The experience of ACA enrollment since OE-6 makes me wonder if we overrated the importance of the mandate all along relative to the other legs of the stool. As you note, we don't exactly have a rigorous counterfactual, because COVID followed by the ARP/IRA subsidy enhancements (and the steady forward march of Medicaid expansion) have all contributed to pretty significant enrollment growth. But this is still useful real-world data! During one year of post-mandate but pre-COVID Open Enrollment, actual coverage loss appears to have been pretty minimal. But expanded financial aid, along with an exogenous motivation to get health coverage, had a pretty large effect to increase enrollment and drive down the uninsured rare. So perhaps candidate Obama was right after all - financial aid combined with people's desire for coverage are a bigger deal IRL than the mandate.
This motivated me to revisit some of the literature about the Swiss and Dutch systems from back when the ACA was being drafted. And while the mandate makes a lot of sense based on microeconomic theory, the practical importance of a mandate tax penalty specifically was far less clear-cut. Both systems have basically universal coverage with low-single-digit uninsured rates, but the reference below indicates some questions as to whether the mandate alone was the biggest factor in achieving this. The Swiss cantons seem to do a variety of things to find and enroll people without coverage, including when they interact with providers or government offices - that is a sort of (semi-)automatic enrollment.
Now, the regulatory features (guaranteed issue, community rating, EHBs) and financial aid are clearly a big deal in both systems as well as here. And our higher uninsured rate also reflects our undocumented population which is mostly a failure of immigration policy. But I think one more thing about the Swiss and Dutch systems that was underrated at the time was that both were implemented by ideologically wide-ranging governing coalitions. So there was more cooperation across levels of government instead of the ideological massive resistance faced by the ACA in its early years.
With each passing year, that massive resistance has faded - fewer Medicaid expansion holdouts, more embrace of the exchanges, etc. And the gradual depolarization around the ACA probably helps enrollment as states play a more productive role and people feel less personal objection to signing up. So as long as we retain enough influence in Congress to keep the funding from being slashed, the ACA can (I think) look forward to a more Swiss/Dutch future even without the mandate penalty.
Great piece!!
The experience of ACA enrollment since OE-6 makes me wonder if we overrated the importance of the mandate all along relative to the other legs of the stool. As you note, we don't exactly have a rigorous counterfactual, because COVID followed by the ARP/IRA subsidy enhancements (and the steady forward march of Medicaid expansion) have all contributed to pretty significant enrollment growth. But this is still useful real-world data! During one year of post-mandate but pre-COVID Open Enrollment, actual coverage loss appears to have been pretty minimal. But expanded financial aid, along with an exogenous motivation to get health coverage, had a pretty large effect to increase enrollment and drive down the uninsured rare. So perhaps candidate Obama was right after all - financial aid combined with people's desire for coverage are a bigger deal IRL than the mandate.
This motivated me to revisit some of the literature about the Swiss and Dutch systems from back when the ACA was being drafted. And while the mandate makes a lot of sense based on microeconomic theory, the practical importance of a mandate tax penalty specifically was far less clear-cut. Both systems have basically universal coverage with low-single-digit uninsured rates, but the reference below indicates some questions as to whether the mandate alone was the biggest factor in achieving this. The Swiss cantons seem to do a variety of things to find and enroll people without coverage, including when they interact with providers or government offices - that is a sort of (semi-)automatic enrollment.
https://www.commonwealthfund.org/sites/default/files/documents/___media_files_publications_fund_report_2009_jan_the_swiss_and_dutch_health_insurance_systems__universal_coverage_and_regulated_competitive_insurance_leu_swissdutchhltinssystems_1220_pdf.pdf
Now, the regulatory features (guaranteed issue, community rating, EHBs) and financial aid are clearly a big deal in both systems as well as here. And our higher uninsured rate also reflects our undocumented population which is mostly a failure of immigration policy. But I think one more thing about the Swiss and Dutch systems that was underrated at the time was that both were implemented by ideologically wide-ranging governing coalitions. So there was more cooperation across levels of government instead of the ideological massive resistance faced by the ACA in its early years.
With each passing year, that massive resistance has faded - fewer Medicaid expansion holdouts, more embrace of the exchanges, etc. And the gradual depolarization around the ACA probably helps enrollment as states play a more productive role and people feel less personal objection to signing up. So as long as we retain enough influence in Congress to keep the funding from being slashed, the ACA can (I think) look forward to a more Swiss/Dutch future even without the mandate penalty.