(The New Republic) After that, they say, they can come back to the problem and, following through on Obama's promise, cover that relatively small portion of the population that still doesn't have coverage. If that requires passing some sort of mandate then, so be it. They're prepared to do so.

I think they mean it. But can they do it? The best studies out there — by Urban Institute researchers, the RAND Corporation, and MIT economist Jonathan Gruber — suggest that, without a mandate, improving affordability will cover roughly one-third of the people who don't have coverage. Mandating that kids (but not adults) have coverage bumps that up to about a half. Obama's advisers think that, by really loading up on the subsidies — and making enrollment a lot easier by, for example, having an automatic enrollment with voluntary opt-out at your place of work — they can goose that up to two-thirds. But that's getting optimistic — and, even then, you still have around 15 million people who are uninsured.

In other words, the "mop-up" job at the end would quite likely be more than a mop-up. It'd be a substantial task, maybe even a huge one. That's why most health care experts believe you can't get that close to universal coverage without some sort of a mandate.

So if it's going to take a mandate to really cover everybody, why not include it up front?

Obama's logic here starts with a policy concern — namely, fearing that a mandate will create more problems than it solves. Obama doesn't want to make people buy insurance until, first, he's sure he's made it affordable. Otherwise, he fears, some working-class people would be forced to buy insurance when, in fact, doing so would impose real financial hardship. Lest this fear seem purely hypothetical, Obama's advisers say this is pretty much what has happened in Massachusetts — where, having passed a mandate, the state has struggled to deliver a good insurance product at rates everybody can afford.

This is a real problem, for sure. But it's also an eminently solvable one. (And, in fact, some would argue Massachusetts is solving it.) You can browbeat the insurers into providing cheaper private coverage; you can spend more money on subsidies; or you beef up public programs as alternatives. In a real pinch, you can even loosen the mandates temporarily, to buy a little extra time. Whatever — the point is that, once the mandate is in place, you've pretty much locked yourself in to providing insurance to everybody, one way or another. And that's precisely what should happen.

Obama's other concern seems to be political — and I don't mean that in a nasty, these-guys-are-so-craven sort of way. Like so many in the Democratic Party, Obama's advisers remember all too well how excessive ambition killed the Clinton plan politically. They don't want to make that mistake again. They fear a mandate sounds scarier to the public, particularly middle-class voters. If, on the other hand, they create the structures for expanding coverage, people will get accustomed to having those mechanisms around — and requiring that everybody get insurance wouldn't be such a big deal.

Like all political arguments, this one comes down to a judgment call. But I, for one, don't see it the way Obama does. Everybody talks about mandates now. Remember, the plan that Mitt Romney passed in Massachusetts and the one Arnold Schwarzenegger has proposed for California both involve mandates. The idea just isn't that controversial anymore.

What's more, there's a good reason you have conservatives, as well liberals, touting this: It's a way of stressing individual responsibility. To people with insurance, the ones you really have to worry about losing in a health-care fight, it signals that you're requiring everybody to start paying their fair share. It's also a way to buy some love from the employer community, for whom the words "individual mandate" seem (mysteriously, in my view) to wash away fears of government involvement in health care.

Does this mean Obama's plan is fatally flawed? Of course not. It still would represent serious progress. (That said, if you want to get into more of the details, Ezra Klein has put his finger on some other valid concerns here.) But, for those of us who will vote in the Democratic primaries, again, the question is how Obama's plan compares to other approaches — and what it tells us about Obama's abilities, as both a candidate and lawmaker-in-chief, relative to his rivals.

With that in mind, let me make one last point via a summertime analogy: Going into your swimming pool on a day when the water might be a little chilly. You can wade in a step at a time, or you can jump into the deep end. The advantage of the former approach is that you minimize the temperature shock at any one time. The downside is that it takes a lot longer to get in, and there's always the chance that, for one reason or another, you won't go all the way. You might chicken out at your waist; or something else might capture your attention and you might forget about swimming altogether.

By contrast, jumping in the deep end involves a little more risk: You might feel really cold for a few seconds. But you'll probably get comfortable pretty quickly. And, once you've made the decision to jump, you're guaranteed to be in the water. You can't get un-wet.

When it comes to achieving universal health care, Obama wants to wade into it: He doesn't want to move everybody into universal coverage until the arrangements are all in place and people feel totally comfortable with it. Yes, he's promising to cover everybody. But the promise is only as good as his word, sincere though it may be.

Those who prefer mandates — a category that, again, happens to include rival John Edwards — prefer to jump in the deep end. They want to seize this opportunity and get the mandate on the books from day one (even if, as practical matter, it's phased in so it becomes fully effective only after a few years). In so doing, they are offering what is, in effect, a stronger guarantee.

Reasonable people can disagree on which approach makes the most sense. And, needless to say, this shouldn't be the only criterion on which to judge these two candidates — or any of their rivals. (We're still waiting to see what Hillary Clinton has to say about coverage and access; her proposal to reduce costs, like Obama's, was impressive.) Still, it'd be foolish to ignore this altogether. As far as I'm concerned, Obama definitely showed us something good on Tuesday. It's just not as good as what I've seen elsewhere.

By Jonathan Cohn
If you like this article, go to www.tnr.com, which breaks down today's top stories and offers nearly 100 years of news, opinion and analysis.

---

If you like this article, go to www.tnr.com, which breaks down today's top stories and offers nearly 100 years of news, opinion, and criticism.

Back To Top