Would These Alternative To Health Reform Mandates Work?

Nine categories of “voluntary alternatives” to the mandates in the Patient Protection and Affordable Care Act (ACA, P.L. 111-148) might encourage more individuals to enroll in private insurance coverage, according to the assessments of health care experts interviewed by the Government Accountability Office (GAO).

After looking over the alternatives, let us know if you think they would reduce the number of uninsured by more than 30 million (the approximate reduction predicted for the ACA)?

At the request of Sen. Ben Nelson (Neb.), the GAO obtained the views of 41 experts from 21 organizations on the range of approaches Congress could consider to encourage voluntary enrollment in private health insurance coverage

The GAO report states that the ACA “mandates that individuals, subject to certain exceptions, obtain health insurance coverage or pay a financial penalty beginning in 2014—the ‘individual mandate.’” At the same time, the ACA also imposes a number of requirement on insurers and employers, including automatic enrollment for employers with more than 200 employees and an assessment on certain employers with 50 or more employees, including employers who do and do not offer health coverage.

Primary Approaches

The experts interviewed in the GAO report discussed several specific approaches to encourage voluntary health insurance enrollment during our interviews. The approaches are summarized below, presented in the order of frequency with which they were proposed

• Modify open enrollment periods and impose late enrollment penalties.


• Expand employers’ roles in auto-enrolling and facilitating employees’ health insurance enrollment.


• Conduct a public education and outreach campaign.


• Provide broad access to personalized assistance for health coverage enrollment.


• Impose a tax to pay for uncompensated care.


• Allow greater variation in premium rates based on enrollee age.


• Condition the receipt of certain government services upon proof of health insurance coverage.


• Use health insurance agents and brokers differently.


• Require or encourage credit rating agencies to use health insurance status as a factor in determining credit ratings.

In discussing these approaches, four key themes emerged, according to the GAO.

• First, experts emphasized that most people would prefer to purchase health insurance coverage; however, to the extent that high cost is a barrier, the use of financial incentives is key.


• Second, they stated that regardless of the particular approach taken to increase voluntary enrollment in the absence of an individual mandate, the availability of affordable, high-quality health care plans with a basic set of benefits, and full coverage of preventive care services is essential to encouraging voluntary enrollment in the coverage.


• Third, experts said that strong marketing and public education from trusted, community-based sources informing people about their health care choices, their costs, and the consequences of not enrolling in a timely manner are important.


• And fourth, they said convenient access to the health insurance system through multiple access points staffed by knowledgeable individuals would further facilitate enrollment.

Some of the experts also noted that two of the approaches, conditioning the receipt of government services upon proof of health insurance and imposing a tax to pay for uncompensated care, could be considered the functional equivalent of a mandate.

The GAO notes that “we did not explore suggestions that primarily emphasized more generous subsidies or significant expansions of publicly funded insurance programs as a means of expanding coverage.” The report also states that “we did not independently evaluate the potential effectiveness or the legal implications of the approaches individually or in combination.”

The GAO report is Private Health Insurance Coverage: Expert Views on Approaches to Encourage Voluntary Enrollment, GAO-11-392R.

For a comprehensive analysis of the Patient Protection and Affordable Care Act, including the full text of the law and additional information on health reform implementation and other recent developments in employee benefits, just click here.