The risks associated with individual mandates suggest that they are no panacea, Sherry A. Glied of Columbia University writes in the New England Journal of Medicine.

One important concern, says Dr. Glied, is that the government will provide insufficient funds for the subsidies intended to accompany the mandate. In that case, the mandate will act as a very regressive tax, penalizing uninsured people who genuinely cannot afford to buy coverage. This concern has led Massachusetts to create a hardship exemption for its mandate -- an escape clause that effectively undoes the mandate if subsidies are inefficient.

The ease with which it is possible to lift the mandate if the legislature fails to appropriate funds may make the individual mandate a rather rickety form of universal coverage. Further, if subsidies are insufficient or benefits inappropriate, the mandate will be very difficult to enforce and draconian in effect.

To be effective, an insurance mandate should be in place at the beginning of an insurance term, ensuring that people have coverage when an adverse event occurs. Developing a system to promptly identify and penalize scofflaws will take effort and ingenuity, particularly in our diverse and mobile country and may require a degree of intrusiveness and bureaucracy that some will find unpalatable.