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.