Balancing on a ladder nearly 8 feet above the cobblestones of Faneuil Hall Marketplace , Daniel Forlano juggles for the crowds many a night. A fall could lead to serious injury, but Forlano does not worry much about that. Understated confidence is part of the comedy act.
At 31, he has been without health insurance for about a decade and cannot remember the last time he saw a doctor. He has heard vaguely about the state law taking effect today that requires every adult to have insurance. But he has tuned out the specifics.
"I didn't want to pay for insurance earlier, so why would I pay now?" he said.
The long-term success of the state's insurance initiative rests in large measure on the response of healthy young people. Without them, the total cost of the program could soar, because those with coverage would be older, sicker, and more likely to require costly services. And people age 19 to 39 make up nearly half of those without insurance -- totaling about 184,000, according to a state survey last year.
But many young people partying and working near the Marketplace on a recent night were not sold on getting insurance. As they smoked and talked outside the area's bars, most of those without insurance said they opposed state-mandated coverage.
Many were worried about how they would pay the premiums. Others said they would not skimp on beer or move to a less expensive apartment to pay for healthcare.
Forlano said he "totally disagrees" with the insurance mandate. Rather than buy coverage, the Cambridge resident said, he would pay the penalty -- $219 next year -- for going uninsured. When the penalty increases in 2009, he said, he may move to New Zealand, where his girlfriend lives. "I can work anywhere," he said.
Most of the young people interviewed were fuzzy on the specifics of the insurance requirement and had not focused on their options for coverage, despite a $3 million advertising campaign by the state agency overseeing the law and additional ad spending by health insurers -- some geared to young adults.
Young people have many options. Comprehensive plans are available to low-income people of all ages for state-subsidized monthly premiums ranging from $0 to $179. Limited coverage plans for 19- to 26-year-olds who do not qualify for subsidies can be purchased for as little as $119 a month in Boston. And other private plans with a variety of coverage options are available starting at about $160 for people age 18 to 39 in the city. Rates are higher in some other locations.
The state does not yet have figures on how many young people have obtained insurance since the law was passed last year.
In a June poll of Massachusetts residents conducted by the Harvard School of Public Health and two other organizations, 21 percent of people age 18 to 34 said they knew nothing about the law. After the details were explained, 38 percent of young people said they thought the law would help them.
Emeen Zarookian would like to have coverage, but said he has not been able to afford it on a musician's wages. Shouting over the din pouring out of Hennessy's on Union Street, Zarookian, 23, said he just paid $100 to be treated for a sinus infection. He was hoping his clogged sinuses would not hurt his performance with the Sterns, a five-member pop-rock band that was about to play the packed bar.
"It makes me nervous to not have insurance," said Zarookian, a Belmont resident who sings and plays bass. "I'd like to be able to go to the doctor more often."
Told that he may qualify for subsidized coverage, Zarookian brightened. "I'd rather see it go more like Canada -- free," he said, but added that a subsidy would help.
Chris Stern, the 24-year-old leader of the band, smoked a cigarette and said he had "no idea" what he was going to do about the insurance requirement.
"I guess I'm going to try to make more money so I can afford it, maybe in the fall," said Stern, who moved from Rhode Island to Allston last year. "I haven't had a checkup in five years. I'm still smoking, but I've had a streak of good health."
"If I can have subsidized health insurance, it will be worth it," he added. "But how do they think they're going to enforce it?"
The state will require all taxpayers to certify on their tax forms next year that they had insurance by Dec. 31 of this year. If they did not have coverage, and if insurance deemed affordable by the state was available, they will lose their personal tax exemption, $219. The following year, those who are not insured or exempted must pay a monthly penalty of up to half the cost of the premium for the least-expensive coverage.
One 24-year-old Boston waitress is not going to risk the fine. Her employer, the owner of the bar Cheers, is offering her insurance for the first time because of the new law, and she plans to buy it. The company, which previously offered coverage only to those working at least 40 hours, is extending the option to anyone with 36 hours.
"Whatever it costs me, it's worth it," said the waitress, as she walked around the Marketplace with a group of friends. She asked to remain anonymous because she is delinquent on several medical bills, she said. "When you're a female, you need health insurance."
Getting out of things is Jason Gardner's gig, and so far paying for insurance has been one of them.
The escape artist wriggles free from a straitjacket and 75 feet of rope, entertaining crowds at Faneuil Hall and elsewhere. Although he said it is unsettling not to have insurance, he is in no rush to buy coverage because of the expense and because he believes the government should provide free insurance to everyone.
"I will probably try to get free care again," said Gardner, 37, who has used state-paid care on occasion in Cambridge. But he may no longer qualify because the state is planning to change the eligibility rules.
One of the goals of the insurance initiative is to reduce what the state spends to reimburse hospitals and health centers for care provided free to low-income residents. The state is counting on shifting much of that money to insurance subsidies to provide more consistent and comprehensive healthcare.
While reluctant to buy insurance, Gardner said he understands the consequences for others if he remains without coverage, and that is spurring him to examine the new options.
"If I get very sick, my mother is going to be forced to take care of me," he said. "I would take away in one operation what she worked all her life to save."
Alice Dembner can be reached at firstname.lastname@example.org.