A recent Health Affairs article by Columbia University’s Sherry Glied and coauthors is figuring prominently in the debate over whether to require individuals to purchase health insurance as part of the proposals to achieve universal coverage. In the race for the Democratic presidential nomination, Sen. Hillary Clinton (NY) and former Sen. John Edwards (NC) have included such an “individual mandate” in their health reform plans, while Sen. Barack Obama (IL) has declined to do so.

In “Consider It Done? The Likely Efficacy of Mandates for Health Insurance,” Glied, Jacob Hartz, and Genessa Giorgi survey compliance with health insurance individual mandates in the Netherlands, Switzerland, and Hawaii, as well as compliance with mandates in other areas ranging from automobile insurance to child support. They find that “high-compliance situations share several features: Compliance is easy and relatively inexpensive; penalties for noncompliance are stiff but not excessive; and enforcement is routine, appropriately timed, and frequent.”

In a Dec. 7 editorial, the Concord Monitor in Concord, New Hampshire, cites Glied’s article in arguing against requiring individuals to purchase health coverage. “Government mandates have been used to force people to buy auto insurance, immunize their children, pay child support and pay workers a minimum wage. But compliance rates, according to the journal Health Affairs, are far from universal; just 77 to 85 percent for immunization and 30 percent for child support.”

But in an article on the same date on The New Republic Web site, Jonathan Cohn cites Glied in arguing for a health insurance individual mandate. Calling Glied’s work “the most definitive paper on the subject” of the effect of mandates, Cohn says the Health Affairs article means that an individual mandate can be effective in expanding health coverage if policymakers get three things right: “Making insurance affordable by restructuring the insurance market and offering subsidies (which . . . all three Democrats would do); creating an infrastructure for tracking exactly who has insurance; and imposing real penalties on those who do not comply.” Cohn adds: “Interestingly, the penalties don’t have to be onerous, according to Glied. They just have to be sufficient to make people think twice about turning down an opportunity to get coverage.”

Cohn also contacted Glied to ask how much difference a mandate would make: “After cautioning that she hadn’t made any formal projections, she speculated that a well-designed mandate might catch half to two-thirds of the people left out by a purely voluntary scheme. And with automatic enrollment into a plan, she added, the take-up could be higher. (All the candidates have indicated they support automatic enrollment; but without a mandate preventing people from opting out of coverage altogether, Glied said, it wouldn’t have the same effect.)” Cohn’s own estimate that Obama’s failure to include an individual mandate could leave 15 million people uncovered has been frequently cited in campaign debates.

Stay tuned for more battles in the mandate wars. To read the Glied article and decide on the meaning of its findings for yourself, click here.