Allison K. Hoffman

Oil and water: mixing individual mandates, fragmented markets, and health reform.

The 2010 federal health insurance reform act includes an individual mandate that will require Americans to carry health insurance. This article argues that even if the mandate were to catalyze universal health insurance coverage, it will fall short on some of the policy objectives many hope to achieve through a mandate if implemented in a fragmented insurance market. To uncover this problem, this article sets forth a novel framework that disentangles three different policy objectives the individual mandate can serve. Namely, supporters of the mandate might hope for it to: (1) facilitate greater health and financial security for the uninsured (“paternalism”); (2) eliminate inefficiencies in health care delivery and financing (“efficiency”); and/or (3) require the healthy to buy insurance to help fund medical care for the sick (“health redistribution”). Health redistribution — the primary focus of this article — is a shifting of wealth from the healthy to the sick through the mechanism of risk pooling. Many see health redistribution as a means to enable all Americans to more equitably access medical care on the basis of need, rather than on the basis of ability or willingness to pay. Drawing on evidence from the implementation of an individual mandate in Massachusettss health reform in 2006, this article reveals that the fragmented American health insurance market will thwart the mandates ability to achieve these objectives— in particular the goal of health redistribution. Fragmentation is an atomization of the insurance market into numerous risk pools that has been driven by market competition and regulation. It prevents Americans from sharing broadly in the risk of poor health and, in doing so, entrenches a system where access to medical care remains tied to ability to pay and individualized characteristics. The final section of this article examines how various policies, including some in the new law (e.g., insurance regulation and exchanges) and others not (e.g., expanded public insurance), can reduce fragmentation so that the mandate can successfully serve all desired objectives and in the process gain greater legitimacy over time.

The Ethics of Medicaid’s Work Requirements and Other Personal Responsibility Policies

Breaking controversial new ground, the Centers for Medicare & Medicaid Services (CMS) recently invited states to consider establishing work requirements as a condition of receiving Medicaid benefits. Noncompliant beneficiaries may lose some or all benefits, and if they do, will incur higher spending if they have to pay for medical care out of pocket. Current evidence suggests work requirements and related policies, which proponents claim promote personal responsibility, can create considerable risks of health and financial harm in vulnerable populations.1-3 Concerns about implementing these policies in Medicaid have been widely expressed, including by major physician organizations, and others have examined their legality.4-6 Setting these issues aside, if the policies survive legal challenges, CMS should act to minimize the potential harms these policies could cause to the health of Medicaid’s vulnerable population. To this end, CMS should create guidance that would minimize risks, ensure proportionality of penalties (ie, that benefits are not eliminated for first-time or relatively minor infractions), and stipulate when harms rise to a level that requires program changes or termination. Federal guidelines establish which populations and benefits states must cover under Medicaid. Section 1115 waivers permit states to propose demonstration projects to test alternative program designs. In the fall of 2017, CMS issued a bulletin “ushering in a new era” for waivers7 by inviting proposals encouraging personal responsibility in the form of incentives for beneficiaries to use fewer services and transition to private insurance. In January 2018, a subsequent CMS letter to state Medicaid directors set out guidelines for the new era. The letter encourages testing work requirements or community engagement (such as job skills training or public service) as a condition of eligibility, coverage, enhanced benefits, or reduced premiums or cost sharing. These guidelines apply to beneficiaries who are not pregnant, elderly, or disabled, and CMS claims such programs will “promote better mental, physical, and emotional health” and “help individuals and families rise out of poverty and attain independence.”8 Recently, CMS approved applications from Kentucky, Indiana, and Arkansas, and applications from other states are pending. CMS emphasizes health improvement as the primary rationale, but the agency and interested states also favor work requirements for their potential to limit enrollment and spending and out of an ideological belief that everyone “do their part.” For example, an executive order by Kentucky’s Governor Matt Bevin announced that the state’s entire Medicaid expansion would be unaffordable if the waiver were not implemented, threatening to end expansion if courts strike down “one or more”9 program elements. Correspondingly, several nonexpansion states have signaled that the option of introducing work requirements might make them reconsider expansion—potentially covering more people but arguably in a way inconsistent with Medicaid’s broader objectives.4,6 Work requirements have attracted the most attention but are just one of many policies CMS has encouraged as part of apparent attempts to promote personal responsibility in Medicaid. Other initiatives tie levels of benefits to confirming eligibility annually, paying premiums on time, meeting wellness program criteria such as completing health risk assessments, or not using the emergency department (ED) for nonemergency care.10 Prior demonstrations of personal responsibility policies have produced heterogeneous outcomes, raising concerns about their ethics and effectiveness. For example, a West Virginia Medicaid demonstration project under the Deficit Reduction Act of 2005 required participants to agree to complete a health-improvement plan, avoid the ED for nonemergency care, and engage in health-conducive behaviors. Adherence with these behaviors enabled access to all previously available services. Nonadherence resulted in access to a reduced set of benefits. The program decreased ED visits for some beneficiaries, but overall, resulted in an increase of approximately 10% in avoidable ED visits.1 In states that implement work requirements, Medicaid beneficiaries who lose access to previously available medical benefits are at risk. One study that reviewed a decade of research reported that insurance coverage losses “produce significant harms to health, particularly among people with lower incomes and chronic conditions.”2 Even though CMS exempts some groups from work requirements, evidence suggests some non-exempted Medicaid beneficiaries encounter major challenges. For Kentucky, it is estimated that nearly 50% of approximately 653 000 nonelderly adults enrolled in Medicaid will be exempt.3 Another 26% (169 000 enrollees) already work, but one-third of this group may not consistently meet the 20-hour-per-week threshold due to contingent work, (hours vary by week or season).3 Twenty-eight percent of nonelderly adults (≈188 000 individuals), are not exempt and do not already work.3 Yet, among this population, 41% have 1 or more serious health limitations, and almost one-fourth have 2 or more such impairments.3 These include 21% with cognitive limitations (serious difficulty concentrating, remembering, or making decisions), 26% with ambulatory limitation (serious problems walking, climbing stairs), and 18% with serious difficulties running errands.3 One-quarterhavenohighschooldegreeand12% have no access to a vehicle.3 It is reasonable to assume that individuals with such limitations will struggle to adhere to the new requirements. VIEWPOINT

Review of The New Eugenics: Selective Breeding in an Era of Reproductive Technologies

InThe New Eugenics, Judith F. Daar compellingly documents how the eugenics movement of old—intended to limit reproduction among ‘undesirables’—has far from disappeared.1 Rather, the eugenics methods have evolved hand in hand with advances in medicine and reproductive technology. Daar’s book provides a careful and easily digestible map of the ways that law, medicine, and, especially, money have perpetuated selective reproductionbyplacing limits onwhohas access to assisted reproductive technology (ART)2 to treat infertility. The same characteristics that motivated earlier eugenicists to deem someone unfit to reproduce—including socioeconomic status, race or ethnicity, marital status, disability, and sexual orientation—now underlie deprivation of access to reproductive technologies. Put simply, she writes ‘both eugenics and ART extract control over reproduction from the closed universe of the progenitors and deliver it to a world of procreative strangers’.3 What I found particularly interesting is that, in addition to the usual suspects such as doctors, these procreative strangers now include the policymakers and corporations whodeterminewhat insurancewill pay for.Theyhold thepurse strings for reproduction in an age of ART, and their decisions shine a light on ways that insurance both reflects and shapes social norms about ‘good’ reproduction and parentage. Daar artfully distills a complicated set of factors that results in differential access to reproduction and the various reasons why ART is inaccessible for the ‘less wealthy, less white, less traditional and less-abled bodied’.4 She starts by distinguishing sources of infertility as either medical or social in origin, ‘with medical infertility caused by the