As The New York Times suggested last week, the fate of President Obama's Affordable Care Act in general, and its mandate that Americans obtain health insurance in particular, may hinge on Justice Anthony Kennedy's notion of "liberty." While Solicitor General Donald Verilli posited "a profound connection" between health care and liberty, his opponent Paul Clement argued, "that it's a very funny conception of liberty that forces somebody to purchase an insurance policy whether they want it or not."
Of course, that very conception of liberty has been the law of the land for decades. Today, tens of millions of Americans must purchase health insurance and a pension plan for their golden years. And as it turns out, the Medicare and Social Security mandates for individuals and employers dwarf anything required by the dreaded Obamacare.
As we learned during the recent debate over the extension of the payroll tax cut, 160 million Americans pay taxes to fund the Medicare and Social Security trusts for today and tomorrow's retirees. Since 1935, workers and their employers have each paid into the Social Security trust fund, a figure which next year will return to its 6.2 percent rate on the first $106,000 of income. In addition, employer and employee alike are on the hook for another 1.45 percent for Medicare, the insurance program for the elderly established in 1965.
In comparison, the Affordable Care Act's individual mandate impacts just a small fraction of Americans. For starters, over 80 percent already have health insurance, compared to roughly 17 percent who do not. The Economic Policy Institute estimates that 59 percent of those under age 65 receive employer-sponsored insurance, while another 22 percent are covered by public programs including Medicaid and SCHIP. Of the 50 million people who are currently uninsured, about 20 million (including undocumented immigrants and those with religious objections or claiming economic hardship), are not covered or are otherwise exempt from the health insurance mandate. As a recent Urban Institute analysis concluded:
What may be surprising, however, is that if the ACA were in effect today, 94 percent of the total population (93 percent of the nonelderly population) or 250.3 million people out of 268.8 million nonelderly people would not face a requirement to newly purchase insurance or pay a fine.
As Ryan Grim noted, that's because "98 percent of Americans would either be exempt from the mandate — because of employer coverage, public health insurance or low income — or given subsidies to comply." The Urban Institute estimated that 8.1 million Americans would have their insurance paid for by the expansion of Medicaid to 133 percent of the federal poverty level. Another 10.9 million people would receive subsidies to buy private insurance in the new state exchanges, while only 7.3 million (2 percent of the total U.S. population) would be required to purchase a health plan using their own resources alone. As for those Americans choosing to instead to pay the penalty for failing to obtain insurance at all, the CBO estimated that number at 4 million. (That forecast is almost double the rate in Massachusetts, where only 48,000 in a state of 6.6 million people opted to pay the penalty rather than acquire health insurance under Mitt Romney's version of the individual mandate.)
But if far more Americans pay the Social Security and Medicare mandates, the number of direct beneficiaries of "Obamacare" is much lower.