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In Washington, Congress is expected to begin working on overhauling the country's health care system this week. The major goals: cover more people with higher quality care at a lower cost. One idea is to require everyone to have health insurance, an experiment that's already underway in Massachusetts.

In 2006, it was the first state to pass a so-called individual mandate, enforced with a hefty fine, and now 97 percent of the state's residents are covered.

But as Karen Brown of member station WFCR reports, the idea of a mandate remains controversial.

KAREN BROWN: A recent survey found that almost 60 percent of Massachusetts residents approve of the state's insurance mandate. Gary Cloutier is not one of them.

Mr. GARY CLOUTIER (Owner, Cloots Auto Body Shop): You're forcing something down on my throat, and then you're penalizing me because I can't afford it.

BROWN: Cloutier is a stocky 47-year-old who owns his own auto body repair shop, two hours west of Boston. After the health care law passed, Cloutier was hoping to find an affordable insurance policy. He didn't qualify for the state's subsidized plan, and the cheapest private policy he could find was about $400 a month.

Mr. CLOUTIER: I'm already cut to the bone to begin with, and now you want me to come up with some money for coverage on something. Where am I supposed to get the money from?

BROWN: So despite the new law, Cloutier, like about 200,000 other people in Massachusetts, decided to go without. Niel Cronin says that's a problem.

Mr. NEIL CRONIN (Policy Analyst, Massachusetts Law Reform Institute): The whole premise behind health reform has been that insurance becomes more affordable when everybody's in the system.

BROWN: Cronin is with the Massachusetts Law Reform Institute which advocates for low-income consumers.

Mr. CRONIN: If you leave an insurance system only to the sick and the elderly, then the costs of that insurance rises dramatically for those people who are heavy utilizers. So the way to spread the risk is to get everybody on board.

BROWN: The state does acknowledge the predicament of middle-income workers like Gary Cloutier who makes too much to qualify for a subsidy but too little to afford insurance. They can apply for a waiver from the penalty, but that still leaves the dilemma of how to get those people insured. Most of them, according to one state survey, are healthy and young, exactly the people the mandate was supposed to bring into the system.

Mr. LUCAS WYANT: You know, I'm kind of nonchalant about it because nothing has ever happened to me. I'm sure if something big were to happen to me, then I would go, oh, man, I should have had health insurance.

BROWN: Lucas Wyant is a house painter, 27 years old and physically fit.

Mr. WYANT: I just try not to do anything too dangerous in my life, you know, like I actually think about not going downhill skiing and stuff.

BROWN: Wyant works for a small company that doesn't offer health benefits. For the past few years, his salary has been in the mid 30s, a hair too high to qualify for the publicly-funded plan. He could get a special policy designed for young people at just under $200 a month.

Mr. WYANT: Which I could pay for, but it would be a little bit hard for me to pay that much a month for something that I don't really use.

BROWN: Wyant says the only way he'll get insurance is if his wages drop and he qualifies for a state subsidy.

And in fact, more than half of the newly insured in Massachusetts are getting help from the state, but as the economy puts a strain on the budget, legislators are considering pulling back on the subsidy. That would leave more people in the private market, people like Mike Delaney, a self-employed title examiner, who bought insurance to comply with the mandate.

Mr. MIKE DELANEY: What it means practically speaking is, I can't take a decent vacation. I'm really not able to save any money toward retirement. I can't prepay my mortgage. I'm pretty much breaking even right now.

BROWN: The challenges facing the mandate in Massachusetts, a relatively wealthy state, could be even more daunting nationally. Most other states are starting with a larger uninsured population than Massachusetts did, and that could mean even greater strains on state and federal budgets, not to mention more opposition to an insurance mandate.

For NPR News, I'm Karen Brown.

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