Why We Need the Minimum Coverage Mandate

SOURCE: AP/M. Spencer Green

Without the individual mandate, health care reform is unworkable and the consumer protections it provides become unenforceable.

By Jonathan Gruber, Judy Feder | December 14, 2010

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A district court judge in Virginia ruled yesterday that the “minimum coverage” requirement in the Affordable Care Act is unconstitutional. The opinion is clearly at odds with other rulings in Virginia and in Michigan, where courts upheld the law.

Judges may disagree, but there’s a consensus among legal and economic scholars that this requirement to purchase health insurance is essential to making health insurance available and affordable to everyone, without regard to health status or “pre-existing conditions.” Without this provision, the law is unworkable and the consumer protections it provides become unenforceable. As the issue wends its way through the courts, it is useful to review why this requirement is in the law and the valuable protections we have to lose if it’s eviscerated.

Today, limited affordable coverage in the small business and individual markets reflects the fact that purchasing health insurance is totally voluntary. Given that health insurance is expensive relative to family or small business incomes, people are reluctant to purchase protection unless and until they need health care. If people who need health care come to dominate an insurer’s policyholders, then insurance can no longer spread or “pool” risk—collect premium dollars from a broadly healthy group of purchasers to distribute to the minority among them who need costly care. For this reason, health insurers do everything they can to screen out or deny protection to people with care needs. The Affordable Care Act ended those practices.

Opponents of the Affordable Care Act claim we can change this behavior without a requirement that people buy health insurance, and simply prohibit insurers from denying health insurance based on pre-existing conditions. But states have tried and failed in this approach. Several states tried what are called “community rating reforms”—requiring health insurers to offer policies within a given area at the same price to all persons without medical underwriting. The result: dramatic increases in insurance prices and a rapidly shrinking insurance market. In other words, the markets failed.

The lesson—incorporated in the Affordable Care Act—is that effective insurance markets require not only requirements on insurers, but requirements that people buy insurance along with subsidies to make insurance affordable. All three legs of this three-legged stool are critical to effective health insurance.

What happens if requirement to purchase coverage is removed as Judge Henry Hudson ruled? One of us has estimated the effects using a microsimulation model similar to that used by the Congressional Budget Office to estimate the Affordable Care Act’s effects. The results are striking. Eliminating the minimum coverage provision would increase the average individual premium by 27 percent in 2019 and reduce the expansion of insurance coverage by three-quarters, from 60 percent to 12 percent of the 55 million people uninsured in 2019.

Removing the mandate would at the same time dramatically alter the “bang for the buck” in federal spending. While removing the mandate cuts the legislation’s coverage gains by more than 75 percent, it would reduce the spending by less than a quarter—as subsidies are increased to cover the higher premiums for the more modest number of the sicker uninsured who are most likely to participate.

Judge Hudson’s decision may be good politics but the policy implications will be devastating for millions of Americans. His decision jeopardizes putting affordable coverage out of reach for those who cannot find it now, especially those with pre-existing conditions. The Affordable Care Act seeks to improve our nation’s health system; Judge Hudson’s decision makes it worse.

Jonathan Gruber is a professor of economics at the Massachusetts Institute of Technology and Judy Feder is a Senior Fellow at the Center for American Progress.