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Kaiser Permanente's Ross: There's No Effective Substitute For The Mandate

Jun 12, 2012

This interview is part of KHN's video series "Supreme Uncertainty: What's Next After The Court Rules," which solicits views from public officials and policy experts about the upcoming Supreme Court ruling on the health law and its implications for the future of health care.

Murray Ross, director of the Kaiser Permanente Institute for Health Policy, believes that the health law’s requirement that most Americans have coverage by 2014 or pay a fine is necessary. By design, says Ross (who is also a vice president in the part of the company that sells health plans), the "individual mandate" would attract both the healthier and sicker individuals to balance risk and the cost of coverage. (Note: KHN is not affiliated with Kaiser Permanente).

MARILYN WERBER SERAFINI:  If the Supreme Court upholds the health care law, what does that mean for health plans and their ability to prepare in time for a lot of new enrollees?

MURRAY ROSS:  I can speak to us.  We have been working all along with the notion that the law will take effect January 1, 2014.  We’re not holding back, asking: What will the decision be, which parts will be left intact or how much will be left intact?  Having said that—as you try to work full-speed ahead—there’s obviously a lot of uncertainty.

There's the uncertainty about where the court will land, there's uncertainty about the election that will follow four or five months later.  And then there's the continued uncertainty about the readiness of different states—will they be up and running on January 1, 2014?  Everyone's in a little bit of a limbo. This is a huge change with a lot of very new uncertainty that we’re not used to.

MARILYN WERBER SERAFINI:  How complex is this?  It’s more than just creating a new health plan.  What do you have to have ready in time, and when do you have to be ready by?

MURRAY ROSS:  Well, everyone talks about January 1, 2014—that’s the date that we expect people to enroll.  Or maybe it will be January 2nd, since the 1st will be a federal holiday.  But if you're talking about January 1, 2014, that means you’re going to have an open enrollment period in the fall of 2013, that means health insurance plans will need to have submitted their benefits and premiums for approval to the exchange sometime in early 2013 to go through the approval process, that means they’ll have to know what the rules are, what the essential health benefits look like and other things, sometime later this year to be able to start crafting that. 

You can obviously do some planning, but you can’t plan for every single contingency.  So, 2014 is much closer than it looks.

MARILYN WERBER SERAFINI:  What happens if the Supreme Court only strikes down the individual mandate to bring most people into the insurance system?  The health law also has a lot of requirements for insurance companies, requiring insurers to take pretty much all comers—regardless of pre-existing conditions and other factors—so what kind of a position does that put health plans in?

MURRAY ROSS:  As you said, the individual mandate is designed to generate, if you will, a balanced risk pool and have everyone in.  If you don’t have it there, you have a recipe for selection. 

In theory, you could imagine the people with the most costly health conditions coming in first.  Insurers in the marketplace will try to price for that, whether or not they're successful.  It's hard to match the prices to what you would expect because you get into this game of ever-rising prices, and that's why there's been such strong support from people who have studied insurance markets for the importance of the mandate. 

Now, there are proposals out there that people talk about might ameliorate some of it.  Could you have delayed enrollment penalties?  Could have you have standardized open-enrollment sessions—things that might mitigate a little bit of the selection issue?  But many of the things that analysts have talked about would require legislative action, either on the part of the Congress or on the part of the states.  And others, we don't know how well they’d work, so there's not an effective substitute for the mandate.

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