The slippery slope to national health care: a mandate forcing individuals to purchase health insurance not only would be impractical, unenforceable, and prohibitively expensive, it would represent yet another unconstitutional breach of the people's right to live free from onerous government regulation.

• Author: Tanner, Michael
• Position: National Affairs

ROUGHLY 46,000,000 Americans do not have health insurance. That has sparked a national debate over how to expand coverage, with many people setting a goal of "universal coverage"--that is, every American would have some form of health insurance. Some have advocated a single-payer plan under which the government would administer a taxpayer-financed system. Others have called for an employer mandate, requiting employers to provide their workers with insurance. Both methods have obvious problems that have prevented them from gaining much public support.

As a result, a third approach to universal coverage now is getting serious attention--an individual mandate, a legal requirement that every American obtain adequate private health insurance coverage. People who do not receive such coverage through their employer or some other group would be required to purchase individual insurance.

Such a mandate would be an unprecedented expansion of government power. As the Congressional Budget Office noted in 1994, "The government has never required people to buy any good or service as a condition of lawful residence in the United States."

Despite that, proposals for an individual mandate have drawn a surprising degree of support from conservatives. The Heritage Foundation has supported such an initiative for more than a decade. Senate Majority Leader Bill Frist (R.-Tenn.) has expressed general support |or the idea. Perhaps the latest such proposal comes from Gov. Mitt Romney of Massachusetts, an expected Republican candidate for president in 2008.

Some observers view an individual mandate as an achievable step on the road to universal coverage. Having long equated insurance coverage with access to health care and better health, they see an individual mandate as producing better health outcomes. They argue, for instance, that people will receive more preventive care if they are covered by insurance. In reality, however, the experience of rationing under national health insurance schemes in other countries shows that insurance coverage and access to care are entirely different things. Moreover, evidence that insurance coverage or access leads to better health outcomes is uncertain at best.

Other observers, including economists of all stripes, have tended to embrace individual mandates for another reason. When a person without health insurance becomes sick or injured, he or she still receives medical treatment. In fact, hospitals legally are required to provide care regardless of ability to pay. Physicians do not face the same legal requirement, but few are willing to deny treatment because a patient lacks insurance.

However, such treatment is not free. The cost simply is shifted to others--those with insurance or, more often, taxpayers. In fact, uncompensated care costs an estimated $40,700,000,000 per year, with 85% of that cost borne by Federal, state, and local governments. Thus, to a large degree, individuals without health insurance are "free riding" on the rest of us.

In addition, those most likely to go without health insurance are the young and relatively healthy. For example, although 18- to 24-year-olds represent 10% of the U.S. population, they constitute 21% of the long-term uninsured. For these young, healthy individuals, going without health insurance often is a logical decision. This, though, becomes a form of adverse selection. Removing the healthy from the insurance pool means that those remaining in the pool will be older and sicker. That results in higher insurance premiums for those who are insured.

Advocates of a mandate maintain that, if we can require automobile insurance in order to protect society from the costs imposed by uninsured drivers, we should be able to do the same for health insurance.

Those are legitimate concerns and cannot be dismissed casually. Yet, regardless of whether a mandate solves this dilemma in theory, the practical problems of implementation make it likely to be costly and difficult to administer. More important, it would set in motion forces that will lead slowly, but almost inevitably, to a government-run national health care system.

To enforce a health insurance mandate, government would need some way to determine whether Americans are insured or not and to penalize those who have not complied with the mandate. However, government's record of enforcing insurance mandates has not been an overwhelming success. For example, 47 states have laws requiring that drivers purchase automobile liability insurance. Yet, roughly 14.5% of drivers in those states are uninsured. In some states, such as Texas, the uninsured motorist rate runs as high as 18%. As many as 25%-30% of Los Angeles drivers are uninsured. By comparison, in the three states without mandatory auto insurance, roughly 15% of drivers are uninsured. So, it would appear that, despite penalties that can run from loss of license to fines as high as $5,000 or even the impounding of vehicles, millions of American drivers have chosen to ignore the law. In fact, millions of Americans purchase "uninsured motorist" coverage to protect themselves in an accident in which the other driver is uninsured. It is interesting to note that the percentage of drivers uninsured despite a mandate is roughly the same as the percentage of Americans who do not have health insurance.

The closest example to a must-have health insurance regulation in the U.S. is in Hawaii, which long has insisted that all employers provide their workers with coverage. Still, roughly 10% of Hawaiian workers remain uncovered. Even under Canada's national health care system, the government has encountered difficulties in ensuring that everyone is registered or pays required premiums, or both. For instance, in British Columbia alone, an estimated 40,000 people slip through the cracks. As a result, physicians in that province provide about $5,000,000 to $10,000,000 per year in unreimbursed services to people without insurance. Although that is a tiny amount compared to the cost of treating the uninsured in the U.S., it demonstrates the difficulties of forcing compliance with an insurance mandate.

How then will an individual health...