Why do we pretend that an insurance mandate will help the health care crisis?

Some time ago, Massachusetts weighed a new, innovative health care plan to cover the uninsured. As a result of a new mandate to buy health insurance, reported the New York Times, "no one would go uninsured" in the state. Following a tough political fight, the bill passed and prompted the same newspaper to editorialize, "Massachusetts last week ventured where no state had gone before: It guaranteed health insurance for every resident."

The year was not 2006 but 1988, and the Democratic governor who presided over this legislation was Michael Dukakis. The result? The proportion of state residents who were uninsured subsequently rose and remained unchanged for almost two decades.

If insanity is doing the same thing repeatedly and expecting different results, state governments across the country became certifiably unhinged. As recently summarized by Steffie Woolhandler and her colleagues at Harvard Medical School, similar bills to eliminate the ranks of the uninsured later passed in Minnesota ("the most sweeping effort yet to provide health insurance to people who lack it," according again to the New YorkTimes), Tennessee ("the most radical health care plan in America," gushed the governor), Vermont (a bill that would "give Vermont universal healthcare by 1995," predicted then-Gov. Howard Dean), and Washington (called "one of the most aggressive health care experiments in the nation … that would extend medical benefits" to all citizens), among others.

Among the six states that later passed health reform loosely based on the 1988 Massachusetts model, Woolhandler reported, not a single one saw a sustained reduction in the percentage of uninsured citizens, despite the largest peacetime economic boom in the nation's history. As health care costs kept rising, making premiums too expensive for employers and individuals, every state repealed key elements of the reforms, including mandates to purchase insurance.

Is there any reason to think a nationwide plan now might do any better? It's likely the federal bills will lead to fewer uninsured citizens in the short term—but very little of the benefit will come from the much-ballyhooed employer and individual mandates to buy insurance. That part of the policy is a brilliant red herring to appeal to moderates and conservatives. The real strategy is much simpler: Mostly, the federal government will just use new tax revenues to buy private health insurance for those who can't afford it.

Consider Massachusetts' most recent health reform effort, from 2006, which combined an individual and employer mandate to buy insurance (appealing to the Republican goal of greater personal responsibility) with subsidies for the poor (appealing to Democratic notions of social justice). Pointing to the success of the Republican aspect of the plan, former Senate Majority Leader Bill Frist claimed that 40 percent of the allegedly 500,000 newly insured state residents bought private insurance and that employer-sponsored private enrollment soared by 160,000 people. According to the state health department, the number of those without insurance fell by half, from 6.4 percent in 2006 to a historic low of 2.7 percent in 2009 following the reform. The Democratic-appointed state health secretary, JudyAnn Bugby, further stroked advocates of personal responsibility in the New England Journal of Medicine, concluding that "only about half of the more than 400,000 residents who gainedcoverage by December 2008 were publicly subsidized."

A more nuanced reading of the data suggests a different conclusion. To begin, no one really knows how many Massachusetts residents gained insurance, since the state's health department suddenly began using a new method to count the uninsured beginning in 2007—oddly, just after health reform passed. Compare the state's estimates with the U.S. Census, which performs a monthly count of the uninsured for the Bureau of Labor Statistics. Using a larger sample size, they estimate that 5.5 percent of Massachusetts residents are still uninsured.