Private Health Insurance Coverage: Expert Views on Approaches to Encourage Voluntary Enrollment Page: 2 of 28
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selection, whereby disproportionately less healthy individuals who need health care
services enroll in coverage, leading to higher premiums that further discourage
healthy individuals from enrolling.4 Some experts have argued that the individual
mandate does not go far enough to ensure that all of the uninsured enroll, and that to
do so would require heavier penalties that are fully enforced to be truly effective.5
Other experts suggest that, rather than requiring individuals to obtain health
insurance coverage, a more appropriate role for the federal government would be to
consider alternatives to encourage voluntary enrollment. Some of these experts also
question the legality of a federal mandate." Since its enactment, the federal mandate
has been subject to a number of court challenges to its constitutionality.
Because of the possibility that legislative or judicial action could result in a change to,
or elimination of, the mandate, you asked us to identify potential alternatives to
encourage, rather than require individuals to obtain private health insurance
coverage. For this report, we obtained the views of multiple experts on the range of
approaches Congress could consider to encourage voluntary enrollment in private
health insurance coverage.7
To obtain the views of experts, we interviewed 41 officials from 21 organizations that
provide research and analysis on health care issues or otherwise are health care
stakeholders. We identified these individuals and organizations based on a literature
search of relevant published research or commentary, referrals from the Institute of
Medicine of the National Academy of Sciences, referrals from those we interviewed,
and internal GAO expertise. We selected the experts based on demonstrated subject
matter expertise; representation of a range of perspectives (specifically including
both proponents and opponents of the individual mandate); and representation from
a wide range of institutions, including academia, business and consumer
organizations, state government, health insurers, professional organizations, and
policy research organizations. See enclosure I for the complete list of experts we
interviewed and their organizational affiliation.
During each phone interview, we asked the experts to identify approaches that might
encourage individuals to voluntarily enroll in health care coverage, regardless of any
views the experts might hold on the importance of a mandate to expand health care
coverage. We solicited comments on a list of approaches we circulated in advance,
based on our preliminary research, as well as comments on approaches that arose
during the discussions and those that arose during previous interviews with other
4For example, see J. Gruber, "Why We Need the Individual Mandate," Center for American Progress,
Washington, DC, April 2010; and L. Blumberg and J. Holahan, "The Individual Mandate-An Affordable
and Fair Approach to Achieving Universal Coverage," New England Journal of Medicine, 361:6-7, July
5For example, see A. C. Enthoven: "A Few Cautions About Exchanges," Kaiser Permanente Institute for
Health Policy, California, January 2011; and "CBO Understates Major Impact Of Weakened Individual
Mandate," Blue Cross Blue Shield Association, Chicago, IL, October 2009.
"For example, see R. E. Moffit, Ph.D: "Choice and Consequences: Transparent Alternatives to the
Individual Insurance Mandate," Harvard Health Policy Review, Vol. 9, No. 1. Cambridge, MA, Spring
2008; and R. Barnett, N. Stewart, T. Gaziano: "Why the Personal Mandate to Buy Health Insurance Is
Unprecedented and Unconstitutional," The Heritage Foundation, Legal Memorandum No. 49,
Washington, DC, Dec 2009.
7Prior to PPACA, Congress has considered other legislation that included requirements for individuals
to obtain health insurance. See, for example, the Health Equity and Access Reform Today Act of 1993,
H.R. 3704, S. 1770, 103rd Cong. (1993). In addition, as of July 2007, Massachusetts required its residents,
subject to certain exceptions, to obtain health insurance. Mass. Gen. Laws ch. 111M, 2.
GAO-11-392R Voluntary Health Insurance Enrollment
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United States. Government Accountability Office. Private Health Insurance Coverage: Expert Views on Approaches to Encourage Voluntary Enrollment, text, February 25, 2011; Washington D.C.. (digital.library.unt.edu/ark:/67531/metadc298648/m1/2/: accessed February 20, 2019), University of North Texas Libraries, Digital Library, digital.library.unt.edu; crediting UNT Libraries Government Documents Department.