If Congress wants all Americans to get health insurance, it will have to win over people like Gary Cloutier, owner of Cloots Auto Body Shop in Westfield, Mass.
The stocky 47-year-old shows up every day to a cluttered, fume-filled garage, even when there are few cars to repair. His business has plunged 40 percent in the past year, since people stopped getting their fenders fixed. Some months he doesn't pay himself a salary, and his utility bills pile up unpaid. So the idea of buying health insurance right now seems ludicrous.
"Where am I supposed to get the money from?" Cloutier asks.
His question is directed squarely at the state of Massachusetts, the first in the nation to require all its residents to have health insurance. But it also goes to the heart of what President Obama and many in Congress are working toward — universal coverage. Achieving that goal would require most Americans to pay some or all of the cost of obtaining policies at a time when people are losing jobs and income.
In this regard, Massachusetts has become a laboratory for national policymakers. Today, three years after its health care law passed, 97 percent of state residents are insured, the highest coverage rate in the country. But a primary tool to achieve that rate — the individual insurance mandate, enforced with a hefty fine at tax time — remains the most controversial part of the state's health reform efforts.
"You're forcing something down my throat, and then penalizing me because I can't afford it," says Cloutier, who lives in Westfield, two hours west of Boston.
Spreading The Risk
Resistance to signing up has mostly revolved around the high cost of private insurance plans and the size of the government subsidies. And it has been an issue since the beginning.
The Massachusetts mandate grew out of a debate on how to bring down the number of uninsured residents, then estimated at 600,000, without bankrupting any one entity. Lawmakers settled on a model of "shared responsibility," in which the growing burden for health costs is shared between government, business and individuals.
"The way to spread the risk is to get everybody on board," says Neil Cronin of the Massachusetts Law Reform Institute, which advocates for low-income consumers. "If you leave an insurance system only to the sick and the elderly, and everybody else gets out of the system, then the cost of that care or that insurance rises dramatically for those people who are heavy utilizers."
Reformers were also taking aim at uninsured people who could afford coverage. When they got sick or had an accident, taxpayers ultimately had to help pay the resulting hospital bills. "The whole system was subsidizing that group of people," says Andrew Dreyfus, vice president of Blue Cross Blue Shield of Massachusetts and an early architect of the reform law. "And I think it makes sense to bring them in."
Cloutier doesn't think it makes sense — at least, not this way. He makes about $40,000 a year, too much to qualify for a state subsidy.
"Given the toxic chemicals that I'm dealing with day in and out in my line of business, I'm probably a walking cancer time bomb right now," he says. "If I could have afforded insurance, I'd have it by now."
Gambling On Good Health
Data reported by the state in December showed that a majority of those still holding out against the mandate are young, healthy adults. That's a key demographic the mandate was designed to bring in, because they tend not to cost as much in health care. And that's exactly why they tend not to buy health insurance.
"We're all arrogant and we all think nothing's ever going to happen to us," says Lucas Wyant, a 27-year-old house painter with long hair and an easy-going manner. "I just try not to do anything too dangerous in my life. I actually think about not going downhill skiing and stuff. ... I test my luck once a year and hope I don't get hurt."
Wyant makes roughly $35,000 a year and would be eligible for a low-cost plan — less than $200 a month — that the state negotiated for young adults. "I could pay for it," he says, "but it would be a little bit hard for me to pay that much a month for something that I don't really use."
On the flip side, hundreds of thousands of previously uninsured people have obtained policies. Since the penalty went into effect, about 150,000 residents have enrolled in their employers' plans. Another 245,000 have signed up for free or subsidized state-funded insurance. And almost 40,000 Massachusetts residents have bought full-price policies on their own, even if they weren't happy about doing so.
Michael Delaney, a self-employed title examiner in Easthampton, used to pay out of pocket for occasional doctor's visits. He now spends $415 a month on an insurance premium — about 10 percent of his income.
"What it means practically speaking is, I can't take a decent vacation," says Delaney, 59. "I can't save any money toward retirement, I can't prepay my mortgage. I'm pretty much breaking even right now." Delaney does concede that, at his age, it's probably wise to have insurance, and even if his income falls below the threshold for a penalty, he'll likely keep his coverage.
Finding Public Acceptance
A poll by Harvard University and the Blue Cross Blue Shield of Massachusetts Foundation, published in October 2008, found that 69 percent of Massachusetts residents approve of the health reform law when it's presented as "universal coverage" for all state residents.
But that number drops to 37 percent among those who say they're directly affected.
The problems with public acceptance in Massachusetts, a relatively wealthy state, could be even more daunting if an insurance mandate were stretched across the nation.
Harvard School of Public Health professor Robert Blendon, who directed the poll, says opposition is likely to be even fiercer in more conservative states. "There are parts of this country where there's sort of the libertarian argument that you just shouldn't make people do things, period."
But prominent Washington Democrats — including Sen. Max Baucus of Montana and Massachusetts Sen. Edward M. Kennedy — see the individual mandate as an essential precondition for universal coverage. By forcing all people into the insurance mix, advocates say, the cost of everyone's premiums will go own.
The arguments against a national mandate come from all political corners. Some on the left say it would put an undue burden on lower-income and middle-class Americans, and that it's essentially a gift of millions of new customers to the insurance industry. It would be fairer, they say, to tax everyone and create a government-run system.
Conservatives are more likely to view the mandate as government interference in health care, and complain about the public cost of subsidizing people who can't afford private insurance.
Whether the American public — and Congress — would support a national mandate remains to be seen. In a December 2008 poll by the Kaiser Family Foundation and Harvard School of Public Health, 67 percent of Americans supported a mandate that included help for people who couldn't afford to buy insurance. But approval fell to 19 percent when they were told some people would be required to buy policies they found too expensive or didn't want.
"I don't think [a national mandate] would be easy to pass, but I think it could pass," says Ron Pollack, president of Families USA, a nonprofit organization that advocates for comprehensive coverage for all Americans. He draws on a lesson from Massachusetts' experience: "But it only makes sense if it is accompanied by enough subsidies so that people can actually afford coverage."
Karen Brown is a reporter for member station WFCR in Amherst, Mass. This story was produced through a collaboration between NPR and Kaiser Health News. KHN is an editorially independent news service and is a program of the Kaiser Family Foundation, a nonpartisan health care policy research organization. Neither KFF nor KHN is affiliated with Kaiser Permanente.
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