Individual Mandates on Health Care: The National Debate and California

Obama says he wants universal coverage and would accept a mandate, but first wants to focus on making coverage available and affordable. Clinton and Edwards say they will make coverage available and affordable (through largely the same mechanisms), and then place a mandate to ensure everyone is in the system.

I am in agreement with Robert Laszewski at the Health Policy and Marketplace Review, in his analysis when he says: "So, when the day is done, I don't see much real difference here."

Some, fairly progressive health policy folks, including those who support single-payer, criticize Obama for not including a mandate. This includes Jonathan Cohn at The New Republic, and Maggie Mahar of HealthBeat, in perhaps the best of the recent articles, who quotes Princeton professor Paul Starr:

“The secret power of the mandate is that it is as much a mandate on government as it is on individuals. It is a mandate on government to make coverage available and affordable. For it would be patently unacceptable to demand that people have coverage and then provide no practical way for many people to get it.”

Having the mandate as a challenge to policymakers to make coverage available and affordable is a good thing--unless the policymakers don't meet the challenge. Governor Schwarzenegger clearly came to the health reform conversation out of a belief in an individual mandate, and as a result he did some--but not all--of the things that a mandate would require. For example, his original plan only had subsidies that were limited to folks up to 250% of the federal poverty level.

Leave it to Ron Brownstein of the National Journal (formerly of the LA Times) to cut through some of the clutter. He appropriately finds the genealogy of the individual mandate and recognizes the critique from both sides of the aisle (including yours truly), but he also identifies that the issue is not ideological, but practical:

“Although Republicans raise mostly ideological objections to an individual mandate, Democrats express more-concrete concerns. For liberals, notes Anthony Wright, a California health care advocate, the key issue is whether the government subsidies are sufficient to ensure that uninsured families can afford the coverage that a mandate compels them to buy...

“It is on this front that Hillary Clinton faces the toughest questions today. She responds to concerns about the mandate's affordability by noting that her plan (like Edwards's) would cap the share of income that individuals must contribute to premiums, with government subsidies covering the rest. But, wary of providing a target for opponents, her campaign won't say what that cap will be. Although Clinton has promised generous funding for the public subsidies, it's difficult to see how uninsured families can judge her proposal without knowing even roughly how much of their income it would require them to contribute to buying insurance.”

The mandate muddle masks the real question: how much actual help does the health plan provide people?

I would much rather that the candidates were competing on the level of subsidies they were providing low- and middle-income Americans, on how much they were going to use group purchasing power to bargain down the cost of coverage and drugs, etc. That's what we should use to rate one proposal superior to another. That's how any California health reform plan should be evaluated.

People want coverage: the question is what does any plan do to help them get the coverage they want and need--and whether that is sufficient for specific populations.

Health Access California is a statewide health care consumer advocacy coalition of over 200 groups. This article has also been published on the Health Access Weblog.