GAO Report Outlines Alternatives To Individual Mandate

Merrill Goozner

First published 3/29/11 on Gooz News

Democratic Senator Ben Nelson of Nebraska, who faces a tough re-election battle in 2012, raised hackles among health care reform supporters in early February when he told Chris Matthews on MSNBC’s “Hardball” that “we need to find an alternative” to the individual mandate, which requires that the uninsured buy coverage once the state-based health insurance exchanges are up and running after 2014. With that mandate under legal assault by governors, state attorneys general and conservative activists at least 20 states, including Nebraska, it appeared the Blue Dog Democrat, who voted for reform, was moving to his right in an effort to shore up his electoral base.

See here.

What Nelson, who chairs the legislative subcommittee of the Appropriations Committee, didn’t reveal was that he simultaneously asked the Government Accountability Office to conduct a far-ranging survey of health care experts to come up with alternatives. The GAO released its report Monday.

The arguments in favor of a mandate are straightforward. Without requiring people to buy coverage, many of the nation’s 50 million uninsured will wait until they get sick before buying policies that under reform can no longer be denied because of pre-existing medical conditions. The GAO estimates the costs that are shifted onto other payers – private insurers, Medicare and Medicaid – totaled $57 billion in 2008.

So what are the alternatives? After interviewing 41 experts in 21 organizations, ranging from the conservative American Enterprise Institute to America’s Health Insurance Plans (the insurance industry’s trade group) to the AFL-CIO, the studiously neutral GAO came up with this list of options, ranked by how often they were mentioned:

• Modify open enrollment periods and impose late enrollment penalties.
• Expand employers’ roles in autoenrolling 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.

Curiously, the GAO didn’t release the report until a full month after the agency released it to Nelson. Why the delay? Under GAO rules, if a requester doesn’t release a report, the agency does so 30 days later. Was Nelson having second thoughts about wandering off the Democratic Party reservation?

Not according to a press statement put out Friday. Nelson noted that “without the individual mandate or a successful alternative, the number of uninsured is certain to grow and Nebraskans, as well as all Americans, will pay a hidden tax for their health care of $57 billion each year,” he said. “Washington needs to explore the GAO report’s alternatives and others to see if there is a successful way to improve health reform.”

Merrill Goozner is an independent health care journalist who maintains a blog at Gooz News.

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