The Washington Post (1/3, Pershing) reported that a "small but vocal contingent of legal scholars and many Republican lawmakers" are arguing that Democratic healthcare measures "are unconstitutional and will be ruled so by the Supreme Court. Their primary target: the individual mandate, which requires people to get health insurance or pay a financial penalty of at least 2 percent of their income to the government." Critics say the bills "would force people to buy a particular product. Laws requiring drivers to carry auto insurance do the same thing, but people can choose not to own a car. The health insurance mandate includes no such alternative."

        Insurance mandate draws criticism. The Los Angeles Times (1/2, Oliphant) reported that the legislation's "mandate for near-universal coverage is generating opposition not only from libertarians," who "object to the guiding hand of government regulation in almost any form, but from some liberals -- and even from some members of the insurance industry." As "right-wing critics talk of legal challenges, critics on the left complain that Americans will be locked into buying a product that threatens to become ever more expensive -- especially if, as seems likely, the final bill does not contain" a government-run public option.

        As many as 23 million could remain uninsured under health reform plans. The Washington Post (1/2, Bacon) reported that "even as Democrats seek the biggest expansion of health coverage in decades, as many as 23 million people could still be without insurance by 2018, illustrating the complexity of achieving the long-held Democratic goal of universal health care." The Senate legislation passed late last month, "which is expected to resemble closely the final bill that is hashed out between the House and Senate over the next month, would leave about 8 percent of the population under age 65 without health insurance," according to the Congressional Budget Office.

        Senate bill seen as inviting problems with state-based health insurance exchanges. USA Today (1/4) editorializes that insurance-exchange provisions in the health reform bills "could be a godsend. ... But in neither the House bill nor the Senate bill would they go into effect" until 2013 or 2014. In part, the delay is a "budgetary gimmick designed to lowball the bill's cost over the next 10 years. ... The delay in the Senate is also due to needless complexity. While the House would create a single national healthcare exchange, with an opt-out provision for states...to create their own exchanges, the Senate would have each of the 50 states creating its own exchange." The 50-state approach would "invite problems" with insurance competition and in "trying to get all 50 states to act," especially considering that some state officials "are already trying to block implementation."

        Experts say states are best equipped to manage regional differences in medical expense. In the USA Today (1/4) "Opposing View," National Association of Insurance Commissioners CEO Therese M. Vaughan and NAIC President Jane L. Cline point out that research has "shown large geographic variations in medical practice and expense," evidenced by insurance policy pricing. There are also state-by-state differences in "labor markets, demography and economics" that effect pricing and regulation; and state-based exchanges "are best equipped to manage these regional differences." State exchanges would "be run by officials with local understanding and experience, attuned to healthcare needs of their communities and motivated to respond quickly." In addition, it is "unrealistic to expect a national exchange to yield meaningful premium reductions" because insurers "operating primarily in lower cost areas would have no incentive to pool risk with higher cost areas."

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