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Who’s Afraid of the Mandate?

BOSTON—One of the most interesting stories about health care reform in Massachusetts, where I’m on a learning tour this week, is a story that never developed: The backlash against the mandate.

In last year’s poll by the Boston Globe and Harvard School of Public Health, the most recent comprehensive survey I’ve found, 51 percent of respondents said they supported the requirement that almost everybody get insurance or pay a fine, while 44 percent said they opposed it. Opposition to the mandate was higher than it had been one year previously, but support for the law as a whole had increased during that span. Sixty-three percent said they supported the Massachusetts scheme, while just 21 percent said they opposed.

To be sure, Massachusetts has people who object to and speak out against the mandate, usually because they believe it violate personal liberty. But a recent effort to repeal the mandate via ballot initiative failed because organizers could not collect the required 69,000 signatures. Even some experts here have been surprised: “I thought we would have had an uprising about the individual mandate,” says Nancy Turnbull, a senior lecturer at the School of Public Health and board member of the Massachusetts Connector Authority, which runs the state's insurance marketplace.

So what happened here? And can it tell us how the mandate would play out nationally?

The first question is easier to answer than the second. The Affordable Care Act’s coverage expansion is nearly identical to the one in Massachusetts, right down to the mandate. But political sentiment in the rest of the country is obviously very different. I haven’t done the math, but I assume sentiments about the mandate (and health reform generally) in Massachusetts partly reflect the relatively high number of liberals and relatively low number of conservatives who reside here.

The political circumstances of the law’s enactment and implementation have been, if anything, more distinct. Mitt Romney, a Republican governor, not only signed the reforms into the law. He also promoted the mandate, regularly and enthusiastically, as a conservative cause. In particular, he said it was an effort to demand personal responsibility of people who could pay for insurance but who, absent a mandate, would remain uninsured and then “free ride” on the system by getting charity care.

Stakeholders (that’s wonkspeak for the industry, labor, and consumer groups with a direct stake in health care) were also unified behind the law. John McDonough, who teaches at the School of Public Health, told my traveling group on Monday that the groups got together the day after the law passed and committed themselves to promoting it. The most visible result of these efforts was a public relations partnership with the Boston Red Sox, the beloved hometown team that was, at the time, on its way to winning a second world championship in four years. But stakeholders also worked with community groups on outreach: Religious groups, for example, went door-to-door in lower income communities to tell people about the new law and encouraging them to enroll.

McDonough had hoped the same scenario would play out nationally; in fact, as member on Senator Ted Kennedy’s committee staff, he helped convene an early set of stakeholder meetings in 2008. But stakeholders have been more ambivalent about the law. After Obama signed the Affordable Care Act in the spring of 2010, Ron Pollack, executive director of FamiliesUSA, established a broad outreach effort called “Enroll America.” But that effort has been the exception. Meanwhile, the mandate has come under sustained attack from the right—even from Republicans like Romney, who not so long ago preached its virtues.

Still, there are reasons to think that the mandate would gain public acceptance, or at least become a lot less controversial, if it survives the Supreme Court and congressional Republicans. Turnbull, who describes herself as an “atheist” or “agnostic” on the mandate, says that the Massachusetts reforms make coverage sufficiently affordable and worthwhile that most people want it anyway. You could make a similar argument about the national law.

Perhaps more important, the mandate didn’t actually change life for most people in Massachusetts, at least in ways they could perceive. Most people already had insurance that satisfied the requirement. And while nationally the proportion of people with insurance is lower than it has been in Massachusetts, overall the same basic truth holds: The majority of people already have insurance that would satisfy the mandate. In fact, according to projections by MIT economist Jonathan Gruber and published by the Kaiser Family Foundation—which is sponsoring this research trip to Massachusetts—about 90 percent of people would either satisfy the mandate or be exempt from its requirements, because premiums would impose a serious financial burden or because they have religious objections.

That doesn’t mean the mandate is meaningless to everybody else. In the positive sense, it enables many of the other reforms—like forcing insurers to provide coverage to people at one price, regardless of medical condition—that people value. In the negative sense, it imposes a new obligation and financial responsibility on most citizens, at least in the eyes of some conservative critics. But the public debate over the mandate has framed it as a major, life-changing requirement that, in practice, it almost surely would not be.

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