The Effect of the Affordable Care Act on Enrollment and Premiums, With and Without the Individual Mandate
Feb 16, 2012
One of the most politically charged provisions of the Patient Protection and Affordable Care Act of 2010 (ACA) is the individual mandate. It requires that most Americans either obtain health coverage or pay an annual fine. Supporters of the mandate contend that by encouraging young, healthy people to get coverage, the individual mandate spreads costs and risks across a larger, healthier group. Without the mandate, supporters argue, the health insurance exchanges (state-based marketplaces for buying and selling small group and individual health insurance policies) established under the ACA will suffer from "adverse selection" — that is, only sicker, higher-risk individuals will sign up for coverage, leading to higher per-member health care costs and, therefore, higher insurance premiums. If pushed to its extreme, this effect could lead to catastrophic failure for health insurance markets as soaring premiums render coverage unaffordable for more and more people.
Opponents of the mandate dispute its constitutionality. They assert that it is unconstitutional to mandate the purchase of a private good (in this case, health insurance). To them, the mandate represents an infringement on individual rights. As a result of a lawsuit filed by 26 states, the individual mandate now faces a Supreme Court test. Oral arguments will occur in March 2012, and a decision will follow some time later.
How would eliminating the individual mandate affect coverage and costs under the ACA when it is fully implemented? To address this question, a RAND team used the COMPARE microsimulation model. Developed by RAND, this model uses publicly available data to estimate how coverage-expansion policies affect (1) the number of people with coverage and (2) insurance costs and spending. Specifically, the team examined how the lack of an individual mandate would affect:
The RAND team used the COMPARE model to simulate the effects of the ACA without the individual mandate. The analysis predicted the following outcomes if the individual mandate is voided:
This analysis shows that the individual mandate contributes to achieving near-universal coverage for all Americans. Without it, an estimated 12.5 million fewer people will get coverage. However, repeal of the mandate will have only modest effects on premium prices for individuals buying insurance through the exchanges. In this regard, the RAND team's results differ from those of other research groups that simulated the effects of eliminating the individual mandate (see the table). Moreover, the RAND team predicts that these relatively modest premium increases will not be enough to trigger catastrophic failure of the exchanges. Why? Because of insurance subsidies, many enrollees will perceive little or no change in the amount of their contribution even when premiums increase. This reduces the chance of a large-scale exodus from the market. For federal costs, the picture is more complicated. Removing the individual mandate will increase federal spending by a relatively modest degree. However, because those who stay in the system will tend to be sicker — and require more federal subsidies — than those who exit, federal spending per new enrollee will be more than twice as high as it would be with an individual mandate. The mandate, therefore, contributes to achieving near-universal coverage by producing more "bang for the buck" in terms of the government spending per new enrollee.
|Number of Newly Insured Under the ACA with Individual Mandate (millions)
|Number of Newly Insured Under the ACA Without Individual Mandate (millions)
|Predicted Change in Individual Premium Price on Exchanges in Absence of Individual Mandate (%)
|+2.4 (+9.3 under assumptions used by other modelers)
|Congressional Budget Office
|Jonathan Gruber (MIT)
SOURCES: Congressional Budget Office, "Effects of Eliminating the Individual Mandate to Obtain Health Insurance," Washington, D.C., 2010. As of August 30, 2011: http://www.cbo.gov/ftpdocs/113xx/doc11379/Eliminate_Individual_Mandate_06_16.pdf
Gruber, J., "Health Care Reform Without the Individual Mandate," Center for American Progress Issue Brief, February 2011.
Sheils, J. F., and R. Haught (The Lewin Group), "Without the Individual Mandate, the Affordable Care Act Would Still Cover 23 Million, Premiums Would Rise Less Than Predicted," Health Affairs, Vol. 30, No. 11, 2011, pp. 2177–2185.
Buettgens, M., and C. Carroll, "Eliminating the Individual Mandate: Effects on Premiums, Coverage, and Uncompensated Care," Washington, D.C.: Urban Institute, 2012.