For thousands of families here struggling to make ends meet, the difficult decision of whether to buy health insurance may soon get easier: They won't have a choice.
Under two major proposals that aim to cover the estimated half million uninsured in Massachusetts, the state would require all residents who can afford it to purchase some type of individual plan or face penalties, such as losing their driver's licenses.
Massachusetts joins a growing number of states grappling with how to expand coverage at a time when employers are pulling back benefits.
But its call for an "individual mandate" is among the most ambitious - and controversial - healthcare reform plans in the country. If passed, its impact could be far- reaching, experts say.
"This is the first time this idea is real and live before a state and legislature," says Robert Blendon, a professor of health policy and management at the Harvard School of Public Health in Boston. "We have entered an age when there is more of a sense that there should be individual responsibility for your life and your family," he says, "that you owe it to your community to have coverage."
Under two separate plans, one proposed by Republican Gov. Mitt Romney, the other approved by the House, insurance companies would offer lower-cost plans, estimated at $200 a month. Residents making up to $28,710 could receive state subsidies that could further lower that premium. Many analysts say that the individual mandate should be considered only after expanding Medicaid or making premiums more affordable - something Massachusetts is also tackling.
Under the House plan, which requires employers to provide insurance or face a payroll tax, residents could lose driver's licenses for not carrying coverage. A third plan approved by the Senate also expands coverage but does not include an individual mandate. The bills will be considered for compromise in conference committee as early as this week.
While each plan is distinct, they share many similarities, and experts applaud the bipartisan ideals they reflect. "There have been two dominant approaches" nationwide, says Alan Weil, executive director of the National Academy for State Health Policy. In general, conservatives support market-based approaches; Democrats want to expand the role of government.
The proposals in Massachusetts may have found common ground. But the political response has yet to fully take shape, analysts warn. "On the one hand, it can sound punitive ... and the libertarian right sees this as big government. The left is worried about mandating people to do something they can't afford to do," says Mr. Weil. "It could be a nice middle ground, or it could be attacked on both sides."
Some residents have balked at the prospect of an individual mandate. Some people don't use traditional medicine for religious or personal reasons; others say they can't afford it.
Michael Craven, a hair stylist in Boston's South End who faces out-of-pocket expenses for a recent emergency room visit and who has forgone other treatment, would like health insurance.
But he disagrees with a mandate, particularly with government deciding where people's money should go. "Some people need a car more than insurance," he says.
Mr. Craven moved to Boston from Syracuse, N.Y., and is launching his own hair business. "Insurance is not my top priority right now. Day-to-day living is, like food," he says. "I have to build up my business before I can afford it."
Some view the mandate with caution, voicing concern over the efficacy of stripped-down policies with high premiums. Questions remain over how "affordability" will be defined.
States have been skeptical of both employer and individual mandates, as they can be viewed as tax hikes. "The fear with individual mandates is that you drive people out of state," says Howard Berliner, a professor of health policy at Milano, the New School for Management and Urban Policy in New York. "Essentially it's a tax no matter how it gets worked out."
But he, and many others, say that given stagnation on healthcare at the federal level, they are willing to watch this experiment. "The individual mandate is not perfect, but I would much prefer in New York that we had that than just a growing number without insurance at all," he says.
If the individual mandate passes, it could steer national dialogue. "If a major bill passes in Massachusetts, it would be viewed as some model that should appear in the next presidential debate," says Professor Blendon, of Harvard. Then again, "If it collapses, people will say, 'There isn't a stomach for [a healthcare overhaul], even in a state like Massachusetts.' "