Simple Question Defines Complex Health Debate
By Christopher LeeWashington Post Staff WriterSunday, February 24, 2008; A10
The defining difference between the Democratic presidential candidates on the top domestic issue in their recent debate and throughout the campaign has been their contrasting views on a seemingly simple question: Should the government require all Americans to have health insurance?
Sen. Hillary Rodham Clinton (N.Y.) says yes, that such a requirement is essential for creating a system in which everyone has health coverage. Sen. Barack Obama (Ill.) disagrees, arguing that the law should not force anyone to buy insurance he or she cannot afford.
The concept of an "individual mandate" became a lightning rod between the two yesterday. Obama said at an Ohio hospital that Clinton would "have the government force you to buy health insurance, and she said that she'd consider 'going after your wages' if you don't," while Clinton criticized her rival for "perpetuating falsehoods" and labeled an Obama mailing on the issue as "right out of Karl Rove's playbook."
The individual mandate also is emerging as a dominant issue in the larger national debate about how best to overhaul the country's ailing health-care system. It is a key component of both Massachusetts's landmark 2006 health insurance law and Clinton's health-care plan, and was one of the most debated features of a failed plan by California Gov. Arnold Schwarzenegger (R) to revamp health care in that state.
Clinton and Obama sparred repeatedly over the subject in their debate Thursday, with Clinton saying that Obama's plan, which would require only that children have coverage, would leave millions of Americans without insurance. She noted that former candidate John Edwards had called for a mandate, too.
Clinton said she and Edwards "took a big risk, because we know it's politically controversial to say we're going to cover everyone. And you chose not to do that. You chose to put forth a health-care plan that will leave out at least 15 million people. . . . I see the results of leaving people out. I am tired of health insurance companies deciding who will live or die in America."
Obama disputed that millions would be left out, saying his plan emphasizes reducing costs so more people can afford insurance. He noted that the requirement in Massachusetts has not meant coverage for all; in fact, state officials had to exempt tens of thousands of people on the grounds that it would be unfair to require them to buy a policy if they could not afford one.
"In some cases, there are people who are paying fines and still can't afford it, so now they're worse off than they were," Obama said. "They don't have health insurance, and they're paying a fine. . . . But understand that both of us seek to get universal health care. I have a substantive difference with Senator Clinton on how to get there."
On its face, the argument is straightforward. If government makes drivers purchase auto insurance, then why not require everyone to get health insurance, something they will surely need at some point? This view is bolstered by the fact that taxpayers foot the bill for much of the care that those without insurance get in emergency rooms.
But the issue is more complex.
There is a growing political consensus among Democrats that universal health care can be achieved by subsidizing coverage for low-income people, establishing new purchasing pools to help others buy affordable insurance, and requiring most businesses to offer health plans to their workers or pay a fee. Both the Obama and Clinton proposals contain these elements, as well as the option to buy into a public plan. Their most striking difference is on whether to require everyone to get a policy.
"If you want to get to universal coverage, then you have to do the individual mandate," said John Holahan, a health economist at the Urban Institute who is not an adviser to any presidential campaign. "You can do it with a single-payer system," under which one entity, the government, would finance all health care, he said. "But assuming that's [politically] off the charts, then I think that's the only way to do it."
Backers say the lack of a mandate would doom any universal coverage system.
Of the 47 million people in the United States who lack coverage, they argue, some are uninsured by choice and would remain so unless required to join. Many of those most likely to stay uninsured are young, healthy people who probably would not need to go to the doctor -- and whose premiums would help cover the cost of care for those who do.
If only the sick and those most likely to need care buy in, insurers would need to charge higher premiums. That, in turn, would make policies harder to afford and increase pressure on the government to further subsidize the plans, driving up the overall cost.
Also, if large numbers choose to remain uninsured, more than a few would still seek emergency-room care, which some would not be able to pay for. Hospitals that now get billions of dollars from the government to partially offset those costs would fight to hang on to the money, rather than see it redirected toward subsidizing coverage.
Finally, if the government were to prohibit insurance companies from refusing to sell policies to all comers, and if coverage were truly affordable, then many people -- not just the young and healthy -- would have an incentive to hold off buying insurance until they needed it.
"You can't . . . make it voluntary and let people wait until they're really sick, and then come in and insurers can't turn them down," Holahan said.
Critics of the individual mandate say forcing people to obtain insurance is unfair and ineffective. Some Americans will not sign up no matter what, they say. In California, for instance, 25 percent of drivers lack auto insurance even though the state requires it, according to the Insurance Research Council, an industry group. That is higher than the share of Californians without health insurance, about 20 percent.
The government would have to enforce a mandate, perhaps through garnishing wages, opponents say.
In Massachusetts, scofflaws who do not buy health insurance this year face a penalty of as much as $912, imposed on their 2008 state tax return.
Critics also say that a mandate would not necessarily make insurance more affordable and that forcing some Americans to purchase coverage beyond their budgets would be unreasonable, especially if it is seen as a boon for insurance companies.
"They're price-gouging," said Rose Ann DeMoro of the California Nurses Association, which favors a government-financed, single-payer system. "The insurance company is still in control."
Critics also argue that by requiring people to get insurance, the government would have an obligation to ensure that policies meet minimum standards, such as offering dental or prescription drug benefits. Special interests then would lobby Congress every year to require new benefits.
"It's not plausible to believe this package can be defined in an apolitical way," Glen Whitman, an associate professor of economics at California State University at Northridge, argued in an analysis published by the Cato Institute. "Each medical specialty, from oncology to acupuncture, will pressure the legislature to include their services in the package. And as the benefits package grows, so will the premiums."
The individual mandate is a political point of contention across parties.
Shortly before Republican Mitt Romney suspended his run for president, rival Sen. John McCain (Ariz.) unveiled an Internet ad blasting the former Massachusetts governor for signing the state's health law. "Mitt Romney's state health-care plan is a big-government mandate," the ad's announcer says. "It's not very good."
Robert Blendon, a public opinion expert at the Harvard School of Public Health, said Democratic primary voters chiefly have been interested in whether candidates are committed to universal coverage, not in haggling over details. The big fight is likely to be in the general election, he said, noting that a 2006 survey by Harvard and the Kaiser Family Foundation showed that while a large majority of Democrats would accept a mandate, most Republicans oppose the idea.
"If you're a Democratic voter, you want a candidate to do something big," Blendon said. "Republican voters are just saying, 'The last thing we need is a new requirement or a new big spending program.' . . . The Republicans will raise this issue very, very clearly, because all of the Republican candidates who ran support no mandates, either on employers or on individuals."
http://www.washingtonpost.com/wp-dyn/content/article/2008/02/23/AR2008022302026_pf.html
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