The individual mandate is perhaps the most controversial feature of the Affordable Care Act. Unless exempt, Americans are required to obtain or face a tax penalty. A recent proposal from leading republicans, Senators Orin Hatch and Richard Burrand and Congressman Fred Upton, contains strong penalties for not signing up during open enrollment and maintaining continuous coverage. Similarly, Medicare’s Part B and Part D contain significant penalties for having periods without qualified coverage. Across all of these policies or proposals, penalties differ in design, but all have a common theme of seeking to avoid the destabilizing effect of allowing individuals to wait until they are sick to obtain coverage. Thus all contain some form of an individual mandate.