Would a Health Insurance Mandate Help?

One of the issues health care reform is grappling with is how to extend health insurance coverage to the uninsured.  At first glance, it would appear that one way to make sure everyone has health insurance is to mandate that everyone has to buy it.  This article indicates that about 16.2% of Americans are currently uninsured.  But (I’m not the first one to point this out) every state requires drivers to have auto insurance, yet this article says that nationwide, 14.6% of drivers are uninsured.

There’s not much difference in the percentage of uninsured motorists and those who don’t have health insurance.  The comparison is slightly unfair, because all uninsured motorists can afford a car, or at least afford access to one, whereas the health statistic includes everyone, regardless of whether they can afford a car or anything else.  Is there any reason to think that a health insurance mandate would be any more successful than an auto insurance mandate at getting people to buy insurance?

I am curious, though, as to how violators would be identified, and how they would be penalized for their violation.  A fine would be levied against the uninsured, but it’s hard to see how one would be identified as uninsured unless the person needed health care and couldn’t produce proof of insurance to the doctor or hospital.  Do we bill the person for hospital and physician services, and on top of that levy the fine?  Would health care providers have the responsibility for turning in violators?

Some uninsured individuals are eligible for programs like Medicaid, but don’t enroll.  When they end up in the hospital, the hospital sees that they enroll, because then the hospital can get paid.  But someone like this would still be in violation of the mandate, so presumably would be subject to the fine even if Medicaid paid for the health care.  If the person didn’t pay the fine, would he or she then be jailed?

Consider a scenario: Joe gets laid off and loses his employer-provided health insurance.  So, Joe looks for another job, and has a number of promising leads.  He’s thinking he should have another job in a month or so, because he’s got good prospects.  But before one pans out, he’s in an auto accident on the way to a job interview and ends up in the hospital.  Does Joe deserve a fine because he didn’t line up health insurance before he went looking for another job?

Let’s face it: Many of the 16% of Americans without health insurance aren’t in the best of financial circumstances, and when one thinks about the mechanics of identifying them and fining them for being uninsured, it just doesn’t seem feasible.  The government might find a few relatively well-to-do uninsured and fine them to make an example of them, but for most uninsured, it’s implausible to think that they actually will have to pay a fine.

The percentages I cited at the beginning make it appear that a mandate would have little effect on the actual share of Americans who have health insurance.  But when you think about how the mandate might actually be enforced, it appears unworkable.  In that respect, it’s not that different from other aspects of the current reform proposals.

Randall G. Holcombe is Research Fellow at the Independent Institute and DeVoe Moore Professor of Economics at Florida State University. His Independent books include Housing America: Building Out of a Crisis (edited with Benjamin Powell); and Writing Off Ideas: Taxation, Foundations, and Philanthropy in America .
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