And it's Illinois in the lead ...

With today's news that Illinois has just enacted a program that will make affordable health insurance readily available to every child in the state, the pressure is (or should be) on Massachusetts lawmakers to take similarly bold action.  At present, things are in limbo here - the House passed a Cadillac version of health care; the Senate passed a Buick; and we now must await the work of a conference committee to see what the final version is.

And now for some random musings on the subject of individual mandate.  I still hate it, and so, apparently, do a lot of those young healthy types that the insurers desperately want in the risk pool.  Yet I recognize the unfairness of these folks unexpectedly getting hurt or getting sick, showing up at the emergency room, and expecting to receive care without paying for it.  What to do?

How about this.  Let's pass something like the House bill, except that the individual mandate would work like this: if you show up seeking medical care but don't have insurance, you get two choices: pay the full freight out of your own pocket, or enroll in a health insurance plan and pay an enrollment fee of one year's worth of premiums (almost certainly less than what the hospital bill will be), whereupon the insurer will cover you.  For people eligible for free or subsidized health insurance, it's a no-brainer: those are people who should have been enrolled in MassHealth or a similar program anyway, and the enrollment fee would be modest or nonexistent.  Those who make too much money for subsidized programs, however, will have to pay the full enrollment fee, and will have to stay enrolled for, say, two more years, or they'll have to reimburse the insurer for the hospital costs.  Perhaps this should be coupled with state-funded reinsurance above a certain level to protect insurers from unanticipated catastrophic costs (I think state reinsurance is a good idea in any case).

This is off the top of my head, so maybe there are good reasons that this wouldn't work (it might, for example, be difficult to administer).  But it strikes me as far less objectionable on policy grounds than an individual mandate, while accomplishing at least some of what the mandate seeks to do. [Update: upon further reflection, I'm not sure this idea works at all - see the comments.]

(For the policy wonks out there: yes, I recognize that the point of the individual mandate is to get young healthy people into the pool before they get sick so that they're improving the pool's risk profile, and enrolling those people only when they get sick seems in tension with that goal.  But I think we can ameliorate that problem somewhat by (1) requiring the payment of a year's worth of back premiums, and (2) requiring that enrollment continue for at least two years.  Assuming that a good number of these folks show up with one-time, non-catastrophic conditions (a broken leg, for example), the insurers' outlay wouldn't be that great, and in exchange they'd get a reasonably healthy enrollee paying at least three years of premiums.  Perhaps my assumption is wrong, in which case this wouldn't work.  But we should think about something along these lines as an alternative to the individual mandate.)