There’s a lot of sound and fury over the Patient Protection and Affordable Care Act, and has been from the very beginning. It’s understandable: healthcare issues hit close to home, money issues hit even closer, and political issues, well, issues of ideology and public policy are made (by the politicians, interest groups, and ratings-hungry media) into some of the most divisive and emotionally stirring issues possible.

The Problem:
Millions of Americans do not have access to healthcare; they can’t (or won’t) pay for insurance, and they definitely can’t pay for medical services. Free Riders abuse the system by buying insurance at the last minute (only when they need healthcare), tapping into the pool of money built by others for medical costs without contributing their share. Other Free Riders are unable to do even that, so they take advantage of the doctors and medical staff, hospitals, and legal protections that are trying to save lives (remember the Hippocratic Oath: to “Do no Harm” and use their skills to preserve life? Some people take it seriously) by getting the care they need but can’t afford, and passing the costs onto everyone else.

The Situation:
The United States of America is the only westernized (i.e. wealthy) nation in the works that does not provide universal healthcare to its citizens. Our healthcare system has developed in the private, for-profit sector. It is argued (with merit) that this has helped foster the medical innovation that has made the U.S. the world leader in the field. It is also argued that is has also excluded classes of citizens from healthcare by making it a financial commodity. National (universal) healthcare has long been a hot-button issue; free-market capitalists hate and fear it, social-minded activists adore and demand it, and most Americans are caught in the middle of extremes, trying to place their values, needs, and beliefs inside the spectrum of gray and unsure of any solution.

The Past:
We won’t get into our founding on ideals of liberty and freedom, on individual choice and responsibility, or the American belief in equality, hard work, and personal achievement. We won’t talk about past wars and boogeymen, of Nazis (aka. the National Socialist Party) or the Cold War and Red Scare of communism. We won’t talk about our nation’s religions and morals, or the sufferings that fuel banding together to help our neighbors and countrymen or the responsibility felt to care for the less fortunate. These are all very present in the American psyche; these are things that shape us; they color our debates. Rather, let’s talk about the facts: what happened and when.

Nationalized Healthcare has came up several times in the 20th century (previously such matters were left to the states, who largely left it alone) and was always ultimately defeated. Healthcare industry groups and other private interests worried that national healthcare would prevent charging appropriate rates to compensate for care, limit care options, stifle innovation, and destroy the industry’s livelihoods, without improvement, and perhaps even a detriment, to the overall health of the nation. Advocates of national healthcare were unable to assuage these fears and sway enough public support.  Its biggest victory came in the 60’s with the formation of Medicare, a compromise that brought the most vulnerable to lack of private health insurance (the elderly, who’s healthcare needs increase exponentially while income-earning ability ends) into a nationalized healthcare entitlement. Later, Medicaid was formed to serve another vulnerable community, the poor (and in particular the children of the poor), based on a means-tested welfare model.
In the 1990’s President Clinton again proposed making national healthcare universal for all citizens. Efforts to prevent that and keep healthcare a private industry created the individual mandate: a Republican-backed idea that would create financial incentive to employ existing market-oriented healthcare models, with levels of government support in existing Medicare and Medicaid sectors. Little of either universal healthcare or the mandate survived the Clinton-era healthcare debate, but the mandate has been a part of other healthcare reform proposals and debates ever since. The Patient Protection and Affordable Care Act passed including the individual mandate under extreme controversy, this time with the mandate opposed by republicans and others.

The Options:
Leave it Alone
The idea that healthcare should be an individual responsibility, not a right or entitlement of citizens. Let it stay 100% in the free market, let people donate to private healthcare charities if they want, let people who can’t, won’t, or fail to manage their own healthcare needs suffer the consequences.
No System Change
This is not really an option; the financial issues of the existing Medicare and Medicaid systems are what prompted the last round, and the previous several rounds, of reforms. It can’t last without change.
Single-Payer
All citizens pay taxes, these guarantee a government-provided health-insurance. There is no option to opt out of taxes; taxes are paid based on income levels and other factors. This is the Medicare model expanded for everyone: national universal healthcare.
Late-Enrollment Penalty
As an aspect of various plans, this stops the last-minute Free-Riders from raiding the insurance funds without contributing. It is also how Medicare part D works: or every month of delayed enrollment the premium rate increases by one percent, making up for payment accumulations contributed by those who did not delay.
Individual Mandate
Buy private insurance or pay a fine of $695 or 2.5% of income, whichever is higher. Exemptions are available for existing Medicare/Medicaid categories (programs which would continue), and some others.
Tax Credit
Buying private insurance earns people a tax credit ($2300 for individuals, $5,700 for families under the Ryan Plan); failure to buy leaves them paying the tax. This plan would either raise taxes or cut services for funding (or some of both) and is not unlike a back-end version of the individual mandate.

A note to the debate: studies have shown people are more likely to take action to avoid penalty than to receive a reward or benefit. In Massachusetts there is an existing individual mandate that has been credited with keeping the private sector health insurance working while preventing Free Rider problems and providing an insured citizen rate of 96%, with an increase in premiums or only .5% to 1.5% (a $25-$75 increase on an average annual premium of $5000).