Figuring out how killing the Affordable Care Act individual health insurance mandate might affect individual major medical enrollment is trickier than it sounds.
One problem is that an individual health insurance market with a repealed mandate might be different from a market that never had a mandate in the first place, according to Alexandra Minicozzi, an analyst at the Congressional Budget Office.
Related: Study says ACA market is stabilizing
Minicozzi, unit chief for the CBO's health insurance modeling unit, talks about the challenges facing ACA mandate repeal forecasters in a new meeting slidedeck.
The drafters of the bills that created the ACA eliminated many of the tools, such as shutting out sick people, and charging higher premiums for sick people, that health insurers once used to manage claim risk.
In an effort to offset some of the effects of those changes, the ACA drafters created an "individual shared responsibility" provision. That provision requires many people to have what the government classifies as "minimum essential coverage," or solid major medical coverage, for much of the year, or else pay a penalty.
The ACA individual mandate offers many types of exemptions.
Only 4.8% of the taxpayers and known nonfilers without minimum essential coverage in 2015, or about 17% of the taxpayers and known nonfilers who might have been expected to pay the individual shared responsibility penalty for 2015, actually paid the penalty, according to Internal Revenue Service data included in Minicozzi's slidedeck.
Another concern is that 58% of the taxpayers who had to pay the penalty for 2015 had an adjusted gross income under $50,000, according to another batch of IRS data included in the slidedeck.
For CBO forecasters and other forecasters, one challenge is that "repealing the mandate is not the same as never having had a mandate," Minicozzi writes.
She lists three major questions that might shape forecasters' thinking about the difference between a post-mandate world and a never-mandate world:
How much will the knowledge about the benefits of having health insurance, subsidies, and the enrollment process that consumers have already gained affect their decisions in the future?
How much has the mandate permanently changed the stigma associated with having Medicaid coverage?
How much persistence in enrollment in health insurance coverage that’s already in force can we expect?
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