The Affordable Care Act (“Obamacare”) was a great victory for our social democracy. The United States finally established universal healthcare – a right to health. Our national collective has decided that, no matter our income or pre-existing condition, every one of us shall have health insurance coverage. It is a matter of duty. Americans who happen to be of better circumstances can’t simply let their fellow citizens suffer and die because treatments are expensive. Fortunate Americans have a solemn humanitarian obligation to help those less fortunate. The Affordable Care Act simply codifies that duty. Yet it only does half the job.

If our nation has an ethical duty to provide for the healthcare of the less-fortunate, then the less-fortunate have a corresponding duty to our nation to practice a healthy lifestyle. There is no reason they should refuse this duty. After all, no American who has asked for his health insurance to be subsidized can smoke cigarettes, eat fast food, or forego exercise in good conscience. That is the same as asking for help paying your college tuition then refusing to study or attend class. A healthy lifestyle is an obvious moral obligation for all subsidy beneficiaries. Thankfully, a healthy lifestyle is also simple and inexpensive. In fact, for those who regularly smoke, drink and over-eat, healthy living will actually reduce complexity and expense. It’s not much to ask in exchange for an average of $6,775 per year in health care expenses being covered by your fellow citizens.

We already have a clear legal precedent to work from. The Affordable Care Act created an “individual mandate” that requires younger, healthier and more affluent Americans to purchase health insurance at higher-than-market rates, in order to help cover those who can’t afford insurance. Now we clearly need a corresponding individual mandate – a “health mandate” that requires Americans who are receiving health insurance subsidies to practice good health, in order to reduce their burden on those who are helping them. Our nation needs all these less-fortunate Americans to uphold their moral duty to practice healthy living, for the good of both our economy and our national unity.

The Affordable Care Act authorized the issue of millions of health insurance subsidies, as well as millions of new Medicaid enrollees. The cost of these entitlements is estimated at $710 billion in the first 5 years alone.  This tremendous expense must obviously be borne by taxpayers, who are also drivers of the economy. There is a risk that the expense of the Affordable Care Act could grow large enough to become a burden on taxpayers, and therefore a drag on the economy. It is clearly in our national interest to minimize this expense to preserve our economic strength. A health mandate would do precisely that.

On another note, the Affordable Care Act was passed without a single Republican vote, and has become an enduring point of contention for American conservatives. At the same time, American progressives continue to support it as both noble and necessary. The political rift has become like an infected wound. A health mandate has the power to heal the wound because it directly addresses some of Republicans’ biggest concerns with the legislation without involving a repeal. Specifically, it ensures that beneficiaries have some level of accountability so that the legislation’s costs are minimized for taxpayers. Democrats would look pragmatic for accepting the proposal for a health mandate, and Republicans would be pleased to offer it.

Congress has both the will and the power to establish the health mandate in law. However, we don’t currently have a government agency capable of enforcing it. We will need a Health Management Bureau (HMB) to ensure that every American who enjoys the benevolent healthcare support of this nation is doing his utmost to maintain and improve his health. The HMB should be responsible for disseminating good practices to these subsidy "beneficiaries," and monitoring their compliance. Its major targets should be the “major modifiable risk factors” that the Centers for Disease Control has identified for our nation’s 5 leading causes of death.  Among other things, the HMB must ensure that beneficiaries:

  • Do not smoke cigarettes
  • Do not drink alcohol
  • Do not use drugs
  • Maintain a healthy diet
  • Maintain a healthy weight
  • Exercise at least 30 minutes per day

Obviously the HMB will need to publish approved dietary guidelines and a variety of approved exercise regimens (including approachable at-home workouts). It will also need to enforce reasonable limitations on things like time spent exposed to the sun, or spent outside in polluted areas (both of which the CDC has identified as leading preventable causes of cancer). Due to the expense and risk of childbirth, the HMB would need to approve any pregnancies that might occur. Furthermore, the HMB’s requirements should reflect new advancements in health science. For example, it has been recently discovered that sitting is a leading cause of obesity and chronic disease in the United States.  It would therefore be the HMB’s responsibility to limit the number of hours beneficiaries are allowed to sit per day. Of course, these are simply examples of what the HMB would be required to regulate.

There can be no objection to the HMB on the basis of financial concerns, because the HMB would have a significant positive effect on the government’s budget. Every dollar spent by the HMB toward beneficiaries’ health maintenance and improvement is surely ten dollars saved on the diagnosis, treatment and medication of preventable conditions. The HMB would require only a modest budget that could be paid out of the cost savings it generates.

The HMB’s financial impact can be further reduced if Congress includes a self-reporting requirement as part of the health mandate. Beneficiaries would be expected to report on their daily diet and exercise performance, and the HMB would then simply be responsible for occasional random performance audits involving records reviews, fitness tests and blood analyses. Again, this process is modeled on the Affordable Care Act’s individual mandate, which obligates citizens to self-report their health insurance coverage to the IRS, and subjects them to occasional IRS audit.

What of beneficiaries who refuse to make a reasonable effort to maintain and improve their health? Generally speaking, failure to comply with a federal regulation results in a fine. However, we know beneficiaries are of limited financial means, so fines are impossible. Furthermore, we have already established that health care is a human right, so we cannot rescind health subsidies without denying that right. The only reasonable punishment for beneficiaries who refuse to comply is incarceration. Sentences should be brief, but beneficiaries that refuse to acknowledge the gravity of their duty to live a healthy life deserve to be punished. Some critics might decry the need to imprison a beneficiary who eats a slice of cake at work, or spends an hour too long outside at her grandchild’s birthday party. But how can we excuse someone who selfishly places her personal happiness ahead of her duty to our nation? Do we excuse tax evasion among the Americans who are responsible for subsidizing her? If we are going to have a national collective in which we all have duties to each other, then we must each satisfy our duties or pay a price.

No doubt some detractors will call the health mandate and the Health Management Bureau “over-reaching” or even “fascist.” Ironically, these detractors will generally be beneficiaries of the Affordable Care Act who have not been previously subject to mandates and aren’t familiar with how they work. The best response is to acknowledge their concerns. Yes, the health mandate is probably somewhat fascist, but it is practically a mirror image of its counterpart, which they overwhelmingly approve of – the individual insurance mandate created by the Affordable Care Act. It is hypocritical to only oppose one mandate on the grounds that it is fascist, when both mandates are equally so. These detractors must either support the health mandate or be labeled hypocrites.

Thankfully, there is no reason to expect significant opposition to a health mandate or a Health Management Bureau. Americans who are subject to the HMB will understand it is a matter of necessary duty, and Americans who aren’t know it’s a fair trade for their own duties.

These measures are obviously necessary if we want to get American politics back on track. They will finally allow mainstream Republicans to align with the Affordable Care Act, and reduce the political discord that the Affordable Care Act has wrought for years. Without them, the Affordable Care Act will continue to be perceived as one-sided and unfair by a significant portion of our nation. With a health mandate to match the insurance mandate, and a Health Management Bureau to match the IRS, the Affordable Care Act will become the first half of an even exchange and will stop being such a contentious issue.

A health mandate is the most reasonable and approachable way to accommodate opponents' concerns to the Affordable Care Act.  More importantly, it is a clear path out of political discord.  A health mandate will allow us to finally put the Affordable Care Act behind us so we can refocus on our nation's more pressing concerns. That’s something we should all look forward to.

Note: This article is satirical.