Both Edwards and Clinton have proposed health care reform which would involve a federal mandate that every individual purchase health insurance. I don’t think either of them has proposed a mechanism of enforcement, but I believe such a mandate is part of the Mass. health care law recently passed. My understanding is that, in Mass., if you don’t list your insurance provider on your state income tax forms, you’ll have to pay more in taxes.
So here’s my question: what, if any, mechanisms of enforcement would be constitutional at the federal level?
Would you have an equal protection claim if the mandate was enforced by making those who fail to purchase health insurance pay more income tax? Would such a claim survive rational basis review?
Could the government enforce the mandate by denying federal funds to hospitals that treat the uninsured?
Are there obvious constitutional mechanisms that I’m missing?
I don’t see Equal Protection working here. Rational Basis review (even new, post-Romer, rational basis with teeth) isn’t going to be enough.
A possible avenue for opposition would be if there weren’t religious exemptions, though I will admit to not knowing if federally based immunization laws exist and if so if they survived challenges under the First Amendment. I seem to remember Ned Flanders had no insurance on the Leftorium because he saw insurance as a form of gambling. It wouldn’t surprise me if you could find a non three-fingered based religion that thought the same.
I tend to agree on the EP claim. Also, even if a higher tax for non-buyers was illegit, they could structure it as a benefit to all who purchase (which would look identical to a tax on those who don’t). Seems to me that we give income tax subsidies for all kinds of things, and this program could just be structured as a subsidy to everyone that buys insurance (in addition, of course, to the actual subsidy given for the purchase itself).
The First Amendment argument is clever. What about religions that simply do not care for modern medical treatment? Seems like forcing christian scientists to buy medical insurance might not be kosher, so to speak.
You can probably get away with making Christian Scientist pay for Health Care, as long as you don’t make them use it. After all, challenges by the Quakers to be exempt from paying for defense spending have, I believe, universally failed.
This is slightly different though, because it is personal spending, not contributing into a tax pool. The question would turn on whether there is a religious prohibition against paying for the right to future health care, and I am not sure there is for the CS.
The Christian Scientists are based in Boston, aren’t they? And I imagine the Mass. state constitution provides for freedom to practice religion, so this must’ve already come up.
I woud imagine some problems with defining the quality of isurance and the quality of healthcare provided.
You might get someone offering medical insurance for $10 but will only pay out for a couple of apsirins once every five years, but the preson would still be insured and thus meeting requirements of the law.
More seriously, what happens to those whose insurance cover is not adequate? or those whose illness falls outside the scope of the policy.
There is bound to be some sort of grey area, you’d probably need some sort of insurance ombudsman or regulator.
This sort of thing has come up before - not in the context of health insurance but in the context of Social Security.
The Old Order Amish resisted paying Social Security taxes, and never collected any benefits. They considered the system an insurance program, and insurance was seen as not trusting in God.
The whole thing was a mess, with IRS agents confiscating cows and horses due to nonpayment of taxes, and federal judges angrily dressing down agents who dragged peaceful farmers into court. Finally, legislation was passed specifically granting the Old Order Amish an exemption from this program.
I nore with interest that the man whose case was most mentioned in the papers, Valentine Byler, fell and broke his neck in the fields in 1965 and was bedridden when this legislation was being passed. He was disabled for the rest of his life, and could have been a recipient of Social Security disability benefits had he wished. His family instead cared for him and he helped support them by handcrafting birdhouses and wooden toys. He died in 1998.
Thanks Mr Moto - I cannot believe I forgot the Amish cases.
Now cantankerous gits like myself would of course argue that exempting groups from general programs is itself unconstitutional if done on religious grounds has its own constitutional problems…
To return to the OP, it is also interesting to consider under what federal power the program would be enacted - given the more restrictive view of the commerce clause post-Morrison (?) this might not be as easy to do.
That’s an interesting thought. I imagine it would be similar to car insurance, but I suppose health insurance is a bit more complicated isn’t it? Anyone know how this works in Mass.?
Probably not, which would explain why they are considering such an ass-backwards way of doing it. I cannot believe I am missing this stuff. My only excuse is I am sick of working on procedural rubbish and I didn’t grow up with federalism, so it isn’t natural to me…
One objectionw hich should be made is that it’s flat, black-letter unConstitutional. It is not in the least an interstate issue. The courts, however, would hand-wave the issue away as they always do. You could tax non-insured poeple more, though that would hardly help.
If they can make the cops enforcers for auto insurance industry collections departments, which is what auto insurance laws are all about, I don’t see why they can’t do the same for health insurance.
Would their law also carry a provision that the insurance companies must sell you insurance?
I can get insurance through work, but I can’t buy it independently because I’m overweight. What happens to me in this system if I lose my job or if I start working for a contract house that doesn’t provide insurance?
In addition to rejecting Social Security, they also do not carry commercial health insurance. Health costs are paid out of pocket, with catastrophic health coverage provided by their own community.
I realize this population is an outlier, and perhaps shouldn’t indicate overall policy, but they and others who do similar things willingly are enough to disprove your absolute statement.
Well, there are some people (myself included) who can afford insurance but figure they’ll take their chances (i’m 25 and have never had a serious health issue) and presume that if they get really sick someone will pick up the tab.
But assuming we’re discussing the Mass model, the law is coupled with subsidies to help people afford the insurance. And indeed it has worked, more then half the uninsured of Massachusettes have signed up, and the penalties haven’t even kicked in yet.
Reading up some more on the Massachusettes plan, it does apparently exempt those who opt out due to “strongly held relgious beliefs” (presumably, Christian Scientists) though employers of Christian Scientists get no such break and will still have to pay the fine for having an uninsured employee.
