All into the insurance pool?

Rent, car repairs and credit card bills.

Add those up, and Kristin Schmitz, a 21-year-old Omaha hair stylist, doesn't have much left from her $20,000 annual salary.

That's why Schmitz, who says colds and the flu are the worst of her health problems, skips buying medical insurance.

“It's risky,” she said. “I just hope I stay healthy.”

But for Schmitz and millions of other Americans without coverage, to insure or not soon may no longer be a choice.

Legislation taking shape in Congress would require nearly all Americans to purchase insurance or face financial penalties. The mandate consistently has been part of key congressional proposals, including a bill the House is preparing to vote on, possibly as soon as this weekend.

The mandate is a pivotal part of leading House and Senate versions. Requiring everyone to carry insurance, supporters say, is essential to making insurance affordable, mainly by broadening the risk pool to include young and healthy people who currently go without coverage.

But the mandate is not a lock.

Senate and House bills still must be passed, merged and voted on by Congress, and unions and other groups continue to question the mandate idea because they fear too many people won't be able to afford the insurance even with government subsidies.

On top of that, some business organizations are leery and say provisions of the mandate could affect employers and potentially derail economic recovery.

Even the constitutionality of the mandate has been questioned.

And it's unclear whether the mandate could be enforced effectively and whether people might choose instead to pay penalties.

One potential benefit of the requirement is that it could slow increases in premiums for those who already have coverage, said Keith Mueller, a health insurance expert at the University of Nebraska Medical Center.

Hospitals that treat the uninsured pass along those expenses to insurance companies in the form of higher costs for medical services, he said. Insurance companies, in turn, pass along the higher costs to consumers through hikes in premiums.

An estimated 220,000 Nebraskans lack health insurance. The count is 288,000 in Iowa.

Schmitz has been uninsured for the past two years and so far has faced no big medical bills.

She figures she can't shell out money for health insurance when she has other bills to pay. She said she already has a tough time covering her $438 rent, $150 credit card payment and $100 phone bill.

“It's pretty tight,'' she said.

She does worry about someday getting slammed with big medical bills if she had a serious illness or accident.

Even though she's leery of a federal mandate, she likes that the congressional proposals would provide government subsidies based on income.

But even with subsidies, individuals and families might have to cover portions of premiums themselves, in some cases large amounts depending on income, according to an online calculator from the Kaiser Family Foundation. The calculator provides rough estimates of what households would pay under the key legislative proposals.

For example, under the Senate Finance Committee's version, a family of four headed by a 45-year-old making $65,000 would receive a subsidy of $3,449 toward an $11,080 premium. That would leave a balance of $7,631 for the family to cover, or about $636 a month.

“Our main concern is, if you are going to have a mandate, you have to make sure the affordability provisions are strong,” said Jennifer Carter of Nebraska Appleseed, a legal advocacy group for low-income people.

Business owners also are concerned about how a mandate would affect them.

Amanda Austin of the National Federation of Independent Business said it's likely that any final Senate bill will include a penalty for businesses not offering health insurance whose employees tap the federal subsidy for coverage. The Senate Finance Committee bill contains such a penalty.

The penalty would be a burden on businesses, particularly those still struggling because of the economy, she said.

Businesses that offer their employees health insurance worry that the congressional plans will create an uneven playing field and shift costs to private insurers, jeopardizing employer-sponsored insurance plans. Nationally, 60 percent of people have coverage through a job.

Cory Jensen owns I-Spy Mystery Shoppers in Ralston and says now would be a bad time to face fines. His business, which provides mystery shoppers to help businesses improve, slowed down slightly during the recession but has started to pick up.

He doesn't offer health insurance to his four employees and says he can't afford to be hit with government penalties. The Finance Committee bill would exempt employers with 50 or fewer workers, but Jensen said it's possible that threshold could change in a final bill.

Plus, he wants his company to grow to at least a couple of dozen employees and worries that he eventually could be affected.

Small businesses like Jensen's could benefit from certain provisions of the health care bills. The House bill would provide small businesses with tax credits to help them provide coverage.

Jensen said the tax credits would be a plus, but only if they are significant enough to make the coverage affordable.

President Barack Obama met with small-business owners last week to try to address their concerns, and administration officials followed up Tuesday with a briefing for small-business owners from across the country.

Obama said few people have a bigger stake in a health care overhaul than they do. He said the House version of a health care bill would help millions of small businesses, cut growing health care costs and was written with small-business owners in mind.

Some people, however, question whether Congress even has the authority to impose a mandate.

Mike Fenner, a professor of constitutional law at Creighton University, said it is likely that the constitutionality of the mandate would be challenged in court.

But he said it's unlikely such a challenge would succeed. The commerce clause of the Constitution would give Congress the authority to require people to have insurance, Fenner said. That clause allows Congress to regulate economic activity that has a substantial effect on the national economy, he said.

Enforceability still could be a problem, though.

January Angeles of the Center on Budget and Policy Priorities in Washington, D.C., said that if the subsidies aren't big enough, some people might choose to pay the penalty and skip the coverage. The House bill requires most Americans to have health insurance by 2013, with fines as much as 2.5 percent of income if they don't. It also would allow people to apply for hardship waivers if coverage is unaffordable.

Those who question whether people will follow the mandate point to how many people fail to follow requirements that drivers buy auto insurance and how many people currently eligible for free Medicaid coverage don't enroll.

Angeles said young, healthy people would be those most likely to take the penalty because they figure they don't have use for health insurance.

It's essential to have more young people buying insurance — and not making claims — to compensate for older Americans in the pool, said Dr. Richard O'Brien of the Center for Health Policy and Ethics at Creighton University.

There already is a problem of uninsured young adults, according to a report by the Commonwealth Fund. Kristin Schmitz is among more than 13 million young adults nationally lacking health insurance.

Contact the writer:

444-1122, michael.oconnor@owh.com