WASHINGTON — The defining difference between the Democratic presidential candidates on the top domestic issue in their recent debate and throughout the campaign has been their contrasting views on a seemingly simple question: Should the government require all Americans to have health insurance?
Sen. Hillary Rodham Clinton of New York says yes, that such a requirement is essential for creating a system in which everyone has health coverage. Sen. Barack Obama of Illinois disagrees, arguing that the law should not force anyone to buy insurance he or she cannot afford.
The concept of an “individual mandate” became a lightning rod between the two Saturday. Obama said at an Ohio hospital that Clinton would “have the government force you to buy health insurance, and she said that she’d consider ‘going after your wages’ if you don’t,” while Clinton criticized her rival for “perpetuating falsehoods” and labeled an Obama mailing on the issue as “right out of Karl Rove’s playbook.”
The individual mandate also is emerging as a dominant issue in the larger national debate about how best to overhaul the country’s ailing health care system.
Clinton and Obama sparred repeatedly over the subject in their debate Thursday, with Clinton saying that Obama’s plan, which would require that only children have coverage, would leave millions of Americans without insurance. She noted that former Democratic candidate John Edwards of North Carolina had called for a mandate too.
Clinton said she and Edwards “took a big risk because we know it’s politically controversial to say we’re going to cover everyone.”
Obama disputed that millions would be left out, saying his plan emphasizes reducing costs so more people can afford insurance. He noted that the requirement in Massachusetts has not meant coverage for all; in fact, state officials had to exempt tens of thousands of people on the grounds that it would be unfair to require them to buy a policy if they could not afford one.
“In some cases, there are people who are paying fines and still can’t afford it, so now they’re worse off than they were,” Obama said. “They don’t have health insurance, and they’re paying a fine. . . . But understand that both of us seek to get universal health care. I have a substantive difference with Sen. Clinton on how to get there.”
On its face, the argument is straightforward. If government makes drivers purchase auto insurance, then why not require everyone to get health insurance, something they will surely need at some point? This view is bolstered by the fact that taxpayers foot the bill for much of the care that those without insurance get in emergency rooms.
But the issue is more complex.
There is a growing political consensus among Democrats that universal health care can be achieved by subsidizing coverage for low-income people, establishing new purchasing pools to help others buy affordable insurance, and requiring most businesses to offer health plans to their workers or pay a fee. Both the Obama and Clinton proposals contain these elements, as well as the option to buy into a public plan. Their most striking difference is on whether to require everyone to get a policy.
The big fight is likely to be in the general election, said Robert Blendon, a public opinion expert at the Harvard School of Public Health. He noted that a 2006 survey by Harvard and the Kaiser Family Foundation showed that while a large majority of Democrats would accept a mandate, most Republicans oppose the idea.
“If you’re a Democratic voter, you want a candidate to do something big,” Blendon said. “Republican voters are just saying, ‘The last thing we need is a new requirement or a new big spending program.’ . . . The Republicans will raise this issue very, very clearly, because all of the Republican candidates who ran support no mandates, either on employers or on individuals.”
