No health care? Expect a requirement to get it

[June 22, 2009]  WASHINGTON (AP) -- Don't have health insurance? Don't want to pay for it? Too bad.

It's looking like President Barack Obama and the Democratic-controlled Congress are going to require you to pick up the bill.

In Washington-speak, it's called an individual mandate -- or a requirement that people who don't already have health insurance to purchase it, much like most states require drivers to have automobile insurance.

Obama long has been wary of the idea, arguing that people cannot be required to buy coverage if they can't afford it. His plan during the presidential primary didn't require all adults to have coverage, only children. He and then-rival Hillary Rodham Clinton, who backed a universal requirement, sparred repeatedly over the issue.

Now in the White House, Obama has set in motion steps toward his broad goal of making health care more affordable, improving quality of care and expanding coverage. Says Obama: "We are not a nation that accepts nearly 46 million uninsured men, women and children."

He largely has left it to the House and Senate to work it out.

But in recent weeks, Congress signaled that legislation overhauling health care was all but certain to require that people have insurance. Of course, details about how to implement such a mandate must be worked out -- and there are many -- but the overall concept increasingly seems on track to be included in any sweeping health care overhaul that makes its way to Obama's desk.

The president's support for the requirement is recent -- and conditional.

In a letter in early June, he told key Senate Democrats writing legislation that he was willing to consider their ideas for "shared responsibility," requiring people to have insurance with employers sharing in the cost. "But," he added, "I believe if we are going to make people responsible for owning health insurance, we must make health care affordable."

He went a smidgen further last week.

"I am confident in our ability to give people the ability to get insurance," he told doctors. Thus, he said: "I am open to a system where every American bears responsibility for owning health insurance, so long as we provide a hardship waiver for those who still can't afford it."

Obama also indicated that if he were giving a little, insurance companies eager for new customers must as well, and called on them to stop denying coverage based on pre-existing conditions. Said Obama: "The days of cherry-picking who to cover and who to deny -- those days are over."

Even before the president took office in January, the insurance industry, which killed former President Bill Clinton's health care overhaul, indicated it was willing to accept that trade-off, making a mandate all the more likely.

Democrats have opposed such a mandate in previous years, fearing it would disadvantage the poor. In fact, it was Republicans, including 1996 presidential nominee and former Sen. Bob Dole, who pushed the idea in the 1990s.

These days, it's hard to find many opposed to a requirement.

Insurers like it: A mandate means a ready pool of new customers. Businesses back it: They say employers alone shouldn't shoulder the responsibility to pay for coverage. Hospitals cheer such a provision: They're tired of absorbing the costs of the uninsured seeking medical attention. Doctors support it: They want to stop providing services for free. And advocates for the poor are conditionally favorable: They want adequate subsidies and so-called hardship waivers.

Even so, at least some conservative Republicans likely will argue that Obama is stepping on individual rights by mandating coverage, expanding government's hand in the health care industry and creating a pathway to socialized medicine. Just last week, congressional conservatives offered their own plan. It would not mandate people to carry insurance.

But even Republicans say a requirement is likely.

"I believe there is a bipartisan consensus to have individual mandates," says Iowa Sen. Chuck Grassley, the top Republican on the Senate Finance Committee. The reason is fairness, he says: "Everybody has some health insurance costs, and if you aren't insured, there's no free lunch. Somebody else is paying for it."

It's support like this that's meant Obama has been able to shift positions with seemingly little political peril.

"Because there's a consensus among both the stakeholders and the legislators that this is the direction to go, the president essentially doesn't have a reason not to support it," said Judy Feder, a senior health care official under Clinton who now is at the liberal Center for American Progress.

Still, Congress must figure out how to enforce such a mandate, eligibility for a so-called hardship waiver, tax credits so people can afford health care and subsidies for the poor to help them buy coverage.

House and Senate committees are in the midst of haggling over such issues, and independent analysts expect a final bill to emerge that includes both waivers and sliding-scale subsidies to meet Obama's conditions

"There's no doubt that to be acceptable, it has to be regarded as fair and that you're not requiring people to buy insurance that's not affordable to them," said John Holahan, the Urban Institute's health policy center director.

Any plan is likely to be modeled after one in Massachusetts, which required that virtually everyone have health insurance or face tax penalties.

People who were deemed able to afford health insurance but who refused to buy it during 2007 faced losing a personal tax exemption and the prospect of monthly fines. The law exempted anyone who made less than the federal poverty level and gave them free care. And, those making up to three times the poverty level could get subsidize plans. Businesses with 11 or more full-time employees who refused to offer insurance also faced fines.

[Associated Press; By LIZ SIDOTI]

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