What's in a Health Care Mandate?

With health care surging into second place (just behind Iraq) in Americans' list of concerns about the near future, the top candidates are seeking to discredit one another's plans for health care reform on the stump. The media has in particular seized on a key difference (and one of the only meaningful differences) between the Clinton and the Obama plans: whether or not the purchase of health insurance should be mandatory for all citizens. On Wednesday Clinton, as reported in the Washington Post (via Reuters), claimed that Obama's refusal to put forward a mandatory system "would leave at least 15 million Americans uninsured, including more 100,000 people right here in Iowa." The Obama campaign, of course, shot back with a stiff defense, and the candidates have continued to trade jabs.

Lost in the flux of this sparring and surface media reporting, however, is the question of precisely what's at stake (if anything) in the debate over a mandatory versus a non-mandatory system. Both Clinton and Edwards have embraced mandating insurance as a means of ensuring universal coverage. Obama has consistently claimed that since "affordability" is the most critical issue in our current health care crisis, any initial reforms must therefore focus on increasing access through cutting costs rather than on attempting to roll out care through a blanket mandate.

The fact is that neither position is particularly wrong, though each risks a potential set of initial deleterious effects. This is nicely summed up by Jonathan Oberlander in a recent piece in the New England Journal of Medicine (Volume 357:2101-2104 November 22, 2007 Number 21):

"The Clinton and Edwards plans include an individual mandate requiring all Americans to have insurance; the Obama plan mandates coverage only for children but does not rule out a broader individual mandate in the future. The Clinton and Edwards proposals follow the precedent of Massachusetts, where under a new law, residents deemed able to afford insurance must purchase coverage or pay a penalty. There is both a substantive and a political rationale for individual mandates. They allow reformers to talk about health care as a responsibility and not simply as a right — a rhetoric with bipartisan appeal — and they ensure that healthy persons join insurance pools, thereby helping to spread risk and ensure universal coverage. However, individual mandates are vulnerable to charges of unfairness, since health insurance remains unaffordable for many Americans; the political risk is that health care reform could appear punitive. The impact of an individual mandate ultimately depends on enforcement mechanisms, the price of insurance, and the generosity of available subsidies — how such a mandate would work in practice in the Democratic plans remains unclear."

If we mandate without simultaneously enhancing affordability and bureaucratic accesss to coverage, we penalize those for whom access is already most difficult. As proper as the rhetoric of responsibility may be, we also risk creating a culture of blame in which those already marginalized from health services (for reasons beyond their control and "responsibility"!) are wrongfully cast as irresponsible. We risk blaming the victim rather than fixing the system that victimizes. On the other hand, affordability and access are not going to change positively overnight. The favorite Obama line that his plan will save each American insurance holder an estimated $2,500 per annum is more than a little bit simplistic. Whoever is inaugurated in January 2009 will face fierce bureaucratic entanglement and debate among the various players of the health care industry, and success will likely be gradual. If this is so, then might mandating coverage provide a sharp spur to get the horse moving?


This blogger is not yet sure which approach is most salient, though he is leaning toward the Obama perspective, in part because it does not rule out future mandating once affordability and access have been enhanced. There's a final point, however, worth making, and that's the question of whether universal coverage--mandated or not--will alone succeed in making us healthier. Access to care is certainly a citizen's right and must be achieved, and the heavy burden of health care costs currently borne by Americans must certaintly be alleviated, but these issues comprise just one side of the coin. Access is about managing disease but cannot achieve the levels of disease prevention that we Americans desperately need. While the top-tier candidates occasionally drop a few lines about prevention, this discussion has barely nicked the surface of what is necessary. The simple fact is that health care costs will continue to spiral high unless the incidence of chronic diseases like cardiovascular diseases, diabetes, and cancers begin to decline. Successful prevention is as much a cure for our woes as is access. Who will be the candidate capable of pushing forth on both fronts?