Health Care

Are Mandate-free Policies A Fix For Some Of The Uninsured?

June 14, 2008

When the word "mandate" is used alongside the phrase "health insurance," it usually refers to the idea that people should be mandated to get health insurance, or employers should be mandated to provide it. Those ideas are swirling around the presidential campaign trail.

But there's another kind of mandate that figures importantly in the nation's problems with health insurance: the mandates states impose, requiring insurers to offer certain kinds of coverage. According to a study by the Council for Affordable Health Insurance in 2005, Virginia's list of mandates is longer than that of most states.

Scan through the list, and most of the things make sense. Generally, insurers in Virginia have to offer mammograms and prostate screenings, well-child and hospice care. The cumulative effect, though, is to drive up the cost of health insurance, beyond the reach of many families and individuals, and many of their employers. The result: Somewhere between 600,000 and 1 million nonelderly Virginians, between 9 and 15 percent of the population (it depends on who's counting), are going without health insurance.

That is a costly problem. For the uninsured, the risks go two ways: They'll go without care they really need, or they'll be bankrupt by care they can't do without. And the costs are shared by people and businesses that do pay for insurance, by hospitals, by taxpayers who fund programs to help those hospitals. Since costs get shifted around, in the end, it drives up the insurance for everybody, making it even less affordable.

There are many ways to bring more people under the coverage umbrella. The ones that get the most attention shift the burden to taxpayers, by expanding Medicaid coverage or subsidizing individual or business policies. They deserve attention, particularly for the low-income people who can't afford insurance even if it costs less than it does now.

There's another option: stripped-down policies. Individuals and families, on their own or through employers, could purchase limited-benefit policies that protect them against medical catastrophes, and figure they'd cover the day-to-day stuff and do without some services.

Many of the uninsured are healthy young adults, who could say: I'll get coverage against the really big bills, but I'll do without maternity benefits. Not everyone needs or wants or is willing to pay for treatment for morbid obesity and alcoholism, or the services of marriage counselors and opticians. In an effort to bring more Virginians under the insurance umbrella, the General Assembly authorized stripped-down plans for small employers. But that hasn't solved the problem of so many uninsured. The idea deserves another serious look.

It's possible, it should be added, that you could strip away a lot of mandates and not really bring down the price of a policy, because the mandated services don't drive costs so much as, for example, the monumental hospital bills for a relatively few patients receiving complex care. It's possible that narrowing coverage would strip insurance of its value and appeal, making policies so bare-bones they don't seem worth even the reduced premium. And it's possible that reducing the ranks of the uninsured would only add to the ranks of another group at risk: the underinsured.

But serious study is the only way to assess the upside and downside of backing off even further from well-intentioned regulation to help people acquire their own health insurance, instead of adding them to the ever-booming burden to taxpayers.

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