To his credit, Gov. Larry Hogan has made several statements of support for the Affordable Care Act during the past year and in opposition to flawed “repeal and replace” bills advanced by members of his party in Congress. With the Senate poised to vote on a tax cut plan that includes a repeal of Obamacare’s requirement that most people have insurance — known as the individual mandate — he has a chance to do more than talk. He can’t stop Congress from making such a destructive move, but he can lend his support to an effort to preserve the benefits of the ACA in Maryland and to stave off the potential havoc in the state’s insurance market that killing the individual mandate would cause.
The individual mandate is a crucial ingredient in the ACA’s policy design. Without it, many young and (at least for the moment) healthy people would skip buying health insurance, leaving only older and sicker people in the risk pool. That’s known as “adverse selection,” and absent the individual mandate, the ACA’s prohibitions on lifetime coverage caps and on refusing coverage to those with pre-existing conditions would make the problem catastrophically worse. But Senate Republicans have tacked an individual mandate repeal onto their tax bill because doing so gives them about $300 billion worth of additional room to cut taxes without blowing past a $1.5 trillion limit on the amount the bill would add to the national debt after a decade. Even if they don’t succeed, the integrity of the policy is threatened by the possibility that the Trump administration will simply stop enforcing the mandate. Already, it has weakened the law by accepting tax returns in which the question about health insurance coverage is left blank.
The policy fix for Maryland is quite simple. Health care advocates are planning to push for legislation that would create a state-level individual mandate to act as a backstop to the federal one. It would work something like this: Maryland would include a question on its state income tax forms asking whether an individual had ACA-compliant health insurance in the previous year and, if not, how much (if anything) the filer had paid in fines to the federal government as a result. If that’s less than the ACA would require — currently either a flat, per-person fee of up to $2,085 per family or 2.5 percent of household income, whichever is higher — Maryland would levy its own fine to make up the difference.
Massachusetts had an individual mandate under “Romneycare” and left it in place after the ACA was passed. There, the state-level fee can be tacked on top of the federal one, but the Maryland proposal would not do so, and that’s something that should matter to Governor Hogan as he considers whether to support, oppose or take no position on it. We certainly understand that the last thing Mr. Hogan wants to do in general and especially in an election year is to support anything that could be construed as a tax increase. But the beauty of this proposal is that it would not increase anyone’s taxes. It would merely ensure that the existing individual mandate is enforced.
Mr. Hogan is effectively on record opposing the elimination of the individual mandate. A letter he co-signed with a bipartisan group of governors in July specifically opposed the “skinny repeal” idea that was then floating around the Senate, the primary component of which was the elimination of the mandate. Such a move would “accelerate health care plans leaving the individual market, increase premiums, and result in fewer Americans having access to coverage,” the governors wrote.
And then there’s this: Although common wisdom has it that the ACA is unpopular and the individual mandate particularly so, that is not at all true in Maryland. A recent poll commissioned by health care advocates and conducted by OpinionWorks (a firm The Sun has used many times in the past) found that 62 percent of Maryland voters favored the ACA, 37 percent of them strongly, compared to 28 percent who opposed it. (The numbers dip to 58-34 if you call it “Obamacare.”) Support for the individual mandate was, incredibly, a tick higher at 65 percent in favor to 27 percent opposed. The idea of creating a state-level mandate also polled well, with 52 percent for the idea and 36 percent against. Just 37 percent construed of the idea as a tax.
It’s good policy and good politics. Governor Hogan, what’s not to like?