which has long had a mandate that all employ-
Advocates of a mandate argue that if we
ers provide their workers with health insurance.
can mandate automobile insurance in order
But roughly 10 percent of Hawaiian workers
to protect society from the costs imposed by
remain uncovered.18 Even under Canada's
uninsured drivers, we should be able to do
the same for health insurance.13
national health care system, the government
has encountered difficulties in ensuring that
Those are legitimate concerns and cannot be
everyone is registered or pays required premi-
casually dismissed. But regardless of whether a
ums, or both. For example, in British Columbia
mandate solves legitimate problems in theory,
alone an estimated 40,000 people slip through
the practical problems of an individual man-
the cracks. As a result, physicians in that
date make it likely to be costly and difficult to
province provide about $5 million to $10 mil-
administer. More important, it would likely set
lion per year in unreimbursed services to people
in motion forces that will lead slowly, but
without insurance.19 Although that is a tiny
almost inevitably, to a government-run nation-
al health care system.
amount compared to the cost of treating the
uninsured in the United States, it demonstrates
the difficulties of forcing compliance with an
The Problem of
insurance mandate.
Government's
Enforcement
How then will an individual health insur-
record of
ance mandate be enforced? The first problem is
to track who is and is not insured. Here again
To enforce a health insurance mandate, gov-
enforcing
the government's record is unpersuasive. No
ernment would need some way to determine
insurance
federal agency invests as much time, money,
whether Americans are insured or not and to
mandates has
and effort in tracking Americans as does the
penalize those who have not complied with the
Internal Revenue Service. Yet it consistently fails
mandate. But government's record of enforcing
not been an
to track down millions of Americans who fail to
insurance mandates has not been an over-
overwhelming
file tax returns. And every 10 years there is a
whelming success. For example, 47 states have
scandal when the Census Bureau cannot locate
laws mandating that drivers purchase automo-
success.
several million citizens.
bile liability insurance. Yet roughly 14.5 percent
of drivers in those states are uninsured.14 In
The most commonly suggested solution is
to require that Americans submit proof of insur-
some states, such as Texas, the uninsured
ance when they file their federal income taxes.
motorist rate runs as high as 18 percent. As
But about 18 million low-income Americans are
many as 2530 percent of Los Angeles drivers
are uninsured.15 By comparison, in the three
not required to file income taxes, mostly because
their incomes are too low.20 Another 9 million
states without mandatory auto insurance,
roughly 15 percent of drivers are uninsured.
Americans who are required to file tax returns
nonetheless fail to do so.21 That is potentially 27
Thus, it would appear that, despite penalties
that can run from loss of license to fines as high
million Americans who would not be providing
as $5,000 or even the impounding of vehicles,
proof of insurance. To deal with that, the cen-
millions of American drivers have chosen to
trist New America Foundation, one of the lead-
ignore the mandate.16 In fact, millions of
ing advocates of an individual mandate, would
mandate that even nonincome tax filers sub-
Americans purchase "uninsured motorist" cov-
mit their proof of coverage.22 But the founda-
erage to protect themselves in an accident in
which the other driver is uninsured. It is also
tion provides no plan to deal with those who
interesting to note that the percentage of driv-
simply refuse to do so. And, after all, some of the
ers uninsured despite a mandate is roughly the
nonfilers will be elderly, homeless, and mentally
same as the percentage of Americans who don't
ill. Others will have changed their address, per-
have health insurance.17
haps multiple times.
Moreover, only about 30 percent of unin-
The closest example to a health insurance
sured Americans have been uninsured for a
mandate in the United States is in Hawaii,
3