Insurance Mandate May Be Health Bill's Undoing

November 16, 2011

New York Times

By SHERYL GAY STOLBERG

WASHINGTON — As Barack Obama battled Hillary Rodham Clinton over health care during the Democratic presidential primaries of 2008, he was adamant about one thing: Americans, he insisted, should not be required to buy health insurance.

“If things were that easy,” Mr. Obama told the talk show host Ellen DeGeneres in February of that year, “I could mandate everybody to buy a house, and that would solve the problem of homelessness. It doesn’t.”

Now President Obama may wish he had stuck to those words. On Monday, the Supreme Court agreed to take up a constitutional challenge to his landmark health care bill, and a decision could come in the midst of Mr. Obama’s 2012 re-election campaign.

At the heart of the challenge is “the mandate” — a provision requiring nearly all Americans to buy coverage or pay a penalty — that he so vigorously opposed as a candidate. If it is struck down, much of his signature legislative achievement could fall with it in a decision that would undoubtedly be construed as a rebuke to the president.

Polls show the mandate is by far the most unpopular provision of the 2010 bill, and now Mr. Obama, who ultimately embraced the idea, is in the awkward position of defending something he once rejected.

“I think his political instincts were right,” said Paul Starr, a health policy expert at Princeton University who argues that it is possible to expand coverage by other means. “I think he saw that there could be a backlash against a mandate and that there needed to be some other kind of approach. So in a way, I’m sorry he didn’t stick to his original position.”

The theory behind the mandate, according to its proponents, is this: Requiring coverage brings both sick and healthy people into the pool of those insured, which is essential because premiums paid by the healthy offset the cost of covering the sick. Otherwise, healthy people wait until they are ill to buy insurance, which leads to what policy analysts call a “death spiral” in which premiums skyrocket out of control.

As a candidate, Mr. Obama did favor requiring all children to have insurance. Once he took office, his top aides began examining other options, said Ezekiel J. Emanuel, a former health policy adviser to Mr. Obama. The aides studied the experience of Massachusetts, which has a mandate, and health laws in other states that do not. They considered voluntary incentives to get healthy people to enroll.

Their internal modeling, Dr. Emanuel said, showed that a mandate would extend coverage to 32 million uninsured people. Without such a requirement, he said, the administration estimated it could cover 16 million people at three-fourths the cost of covering the 32 million. In the face of such evidence, Mr. Obama reversed himself.

“I don’t think it was a slam-dunk,” said Dr. Emanuel, now a vice provost at the University of Pennsylvania and a regular contributor to The New York Times’s Op-Ed page. “The president did take very seriously his reputation for following what he said, so he was very reluctant to change his opinion unless he was very convinced.”

Health insurers also insisted on a mandate, as did the Democrats who controlled Congress. In July 2009, Mr. Obama told CBS News that he was “now in favor of some sort of individual mandate as long as there’s a hardship exemption” for people who truly could not afford to buy insurance.

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