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ance on their own if it were affordable. "My

achieving universal coverage. Coverage and

belief is the reason that people don't have it is

costs are, of course, inextricably linked. But

not because they don't want it, but because

most Democrats, including Obama's primary

they can't afford it," he says.18 Most of his pro-

opponents, were focused almost exclusively on

posals are focused on making health insur-

the question of how to provide health insur-

ance more affordable, either by reducing the

ance to those without it. That was the battle

cost of the insurance itself or subsidizing its

cry of Sen. Hillary Clinton, who promised to

purchase.

provide "health insurance for every single

American."12

He would require all employers to provide

In contrast, Obama, while continuing to

their workers with insurance through a

call his proposal a "universal health care

"play-or-pay" mandate. Employers who do

plan," has focused more on a combination of

not provide "meaningful coverage" for their

regulations, cost cutting, and subsidies to

workers would be required to pay a penalty

reduce both overall health care spending and

equal to some percentage of their payroll into

the price of insurance. He even appears will-

a national fund that would provide insurance

to those uncovered workers.19 Obama's cam-

ing to concede that universal coverage is not

paign materials do not specify how much

immediately achievable, and his own plan

Obama appears

that penalty (which is effectively a tax) would

does not aim for 100 percent coverage.

to break

be. However, similar proposals have ranged

Even so, Obama clearly seeks greater govern-

from 4 to 7 percent of payroll.20

ment control over the U.S. health care system.

somewhat with

Obama also leaves undefined the term

In his book, the Audacity of Hope, he argues that

recent

"meaningful coverage," although elsewhere he

"the market alone cannot solve our health care

Democratic

suggests that all insurance plans should offer

woes--in part because the market has proven

benefits at least as generous as those provided

incapable of creating large enough insurance

orthodoxy by

through the Federal Employees Health Bene-

pools to keep costs to individuals affordable, in

making the

fit Program.

part because health care is not like other prod-

Finally, Obama does not appear to make

ucts or services (when your child gets sick, you

reduction of

don't go shopping for the best bargain)."13

clear distinctions based on the size of the

health care costs

As a result, he has been actively hostile to

employer, although in one speech he did say

at least as central

market-based reforms such as Health Savings

that his mandate would apply to "all but the

smallest businesses."21 Elsewhere he suggests

Accounts, which he dismisses as being based

to his proposals

that "very small businesses and startups" would

on the idea that people have "an irrational

as achieving

desire to purchase more than they need."14

be exempt.22 Campaign officials have said unof-

universal

"The "freedom to choose," he argues, "mag-

ficially that the exemption would apply to

"some number less than 15" employees.23 It

nifies the uneven risks and rewards of today's

coverage.

winner-take-all economy."15

seems likely, therefore, that many of what

would normally be considered small businesses

would fall under the mandate. This is signifi-

Not Quite Universal Coverage

cant because small businesses are far less likely

Throughout the Democratic primaries, one

to offer insurance today. Roughly 45 percent of

of the key points of contention between Barak

uninsured workers are employed by companies

Obama and Hillary Clinton was the question

of an individual mandate.16 Clinton supported

with 25 or fewer workers.24

a requirement that every American buy health

There are several problems with an employ-

insurance, whereas Obama eschewed a man-

er mandate. First, while it might be politically

date for adults. He would, though, require that

appealing to claim that business will bear the

parents purchase insurance to cover their chil-

new tax burden, nearly all economists would

dren (generously defined as up to age 25).17

see it quite differently. The amount of com-

pensation that a worker receives is a function

Obama argues that a mandate is unneces-

of his or her productivity. The employer is gen-

sary since Americans would buy health insur-

3