The OBAMA HC plan could not serve the private insurance companies any better than it already does.
That's not quite true. Let's review some of the main insurance-related provisions of reform. Insurance companies can
no longer:
- Put lifetime or annual limits on coverage
- Rescind coverage
- Kick dependents off insurance policies when they graduate from college
- Charge people differently for the same policy based on things like gender or medical history
Insurance companies
must:
- Cover preventive services
- Post medical loss ratios of 80% in the individual market and 85% in the group market--if they don't, they're required to send out rebates to their customers
- Publicly disclose and justify all rate increases--increases deemed to be excessive will result in expulsion from the Exchange
- Obey guaranteed issue and guaranteed renewal rules
- Cover pre-existing conditions
- Offer plans that at least meet essential benefits requirements and meet a minimum actuarial value
- Post all prices and plan details on a central website, side-by-side with every other plan in the state exchange
The individual mandate isn't so much a gift to them as a necessary provision to prevent adverse selection from bankrupting them. The mandate's role is functional. At present, health insurers underwrite policies, meaning when someone comes to them for insurance, they decide whether to avoid covering certain pre-existing conditions--or reject the applicant altogether--and they decide whether to charge that person higher premiums than other policyholders. These activities make perfect sense but raise some basic equity concerns. After all, we're not talking about the car of a daredevil driver or a house built on a hurricane-prone coast, we're talking about someone seeking health care for himself or his family. As such, these restrictions levied through the underwriting process are unpopular, despite being a good business model.
The new reforms largely do away with them. The modified community rating provisions of the law limit the ability of insurers to charge people different rates for identical plans (some variations are allowed for things like age, smoking status, geography, etc but within limits) and the guaranteed issue provisions forbid insurers from turning people away for having pre-existing conditions. If health insurers can, for the most part, no longer price for risk, something extra is needed. That something is risk adjustment, in which insurers who get riskier pools get reimbursed for it and insurers who get less risky pools make payments (it works a bit like the NBA's soft salary cap with luxury tax).
But we still have a problem well-known to economists: adverse selection. Setting up these rules and providing subsidies to low-to-middle income people buying insurance on their own--i.e. not getting it through their employer with the associated subsidy for that--creates the potential for a universal system but it runs into the adverse selection problem. Namely, that people who need health insurance immediately are more likely to want it than people who think they're invincible. Now, one of the incentives for buying insurance when you don't currently have any great need for it is that you might eventually need it (despite criticisms that it's used to pay for too many things, health insurance is still insurance) but if you wait until you do need it, you may be rejected by insurers or charged higher premiums. That is, underwriting encourages people not to free ride because it makes it impossible to do so. But we're getting rid of underwriting because it's a barrier to a universal system.
Its replacement is the individual mandate. Without it, the healthy can opt out of buying insurance, secure in their knowledge that if they need it, they won't be rejected (guaranteed issue) and they won't be charged more for a given plan (community rating) than someone who's been diligently paying premiums for years. They may have to wait for an annual open enrollment period to get insurance but as long as they develop a noncritical condition, that won't deter them from waiting (here it simply depends on how risk-averse a given individual is).
Obviously this kind of free-riding is problematic. Indeed, it can lead to what economists call a death spiral, in which premiums rise as healthy individuals leave insurance pools (leaving them disproportionately unhealthy and expensive), pushing more healthy individuals out and sending premiums up further in a vicious cycle. (This, incidentally, is also a very possible outcome when you allow multi-state insurance sales, with only state-level governance structures to police it--i.e. governance smaller than the scale of what it's governing. That's why the new reform law allows insurance to be sold across state lines but requires multi-state governance of the insurance market if that happens.)
So to recap: private systems require underwriting because they're financed by people choosing this or that insurance company, as opposed to universal taxation. At the same time, underwriting is unpopular and stands in opposition to universality. So if we compromise between a universal public system and a non-universal private system to get a universal private system we need an individual mandate to keep insurance markets from blowing up. Note that neither universal public or non-universal private systems require individual mandates.