What to do about people who choose not to get health insurance?

A good friend and observer of the Health Reform debate asked:

"Satish, How do you see the government enforcing mandatory coverage? The current example of how difficult it is to make people buy auto insurace comes to mind."

Some thoughts come to mind:
I think some of the "uninsured" are involuntary, i.e. they would get insurance if they could afford it. These folks will get insurance if it is available and affordable. I have dealt with this in other posts.

Others are "discretionary", i.e. they are treat health insurance as a discretionary expense and choose to spend it instead on some thing else.

Recent research in Human decision making suggests a good method to address this is by changing the default. If we make the default option for every person who files an Income Tax form registration in some health insurance option then people who have insurance can send a "Certificate of Credible Coverage" to get a waiver, others get some "default" insurance. Just add it to the "tax" bill along with any applicable subsidies. Give folks some process for opting out but make opting in standard.

Naturally we would need to work out how the defaults are defined, what happens to gaps in coverage during the year etc. However the model of asking people to take specific action to opt out seems to lead to a superior public policy outcome.