Yesterday's House repeal of the Patient Protection and Affordable Care Act means that Republicans will now hone in on specific provisions of the law, most notably the individual insurance mandate that declares that all citizens must have health insurance coverage by 2014. Critics of this measure, including some Democrats, say that it is an unconstitutional assertion of government power. Supporters say that health care reform won't work without it, and that, with additional provisions that prevent insurers from denying coverage based on pre-existing conditions, insurers will find themselves in a financial bind, providing expensive care for the ill, with no healthy people to help cover costs.
Twenty-six states have launched lawsuits opposing the mandate, and the public continues to debate its potential impact, as well as what its elimination would mean for PPACA as a whole. For many of us, the biggest question is: what are our alternatives? Kaiser Health News spoke with seven health policy experts about their ideas for change.
Keeping the mandate
Judy Feder, professor at the Georgetown Public Policy Institute and senior fellow at the Center for American Progress, a public policy think tank in Washington, says that she's not ready to consider alternatives. "The requirement [that almost everyone have health insurance] is key to getting participation from the healthy as well as those more likely to be sick, people with preexisting conditions. That actually makes insurance effective in spreading risk so that we have people who are not sick helping people who are sick. That's what insurance is about. So the mandate is really quite critical to making insurance work and that's why it's part of the law. That says to me that fighting for it is the right thing to do."
Kavita Patel, a health policy expert and former Obama White House adviser, agrees that there is no real effective way to separate health care reform from this mandate. "It's the only way to make sure that everyone is on a level playing field, so we don't have to roll back the preexisting condition ban. The things that are great about the [health law] are not just in silos, they have to be connected, and the individual mandate is the one thing that holds them together. "
Robert D. Reischauer, president of the Urban Institute, also sees the mandate as something Democrats must cling to. "All the other policies are distant second bests," he says. "I don't think there is an alternative strategy especially if the government is fiscally constrained. If you had money to throw at the problem, then you could bribe people to participate, but we don't have the resources nor should they devote resources to something that can be effectively done through a regulation enforced with penalties."
Scheduled open enrollment
Robert Laszewski, consultant and president of Health Policy and Strategy Associates, says that the smart choice for Democrats is to eliminate the mandate and instead invoke scheduled open enrollments and increased premiums for people who enroll late. "We should let anybody buy health insurance, any time they want," he told KHN. "But if they don't buy it at the first enrollment, there should be a significant waiting period for preexisting conditions. So if you don't buy insurance right away, you can't expect to have your preexisting condition covered."
Paul B. Ginsburg, president of the Center for Studying Health System Change, agrees that the scheduled open enrollment approach would be an effective alternative. He also suggests reducing subsidies for late enrollees who are under 400 percent of the poverty line.
Subsidies first
Mark Pauly, health care economist at the Wharton School of Business and former adviser to President George H.W. Bush, helped develop the idea of an individual mandate back when he was an advisor. He believes the mandate is a critical piece of health care reform, but suggests testing the waters without it in the face of such strong objections. "I would prefer to have a mandate to mop up for the well-off uninsured, but I think in the short run we could make a lot of progress with the generous subsidies that are aimed at bringing in the great bulk of the uninsured," he says. "Then, we could see where we are and then we could talk about an individual mandate to round up the stragglers. I'd prefer to have one to be safe, but if people are going to get themselves all up in an uproar, then why don't we use the effective tool – subsidies – first and see if we really need it."
[Source: Kaiser Health News]
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