The complex health care overhaul underway in Congress would require nearly all Americans to have health insurance – a provision known as “individual responsibility” or an “individual mandate.” Supporters warn other reforms are not possible without this requirement.  But many opponents say such a mandate is unaffordable, and unacceptable in a free society. 

A new Health Policy Brief  from Health Affairs and the Robert Wood Johnson Foundation, the latest in a series of briefs, examines this issue.

The leading health reform bills in Congress would impose this new national individual mandate in the context of many other changes as follows:

  • New rules would determine what minimal coverage is acceptable and spell out how much people should pay for it out of their own pockets. 
  • Coverage could be obtained in various ways, including through employers, through government health programs or through new federal or state health insurance exchanges.
  • Subsidies would make coverage more affordable for low- and moderate income people, and insurance market reforms would make coverage more reliable.
  • Penalties, most likely in the form of a tax, would be imposed on individuals who had not obtained coverage or who were not exempted from the requirement for various reasons.

The free policy briefs are geared to policymakers, congressional staffers, news media as well as other readers who may not have a background in health issues but want to better understand the basics of proposed changes in the nation’s health care system. The briefs provide short, jargon-free overviews that include arguments from competing sides of policy proposals and the relevant research supporting each perspective.

More From Health Affairs On The Individual Mandate

For additional information on the individual mandate, see this 2007 Health Affairs paper by Sherry Glied and coauthors. Glied and her colleagues summarize and analyze existing evidence on the effectiveness of mandates, drawing on examples both from health insurance and from other arenas where mandates are often used. They find that mandates can, but do not always, increase participation in programs. The effectiveness of a mandate depends critically on the cost of compliance, the penalties for noncompliance, and the timely enforcement of compliance.

An individual mandate is also one of the main features of Massachusetts’ landmark 2006 health reform legislation. Health Affairs has published a series of updates on the implementation of that legislation by the Urban Institute’s Sharon Long and coauthors. The most recent update, published May 28 of this year, found that, in the face of economic hard times,  Massachusetts has sustained gains in insurance coverage and access to care stemming from the legislation. However, some of the early gains in reducing barriers to care and improving the affordability of care had eroded by the fall of 2008.

In a Perspective on the May 28 paper by Long and Urban Institute colleague Paul Masi, Jon Kingsdale highlights the role of the individual mandate in the state’s reforms. The individual mandate spreads the cost of expanding coverage over a broad spectrum of Bay State residents, says Kingsdale, the executive director of the Commonwealth Health Insurance ConnectorAuthority in Boston, Massachusetts. He also emphasizes the mandate’s role in bringing to light the normally hidden cost of coverage.

Health Affairs will publish a new update on Massachusetts this Thursday, October 1.