By KEVIN SACK
Published: February 4, 2008
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.
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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.”
moreSTEPHANOPOULOS: You didn't get the chance to answer that question in the debate.
What is the answer to those two questions? Will you have fines for people who don't buy health care, don't apply -- don't go by the mandate? Will you garnish their wages? CLINTON: George, let's put this in context, because this is a big difference between us. I think universal health care is a core Democratic value and a moral principle, and I'm absolutely going to doeverything I can to achieve that.
You know, if you look at my plan, it's a misstatement to say that people won't be able to afford it, because I have a very detailed approach about giving people health care tax credits,limiting --
I'm the only person who does -- limiting the percentage of what you would have to pay for a premium to a low percent of yourincome.
This plan has been examined by independent experts, and they agree with me, just as they agreed with Senator Edwards, as well, that if you do not start with a plan that attempts to achieve universal health care, you will not get there.
The insurance companies will continue to cherry-pick. The emergency rooms will be crowded. And once again, we will slide into the morass we're in now, where more and more people are uninsured and we don't get the quality outcomes that we should.
With respect to how do you get people to do it, I find this somewhat bewildering. Senator Obama has a mandate. He has a mandate on children. He has talked a lot about requiring people, if they show up to get some kind of health care, like in the emergency room, and they don't have health insurance, hitting them right then to make sure that they get some kind of health insurance.
Well, I don't think you should wait until someone's in distress or sick. I think you should look to sign people up when they come into contact with the health-care system or government agencies.
About 20 percent of the people who don't have health insurance in America today could well afford it, even at the cost that it is, which is exorbitant. So what we've got to do is have shared responsibility. Everybody has to pay something, but, obviously, on a sliding scale.
That's why my health care tax credit...
STEPHANOPOULOS: But let me interrupt you there.
CLINTON: ... and the premium cap will work.
STEPHANOPOULOS: Let me interrupt you there, because the other night at the debate, you said that you and Senator Edwards bit the bullet on this question...
CLINTON: That's right.
STEPHANOPOULOS: ... of mandates, and Senator Edwards was quite clear in his plan. He said if people still didn't buy the insurance, their wages would be garnished.
And I still haven't heard, if people can afford it and they don't buy the insurance, will their wages be garnished under your plan? Will they have to pay fines?
CLINTON: Well, they don't have to pay fines, George. We want them to have insurance. We want it to be affordable.
And what I have said is that there are a number of ways of doing that. Now, there's not just one way of getting to that.
I think you can automatically enroll people, and you will then say you've got to be part of this. It's what Senator Obama does for children. Clearly, he has a mandate, and he has a means of enforcing it or at least it appears he does.
And what I have learned over the last many years is that I'm sure the Congress has some ideas about this. But if you don't start with universal health care, if you don't say everybody's going to be in the system, we'll never get there.
And if you look at some of the misleading mailings that Senator Obama is sending out around the country, honest to goodness, it looks like it was written by the health-insurance companies.
It's so reminiscent of old "Harry and Louise" talking about how, oh, the sky will fall if we try to have universal health care.
He's playing right in to all of the arguments against this core value of the Democratic Party.
I will stand on the stage with John McCain and engage in that debate. Why would we want a nominee who leaves people out? And Senator McCain will say, well, I've got a plan and, yes, it leaves people out. So we're even.
That is not the kind of contrast we should be drawing going into this general election.
STEPHANOPOULOS: But, yet, Senator Clinton, we actually have that mailing and let me show our viewers quickly what you were talking about, because you referred to it.
It says that Hillary's plan will -- excuse me, let me read this again -- "forces everyone to buy insurance, even if you can't afford it. You pay a penalty if you don't." And I want to bear down on this question one more time, because they're claiming this issue of the penalty. And a lot of independent health care experts, many who worked with you in 1994, say that without these enforcement mechanisms, you simply can't get to universal coverage, you can't claim to have universal coverage, so there's no difference between your plan and Senator Obama's.
And, I mean, you talked about automatic enrollment. Will you garnish wages of people who don't comply, don't buy the insurance?
CLINTON: George, we will have an enforcement mechanism. Whether it's that or it's some other mechanism through the tax system or automatic enrollments. But you're missing, I believe, the key point. If you don't start with universal health care, and I have very aggressive cost controls and quality improvements, and my health care tax credits plus the premium cap that I am the only person to put in to a health care plan to say, your income will be adjusted so that a small percentage will be always the limit of what you have to pay for premiums.
If you don't do what I am saying we do, we will never even attempt to get to universal health care.
And the reason why I think there are a number of mechanisms, going after people's wages, automatic enrollment, when you are at the place of employment, you will be automatically enrolled, whatever the mechanism is is not as important as, number one, the fundamental commitment to universal health care, the appreciation that, with health care tax credits and with a premium cap, it will be affordable for everyone. And the misleading information that Senator Obama's campaign is putting out, that I will force people to do it even if they can't afford it, is absolutely untrue.
CLINTON: There will be mechanisms to enable everyone to afford it. We have costed this out, and we will be able to achieve it.
So isn't it better that we start with a system that gets everybody in than starting with a plan that leaves 15 million people out to start, which will only get bigger and bigger as time goes on?
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