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How states can save the individual mandate

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As Congress moves toward repealing Obamacare's individual mandate, a growing number of states are exploring creating their own.

In California, Maryland, and the District of Columbia, there are already discussions swirling about how a state could set up its own requirement to purchase health coverage. These are states (and one district) that have their own insurance marketplaces and are generally supportive of the Affordable Care Act.

So as Congress looks for ways to destabilize the Affordable Care Act — repealing the individual mandate is expected to raise premiums and reduce the number of people with coverage — these states are looking at how to save it.

Here's the state-level action I'm aware of at this point:

California: The state marketplace, Covered California, held a board meeting yesterday where executive director Peter Lee raised the idea of a state-level individual mandate should the federal one disappear. Here's one of the slides that Lee shared, where he mentions a California health insurance mandate.

Covered California

It's notable that California is thinking through different policies that could replace the individual mandate, like a continuous coverage requirement (requiring people to remain enrolled in health insurance or pay higher premiums later) or automatically enrolling Californians into insurance.

"We don't know what a federal action will be," Lee said yesterday. "This is where our current pulse check is, among uncertainties that are still unfolding."

District of Columbia: Earlier this year — before the tax bill was a twinkle in the Senate's eye — DC was already thinking about what would happen if the individual mandate went away.

On October 27, the Affordable Care Act working group (which advises the DC health insurance marketplace) recommended that the District of Columbia continue to enforce the individual mandate should the federal government not do so.

This is not quite the same as creating a District-level mandate, but that's mostly because the board was meeting in a different context — when there were worries that the Trump administration simply wouldn't enforce the fine. The DC marketplace hasn't yet addressed the idea of creating their own mandate to replace the federal one, but this recommendation (which passed unanimously) seems to suggest an openness to the idea.

Maryland: Activists are looking for legislators to sponsor a bill creating a Maryland health insurance mandate, local news site Maryland Matters reported earlier this week.

Health experts who spoke before a state commission on Tuesday suggested ways that, like California, Maryland could consider slightly different policies to nudge people into health insurance. Rachel Baye, a reporter for radio station WYPR, reported on their ideas:

Stan Dorn, senior fellow at the advocacy nonprofit Families USA, suggested pilot-testing a variation on the mandate and the financial penalties for not having insurance.

“When somebody files their state income tax return, they could be given the option to pay their penalty to the state and get nothing,” he said, “or to pay their penalty to an insurance company and couple with their premium tax credit and get health coverage.”

But [Deb] Rivkin, at Carefirst, cautioned that this option would create problems for insurers.

To encourage more insurers to participate in the market, Miller suggested incentives, as well as tighter rules. For example, if an insurer wanted to sell plans in the small group market, it would also have to sell to individuals, or else pay a penalty.

Additionally, I have heard from policy types in Washington state who are interested in creating their own individual mandate. The situation is a bit more complex there, however, because Washington is one of seven states that does not have an income tax.

The upshot of these actions could be a version of Obamacare that looks very different depending on where you live. In California, for example, Obamacare next year may look a lot like Obamacare last year because they replace the individual mandate. But in states that aren't so keen on creating their own mandates, you could see marketplaces facing rising premiums and less coverage.

Video of the Day: The robot-proof job men aren't taking

Nursing is the job of the future. So why have men stayed away? My colleague over on Vox's video team, Liz Scheltens, has a fascinating new piece that looks at why nursing — with its high wages and bright prospects — remains a female-dominated profession. Watch it here.

Kliff’s Notes

Today's top news

  • “Collins' Obamacare deal faces moment of truth”: “Republicans who watched Collins lead the rebellion over the GOP’s Obamacare repeal effort just three months ago are playing tough on yet another high-stakes bill, wagering they can do without the Maine moderate’s swing vote and still claim a narrow year-end legislative win on tax reform. Collins went along with the tax bill that repeals Obamacare’s individual mandate after Senate Majority Leader Mitch McConnell pledged to pass a pair of bills propping up Obamacare’s shaky insurance markets.” —Adam Cancryn, Politico
  • “Pro-Obamacare group targets Susan Collins in new ad over her tax vote”: “Save My Care, a group working to defend Obamacare, is launching a new TV ad against Sen. Susan Collins, R-Maine, to urge her to vote against the final version of the GOP tax plan.” —Kimberly Leonard, Washington Examiner
  • “CMS could demand CSR repayments from insurers if Congress doesn't act”: “It's still not clear whether Congress will appropriate cost-sharing reduction payments, as lawmakers race toward a short-term spending agreement before Christmas. This means insurers may have to return any surplus they used to cover CSR costs since the Trump administration cut off the payments in October.” —Susannah Luthi, Modern Healthcare

Analysis and longer reads

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