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." (Photo: David Kohl -- AP)

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."