HillaryCare 2.0: individual mandates
Wall Street Journal - September 17, 2007
Clinton Health Plan Due
Mandated Coverage May Draw Support of Wide Spectrum
By LAURA MECKLER
WASHINGTON — When Democratic presidential front-runner Hillary
Clinton unveils her health plan today, it is expected to require all
Americans to get health insurance. It is a concept that has evolved
quietly in recent years and, unlike most ideas for health reform,
enjoys support across the political spectrum.
The thrust is to get everyone into the health-insurance pool so that
healthy people, who are cheap to cover, help balance out the sick,
who are expensive. One of Sen. Clinton’s top aides says that it is
impossible to achieve universal coverage without this requirement,
and polls suggest the public supports the idea.
Known as an “individual mandate,” it has been proposed by two
Republican governors, Arnold Schwarzenegger in California and former
Gov. Mitt Romney of Massachusetts. It is being tried in Massachusetts
and considered in at least six other states. It is also an important
feature of a health-care-overhaul bill sponsored by Democratic Sen.
Ron Wyden of Oregon. “The individual mandate is central, in my view,
to universal coverage,” Sen. Wyden said in an interview.
Mrs. Clinton’s plan, set to be unveiled at an Iowa hospital this
morning, also is expected to include subsidies for lower-income
Americans who can’t afford premiums and new options for buying
coverage. She plans to propose changes that would bar insurance
companies from “cherry-picking” healthy people and refusing to cover
the sick, and from charging more to people with pre-existing conditions.
Overall, her plan to cover the 47 million people without insurance
builds on the existing U.S. system, a mix of public and private
coverage. That is a contrast to her effort in the first two years of
her husband’s presidency, which would have more fundamentally remade
the health-care system. It is expected to require that large
employers cover their workers or pay some sort of penalty. And she
supports expansion of the state-federal Children’s Health Insurance
Program.
The individual mandate tends to win support from centrists while
drawing opposition from libertarian-minded voters, who object to such
a sweeping government mandate, and some liberals, who would prefer
that the government cover everyone through a single-payer system or
that employers pick up more of the tab.
“It is really a coalition of center-left and center-right opposed by
both of the extremes,” said Jonathan Gruber, an MIT health economist
who has advised Massachusetts and California.
A Democracy Corp. poll in May found that 66% of likely voters would
be much more or somewhat more likely to support a candidate for
Congress who proposed a mandate combined with subsidies. Just 15%
said they would be less likely to support such a candidate.
More details of how a national mandate would work might be given when
Mrs. Clinton unveils her plan. In Massachusetts, where the mandate is
coupled with new options to buy coverage, people who fail to get
insurance suffer a penalty on their state taxes that will eventually
top $1,000 a year for some. But not every resident is subject to the
requirement. About 20% of the uninsured — or 1% of the state’s
population — were exempted after a state board determined they
weren’t poor enough to qualify for subsidies but weren’t wealthy
enough to afford the premiums on their own.
Any attempt at a national mandate will bring with it the tough
questions that Massachusetts faced: How comprehensive must benefits
be to qualify as coverage? What about prescription drugs, mental
health, dental coverage? What happens if someone can’t afford the
premiums but doesn’t qualify for a subsidy?
It isn’t clear whether Mrs. Clinton will answer these questions as a
candidate or wait to work them out with Congress if elected. Her
aides say one of the biggest mistakes the White House made when she
first tried to win universal coverage was proposing too many details
up front.
The individual-mandate idea has been around for several years. Some
Republicans like its message of personal responsibility, noting that
when the uninsured get emergency-room care and can’t pay the bill,
the costs are passed on indirectly to everyone else. “It focuses the
responsibility for insurance on the person who is getting care,
rather than the rest of us,” said Stuart Butler of the Heritage
Foundation.
Democrats tend to support it, too, as long as there are reasonable
subsidies, said Robert Blendon, an expert on health policy and public
opinion at the Harvard School of Public Health. “It is a mainstream
idea even though we don’t have a lot of experience in the U.S. with
how it works.”
The Service Employees International Union, which has yet to endorse a
Democratic candidate, is open to the idea. “We support an individual
mandate that is affordable and meaningful,” spokeswoman Stephanie
Mueller said.
The idea has been endorsed by John Edwards, one of Mrs. Clinton’s
rivals for the Democratic presidential nomination, but not by Sen.
Barack Obama of Illinois, who would require coverage only for
children. Mr. Obama’s aides have argued that the mandate is less
important than subsidies and other measures to make health care more
affordable. Yesterday, a spokesman for Mr. Obama said many drivers go
without insurance despite mandatory auto insurance laws and noted
that in Massachusetts, some have been exempted from the new
requirement because of the cost.
Mr. Romney supported the mandate while he was governor there but
declined to propose something similar in the health-care plan he
presented as a presidential candidate. Indeed, no leading Republican
presidential candidate has proposed a national mandate.