Congress crossed a big threshold Tuesday with a vote by the Senate Finance Committee in favor of a healthcare bill. But the vote itself, which garnered only one Republican in support, only underscores the most challenging issue in the still-unsettled debate over government's role in private health decisions.
To win the support of centrist Olympia Snowe, a committee member and a GOP senator from Maine, Democrats had to lower the size of a proposed penalty on individuals who do not buy healthcare insurance. She objected to imposing a large burden on Americans who want to opt out of mandated coverage.
According to the Congressional Research Service – the official nonpartisan think tank that lawmakers rely on – requiring individuals with middle-class incomes or higher to buy insurance will be a contentious issue for years to come.
Without a mandate, however, President Obama's healthcare plan falls apart. Its funding relies largely on expanding the risk pool by forcing the young and healthy to buy insurance. With income from those involuntary premiums, the insurance industry would then be able to pay for coverage of the poor and sick. Those people who refuse to buy insurance would be penalized, or in essence, taxed.
Mr. Obama was once against such a mandate (although he favored it for children). He said during the 2008 campaign that government should simply make healthcare more affordable. Now he wants a mandate – although he calls it "shared responsibility."
A similar idea for a mandate helped put an end to President Clinton's healthcare plan in the 1990s. And in fact, after the Senate Finance Committee lowered the penalty on those who refuse coverage, the health insurance industry last weekcame out against the Senate bill, jeopardizing its future.
The idea of government forcing private citizens to buy a private service has raised a lively legal debate over whether the Supreme Court might find it unconstitutional – if a court challenge is ever made to a final healthcare law. This mandate would be unlike current state laws that require people to buy car insurance, because no one is forced to buy a car.
A mandate on health insurance would be more akin to telling everyone to find work in order to reduce unemployment.
Being forced to buy health insurance, of course, isn't the same as forcing medical decisions on people. Yet it may be a step toward losing the freedom to make one's own health decisions.
One example of government becoming more coercive in health matters is a requirement, begun under President Clinton, that seniors who sign up for Social Security must also sign up for Medicare (Part A) – or else they cannot receive their Social Security savings.
This month, a judge in a federal court case brought by seniors who don't want Medicare cited little basis for this rule, which compels a linkage between two optional entitlement programs. She allowed the suit to proceed. Obama, in a reflection of his new-found favoritism toward mandates, wants to keep the requirement and his administration is battling the suit in court.
Polls show Americans divided over a health insurance mandate. And there are ways to achieve universal healthcare other than by forcing people to forfeit their freedom on health insurance.
Before Congress makes a final vote on a bill, Americans must be made fully aware of how mandates might impinge on their choices – and how vulnerable Obama's healthcare plan might ultimately be to court challenge.