BOSTON (AP) — It's the single most contentious element in the Patient Protection and Affordable Care Act of 2010 (PPACA): The requirement that nearly everyone have insurance or face a financial hit.
But in Massachusetts, the only state with a so-called individual mandate, the threat of a tax penalty has sparked little public outcry since the state's landmark health care law was signed in 2006 by the governor, Mitt Romney.
Romney, now the presumptive Republican presidential nominee, pushed for the mandate saying it would discourage "free riders," those who can afford health coverage but instead rely on emergency rooms for free care and drive up insurance premiums for everyone else.
"What we are mandating is that individuals have personal responsibility either to pay for their own health care bill or to receive insurance," Romney said at the time.
As a presidential candidate, Romney has tried to draw a line between his law and President Obama's, in most instances saying that states and not the federal government should decide whether to impose the requirement.
The Republican's record as Massachusetts governor — specifically his economic and fiscal policies — has been thrust into the spotlight by Obama to argue that Romney's prescriptions for an ailing nation are wrongheaded. Largely missing from that critique has been Romney's record on health care. That's probably because Romney's health care plan provided a blueprint for PPACA.
Romney, who these days all but ignores the health care measure that was his signature achievement as governor even as he assails Obama's, was vulnerable on the issue during the Republican primary race because conservatives largely are opposed to the mandate, arguing that it amounts to government overreach. It's unclear how the issue will play in the general election as Romney seeks to woo voters across the political spectrum.
Even with the mandate, the Massachusetts law remains popular. Two polls taken in the past year show more than 60% of Massachusetts residents approve of the law.
One reason the mandate has failed to undermine that support is that so few people have had to pay. In 2009, the most recent year for which the state has figures, less than 1% of residents drew the penalty.
Another reason for the law's success is that Massachusetts had a high rate of insured residents even before the 2006 law, meaning the state had an easier climb to its goal of near-universal coverage.
About 400,000 have become insured since the law took effect. More than 98% of Massachusetts residents are now insured, including nearly all children, according to state officials.
Not everyone has escaped the mandate. Massachusetts collected about $77 million in penalties from residents as a result the requirement from 2007-2009. While that may seem like a lot of money, the penalties have touched just a tiny fraction of the state's population of more than 6.5 million.
In 2007, about 67,000 people were required to pay a penalty. That declined to 53,000 in 2008 and 48,000 in 2009. The 2010 numbers are expected later this year.
For the majority of Massachusetts residents who already receive health care benefits through work or other programs, the individual mandate is largely invisible, the sole reminder being a form that must be attached to state tax returns each year.
The document, known as a 1099-HC, confirms that an individual has been enrolled in a health care plan with "minimum creditable coverage" — that's the level of coverage deemed mandatory by the state to meet the goals of the law — during each month of the prior year.
