Senator Hillary Rodham Clinton inched closer Sunday to explaining how she would enforce her proposal that everyone have health insurance, but declined to specify — as she has throughout the campaign — how she would penalize those who refuse.
Mrs. Clinton, who did not answer Senator Barack Obama’s question on the topic in a debate last Thursday, was pressed repeatedly to do so Sunday by George Stephanopoulos on the ABC program “This Week.” When Mr. Stephanopoulos asked a third time whether she would garnish people’s wages, Mrs. Clinton responded, “George, we will have an enforcement mechanism, whether it’s that or it’s some other mechanism through the tax system or automatic enrollments.”
She then added that the focus on enforcement clouded a more important point, that her proposal to cover the uninsured was superior to Mr. Obama’s because she would mandate coverage for all, while he would require it only for children.
What might seem a mundane debate over health policy has taken on outsized importance in the approach to Tuesday’s voting because it is one of the few substantive differences between the two leading Democratic presidential candidates.
Polling has found that health care is a top concern of Democratic voters, and that they rank covering the uninsured as more important than reducing health costs or improving quality.
Mrs. Clinton, therefore, has argued that her plan, because of its mandate, would achieve universal coverage while Mr. Obama’s would not. She has taken recently to calling universal coverage “a core Democratic value and a moral principle.”
Mr. Obama asserts that his plan, which is like Mrs. Clinton’s in its use of government subsidies to reduce the cost of insurance, would effectively guarantee coverage to anyone who wants it.
But about 20 percent of the uninsured have household incomes of $75,000 or more, according to the Census Bureau, meaning they presumably can afford coverage but prefer to take the risk. Mrs. Clinton argues that these “free riders” impose a hidden tax on the insured because their uncompensated care must be factored into medical charges and insurance rates.
Mr. Obama’s campaign has tried for months to move from defense to offense by pressing Mrs. Clinton to explain how she would enforce her mandate. A recent study published in the journal Health Affairs concluded that compliance with government mandates varied greatly, both in the United States and in other countries. But compliance is greatest, the authors wrote, when “penalties for noncompliance are stiff but not excessive.”
A group of doctors and health policy analysts, including a number of Obama advisers, pointed out in a letter released Thursday that Massachusetts, the only state with an insurance mandate, has thus far failed to enroll nearly half of its uninsured despite imposing a modest first-year tax penalty of $219 (the fine increases significantly this year). Because the Massachusetts program is less than a year old, it is not yet possible to fully judge the effectiveness of its mandate.
Mr. Obama raised the Clinton campaign’s ire late last week by charging in a voter mailing that “Hillary’s health care plan forces everyone to buy insurance, even if you can’t afford it... and you pay a penalty if you don’t.”
Mrs. Clinton argues that she can make premiums affordable for low-income workers by spending $110 billion on subsidies and cost-saving devices. Like Mr. Obama, she would pay for her plan primarily by allowing the Bush tax cuts to expire for the wealthiest Americans. She would not allow exemptions from the insurance mandate, as Massachusetts does for those who cannot afford even subsidized premiums.
Aides to Mrs. Clinton had said previously that she would consider garnishing people’s wages, and that the uninsured could be automatically enrolled when they present themselves at hospitals or government offices. But Mrs. Clinton, who faced criticism in the 1990s for not adequately consulting Congress on her husband’s health plan, has typically said she would leave such details to negotiations with lawmakers.
She said Sunday she would not impose fines, as Mr. Obama has said he would to enforce his insurance mandate for children. “We want them to have insurance,” she said. “We want it to be affordable.”
The reason for the continuing vagueness is simple, said Robert J. Blendon, a Harvard professor of health policy and political analysis. “Whenever you talk about penalties, you lose some number of people who support the principle of universal coverage,” he said. “It’s the equivalent of candidates proposing new programs that may lead to a tax increase but never wanting to discuss it.”
The Obama campaign hopes to make Mrs. Clinton pay a price, not just on health policy but on the issue of character. Bill Burton, the Obama campaign’s spokesman, said on Sunday that Mrs. Clinton had “again refused to directly answer the question,” and added, “America needs a leader they can trust, not someone who will avoid hard questions.”