The federal health-reform train began rolling across America this summer, dropping off benefits at every stop along the way, offering coverage to children with pre-existing conditions, giving added protection to young people about to be removed from their parents' health plans, and setting up temporary high-risk pools for some unable to buy affordable insurance.

That's one view of the Patient Protection and Affordable Care Act, which President Barack Obama signed into law four months ago Friday. Another view is that this train is on an illegal run, set into motion by an overreaching federal government that is trying to force everyone to buy a product, health insurance, they might not want or need.

The prolonged debate over the law comes to a head in Missouri with the Aug. 3 primary, the day the state's voters will become the first in the nation to have their say on the federal health-insurance law. On the ballot is Proposition C, which asks voters whether Missouri law should be amended to deny the federal government authority to penalize a resident for refusing to buy health insurance. 

A Hot Issue

It's a measure on which voters like Jen Amunategui and Nick Kasoff don't see eye to eye. There are times when Amunategui asks herself whether the $240 she pays in premiums each month might be put to better use in the family's budget. But she dismisses the thought the minute she looks at her two young children and decides it would be irresponsible not to have coverage. A resident of Florissant, Amunategui, 44, manages a Starbucks and is grateful to have medical benefits. She dislikes Proposition C, fearing it could undermine a federal efforts to put affordable health insurance within nearly everyone's reach. According to the Congressional Budget Office, the new federal law means about 95 percent of Americans would have health insurance.

Kasoff, 44, a self-employed computer consultant from Ferguson, doesn't buy Amunategui's argument. The father of two, he thinks his $750 monthly health insurance premium is a pretty good deal. The only thing the federal law is guaranteed to do, he argues, is raise his premiums, perhaps beyond what he can afford. Not surprisingly, he will say yes to Proposition C when he walks into the voting booth on Aug. 3.

Though he will vote for Proposition C, Kasoff isn't convinced the measure will slow the momentum of the health reform train. So why support it?

"Because it takes the same amount time to say yes" as it does to vote no, Kasoff jokes, then adds in a serious tone, "I don't think it's going to do anything really, but I think it's making a statement" about mandates.

A statement about mandates is probably the key reason some voters are attracted to Prop C, says Dave Roland, policy analyst at the Show-Me Institute.

"I do think that a lot of people in this state are very unsettled by the idea that Congress can force people to purchase something that they don't want," he says. "It's helpful to recognize that the issue is not just health-care reform; that just happens to be the issue's current face. Rather, they're worried about what they see as a government willing and able to dictate more and more of their daily decisions."

Will this view prevail at the polls? There's a perception that proponents of the state measure are more organized and energized, but Roland cautions that "the timing of the vote leaves both parties room for all sorts of spin, given the unpredictable turnout of primary elections." The Missouri Secretary of State’s office says it expects only a quarter of Missouri's voters to turn out.

Hospital Association Raises Questions

Dave Dillon, vice president of media relations for the Missouri Hospital Association, confirms that the group is spending about $200,000 in direct mail to tell likely voters that approving the measure could mean higher health care cost for Missourians. But Dillon says that, contrary to some recent blog assertions, the association has been speaking publicly about the consequences of Proposition C from the time state lawmakers were holding hearings about putting the measure on the ballot. In addition to testimony at hearings, he says that the group posted its position on its website and that the association's CEO, Herb Kuhn, had written oped pieces about the proposal.

Dillon says the view that the association was making a last-ditch effort to tank the proposal probably stemmed from the fact that "everyone is looking for a counterpoint" to Prop C proponents, "and we've become by default a counterpoint."

Hospitals now get millions of dollars in federal subsidies for uncompensated care for uninsured patients. The health reform law requires more people to have health insurance. That will allow them to cover more of their medical expenses, lowering the amount of uncompensated care hospitals provide. It also will mean that hospitals will get fewer tax dollars, but the expansion of private insurance will ease the decline in this hospital revenue. If Missouri succeeds in opting out of the mandate that people buy insurance, the association notes that those without coverage would still get sick, and the state would be forced to pick up the tab for the care. The association estimates this could cost Missouri about $500 million.

Dillon also stressed that the association "is not against it (Proposition C) per se, but thinks people should know it will cost a lot if it passes" and is upheld by the courts. "We're not telling people to vote no, but that if you vote for it and it's upheld, there will be consequences. They (proponents of Prop C) talk about freedom. What we're saying is that the freedom to make a choice could cost more."

Two Kinds of Mandates

Ironically, some of those who complain about federal health-insurance mandates have no problem with mandates like the one requiring some coverage in Missouri for autism.

Roland makes a distinction between these two types of mandates, both of which he says are bad public policy. He says mandates like the one for autism mean people end up having to pay for “a whole set of coverages that they may not want or need. This makes insurance policies more expensive than they would otherwise need to be for the majority of people -- meaning that fewer people can afford to purchase coverage."

On the other hand, he says the federal health-care law not only mandates certain coverage but it "requires all adults to purchase one of these policies." Citizens would be better off, he says, if they could make their own decisions about what insurance coverage they need or whether they need insurance at all.

Notwithstanding the distinctions between the two kinds of mandates, Roland says "it is something of a contradiction" for a person to be for or against one mandate and not the other.

If Proposition C passes, Roland says, it has the potential of having a political effect, but not a legal effect. He cites the case of the Real ID act, the post-9/11 mandate involving federal regulations concerning state-issued driver's license and identification cards. Half the states passed laws or resolutions opposing the act. The upshot, Roland says, is that Congress has been unable to implement the bill's provisions.

If enough states balk, he predicts that "Congress will have little choice but to refrain from enforcing the health-insurance mandate -- and they may feel compelled to repeal it altogether."

Some States Oppose Health Mandate

It’s probably significant that about half the states did not approve initiatives challenging the federal health reform law. But opposition to it the health mandate has cropped up in many forms. Ballot measures similar to Proposition C will be put to voters in the November general election in Arizona, Florida, Louisiana and Oklahoma. Also, some state attorneys general, along with Missouri Lt. Gov. Peter Kinder, have filed lawsuits against the federal health provisions. These developments are in addition to decisions by Georgia, Idaho, Utah and Virginia to enact state statutes against the federal law.

The statutes are all similar, except in Utah, says Richard Cauchi, program director of the National Conference of State Legislatures health program. Utah seemed to have given more thought to the ramificaitons of saying no to the federal law. It's statute requires state agencies to report to the Utah Legislature the consequences of noncompliance with the federal health-care legislation and the effect that noncompliance would have on Utah's citizens.

Without taking sides in the national health reform debate, Cauchi says it's misleading to argue that regulatory control over insurance rests solely with states.

"Right now, states have a right to regulate insurance, but there is a big federal exception," he say, pointing to self-insurance programs set up by large employers, which are regulated by the federal government. 

for Health-care Law, against Prop C

Notwithstanding arguments by Proposition C proponents, the public should embrace rather than fear the public health-care law, says Ruth Ehresman, director of health and budget policy at the Missouri Budget Project. Speaking as a consumer, she acknowledges that the federal law might cause her own health premiums to rise, but says she expects them to rise at a slower rate because of health reforms.

Unlike Roland of the Show-Me Institute, Ehresman regards Proposition C as meaningless, a measure that, if approved, is likely to cause "a waste of state resources to defend against a constitutional challenge in the courts." It's a legal challenge that Ehresman and many others argue the state will lose. She adds that it is essential to develop insurance pools that include healthy people to extend affordable coverage to people with pre-existing conditions.

"Healthy people cannot be allowed to choose not to purchase insurance until they get sick," she says, adding that Missourians should focus on carrying out the federal law as efficiently as possible instead of "throwing up roadblocks." 

The Tea Party

One of the biggest roadblocks is perceived as coming from the Tea Party movement, a loosely organized operation that has come in for both praise and criticism as health reform moved through Congress and became law.

Some Republicans who say they do not belong to the Tea Party praise both the group and Proposition C alike. One is William Middleton, 62, who has retired from sales and marketing and now sells real estate part-time.

He's in favor of Proposition C, he says, because he lacks faith in the competence and integrity of Obama and other Democrats who had a hand in drafting the federal legislation.

On the other hand, no legislation out of Congress is perfect, argues Karl Frank, 34, a Democrat who is a computer consultant and a member of the Mehlville School Board. "I am very happy that something was finally done."

He feels the proponents have "created an environment of ignorance" by spreading misinformation about what Proposition C would do in relation to the federal law. He says the rhetoric by Proposition C proponents amounts to shouting to the rest of the country: "It's true! We really have no idea what we are talking about, and we don't care!"

But Frank's computer consultant counterpart from Ferguson, Nick Kasoff, would take issue with that characterization.

Sure, Kasoff says, Proposition C is the equivalent of "a politician making a speech." But there are grains of truth in what's being said, Kasoff adds. He especially believes the part about how federal spending causes taxes to rise.

"We don't have an experience of any federal program coming in below the estimated cost," he says.