Prof. Sherry Glied is chair of the Department of Health Policy and Management at Columbia University's Mailman School of Public Health. In this week's New England Journal of Medicine, she gives a fair account of the difficulties of forcing people to purchase health insurance via an "individual mandate." Glied writes that an individual mandate "may require a degree of intrusiveness and bureaucracy that some will find unpalatable," and, "The risks associated with individual mandates suggest that they are no panacea."
Her closing observation, though, is novel and particularly noteworthy:
Perhaps the most important benefit of mandates is symbolic. By mandating the purchase of health insurance, governments signal to their citizens that coverage is critical. For many uninsured people as well as their families, communities, and elected representatives, this public commitment to coverage may lead to a reassessment of priorities. Although making mandates functional will be demanding, just passing a mandate may serve an important purpose by moving health insurance higher on the agendas of all these constituencies.
This illuminates a driving force behind mandates. Advocates do not merely want to improve health and longevity. They want to change other people's values. They want to make the uninsured value health and longevity more than the things that must be sacrificed to comply with the mandate -- things like barhopping, education, starting their own business, etc. And they are willing to use coercion (or the threat of coercion) to do so. The debate over mandates is not just about how to reform health care. It is also about who shapes your values.
No wonder there are so many people in the health care industry who support mandates.