Call it mandated health-care socialism. Those favoring complete government control of medical care in America know their dreams can’t come true right away. The demise of the Clinton scheme in 1993 showed that. So advocates of socialized medicine are applying the death of a thousand scalpel cuts to what remains of private-sector medical care. Two methods are being used: mandated coverage and mandated benefits.

So far only Hawaii and Massachusetts have mandated coverage supposedly for every state resident, while Tennessee has had a nonmandated “universal coverage plan” since 1994. Hawaii’s mandate began in 1974. Not surprisingly, the government mandate distorted the market. The law applies only to employees working more than 20 hours a week. The result: Today 10 percent of residents still are not covered under “universal” coverage, according to a 2006 study of health-insurance mandates by Michael Tanner of the Cato Institute.

Meanwhile, doctors are fleeing the islands. Smaller medical providers lack the financial resources to deal with the expense, red tape, and unpredictability of the most socialized medicine scheme in any of the 50 states.

In April 2006 then-Massachusetts Gov. Mitt Romney, now a Republican candidate for president, signed his state’s universal-coverage bill. A previous socialized-medicine scheme in the Bay State was pushed into law in 1988 by Gov. Michael Dukakis, a Democrat, as part of his “Massachusetts miracle.” During a three-year phase-in, costs rose so high that the program was shelved by the legislature.

Romney’s new law caused problems even before it went into effect on July 1, when everyone had to have coverage or pay a “fee,” really a new tax. “Early bids suggest the soon-to-be compulsory insurance policies that will pass muster under the scheme will be expensive, starting at a whopping $380 per month, or $4,560 a year, for an individual,” a January 23, 2007, Wall Street Journal editorial noted. “That’s hardly surprising when you look at costs in other states that overregulate their insurance markets, such as New York.”

Now the new Massachusetts contagion has spread to California, whose governor, Republican Arnold Schwarzenegger, is an in-law of longtime socialized-medicine and mandated-insurance-benefit advocate Sen. Edward M. Kennedy, a Massachusetts Democrat. Schwarzenegger’s plan is similar to Romney’s.

It’s not clear yet how far Schwarzenegger will be able to push his proposal. If state courts rule that his “fee” increases really are taxes, then a two-thirds vote in the legislature will be required for passage. In that case, the legislature’s GOP minority, whom the governor has shunned and taken for granted, would have the power to play spoiler.

However, a poll released last January by the Public Policy Institute of California found that 71 percent of state residents support the governor’s proposal, with only 23 percent opposed. (Six percent don’t know.) Even 55 percent of Republicans favored the proposal, with 39 percent opposed.

So it’s likely some sort of mandated health care will be passed, although probably not as comprehensive or expensive as the governor proposed.

This has national importance because, for better or worse, California is a major incubator of ideas, from surf music to environmental policy.

A final factor in mandated coverage is that the Massachusetts and California schemes may violate a 1974 federal law, the Employee Retirement Income Security Act (ERISA), which was designed to standardize medical and retirement coverage across state lines. (After the U.S. Supreme Court upheld a challenge to the Hawaii plan under ERISA in 1983, it was exempted by Congress and President Reagan.)

Last July U.S. District Judge Frederick J. Motz cited ERISA in throwing out the so-called “Wal-Mart Law” passed in Maryland. The law mandated that any company with more than 10,000 employees must spend at least 8 percent of the payroll on health-care benefits. Motz wrote, “The Act violates Erisa’s fundamental purpose of permitting multi-state employers to maintain nationwide health and welfare plans, providing uniform nationwide benefits and permitting uniform national administration.” The ruling was upheld on appeal.

The Wall Street Journal editorialized that the ruling “could spell trouble for the California and Massachusetts schemes.”

TennCare, another experiment in medical socialism, was different from the other systems because it didn’t have a mandate. Nevertheless, it also proved to be an expensive disaster. In 1994 then-Vice President Al Gore, a Tennessee native, convinced the state’s Democratic governor, Ned McWherter, to implement a portion of the Clinton plan at the state level. The hope was that it would prove so successful that other states would adopt it and then the plan could make a comeback at the national level.

TennCare, explains the entry in Wikipedia, “was designed to expand health insurance to the uninsured through the state’s Medicaid program by utilizing managed care.” Centralization was supposed to reduce costs, with “free” money from the federal government picking up any financial slack.

But predictably, many companies stopped providing medical insurance, forcing employees to sign up with TennCare. “In short order, one quarter of the state’s population was on TennCare,” Patrick Poole wrote on AmericanThinker.com last January. TennCare “has forced dozens of hospitals out of business, pushed thousands of doctors and other health care professionals out of the state, destroyed any semblance of competitive health insurance market, and nearly drove the state government into bankruptcy.

There was one good result of imposing TennCare. When costs soared so high that in 2000 the state legislature was about to pass the first Tennessee income tax—with a 5 percent top rate—thousands of irate citizens marched on Nashville and forced the politicians to abandon the tax. Several legislators, upset at actually hearing their constituents’ views, were carted off to emergency wards. Citizens held up signs reading, “Carry them all to the ER!”

Mandated Benefits

A less obvious path to socialized medicine is mandated benefits, which require insurance providers to cover everything from athletic trainers in Arkansas to breast reduction in Maine. With mandated coverage, however bad a scheme is, people notice that a mammoth new bureaucracy and tax increases have been imposed. But with mandated benefits, the state or federal legislature simply passes a law requiring medical insurance to include coverage for a particular ailment. Except for the special interests that benefit monetarily, few people even know what’s going on.

“Mandated coverage is a dagger to the heart of the private health care system,” says Grace-Marie Turner, president of the Galen Institute, which advocates free-market medical reforms. “But coverage mandates are slow poison.”

Currently, the federal government only mandates coverage for prenatal care and two nights in the hospital for new mothers. The real action is at the state level, where the number of mandates has risen from seven in 1965 to 1,843 as of 2006, according to a March 2006 study by the Council for Affordable Health Insurance (CAHI), an insurance-carrier group that favors market solutions. Turner said health-care mandates are like requiring that everyone drive a fully loaded Lexus, while prohibiting anyone from purchasing a Ford, Chevy, or Honda. Even if someone wants medical insurance without the mandates, that option is not available, leading to some people not having any insurance.

According to CAHI, the states with the most mandates are Minnesota—62—and Maryland—59. The fewest mandates are 13 in Idaho and 17 in the District of Columbia. The average is 36.

Here are some of the mandates the 50 states and District of Columbia have imposed, followed by the number of states. Unless indicated otherwise, the added cost to insurance is less than 1 percent:

Benefits mandates:

• Alcoholism, 45 states (1 percent to 3 percent added cost)

• Alzheimer’s, 2 states

• Ambulance services, 8 states

• Breast reconstruction, 48 states

• Chlamydia, 3 states

• Cleft palate, 14 states

• Contraceptives, 30 states (1 percent to 3 percent added cost)

• Dental anesthesia, 29 states

• Diabetic supplies, 47 states

• Drug-abuse treatment, 34 states

• In vitro fertilization, 14 states (3 percent to 5 percent added cost)

• Mental health general, 40 states (1 percent to 3 percent added cost)

• Mental-health parity, 42 states (5 percent to 10 percent added cost)

• Newborn hearing screening, 16 states

• Newborn sickle-cell testing, 3 states

• Off-label drug use, 37 states

• Port-wine stain (a skin discoloration) elimination, 2 states

• Prescription drugs, 3 states (5 percent to 10 percent added cost)

• Prostate screening, 32 states

• Second surgical opinion, 9 states

• Well-child care, 31 states (1 percent to 3 percent added cost)

Provider mandates:

• Acupuncturists, 11 states (1 percent to 3 percent added cost)

• Chiropractors, 46 states (1 percent to 3 percent added cost)

• Dentists, 36 states (3 percent to 5 percent added cost)

• Dieticians, 3 states

• Marriage therapists, 13 states

• Massage therapists, 5 states

• Naturopaths, 3 states

• Osteopaths, 21 states (1 percent to 3 percent added cost)

• Physical therapists, 16 states (1 percent to 3 percent added cost)

• Podiatrists, 35 states

• Psychiatric nurses, 16 states

• Psychologists, 44 states (1 percent to 3 percent added cost)

• Social workers, 27 states (1 percent to 3 percent added cost)

• Speech or hearing therapists, 18 states

Covered-persons mandates:

• Adopted children, 42 states

• Conversion to nongroup insurance, 42 states (1 percent to 3 percent added cost)

• Dependent students, 12 states

• Handicapped dependents, 39 states (1 percent to 3 percent added cost)

• Newborns, 51 states (1 percent to 3 percent added cost)

• Noncustodial children, 10 states

• Domestic partners, 2 states

Some other mandates not yet prevalent nationwide are: the aforementioned athletic trainers in Arkansas and breast reduction in Maine, smoking cessation in Maryland, varicose-vein removal in Maine, hormone-replacement therapy in Nevada and New York, early intervention service in Rhode Island, and psychotropic drugs in New York and Wisconsin.

What next, full coverage for nips and tucks?

What if you are a teetotaler who never touches a drop of booze, think chiropractors and acupuncturists are quacks, or take Thomas Szasz’s critical view of psychiatry? Shut up and pay anyway. Government knows better what should be included in your medical insurance.

Turner said that “everybody has a vested interest in getting their interest covered, from the counselors to the chiropractors. It’s so self-interested.” She added that, according to Congressional Budget Office numbers, for every 1 percent increase in the cost of insurance, 200,000 to 300,000 people nationwide lose their insurance. State mandates keep about one quarter of Americans from getting health insurance, according to John C. Goodman, president of the Dallas-based National Center for Policy Analysis, a free-market think tank.

Costs in One State

Using that estimate of coverage loss caused by insurance mandates, let’s look at how the system works in California, with one-ninth of America’s population. Every 1 percent increase in the cost of insurance therefore means 22,222 to 33,333 people lose insurance. In-vitro fertilization coverage mandated by the state raises costs 3 percent to 5 percent. So this mandate alone means 66,666 to 166,665 people lose health insurance.

California also mandates mental-health parity, which raises costs 5 to 10 percent. This mandate causes 111,110 to 333,330 people to lose coverage.

Put another way, if just these two mandates were repealed in California, from 177,776 to 499,995 people could again afford insurance. That would go a long way toward helping the 6.5 million Californians Schwarzenegger says are uninsured and supposedly would be helped by his universal-coverage proposal.

A 1998 study Turner co-wrote with Melinda L. Schriver for the Heritage Foundation looked at 16 states that “were most aggressive in passing laws designed to increase access to health insurance for their uninsured citizens. They imposed mandates and regulations which primarily affected health insurance for small employers and individual citizens, and put into law at the state level many of the provisions contained in the failed Clinton health care bill.”

The result: the uninsured populations in those 16 states rose eight times faster than in the other 34 states: “Each of the 16 states experienced a decline in private and individual health insurance coverage and an increase in the number of uninsured citizens.” These 16 states “actually ended up harming their citizens by increasing the regulation of their insurance markets, inadvertently squeezing more and more people out of the system.”

Mandates may seem to benefit those who use the services or need the treatments, but even seemingly obvious mandates—such as care for infants—push medical care toward a centralized system. And even the obvious mandates raise costs and so cut some people out of coverage.

Good and Bad Trends

As most states have already imposed some of the more “basic” mandates, such as prenatal care, more obscure ones are cropping up, such as those called “slacker mandates.” Is your lazy college grad hanging around playing video games? Well, New Jersey mandates health insurance for unmarried dependents until age 30, and New Mexico does so until 25. Most other states mandate coverage only until 19—22 or 23 for college students.

CAHI warned in its 2006 study that new mandates “have a way of ‘making the rounds,’ finding their way into bills all over the country.” On the positive side, 30 or more states now require that the costs of a mandate be assessed before it is imposed. So at least legislators, and citizens, know how costly a mandate will be before it takes effect.

And a May 2007 “Trends & Ends” memo from CAHI found the imposition of “state-mandated benefit legislation is slowing down. That change implies that state legislators are finally getting the message.”

CAHI Research and Policy Director Victoria Bunce said that tallies of the numbers of mandates are sketchy until 2004. But her research showed mandates growing at about a 3.7 percent rate per year from 1992 to 2004.

In 2006, total state mandates rose by only 0.7 percent over 2005, a sharp downturn. However, through May 2007, total state mandates increased by 2.9 percent over 2006. Although higher than the previous year, that amount still is less than the average increase of what Bunce called the “explosion” of mandates in the 1992–2004 period. But the 2006 uptick shows that the mandate cancer is far from being in remission.

One obvious way out of this problem is for states to follow Utah’s example, which has stopped 15 mandates,  and begin repealing as many mandates as possible.

Goodman provided some other ideas:

• Create huge exceptions to some or all mandates for groups such as small businesses, individuals, or people on Medicare.

• Allow people to buy insurance policies just like those carried by state employees, often including legislators themselves, which frequently are exempted from state mandates. Not allowing regular citizens the same choices as legislators themselves is sheer hypocrisy.

• Don’t increase federal involvement in medicine. Goodman warned that more federal meddling means “there will be lots more federal mandates.”

• Allow citizens of one state to purchase any insurance policy from a carrier in any other state. It’s silly that such purchases are banned. People buy goods and services from out of state all the time, often over the Internet. Why not health insurance?

There still is time for Americans to reverse the piecemeal advance toward health socialism known as mandated benefits. Reducing even one mandated benefit a year in every state would be a better prescription for health care than an apple a day.

But here’s the irony. The proposal would reduce the number of jobs available to people here legally and give illegal immigrants an advantage in the competition for jobs. Dukakis and Mitchell reach a mistaken conclusion by confusing demand and supply, and showing a misunderstanding of how the minimum wage is enforced. That Dukakis, a former presidential candidate and a political science professor at Northeastern University , made such a mistake in economic reasoning is understandable. That Mitchell, a professor of management and public policy at UCLA, did so is less understandable: both his B.A. (Columbia) and his Ph.D. (MIT) are in economics.

When the minimum wage rises, what happens? Some jobs that were worth hiring someone to do are no longer worth filling. The jobs lost are the most marginal ones, the ones that had low value and that paid little. That’s why the vast majority of studies of the minimum wage have found that increases, all other things equal, reduce the number of low-skilled jobs offered and filled.

Surely Dukakis, a public-policy wonk for the whole of his adult life, and Mitchell, a trained economist, must know that. So how do Dukakis and Mitchell contend with that fact? First, they admit it—kind of. They write, “If we raise the minimum wage, it’s possible some low-end jobs may be lost.” Notice the redundancy in “it’s possible” and “may.” A good editor, and I’m sure the New York Times has many, would have caught this and said: “ ‘It’s possible’ means the same thing as ‘may’ and so you should drop one.” Why didn’t an editor do this? My guess is that the editor, like Dukakis and Mitchell, wanted to create the idea that the job loss would be small. By hedging twice, the authors leave that impression in many readers’ minds.

But still, there’s job loss, and even they, in their “just maybe” way, admit it. So how do they get to the conclusion that a higher minimum wage would help Americans? They write that if the government increased the minimum wage, “more Americans would also be willing to work in such [previously low-paying] jobs.” That’s true. When the minimum wage goes up, jobs that wouldn’t have been attractive to some people will be attractive to them. But the objection to the minimum wage has never been about whether more people would be willing to work at a higher wage than would be willing to work at a lower wage. The problem is that being willing to work at a job isn’t enough: someone has to be willing to offer you that job. If simple willingness to work were enough to get you a job, then a classic “Seinfeld” episode wouldn’t have been funny. In that episode George Costanza is out of work and wants a job. He sits around with Jerry Seinfeld trying to decide what kind of job he should get. George comes up with the idea of being a sports commentator and lays out how much fun that would be. The audience laughs because they realize that George’s simple willingness to work is not enough: another necessary condition is that someone think he’s good enough to be worth the high pay that sports commentators get. I bet even Dukakis and Mitchell, if they saw that episode, would laugh. Which is why they should laugh at their own proposal—if not for its tragic consequences.

But wait a minute, Dukakis and Mitchell might say: there’s still a thin spot of light at the end of our constructed tunnel. They argue that raising the minimum wage and increasing its enforcement will push illegal immigrants out of jobs and make these jobs available for Americans. It is true that if the minimum wage caused the number of illegal immigrants working to fall more than the total number of jobs fell, there would be more minimum-wage jobs for Americans. But is this likely? No, and in thinking it likely, they show a misunderstanding of how the minimum wage is enforced.

Their model of enforcement, it seems, is of diligent federal workers going into workplaces and checking records on wages paid. But employers willing to break the law on wages are likely to be willing to break the law on record-keeping. In 2005 the U.S. Department of Labor’s Wage and Hour Division put 969,776 hours into enforcement of all parts of the federal wage regulations. This would translate into only 500 full-time workers nationwide. And not all of these were involved in enforcing the minimum wage: some were enforcing overtime regulations, child-labor regulations, and more. So even quadrupling the number of enforcers would not make a major dent when the number of low-wage employers would likely be in the hundreds of thousands.

The main enforcement of the minimum wage is initiated by employees, not by the government. An employee who thinks he was paid less than the minimum can contact the federal government or the state labor board and show his pay records. Then the government collects back wages and a fine from the employer. In 2005 the Labor Department reported 30,375 complaints registered about employer violations of wage and hours laws. The vast majority of these complaints were likely by employees. That’s why the minimum wage is so effective. But employers aren’t typically stupid. They know this risk, which is why even employers who have no ethical qualms about breaking the law hesitate to hire people at less than the minimum wage.

They Won’t Complain

But there’s one type of employee that the employer is not so afraid of hiring and paying less than the minimum: an illegal immigrant. Illegal immigrants are nervous about going to the government to report that they were paid less than the minimum. Employers, knowing this, are more willing to hire them. So while reducing the overall number of jobs, an increase in the minimum wage will actually open up more jobs for illegal immigrants, making it even harder for unskilled legal residents to find work.

How can not being able to sic the government on an employer be an advantage? However much someone might plead with an employer to offer him a job at below minimum wage, if the employer knows the employee can sue for back wages, he probably won’t offer the job. But not being able to sue because the job candidate is here illegally makes his promise not to sue credible, which also means he doesn’t even need to make such a promise. The illegal immigrant gets the job.