A PERSPECTIVE ON THE HEALTH INSURANCE MANDATE by Charles Joffe-Halpern

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