One of the more thoughtful perspectives on health insurance mandates is published in the current issue of Health Affairs titled “Consider it Done? The Likely Efficacy Of Mandates For Health Insurance”, written by Sherry Glied, Jacob Hertz, and Genessa Giogi.
In presenting both the benefits and the challenges of using mandates to expand coverage, the authors make the observation that health insurance mandates are attractive to policy makers for the following reasons:
· “Mandates offer a way to address the problem of those who are already eligible for public programs but fail to obtain coverage, thus making coverage a more urgent concern.
· Mandates level the playing field, forcing employers or individuals who have been using publicly funded services to pay their fair share of the cost of coverage.
· Mandates can reduce the need for explicit public funding of new coverage, by substituting funds generated through the mandate for tax funds.
· Mandates can ease insurers concerns that only less healthy people will choose to participate in a new voluntary insurance program.
· And mandates can act as a legislative self-control device, binding the government to provide adequate subsidies to make compliance feasible.”
They note there are already in place a number of mandates outside of heath insurance that have existed for years including: automobile insurance, individual income tax (we don’t typically see income tax as a mandate, but it is), child support, childhood immunization, and minimum wage laws.
The efficacy of these mandates varies: The percentage of motorists who comply with automobile insurance mandates ranges from 66% to 96%, depending on each state; the number of people who voluntarily file the correct amount of taxes they owe on time is 84.5%; childhood immunization compliance ranges from 85% for states with immunization mandates to 77% in states without a mandate; studies of the minimum wage laws find compliance rates of 65-75%, with much variation among industries. The least successful mandate appears to be child support at 30%, depending on income level and the quality of the relationship between the parents.
The authors also suggest that the more successful mandates include several features: “Compliance is easy and relatively inexpensive; penalties for non-compliance are stiff but not excessive; and enforcement is routine, appropriately timed, and frequent.”
While it is difficult to predict the efficacy of the Massachusetts health insurance mandate, there are already significant initial accomplishments: Since July 2006, over 200,000 previously uninsured residents now have health coverage through the expansion of MassHealth and the implementation of Commonwealth Care, the health insurance program created to make the mandate more feasible. And it is also anticipated that thousands more will now purchase insurance through their employers, these are individuals who otherwise would have gone uninsured without the coercion of the mandate.
Recently I interviewed an uninsured woman who expressed resentment at being mandated to apply for health coverage. She explained that she’s relied on non-traditional health care not covered by health insurance, and she asked how could the mandate possibly help her. After some discussion, she did acknowledge that if she developed heart disease, cancer, or if she incurred other serious illnesses, or if she suffered an accident she could be vulnerable to thousands of dollars of medical debt.
My sense is that, unable to afford health coverage, she understandably protected herself by denying how vulnerable she really felt being uninsured. At its core, effective health insurance removes the financial barriers that prevent individuals from receiving health care, and protects individuals from financial harm.
At the end of the interview, she applied for Commonwealth Care, where the premium will cost her $70 a month. When she left the office she admitted she felt secure knowing that, if needed, she could now pursue medical care without fear of medical debt.
Over the next few years we will learn a lot from our experiences with the Massachusetts health insurance mandate. But already we are seeing some early successes, and these successes should be acknowledged from both a policy and a human perspective.
Charles Joffe-Halpern is the executive director of Ecu-Heath Care and the president of the Board of Directors of Health Care for All in Boston. He can be contacted at cjoffehalpern@nbhealth.org
A different perspective on the health insurance mandate.
Correct me if I’m wrong but it seems that this post’s author omitted a relevant fact about the newly insured that makes the final sentence below blatantly false and misleading to readers. The fact is that the vast majority of the newly insured are either totally state subsidized or significantly state subsidized and were automatically enrolled. In addition there is thus far scant evidence that we will witness any (cringe) success from “coercion of the mandate.”
To clarify, this is the post section to which I refer:
“…there are already significant initial accomplishments: Since July 2006, over 200,000 previously uninsured residents now have health coverage through the expansion of MassHealth and the implementation of Commonwealth Care, the health insurance program created to make the mandate more feasible. And it is also anticipated that thousands more will now purchase insurance through their employers, these are individuals who otherwise would have gone uninsured without the coercion of the mandate.”
As a health professional I have ethical and professional obligations to speak up on matters such as this flawed policy that is likely to have a major negative impact on the ability of my patients and the larger community to receive needed care.
The basic construct of a mandate approach that forces people to purchase a private insurance product that is sold to them at a profit is horribly flawed and morally wrong. Combine this inherent and glaring flaw with the law’s lack of any sensible cost controls and what you have is a landmark mandate plan that is reprehensible.
Plus a mandate approach such as this will not come anywhere near universal coverage granting timely affordable access to needed care for all.
Barack Obama gets this fact very clearly. See his great quotes disparaging private insurance mandates in the NYT’s article “It Was Clinton vs. Obama on Health Care” by Michael Cooper.
article link: http://www.nytimes.com/2007/11/16/us/politics/16facts.html?_r=1&n=Top/Reference/Times%20Topics/People/C/Cooper,%20Michael&oref=slogin
What will it take for other leaders to see through the misleading but feel good rhetoric, acknowledge the facts, and stop the mandate? The insurance industry along with the Heritage Foundation and Romney created this fiasco. Who will stop it before more people are traumatized by government threats and more are forced (”coerced”) to spend money that they really need for heat, food, and clothes for their kids?
On the cost aspect: Leading policy experts and even a few brave politicians have suggested that a place to start on cost controls is with excising the corporate profiteering out of the provision of health insurance. This profiteering and associated layers of wasteful bureaucracy diverts huge sums of healthcare dollars away from needed healthcare services. Let us not overlook the fact that a large portion of these funds are public funds paying for private insurance products and bloated CEO salaries etc.
If there are readers interested to gain a fuller sense of the Health Affairs article that is the subject of this post, the following line written by the authors in their article abstract might be useful:
“We find that mandates can, but do not always, increase participation in programs.”
The MA mandate law is an inherently flawed and cruel experiment. Sooner rather than later a new course must be charted toward real health reform.
P.S. to my above comment: While it is a very good thing that 200k people are newly insured, most with quality coverage (MCaid and Comm.Care, in contrast to a lot of stripped down coverage in Comm.”Choice”), it is still a very real fact that in full measure this new law with its mandate plan is bad health policy. The emperor has no clothes here, folks. More and more people are starting to see this. Soon they will act, as they should.
The financing mechanisms in the Chap 58 law bring us nowhere near “Fair Share Responsibility” (feel good false rhetoric) because many employers will largely get out of any shared responsibility by paying a measly $295 per year per uninsured employee fine while other employers who are trying to do their fair share will continue to carry an unfair burden, as will many families and individuals under “coercion of the mandate”. For more on this click here http://www.compartners.org/talk/2007/11/27/how-close-are-we-to-universal-coverage/
The state budget cannot sustain over time to maintain the subsidies using such an expensive and wasteful financing approach as private insurance with means-tested eligibility. The woman described in the original post here might soon be told by the state that to keep her new coverage she must pay much higher premiums along with co-pays and deductibles. This would occur if she was to earn a bit more income or if the state, as is being discussed, shifts costs by reducing subsidies in an effort to sustain this house of cards.
I wish the MA legislature had passed a better law. They didn’t. Now its time for them to get to work to honestly identify and acknowledge the problems and to fix them.
Why doesn’t someone actually look at the high cost of the medical care itself? It is easy to point to the insurance companies since everyone loves to hate insurance companies. Why does it cost between $25,000 and $100,000 per month, yes per month, for a hemopheliac to have a supply of factor VIII coogulant on hand? Why do premature babies cost between $1,000,000 and $2,000,000? Each chemotherapy treatment costs between $8,000 and $12,000. What about the CEO pay for some of the larger hospital organizations such as HCA? Have you been to a hospital lately? Nice big private rooms, flat screen TV’s, marble floors and mahogany paneling – where do you think they get the money to pay for that? I work for a Not-For-Profit insurance company with administrative expense running at about 12% which is comparable to some Non-Profit organizations. You can go ahead and point to the insurance companies all you want but when you get down to it, it is the cost of the care itself. In the U.S. our costs are double that of any other civilized western nation. I always love it when i hear someone say, “just let Medicare handle all the claims and cover everything”. Who do you think processes all the claims for Medicare? Not Medicare, the insurance companies.
Well said in both above posts, but let it be known from this working stiff’s perspective that BOTH aforementioned tentacles of our Sick-care Industrial Octopus are well beyond reasonable financial reach for many of us not ‘fortunate’ enough to be employed by corporate entities.
Mr. Frazier, I can respect your position of standing up for well-loathed insurance firms, though from out here in the trenches, the very existence of this newly-empowered middleman (’non’ -profit or no) isn’t adding any equity to the equation. For it to be so defies logic.
Would, say, a Pufts, Harvard Pillager (Pilgrim) or other ‘health’ insurance lackey think any given working stiff can be milked for $500. per month – and that this figure be indefinitely sustainable?
Sir, I can tell you that nothing makes the blood boil more quickly than sending off hard-earned dollars to said middleman each month, knowing you’ll get nothing in return, but certain beyond a doubt that next year’s premium will be 10% higher.
That’s why I haven’t had ‘health’ insurance coverage for 20 years, and I’m not going to pay for it now, either – regardless of how “fair” or “reasonable” it’s purported to be.
Mandates level the playing field, alright – for ‘health’ care corporations seeking to dip their greedy fingers deeper into what they see as a bottomless jar of cookies.
And you can take THAT to the bank, Pilgrim!
Dan Frazier makes excellent points. I agree that the excessively high prices of medical services, drugs, technology, etc, that we pay in the U.S. is a MAJOR cost control issue that must be tackled, and soon. My comment above is focused on insurance company waste b/c the topic of this thread is the state mandate law to purchase a private insurance product. I appreciate Dan’s additional comments. Dave H’s perspective has a lot of merit for this discussion, too!
Perhaps Mr. Joffe-Halpern could benefit from the following with regard to his continual support of this heinous mandate that will so adversely affect the majority of people it targets:
“We can have democracy in this country, or we can have great wealth concentrated in the hands of a few, but we can’t have both.”
United States Supreme Court Justice Louis Brandeis
Experience should teach us to be most on our guard to protect liberty when the Government’s purposes are beneficent. Men born to freedom are naturally alert to repel invasion of their liberty by evil-minded rulers. The greatest dangers to liberty lurk in insidious encroachment by men of zeal, well-meaning but without understanding.
United States Supreme Court Justice Louis Brandeis
And he, along with the our elected state officials, including Deval Patrick, should take notice of the following:
“The most important political office is that of the private citizen.”
United States Supreme Court Justice Louis Brandeis
Hey, this is personal. I’m 57 and my wife is 61. Too young for medicare. We’re both self employed (she’s partly retired). The critical line on our 1040 says we made $75K last year. I called Health Care for All and they told me that we “can only afford” (according to the state’s official schedules) $500 per month in premiums. But at our age and location, the cheapest plan available for us is $740 per month, they told us (which does not include prescription coverage). So, we won’t be penalized on our tax form next year because, “officially, we cannpt afford” insurance. Great! But what if I’d like to be covered for those big scary possibilities, like cancer or an accident. I was told I’m on my own to negotiate with the insurance companies.
So, I have spent hours pouring over plans, trying to figure out whether they cover my wife’s doctor (nobody covers mine), what our costs will be, etc. Our mortgage & real estate tax, on our condominium is $1500 a month. Well, many of these plans are close to that same amount, for the two of us! You do the math. Mortgage, real estate tax, and medical insurance. $1500 + another $1500 = $3000 per month. That’s $36000 per year. Almost half our entire income just for shelter and medical insurance! And this is mandated? We might as well move out of the Commonwealth. It is my back on which this entire thing is being balanced, and at this rate it’ll break before long.
So I hear the writers are on strike in California. The stage hands are on strike in New York. What I want to know is when do I get the chance to go on strike? Oh, it’s fault for being self employed and trying to create my own job in the economy, right?
Correct me if I’m wrong but it seems that this post’s author omitted a relevant fact about the newly insured that makes the final sentence below blatantly false and misleading to readers. The fact is that the vast majority of the newly insured are either totally state subsidized or significantly state subsidized and were automatically enrolled. In addition there is thus far scant evidence that we will witness any (cringe) success from “coercion of the mandate.”