How the ACA’s ‘individual mandate’ came to be—and where it stands now

The “individual mandate”—the requirement under the Affordable Care Act (ACA) that most Americans obtain health insurance—has been the most disputed feature of the often-contested law, according to John McDonough of Harvard T.H. Chan School of Public Health.

McDonough, professor of the practice of public health, explored the origins of the mandate and its future prospects in an in-depth Politico article published on May 22, 2021. The piece explored how the concept of the individual mandate was introduced in 1989 by Stuart Butler, who worked at the time at the conservative Heritage Foundation, and traced how Butler’s thinking on the mandate and health policy at large has evolved over more than 30 years.

“For 33 years, and especially since President Barack Obama signed the ACA into law in 2010, the mandate has been a prize and a booby trap for Republicans and Democrats, conservatives and progressives alike, rarely at the same time,” McDonough wrote. “Initially a policy favored by many Republicans and conservatives and reviled by most Democrats, both sides swapped roles during the ACA’s creation between 2008 and 2010. Since then, the mandate has been the least favored part of the now popular health law, and the most disputed featured of one of U.S. history’s most contested laws.”

McDonough noted that, by the end of June, the U.S. Supreme Court will rule on a lawsuit seeking to overturn the entirety of the ACA. The lawsuit argues that the individual mandate, which Congress defanged in 2017 by eliminating its financial penalty, is no longer constitutional because it’s no longer a tax—and that therefore the entire ACA should be invalidated.

McDonough, who was instrumental in developing and passing the ACA while working as an adviser to a U.S. Senate committee from 2008 to 2010, wrote, “Now, I find myself in the uncomfortable position of hoping that the Supreme Court will kill [the individual mandate] rather than use it to kill the Affordable Care Act.” He added that, regardless of the Supreme Court’s decision, individual states may choose to keep the mandate.

Read the Politico article: The Tortured Saga of America’s Least-Loved Policy Idea

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A chance to improve the Affordable Care Act (Harvard Chan School feature)