Individual Mandate Research Articles

Health Expenditure Difference according to Individual Copayment in National Health Insurance System

Background: South Korea adopt a mandatory national health care system covering all citizens and consisting of the National Health Insurance System (NHIS) and Medical Aid Program (MAP), which cover individuals of non-low and low Socioeconomic Status (SES), respectively. Objective: We investigated and compared the medical expenses per claim in South Korea for SES individuals, to predict health care expenditure and provide fundamental data regarding care for individuals with limited finances. Methods: The inpatient data on NHIS and MAP beneficiaries were derived from the National Health Insurance Statistical Annual Report of South Korea from 2011 to 2015. Medical expenses per claim for the NHIS and MAP were investigated by gender and age, and the ratio of expenses per claim under MAP to that under NHIS was calculated. Results: The ratio from 2011 to 2015 was consistently larger than 1 and increased at an inconsistent rate with each consecutive age group until 30-39 years, and decreased thereafter (Males: 1.09-3.47, Females: 1.07-1.95). Conclusion: The results of this study indicated that higher medical expenditures and longer durations of claim in the low SES group may become obstacles to developing a sustainable health care system. The government should induce social activities of working-age low-SES people to reduce the burden on the government and help them lead a healthy life.

Does the Individual Mandate Affect Insurance Coverage? Evidence from Tax Returns

We estimate the effect of the ACA’s individual mandate on insurance coverage using regression discontinuity and regression kink designs with tax return data. We have four key results. First, the actual penalty paid per uninsured month is less than half the statutory amount. Second, nonetheless, we find visually clear and statistically signifi-cant responses to both extensive margin exposure to the mandate and to marginal increases in the mandate penalty. Third, we find substantial heterogeneity in who responds; men are especially responsive. Fourth, our estimates imply fairly small quantitative responses to the individual mandate, especially in the Health Insurance Exchanges. (JEL G22, H24, H51, I13, I18)

Regulations and Standards Aware Framework for Recording of mHealth App Vulnerabilities

The authors describe a standards-based security framework for the purposes of recording security and privacy vulnerabilities discovered in mHealth apps. The proposed framework is compliant with the international standard for software architecture descriptions, ISO/IEC/IEEE 42010, relevant state-agency regulations, and US federal healthcare mandates, as well as computing standards for data interchange formats. Future real-life implementations are envisioned to consists of three key components: (1) design and implementation of a repository that links vulnerabilities to concepts from the taxonomy used by legislative and standardization bodies; (2) population of the repository with security vulnerability descriptions that follow a standard format, such as JavaScript Object Notation (JSON); and (3) implementation of a searchable user interface (e.g., Google's Firebase UI), which allows for aggregation statistics, data analytics, as well as public access to the repository. The proposed framework design promotes timely updates of regulations, standardization drafts, and app development platforms.

Causes, pattern, predictors, and prognostic implications of new hospitalizations after transcatheter aortic valve implantation: a long-term nationwide observational study.

AimsThe aim of this study was to investigate the pattern, causes, and predictors of all new hospitalizations in patients who underwent transcatheter aortic valve implantation (TAVI).Methods and resultsThe nationwide Swedish TAVI registry was merged with other mandatory healthcare registries, which enabled the analysis of all TAVI procedures, new hospital admissions, and death between the years 2008 and 2017. A total of 2821 patients underwent TAVI with a mean of 2.5 hospitalizations during a mean follow-up of 2.2 years. Hospitalizations were associated with worse prognosis. Heart failure (HF) was the most common cause of hospitalization with 19% having at least one hospitalization due to HF causing, 16% of all-cause admissions, and 50% of cardiovascular admissions. Male gender, age >90 years, high Charlson Comorbidity Index, atrial fibrillation, present neurologic disease, severe renal impairment, peripheral vascular disease, New York Heart Association class IV, mild or moderate mean aortic valve gradients, and pulmonary hypertension were associated with an increased risk for all-cause hospitalizations or death. For cardiovascular hospitalization or death, the pattern was similar, with the addition of impaired systolic left ventricular function as a predictor.ConclusionMultiple hospitalizations after TAVI are common and are often caused by HF. Reducing the rate of HF hospitalizations is important to mitigate the burden on the healthcare system due to new hospitalizations after TAVI.

Protecting and Expanding Medicaid Access: Confronting Health Disparities Compounded by COVID-19.

Protecting and Expanding Medicaid Access: Confronting Health Disparities Compounded by COVID-19.

Are the costs of employer-sponsored health insurance passed on to workers at the individual level?

Because employer-sponsored health insurance (ESI) is experience rated, employers have an incentive to try to offset its cost by paying lower wages to employees who have greater medical expenditures. The existing evidence on this topic, however, illustrates only that ESI is associated with lower wages for groups of workers who are costlier to cover. In contrast, I use the variation provided by the Affordable Care Act's employer mandate to examine if differences in medical expenditures are passed on to workers at the individual level. My estimates rely on Medical Expenditure Panel Survey data in a dose response difference-in-difference framework that examines how wages change for workers with varying medical expenditures when they must soon be offered ESI. I find that each $1 difference in medical expenditures is associated with a $0.35 to $0.51 wage offset after the employer mandate's announcement wherever ESI must soon be offered to workers. Placebo analyses, focusing on workers whose employers are not affected by the mandate, provide support for a causal interpretation. I also show that my findings are not sensitive to sample selection or data reliability issues and that they cannot be explained by the effects of the Great Recession, demographic characteristics that correlate with medical expenditures, or location- or industry-specific idiosyncratic shocks.

Threats to the Affordable Care Act and surgical care: What has been gained, and what could be lost

Eleven years after the passage of the Affordable Care Act (ACA) in 2010, it remains under attack from its political opponents and defended by its supporters. As the most sweeping health reform legislation since Medicare and Medicaid were enacted in 1965, the ACA had 3 primary goals, namely (1) increasing access to affordable health insurance, (2) reducing the cost of health care, and (3) improving health care quality. Although some ACA policies have garnered bipartisan support (eg, the dependent coverage provision enabling young adults to remain on their parents’ health insurance plans until age 26), other policies have been met with numerous legislative and judicial challenges and claims of unconstitutionality (eg, the individual mandate which financially penalized anyone who did not have health insurance).

Optimal Public Provision of Private Goods

How does a private market influence the optimal design of a public program? In this paper, I study a designer who has preferences over how a public option and a private good are allocated. However, she can design only the public option. Her design affects the distribution of consumers who purchase the private good—and hence equilibrium outcomes. I characterize the optimal mechanism and show how it can be computed explicitly. I derive comparative statics on the value of the public option and show that the optimal mechanism generally rations the public option. Finally, I examine implications on the optimal design when the designer can intervene in the private market or introduce an individual mandate.

The Affordable Care Act's Coverage Impacts in the Trump Era.

The 2016 US presidential election created uncertainty about the future of the Affordable Care Act (ACA) and led to postponed implementation of certain provisions, reduced funding for outreach, and the removal of the individual mandate tax penalty. In this article, we estimate how the causal impact of the ACA on insurance coverage changed during 2017 through 2019, the first 3 years of the Trump administration, compared to 2016. Data come from the 2011–2019 waves of the American Community Survey (ACS), with the sample restricted to non-elderly adults. Our model leverages variation in treatment intensity from state Medicaid expansion decisions and pre-ACA uninsured rates. We find that the coverage gains from the components of the law that took effect nationally—such as the individual mandate and regulations and subsidies in the private non-group market—fell from 5 percentage points in 2016 to 3.6 percentage points in 2019. In contrast, the coverage gains from the Medicaid expansion increased in 2017 (7.0 percentage points) before returning to the 2016 level of coverage gains in 2019 (5.9 percentage points). The net effect of the ACA in expansion states is a combination of these trends, with coverage gains falling from 10.8 percentage points in 2016 to 9.6 percentage points in 2019.

Suggested Version of the Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act, abbreviated as PPACA or ACA, was enacted by former President Barack H. Obama on March 23, 2010. The purpose of creating this welfare is to make more people have better insurance. After six years of implementation, in 2016 the people covered by this plan were estimated from 20 to 24 million, representing the most influential healthcare policy after Medicare and Medicaid laws passed in 1965. Asserting that the policy will harm the economy, President Donald J. Trump eliminated the individual mandate of purchasing insurance, allowed states to remove insurance to unemployed people, and reduced governmental subsidy of purchasing insurance, which significantly decreased the number of people insured. Critics of Obama’s version of the ACA have claimed that such policies will harm the economy, increase debt, and severe unemployment (Manchikanti et al., 2016). However, after analyzing data, economic theories, and current economic situations, it was concluded that this policy will provide $1 trillion of spillover revenue to the economy, pay off all the previous debts, and increase employment (Furman, 2015). Therefore, Obama’s 2010 original ACAshould be re-implemented. Also, to maximize the positive impact on the economy, Obama’s original version of the ACA should provide more financial assistance. The proposed policy for the 2021 healthcare plan contains the following: To mandate the government, employers, and individualsto provide or purchase insurance, as well as to cancel the Bronze class in the ACA and increase the coinsurance rate of all other classes for 10% each. This policy issue is important as it will improve the living conditions ofmillions of people; and will positively influence the economy. In the following contents, Obama’s 2010 original ACA policy will be abbreviated as “original ACA”, and Trump’s 2017 ACA will be abbreviated as “2017 ACA”.

Constitutional Review of Federal Fiscal Legislation

What does the Constitution mean when it says that “The Congress shall have Power To lay and collect Taxes, Duties, Imposts and Excises, to pay the Debts and provide for the common Defence and general Welfare of the United States” (US Const. Article I, Section 8, Clause 1)? The definition of “tax” for constitutional purposes has become important in light of the Supreme Court’s 2012 decision in NFIB v. Sebelius, in which Chief Justice Roberts for the Court upheld the constitutionality of the individual mandate of the Affordable Care Act under the taxing power. This has led to commentators questioning the utility of Roberts’ distinction between a “tax” (where Congress’ power is almost unlimited) and a “regulation” (where Congress’ power under the Commerce Cause is limited). We would propose a different distinction. A “tax” for purposes of the Taxing Clause is a pure tax, namely a tax implemented for raising revenue for the government “to pay the Debts and provide for the common Defence and general Welfare of the United States”. In addition, pure taxes can legitimately be used for distributive purposes, i.e., to reduce inequality. Even a pure tax has constitutional limits, but they are relatively few. This should be distinguished from a regulatory tax, i.e., a tax whose main purpose is not to raise revenue but to change taxpayer behavior. Regulatory taxes include Pigouvian taxes (e.g., tobacco taxes and carbon taxes) designed to reduce negative externalities and tax expenditures (deviations from a normative tax base). Regulatory taxes should be subject to constitutional review under various clauses of the Constitution including the Due Process Clause, the Equal Protection Clause, and the limits on the Commerce Clause. The penalty imposed by the individual mandate of the ACA, which was repealed in 2017, was a regulatory tax and therefore (contrary to Chief Justice Roberts’ view) subject to the limits on Congressional power under the Commerce Clause. Any actual tax has more than one purpose. All taxes influence behavior, and therefore come within our definition of regulatory taxes, and all taxes produce some revenue and effect some redistribution, and therefore come within our definition of pure taxes. But some taxes are primarily regulatory (e.g., Pigouvian taxes) while others are primarily for revenue (e.g., Value Added Tax, VAT) or redistribution (e.g., the personal income tax, PIT). Other taxes have multiple purposes (e.g., corporate income tax, CIT, which has revenue and redistribution as well as regulatory aims). Moreover, any given tax may have multiple provisions with different aims (e.g., the many tax expenditures embedded within PIT and CIT). When evaluating the constitutionality of any given tax provision, a court should first classify it as either a pure tax provision or a regulatory tax provision. If it is the former, the court should generally hold that it is constitutional under the Taxing Clause. If it is the latter, the court should evaluate it against the limits imposed by the rest of the Constitution.

Suspect Spheres, Not Enumerated Powers: A Guide for Leaving the Lamppost

Despite longstanding orthodoxy, the Constitution’s enumeration of congressional powers does virtually nothing to limit federal lawmaking. That’s not because of some bizarrely persistent judicial failure to read the Constitution correctly. It’s because the enumeration of congressional powers is not a well-designed technology for limiting federal legislation. Rather than trying to make the enumeration do work that it will not do, decisionmakers should find better ways of thinking about what lawmaking should be done locally rather than nationally. This Article suggests such a rubric, one that asks not whether Congress has permission to do a certain thing but whether a certain kind of lawmaking is more prone to pathology at the national or the state level. That inquiry could identify “suspect spheres”: areas of policymaking where federal law calls for more justification than elsewhere. Federal legislation within suspect spheres would not necessarily be subject to judicial invalidation, but the judgment that legislation falls within a suspect sphere could underwrite softer forms of judicial resistance to nationalization. We illustrate the suspect-spheres model with a principle of federalism we call the corporate nondelegation doctrine, by which federal delegations of power to private corporations are to be treated skeptically. Early on, that principle animated Madison’s opposition to the Bank of the United States and much of the Jacksonian approach to federalism. It later underwrote the Supreme Court’s decision in Schechter Poultry. In the current century, the idea that the corporate nondelegation doctrine defines a suspect sphere helps explain otherwise puzzling judicial behaviors in federalism cases, including the presumption against preemption and the resistance to the individual mandate of the Affordable Care Act. By illustrating the possibility of a suspect-sphere approach, we suggest a tool that might be useful at a time of destructively polarized national politics, when rubrics for allocating some polarizing issue spaces to state-level decisionmakers might help lower the national temperature.

Healthcare financing and social protection policies for migrant workers in Malaysia.

For Malaysia, a nation highly dependent on migrant labour, the large non-citizen workforce presents a unique health system challenge. Although documented migrant workers are covered by mandatory healthcare insurance (SPIKPA), financial constraints remain a major barrier for non-citizen healthcare access. Malaysia recently extended protection for migrant workers under the national social security scheme (SOCSO), previously exclusive to citizens. This study aims to evaluate healthcare financing and social security policies for migrant workers to identify policy gaps and opportunities for intervention. A total of 37 in-depth interviews were conducted of 44 stakeholders from July 2018 to July 2019. A mixed-methods analysis combining major themes from qualitative interviews with policy document reviews was conducted. Descriptive analysis of publicly available secondary data, namely revenues collected at government healthcare facilities, was conducted to contextualise the policy review and qualitative findings. We found that migrant workers and employers were unaware of SPIKPA enrolment and entitlements. Higher fees for non-citizens result in delayed care-seeking. While the Malaysian government nearly doubled non-citizen healthcare fees revenues from RM 104 to 182 million (USD 26 to 45 million) between 2014 to 2018, outstanding revenues tripled from RM 16 to 50 million (USD 4 to 12 million) in the same period. SPIKPA coverage is likely inadequate in providing financial risk protection to migrant workers, especially with increased non-citizens fees at public hospitals. Undocumented workers and other migrant populations excluded from SPIKPA contribution to unpaid fees revenues are unknown. Problems described with the previous Foreign Workers Compensation Scheme (FWCS), could be partially addressed by SOCSO, in theory. Nevertheless, questions remain on the feasibility of implementing elements of SOCSO, such as recurring payments to workers and next-of-kin overseas. Malaysia is moving towards migrant inclusion with the provision of SOCSO for documented migrant workers, but more needs to be done. Here we suggest the expansion of the SPIKPA insurance scheme to include all migrant populations, while broadening its scope towards more comprehensive coverage, including essential primary care.

Empowering Nurse Executives to Advocate for Surgical Smoke–Free Operating Rooms

Evacuating surgical smoke in the operating room protects patients and perioperative teams from the hazards associated with inhaling surgical smoke. States have passed bills mandating health care facilities and ambulatory surgery centers adopt policies to evacuate surgical smoke. We use a 5-step process for identifying options to reduce exposure to the harmful toxins found in surgical smoke and recommend executive nurse leaders collaborate with states and professional organizations to pursue smoke evacuation legislation. This strategy empowers executive nurse leaders and perioperative teams to work with professional organizations and state legislators to reduce exposure to the harmful health hazards associated from surgical smoke.

"Sex Can Be a Great Medicine": Sexual Health in Oncology Care for Sexual and Gender Minority Cancer Patients.

Until recently, sexual and gender minority (SGM) people have been largely invisible in health care and health services research. However, understanding the needs and experiences of SGM cancer patients is critical to providing high-quality care, including needs and experiences related to sexual health. In this narrative review, we highlight that the literature on sexual health for SGM people with cancer is lacking, summarize existing literature on disparities affecting SGM patients with cancer, and discuss factors associated with these disparities. We conclude with recommendations and suggestions for future research in this area. Emerging evidence suggests that SGM people are at a higher risk for breast, cervical, endometrial, HPV-related, and lung cancers, as well as poor cancer outcomes, due to behavioral risk factors and health care system factors (e.g. lower access to health care insurance, discrimination in non-affirming care settings, negative health care interactions with providers). Additional research suggests that lack of clear guidelines for cancer screening in SGM patients, particularly for transgender and gender diverse patients, negatively impacts cancer screening uptake among SGM people. A growing number of studies have suggested greater sexual challenges following cancer treatment for sexual minority men with prostate cancer, while other studies highlight positive outcomes for sexual minority women following cancer treatment, such as benefit finding and resilience. Research on transgender and gender diverse patients is lacking. Collection of sexual orientation and gender identity data across clinical enterprises and population-based surveys, mandatory health care provider training on cultural and clinical competency with SGM patients, and additional research inclusive of and focused on SGM cancer patients are key strategies to advance evidence-based clinical cancer care for diverse SGM populations.

Pandemics, Paid Sick Leaves, and Tax Institutions

The COVID-19 pandemic is currently ravaging the world, and the United States has been largely unsuccessful at containing the coronavirus. One long-standing policy failure stands out as having exacerbated the pandemic in our country: the lack of a national mandate of paid sick leaves, without which workers face financial and workplace-cultural pressures to attend work while sick, thus spreading the virus to their fellow employees and the public at large.This Article provides the blueprint for a national, subsidized mandate of paid sick leaves and two additional insights about our tax institutions as mechanisms of effectuating broader societal goals. It first justifies a paid-sick-leave mandate on the grounds of market failures (both cognitive biases and externalities) and workplace equality. It also argues for the need of subsidies in order to protect lower-income workers from unemployment risks imposed by a national mandate. Second, the Article critically assesses the current federal legislative approach utilized in the Families First Coronavirus Response Act (FFCRA). The Article then proposes designing a national employer mandate of paid sick leaves funded by general-revenue business tax credits and providing partial wage replacement.This Article’s discussion of paid sick leaves yields two insights about our tax institutions. First, it questions the role of payroll taxes, which are highly regressive, impose burdens almost exclusively on labor, and are normatively unjustified when the spending funded by payroll taxes benefits the broader non-wage-earning public. Second, the Article reveals the malleability of tax institutions with respect to funding, administrability, and costs. These comparative advantages of tax institutions make them perennially popular in times of crisis.

Expanding mandatory healthcare personnel immunization beyond influenza: Impact of a broad immunization program with enhanced accountability.

Evaluation of a mandatory immunization program to increase and sustain high immunization coverage for healthcare personnel (HCP). Descriptive study with before-and-after analysis. Tertiary-care academic medical center. Medical center HCP. A comprehensive mandatory immunization initiative was implemented in 2 phases, starting in July 2014. Key facets of the initiative included a formalized exemption review process, incorporation into institutional quality goals, data feedback, and accountability to support compliance. Both immunization and overall compliance rates with targeted immunizations increased significantly in the years after the implementation period. The influenza immunization rate increased from 80% the year prior to the initiative to >97% for the 3 subsequent influenza seasons (P < .0001). Mumps, measles and varicella vaccination compliance increased from 94% in January 2014 to >99% by January 2017, rubella vaccination compliance increased from 93% to 99.5%, and hepatitis B vaccination compliance from 95% to 99% (P < .0001 for all comparisons). An associated positive effect on TB testing compliance, which was not included in the mandatory program, was also noted; it increased from 76% to 92% over the same period (P < .0001). Thoughtful, step-wise implementation of a mandatory immunization program linked to professional accountability can be successful in increasing immunization rates as well as overall compliance with policy requirements to cover all recommended HCP immunizations.

Freed from insurance: Health care sharing ministries and the moralization of health care.

Since the Affordable Care Act (ACA) was passed in 2010, health care freedom has become a kind of mega-narrative trumpeted by Republicans leaders who decry government overreach. I turn to faith-based, non-profit organizations called "health care sharing ministries"(HCSMs) to consider the work that this mega-narrative does in everyday health care lives. While HCSMs are not insurance, HCSMs share in the payment of medical bills and are written into the ACA as one religious exemption to the individual mandate. Based on ethnographic interviewing done with 31 people in Maryland, Ohio, Virginia, and Pennsylvania between 2015 and 2020, I examine the ways that Americans who belong to HCSMs take up freedom as a guiding frame to reflect on and moralize their health care. I argue that articulations of freedom in HCSMs involve freedom from the constraints of bureaucratic care and governmental control and are tethered to a single, overarching moral discourse that presents freedom as the freedom of choice. I suggest, therefore, that being a part of an HCSM is about getting health care-including getting it cheap-but it is also about how the health care makes people feel as moral persons in the current political climate of U.S. life.

Equilibrium Labor Market Search and Health Insurance Reform

We present and empirically implement an equilibrium labor market search model where risk averse workers facing medical expenditure shocks are matched with firms making health insurance coverage decisions. Our model delivers a rich set of predictions that can account for a wide variety of phenomenon observed in the data including the correlations among firm sizes, wages, health insurance offering rates, turnover rates and workers' health compositions. We estimate our model by Generalized Method of Moments using a combination of micro data sources including Survey of Income and Program Participation (SIPP), Medical Expenditure Panel Survey (MEPS) and Robert Wood Johnson Foundation Employer Health Insurance Survey. We use our estimated model to evaluate the equilibrium impact of the 2010 Affordable Care Act (ACA) and find that it would reduce the uninsured rate among the workers in our estimation sample from 20.12% to 7.27%. We also examine a variety of alternative policies to understand the roles of different components of the ACA in contributing to these equilibrium changes. Interestingly, we find that the uninsured rate will be even lower (at 6.44%) if the employer mandate in the ACA is eliminated.

Long‐standing lawsuit settlement marks continued reform of LA County MH system

A settlement agreement reached in the long‐standing Katie A. et al. v. Diana Bontá et al. case will require Los Angeles County to increase intensive home‐based mental health services for foster children who have been through multiple placements and/or in group homes or psychiatric hospitals. The class action lawsuit, originally filed on July 18, 2002, challenged the county and state agencies for not providing legally mandated health care services to treat the mental health conditions of children.