debates the tax bill, let us remember to call our representatives and remind them we want to improve the ACA, not destroy it.

Angira Patel, MD, MPH, is assistant professor of pediatrics and medical education and a member of the Center for Bioethics and Medical Humanities, both at Northwestern University Feinberg School of Medicine, a pediatric cardiologist at Ann & Robert H. Lurie Children’s Hospital of Chicago, and a Public Voice Fellow of the OpEd Project.