A [1] recent Health Affairs article by Columbia
Universityfs Sherry Glied and coauthors is figuring prominently in the debate
over whether to require individuals to purchase health insurance as part of the
proposals to achieve universal coverage. In the race for the Democratic
presidential nomination, Sen. Hillary Clinton (NY) and former Sen. John Edwards
(NC) have included such an gindividual mandateh in their health reform plans,
while Sen. Barack Obama (IL) has declined to do so.
In gConsider It Done? The Likely Efficacy of Mandates for Health Insurance,h
Glied, Jacob Hartz, and Genessa Giorgi survey compliance with health insurance
individual mandates in the Netherlands, Switzerland, and Hawaii, as well as
compliance with mandates in other areas ranging from automobile insurance to
child support. They find that ghigh-compliance situations share several
features: Compliance is easy and relatively inexpensive; penalties for
noncompliance are stiff but not excessive; and enforcement is routine,
appropriately timed, and frequent.h
In [2] a Dec. 7 editorial, the Concord Monitor in Concord,
New Hampshire, cites Gliedfs article in arguing against requiring individuals to
purchase health coverage. gGovernment mandates have been used to force people to
buy auto insurance, immunize their children, pay child support and pay workers a
minimum wage. But compliance rates, according to the journal Health Affairs, are
far from universal; just 77 to 85 percent for immunization and 30 percent for
child support.h
But in [3] an article on the same date on The New Republic Web
site, Jonathan Cohn cites Glied in arguing for a health insurance individual
mandate. Calling Gliedfs work gthe most definitive paper on the subjecth of the
effect of mandates, Cohn says the Health Affairs article means that an
individual mandate can be effective in expanding health coverage if policymakers
get three things right: gMaking insurance affordable by restructuring the
insurance market and offering subsidies (which . . . all three Democrats would
do); creating an infrastructure for tracking exactly who has insurance; and
imposing real penalties on those who do not comply.h Cohn adds: gInterestingly,
the penalties donft have to be onerous, according to Glied. They just have to be
sufficient to make people think twice about turning down an opportunity to get
coverage.h
Cohn also contacted Glied to ask how much difference a mandate would make:
gAfter cautioning that she hadnft made any formal projections, she speculated
that a well-designed mandate might catch half to two-thirds of the people left
out by a purely voluntary scheme. And with automatic enrollment into a plan, she
added, the take-up could be higher. (All the candidates have indicated they
support automatic enrollment; but without a mandate preventing people from
opting out of coverage altogether, Glied said, it wouldnft have the same
effect.)h Cohnfs own estimate that Obamafs failure to include an individual
mandate could leave [4] 15 million people uncovered has been frequently cited in
campaign debates.
Stay tuned for more battles in the mandate wars. To read the Glied article
and decide on the meaning of its findings for yourself, click [5] here.