One area of agreement likely to be quickly identified at President Barack Obama’s bi-partisan health care reform summit on Thursday is the principal that carriers should be required to accept all applicants for coverage regardless of their health status. This concept, known as “guarantee issue,” is high on the wish list of Republicans and Democrats alike. What will be far more divisive is whether a requirement that carriers sell health insurance coverage to all consumers should be balanced against a requirement that all consumers buy health insurance coverage.
The issue has both a political and a substantive component. Politically Republicans, and some Democrats, consider forcing individuals to purchase coverage to be overly paternalistic, unfair, a tax-by-another-name, and/or yet another step toward socialism.
From a public policy point of view, it’s hard to see how a system can work without a balance between the requirement to sell and to buy coverage. Otherwise people will wait until they need the insurance before they obtain it. It’s the equivalent of allowing motorists to buy auto insurance from the tow truck driver who shows up at a car wreck. Why buy it before you need it?
Noam Levey, in a thorough article running in the Los Angeles Times describes the costly mistake New York made when it required carriers to sell coverage to all applicants without mandating that individuals purchase coverage. After nearly two decades of this situation health insurance premiums in New York “are now the highest in the nation by some measures, with individual health coverage costing about $9,000 a year on average. And nearly one in seven New Yorkers still lacks health coverage, a greater proportion than before the law was passed.” In some New York counties, Mr. Levey reports “it is impossible to buy an individual plan for less than $12,000 a year.” For some older residents in other states, premiums of $1,000 per month may be close to what they’re paying now. But because New York has pure community rating (meaning all insureds pay the same premium regardless of their age) $12,000 is the premium facing 24 year olds, not just 64 year olds.
I’ve written about this health care reform surcharge frequently and for a long time. The Los Angeles Times article does a great job of showing why New York should serve as a case study on the issue for negotiators at the health care reform summit in Washington. The message is simple. Mark Hall, a Wake Forest University economist who has studied New York’s experience, summarizes it well in the Los Angeles Times article: “You basically can’t have a functioning insurance market if people can buy insurance on the way to the hospital.”
If those at the summit are serious about solving problems they’ll recognize this reality. However, even folks who should know better, by which I mean anyone with an insurance license, condemn requiring individuals to obtain coverage as un-American in some way. (Never mind the various other duties we impose on citizens in this country.) The Administration and Republicans are likely to reach an impasse on this issue.
There is at least one other way to balance guarantee issue with the need to prevent gaming with the system. As I’ve suggested before, the solution is to allow carriers to exclude coverage for existing health conditions and to impose a premium surcharge on those applying for coverage who have gone without health insurance for a significant period of time. The premium surcharge and pre-existing exclusion period could vary depending on how long the individual went without coverage. This approach is a part of the California Association of Health Underwriter’s Healthy Solutions health care reform plan.
Yes, premium subsidies would be required to help lower income Americans purchase the coverage. Republicans have supported refundable tax credits for this purpose in the past while Democrats have put forward direct subsidies. At the end of the day, however, both parties recognize the need to provide premium support. The debate is only over methodology.
The problem with this compromise is that “pre-existing conditions” have become a blasphemous word in Washington, at least among Democrats. Whether they would allow carriers to impose restrictions on existing health problems as an alternative means of encouraging (if not requiring) all consumers to obtain health insurance is unlikely. This is where presidential leadership could make the difference. If President Obama wants bi-partisan health care reform legislation — and, a big if here, the Republicans are willing to negotiate in good faith — the Healthy Solutions method of balancing the need to balance a requirement to sell health insurance with a requirement that consumers obtain it makes sense.
The health care and health insurance status quo in this country can not long stand. Health care reform is needed. Democrats and Republicans can insist on the purity of their positions. But if they are sincere about solving problems, there are ways to get the job done. The question is, whether there’s the will.