Individual Health Insurance Mandate Research Articles

Effects of State-Level Individual Mandate on Veterans’ Access to Health Care in the United States

Following the repeal of the federal individual health insurance mandate, five states and D.C. adopted their own state-level individual mandates to counteract the potential negative consequences of the repeal. This study examines the actual changes in veterans’ enrollments in private and Veterans Affairs (VA) insurance following the 2019 repeal. By analyzing data from 65,297 non-elderly veterans aged 18 to 64 in the U.S. between 2019 and 2021, we found that state-level individual mandates have positive effects on veterans’ enrollments in private and VA insurance, but the effects vary depending on individual income levels. The state-level individual mandate successfully serves as a substitute for the federal mandate. The results imply that veterans in states without individual mandate policies are more likely to worry about health insurance premiums and medical bills, limiting access to health care and potentially worsening health outcomes. Thus, the Veterans Health Administration should endeavor to encourage more state governments to adopt individual mandate policies.

The Individual Health Insurance Mandate and Veterans Health Coverage

In December 2017, Congress repealed the individual insurance mandate penalty. Given the poor health status of veterans, their higher demands for health insurance, and the substantial number of uninsured veterans, the repeal of the individual mandate should have a significant impact on the veterans. This article investigates how the repeal of the individual mandate effective in January 2019 is likely to affect the number of uninsured veterans and their enrollments in Veterans Affairs (VA) insurance. By analyzing 52,692 nonelderly veterans in Florida and California from 2008 to 2017, the findings suggest that the repeal will lead to a considerable increase in the number of uninsured veterans. Veterans who are unemployed, poor, and suffering disabilities are more likely to sign up for the VA insurance than better-off veterans. Thus, one of the important functions of veteran health care is to serve as a social safety net for vulnerable veterans. Thus, the Veterans Health Administration should establish a policy to minimize the expected negative repercussions of the repeal.

Universal Healthcare Coverage and Subjective Wellbeing: Evidence From Massachusetts Healthcare Reform

In 2006, the state of Massachusetts sanctioned the individual health insurance mandate and the expansion of health insurance coverage through Healthcare Reform Law. I design a quasi-experimental study using the Behavioral Risk Factor Surveillance System (BRFSS) survey data sets from 2005 through 2010. In this study, I aim to analyze the trends in self-reported wellbeing before and after the Massachusetts healthcare reform. As most of the provisions took effect in late 2006, I consider 2007 as the first year post healthcare reform. I consider Connecticut as well as Other New England States including Connecticut (ONES) as control states where no healthcare reform was enacted. The difference-in-difference estimation approach is used to perform multivariate analysis. I find that individuals belonging to the state of Massachusetts post healthcare reform experienced significant improvement in the self-reported wellbeing relative to those living in Connecticut and ONES. This finding may results from the expansion of health insurance coverage, which reduces the financial stress and improves the mental health and wellbeing particularly among the low income families.

Solidarity and cost management: Swiss citizens' reasons for priorities regarding health insurance coverage.

ContextApproaches to priority‐setting for scarce resources have shifted to public deliberation as trade‐offs become more difficult. We report results of a qualitative analysis of public deliberation in Switzerland, a country with high health‐care costs, an individual health insurance mandate and a strong tradition of direct democracy with frequent votes related to health care.MethodsWe adapted the Choosing Healthplans All Together (CHAT) tool, an exercise developed to transform complex health‐care allocation decisions into easily understandable choices, for use in Switzerland. We conducted focus groups in twelve Swiss cities, recruiting from a range of socio‐economic backgrounds in the three language regions.FindingsParticipants developed strategic arguments based on the importance of basic coverage for all, and of cost‐benefit evaluation. They also expressed arguments relying on a principle of solidarity, in particular the importance of protection for vulnerable groups, and on the importance of medical care. They struggled with the place of personal responsibility in coverage decisions. In commenting on the exercise, participants found the degree of consensus despite differing opinions surprising and valuable.ConclusionThe Swiss population is particularly attentive to the costs of health care and means of reducing these costs. Swiss citizens are capable of making trade‐offs and setting priorities for complex health issues.

NFIB v. Sebelius and the Individual Mandate: Thoughts on the Tax/Regulation Distinction

Should Congress’s taxing power be broader than its regulatory power? Put differently, should the courts, on federalism grounds, be more willing to strike down federal laws that are adopted under the Commerce Clause than federal laws that are adopted under the taxing power? The Supreme Court thinks so. While the Court has on occasion held that Congress’s has exceeded its regulatory power by unconstitutionally encroaching on the regulatory domain properly reserved to the states, the Court has never found that Congress has exceeded its taxing power. Moreover, the Court recently (and famously) doubled-down on the position that Congress’s taxing power exceeds it regulatory power in the landmark case of National Federation of Independent Businesses v. Sebelius [“NFIB”], which upheld the Affordable Care Act’s “individual mandate” on taxing-power grounds. Whether it makes normative sense for the Court to treat Congress’s taxing-power as being broader than its regulatory power is the question this Article explores. The Article concludes that the way the Court has drawn the distinction between taxes and regulations, or between taxes and penalties (which, as I will point out, are a type of regulatory provisions), is both counter-intuitive and could create incentives that inefficiently alter Congress’s choices among various policy instruments. The Article also provides an alternative way of drawing the tax/regulation distinction that does not suffer from this problem. The Article ultimately concludes, however, that the tax/regulation dichotomy should probably be abandoned; and it concludes that the Supreme Court was right to uphold the Affordable Care Act’s individual health-insurance mandate, though for reasons different than ones the Court offered.

Is the Individual Health Insurance Mandate Constitutional?

The Supreme Court is about to hear a case of great legal and political importance. At issue is the constitutionality of the so-called “individual mandate” in the Patient Protection and Affordable Care Act, which requires most Americans to purchase health insurance starting in 2014 or pay a monetary penalty.The question is whether Congress exceeded its Constitutional power to regulate “Commerce...among the several States” (i.e., regulate interstate commerce) and to make laws “necessary and proper” to carry into effect that power. It’s unlikely the Obama Administration can justify the individual mandate as a regulation of interstate commerce. How can the failure to purchase health insurance in itself be considered commerce, let alone interstate commerce? If that is interstate commerce, what can’t Congress force us to purchase? For that reason, the outcome of the case will likely turn on whether the individual mandate is both “necessary” and “proper” to carry into effect Congress’s power to regulate interstate commerce. To succeed on the “necessary” test, the Obama Administration must make constitutional arguments that don’t have any logical limits and therefore give Congress vast powers over our lives, and this undermines its ability to show that the individual mandate also meets the “proper” test, which requires that it be consistent with “the letter and spirit of the constitution.”On its face, the individual mandate fails the proper test. It abandons the long-standing legal principle that legally binding contracts require mutual assent and cannot be coerced. This crosses a line the federal government has never crossed and effectively tramples on “The powers...reserved...to the people” under the Tenth Amendment. It is inconsistent with the fundamental concept of self-ownership that underlies the theory of natural rights in the Declaration of Independence - the idea that we own ourselves and, therefore, have the right to be left alone as long as we honor the equal right of others to be left alone.Beyond that, the Administration’s expansive view of the commerce power creates a sea of federal power limited only by islands of individual rights (and limits on using the commerce power to regulate non-economic activity), and that is inconsistent with the letter and spirit of the Constitution: It imposes virtually the same limits on federal and state power and, therefore, effectively gives the federal government the same “police powers” as the states. It puts liberty at risk by relying entirely on individual rights to protect us against things like mandated doctor visits and exercise. For example, the Supreme Court has found an unenumerated “right to liberty” only where there is no harm to others. The courts could easily decide that skipping annual physicals or living a sedentary life harms others by raising medical costs for some and insurance premiums for all. The Administration makes the following arguments to allay concerns about the threat to liberty its theories pose, but those arguments don’t stand up to scrutiny: The government imposes the equivalent of mandates all the time. Economic mandates are no more intrusive than regulations or prohibitions of chosen activity. Congress can use its taxing power to achieve the same ends, so using the commerce power is permitted. We can rely on the political process to protect our liberty.

Somebody Has to Pay

Somebody Has to Pay

Without The Individual Mandate, The Affordable Care Act Would Still Cover 23 Million; Premiums Would Rise Less Than Predicted

Many policy analysts fear that eliminating the individual health insurance mandate and penalty from the Affordable Care Act of 2010 would lead to a "premium spiral," in which healthy people would drop coverage, premiums would soar, and the number of people with coverage would plummet. However, there are other provisions of the law that would greatly mitigate this effect. For example, the subsidies provided in the law to help people purchase coverage through health insurance exchanges would restrain a premium spiral by absorbing much of the impact of premium increases. We estimate that if the mandate were lifted, premiums in the individual market would increase by 12.6percent-somewhat less than other estimates-with 7.8million people losing coverage, versus other estimates for coverage loss of 16-24million people. In sum, the Affordable Care Act would still cover 23million people who would have been uninsured without the law. Our study suggests that although the mandate would have important effects on premiums and coverage, it might not be essential to the act's successful implementation.

Effects of Healthcare Reforms on Coverage, Access, and Disparities: Quasi-Experimental Analysis of Evidence from Massachusetts

The 2010 Patient Protection and Affordable Care Act (PPACA) has been controversial. The potential impact of national healthcare reform may be considered using a similar set of state-level reforms including exchanges and a mandate, enacted in 2006 in Massachusetts. To evaluate the effects of reforms on healthcare access, affordability, and disparities. Interrupted time series with comparison series. Longitudinal survey data from 2002 to 2009 from the Behavioral Risk Factor Surveillance System including 178,040 nonelderly adults residing in Massachusetts, Vermont, New Hampshire, Rhode Island, and Connecticut. Analysis was conducted from January to August 2010. Massachusetts 2006 healthcare reform, which included an individual health insurance mandate. Being uninsured, having no personal doctor, and forgoing care because of cost, evaluated in Massachusetts and four comparison states before (2002-2005) and after (2007-2009) the healthcare reform. Effects on disparities defined by race, education, income, and employment also were assessed. Living in Massachusetts in 2009 was associated with a 7.6 percentage point (95% CI=3.9, 11.3) higher probability of being insured; 4.8 percentage point (-0.9, 10.6) lower probability of forgoing care because of cost; and a 6.6 percentage point (1.9, 11.3) higher probability of having a personal doctor, compared to expected levels in the absence of reform, defined by trends in control states and adjusting for socioeconomic factors. The effects of the reform on insurance coverage attenuated from 2008 to 2009. In a socioeconomically disadvantaged group, the reforms had a greater effect in improving outcomes on the absolute but not relative scale. Healthcare reforms in Massachusetts, which included a health insurance mandate, were associated with significant increases in insurance coverage and access. The absolute effects of the reform were greater for disadvantaged populations. This is important evidence to consider as debate over national healthcare reform continues.

Estimating Obamacare's Effect on State Medicaid Expenditure Growth: A Study of Five Most Populous U.S. States

Unless repeal attempts succeed, the Patient Protection and Affordable Care Act of 2010 (ObamaCare) promises to increase state government obligations on account of Medicaid by expanding Medicaid eligibility and introducing an individual health insurance mandate for all US citizens and legal permanent residents. Once ObamaCare becomes fully effective in 2014, the cost of newly eligible Medicaid enrollees will be almost fully covered by the federal government through 2019, with federal financial support expected to be extended thereafter. But ObamaCare provides states with zero additional federal financial support for new enrollees among those eligible for Medicaid under the old laws. That makes increased state Medicaid costs from higher enrollments by “old-eligibles” virtually certain as they enroll into Medicaid to comply with the mandate to purchase health insurance. This study estimates and compares potential increases in Medicaid costs from ObamaCare for the five most populous states: California, Florida, Illinois, New York, and Texas.The results suggest that Medicaid costs would increase considerably even on a pre-ObamaCare basis in California, Florida, and Texas — states with rising populations across many Medicaid eligibility and enrollment groups by age and gender. Cost increases on a pre-ObamaCare basis are projected to be smaller in Illinois and New York — states whose populations are projected to remain generally stagnant or decline during the next two decades. On a post-ObamaCare basis, the projected cost increase is small for California — just 4.5 percentage points in cumulative costs during 2014-23 compared to the pre-ObamaCare ten-year total cost projection. That’s because enrollment rates among “old-eligibles” are already high in California on a pre-ObamaCare basis, implying little scope for additional enrollment increases from the introduction of ObamaCare. In Florida and Texas, projected post-ObamaCare increases in Medicaid costs are larger, because these states are projected to have larger populations of non-enrolled “old eligibles.” Illinois and New York exhibit historically stable or declining enrollment rates among “old eligibles,” implying larger potentials for higher enrollments and increased costs when ObamaCare becomes effective after the year 2014.

Judge Strikes Down Individual Health Insurance Mandate

Judge Strikes Down Individual Health Insurance Mandate

The Private Action Requirement

The crucial issue in the ongoing litigation over the individual health insurance mandate is whether there is a constitutional distinction between the congressional regulation of action and inaction. Critics of the Patient Protection and Affordable Care Act say that Congress lacks the authority under the Commerce Clause to make citizens buy health insurance against their will. The individual mandate, they contend, is not a regulation or a prohibition of economic activity, which fall within the commerce power. Instead, the requirement is a regulation of inactivity (or compelled activity) that is unprecedented under the Commerce Clause and invalid.

Purchase Health Insurance or Else: Why Individual Health Insurance Mandates Enacted by the Federal Government are Unconstitutional

On March 23, 2010, President Obama signed comprehensive health care legislation into law. Although historic, attorneys general from twelve states have filed suit against the federal government challenging the constitutionality of the bill. Specifically, the constitutional challenges focus on the individual health insurance mandate included in the bill. The mandate requires that all citizens have health insurance by 2014 or pay a fine. This Comment analyzes the congressional powers provided by the United States Constitution and the Supreme Court's interpretation of those powers to show why the individual health insurance mandate is unconstitutional.

Health Care Reform in Massachusetts: Implementation of Coverage Expansions and a Health Insurance Mandate

Much can be learned from Massachusetts's experience implementing health insurance coverage expansions and an individual health insurance mandate. While achieving political consensus on reform is difficult, implementation can be equally or even more challenging. The data in this article are based on a case study of Massachusetts, including interviews with key stakeholders, state government, and Commonwealth Health Insurance Connector Authority officials during the first three years of the program and a detailed analysis of primary and secondary documents. Coverage expansion and an individual mandate led Massachusetts to define affordability standards, establish a minimum level of insurance coverage, adopt insurance market reforms, and institute incentives and penalties to encourage coverage. Implementation entailed trade-offs between the comprehensiveness of benefits and premium costs, the subsidy levels and affordability, and among the level of mandate penalties, public support, and coverage gains. National lessons from the Massachusetts experience come not only from the specific decisions made but also from the process of decision making, the need to keep stakeholders engaged, the relationship of decisions to existing programs and regulations, and the interactions among program components.

The National Individual Health Insurance Mandate

On March 23, 2010, President Obama signed into law the nation's first comprehensive health care reform bill, the Patient Protection and Affordable Care Act. Within weeks, twenty states filed lawsuits challenging the constitutionality of its most politically charged feature--an individual purchase mandate. By 2014, the bill requires most individuals to have health insurance. With certain exceptions (pertaining to income level and religious objections), individuals without qualifying coverage will pay an annual tax penalty reaching the greater of $695 ($2,085 per family maximum) or 2.5 percent of household income. (1) If anything, the tax penalty is too low compared with the cost of insurance, so it may not provide sufficient incentive for healthy individuals to purchase insurance. But it remains controversial because it compels people to purchase coverage they choose not to have, raising the question whether Congress can lawfully and ethically require individuals to contract with, and transfer money to, a private party. (2) To be sure, the individual mandate lacks a clear American precedent. (It has worked successfully in other countries, such as Australia.) Compulsory automobile insurance, for example, is a state requirement, operates as a condition of exercising the privilege of driving, and requires coverage for injuries to others (not the insured). Personal Freedom and Collective Goods in Conflict Opposing a mandate is understandable when viewed from an individual perspective: it interferes with economic freedom and constrains personal choice. In economic terms, it represents a compelled cross-subsidy. However, when viewed from a collective perspective, the mandate offers valuable social benefits. The absence of health insurance creates harmful consequences, including lower quality of life, increased morbidity and mortality, and higher financial burdens.(3) Since these consequences fall mostly on those who lack insurance, the decision to seek insurance arguably should be left to them. However, government is responsible for the wellbeing of the community, not particular individuals. Even if the decision were primarily self-regarding, its effects--illness and death--can be felt by all. Many individuals cannot afford insurance, but others choose not to insure; over nine million people with annual incomes over seventy-five thousand dollars had no coverage in 2007. (4) Yet many previously healthy people suffer illness or injury and end up requiring treatment in emergency departments, most of which is uncompensated. Free riders rely on society to pick up the costs (forty-three billion dollars in 2008) through higher insurance premiums (above one thousand dollars annually) and higher taxes (such as hospital subsidies, Medicaid, and Medicare). Individuals often delay purchasing insurance until they become ill, creating an adverse problem for insurers. At its worst, free-riding and selection create a downward spiral of higher premiums and a shrinking insurance pool, making everyone's health care less affordable. (5) The Mandate's Constitutionality The pivotal constitutional concern is that government will penalize individuals for failing to buy health insurance--for doing nothing--simply because they are legal residents of the United States. The states could undoubtedly mandate health coverage, as with the Massachusetts Health Care Reform Plan of 2006. But the federal government has limited power; its principal enumerated are to regulate interstate commerce and to tax for the general welfare. The Supreme Court, however, has broadly construed federal powers--known as the implied powers doctrine--to uphold laws that are necessary and proper. By this reasoning, the Court ought to uphold the constitutionality of the health insurance mandate. The power to regulate interstate commerce. The Supreme Court has interpreted the commerce power broadly, applying it to virtually every aspect of economic and social life. …

Emergency department use by the uninsured after health care reform in Massachusetts

The objective of this article is to determine if health care reform in Massachusetts in 2006 was associated with a change in ED utilization by the uninsured for asthma and upper respiratory tract infection (URI). We performed a retrospective pre-post study in an urban tertiary-care teaching hospital. Subjects included all patients, ages 2-54, who presented to the ED with asthma or URI from January 1 to July 31 for each of the 3 years before health care reform and for the period after the insurance mandate officially went into effect on January 1, 2008. We used chi-square analysis to compare the frequency of utilization of the ED by uninsured patients before and after the implementation of an individual health insurance mandate in Massachusetts. For the period before the implementation of health reform, an annual average of 301 ED visits for patients with either URI (average n = 131) or asthma (average n = 170) were identified. After health care reform, there were 366 visits found for URI (n = 132) and asthma (n = 234) over a similar time period. There was a statistically significant decrease in ED utilization by the uninsured for URI but not for asthma. As a secondary analysis, visits for patients covered by the uncompensated care pool (UCP) before health care reform was not different from the combined frequency of visits by the remaining uninsured covered by a health safety net pool and those who qualified for the state subsidized Commonwealth Care program after health care reform. In this study, health care reform was associated with a decrease in the number of uninsured patients who presented to the ED with URI but not asthma. This study is limited by its analysis of a single large institution and a limited set of diagnoses.

Health Policy And Political Will

Health Policy And Political Will

Breaux Calls for Individual Health Insurance Mandate

Breaux Calls for Individual Health Insurance Mandate

Did Medicaid expansions for pregnant women crowd out private coverage?

This paper documents the changing picture of health insurance coverage for pregnant women in the four-year period following Medicaid expansion and assesses the extent to which the crowding-out phenomenon may have influenced the observed trends. The report documents the distribution of insurance coverage for pregnant women in the post-expansion period and describes demographic characteristics of women covered under Medicaid. It examines the rate at which Medicaid-eligible women enroll in the program and addresses the crowding-out issue by comparing the trend in employer-sponsored coverage among poor and near-poor pregnant women with those among nonpregnant women and men of similar ages and incomes.