Update: Mandates

The New Hampshire Concord Monitor has an interesting, though perhaps unabashedly partisan, editorial on the paucity of the debate regarding mandates. Read the editors' full discussion here. Again, the issue is that it often takes a lot more than the mere framework of a compulsory system for universal coverage to be achieved.

The article from a recent issue of Health Affairs to which the editorial refers is more illuminating, tracing the relative success of mandates in other public regulations (highway safety, etc.) as well as the fledgling compulsory health insurance program of the fine state of Massachusetts. Worth reading for those of you who have university access to online journals. For those who don't, here's the essay's conclusion (Glied, S.A. et. al., "Consider It Done? The Likely Efficacy of Mandates for Health Insurance", Health Affairs, 26 (2007): 1612-21) :

"Overall, our review suggests that compliance with mandates can be quite low. In some cases, however, compliance is nearly perfect. High-compliance situations share several features: Compliance is easy and relatively inexpensive; penalties for noncompliance are stiff but not excessive; and enforcement is routine, appropriately timed, and frequent. Enforcement is simplified if all (or nearly all) of those subject to the mandate must purchase coverage at one specified time and if enforcement occurs concurrently with purchasing coverage. States contemplating the use of health insurance mandates should recognize that success will likely be determined by the processes governing compliance and enforcement that are established long after the legislation has passed. Putting these often intrusive and costly pieces into place will require much political will. And even the best mandate is unlikely to affect the behavior of those who are transient and have few assets. To reach them, health policymakers will need to go beyond a mandate and make coverage more nearly automatic."

It's worth noting the obvious point that much of this research involves either state-initiated compulsory coverage systems, or comparison with streamlined single-payer health systems in Europe. Health coverage through a U.S. federal mandate (and enforcement of it) without a single-payer system is likely to only magnify the challenges experienced by specific states. No matter what, the process will be gradual, and will require constant tinkering, not to mention (as the Health Affairs authors note explicitly) an oversupply of political will and the capacity to bring disparate groups together productively and efficiency over an extended period of time. For these purposes - I have to agree with the Concord Monitor - Obama may have a leg-up on other candidates.