The May issue of The American Prospect has a very interesting article by Paul Starr on an alternative to the so-called “individual mandate” in the Affordable Care Act.

I write “so-called” because it doesn’t actually require anyone to buy insurance. What it says is that if you’re an adult legal resident of the United States who doesn’t already have insurance, isn’t a member of some excluded group, makes over a minimum income, and has access to a reasonable health insurance policy costing no more than 9 percent of your income, then you either have to buy the policy or pay a little additional income tax or, really, do neither. The sole enforcement mechanism permitted by the law is to withhold the extra tax from your refund if you have a refund coming.

Starr is a Princeton professor who co-founded the magazine the article appears in and has written quite a lot on health care over the years, most recently the book Remedy and Reaction on the history of the Affordable Care Act.

As Starr notes, the enforcement mechanism on the so-called “mandate” is so weak that it might not even encourage very many people to buy insurance. It might well have been more effective, Starr suggests, to use carrots rather than sticks (or in this case, an itty bitty twig) to make it in people’s interests to buy insurance, and the alternatives wouldn’t have run the risk handing an excuse to a politically activist Supreme Court to overturn the law.

Isn’t this a little late to bring that up? Actually, Starr suggested the alternatives well before the act was passed. So, in fact, did Obama. A combination of forces in Congress insisted on adopting the “individual mandate” in imitation of the health care reform introduced by Mitt Romney and originally proposed by the conservative Heritage Foundation.

Unfortunately, as Starr notes, if the Supreme Court overturns the “mandate,” it’s going to be hard to get an alternative passed over the votes of Republicans who don’t want to see the reform succeed. What’s likely to happen is that individual states will follow the lead of Massachussetts (which has almost exactly Obamacare in place thanks to Mitt Romney) or Vermont (which is on the road to implementing what amounts to Medicare for all). Or, I would add, Hawaii, which has achieved coverage rates not much lower than Massachussetts  by requiring all employers, even fast-food places, to provide health insurance for all their full-time employees.

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