Simple Question Defines Complex Health Debate

Holding a mailing by Barack Obama's campaign that criticizes her health-care plan, which includes an individual mandate, Hillary Rodham Clinton described it as "out of Karl Rove's playbook."
Holding a mailing by Barack Obama's campaign that criticizes her health-care plan, which includes an individual mandate, Hillary Rodham Clinton described it as "out of Karl Rove's playbook." (Photo: David Kohl -- AP)
By Christopher Lee
Washington Post Staff Writer
Sunday, February 24, 2008

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."

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