GAO Lays Out Ways to Encourage Health Care Enrollment

March 28, 2011 ( – One of the most controversial – and yet to some one of the most essential – aspects of the health care reform legislation is the so-called individual mandate.


Recognizing that there was a possibility that legislative or judicial action could result in a change to, or elimination of, the mandate, Senator Ben Nelson (D-Nebraska), Chairman, Subcommittee on the Legislative Branch Committee on Appropriations, asked the Government Accountability Office (GAO) to identify potential alternatives to encourage, rather than require individuals to obtain private health insurance coverage. 

Expert Advice

GAO noted that for this report, it obtained the views of multiple experts on the range of approaches Congress could consider to encourage voluntary enrollment in private health insurance coverage.  To gather those views, GAO interviewed 41 officials from 21 organizations that provide research and analysis on health care issues or otherwise are health care stakeholders, and asked those experts to identify approaches that might encourage individuals to voluntarily enroll in health care coverage, regardless of any views the experts might hold on the importance of a mandate to expand health care coverage.

The GAO report noted that most employees participate in employer-sponsored insurance where available, in part because employers typically subsidize a large share of employees’ premiums and premium contributions are tax-deductible. Premiums for individual health insurance coverage usually depend on individuals’ risk factors such as health status and age and thus may vary substantially, with individuals paying the full premium. In addition, a total of 50 million—one in five nonelderly Americans—were uninsured, with more than three-quarters of the uninsured from working

GAO noted that the experts interviewed discussed several specific approaches to encourage voluntary health insurance enrolment, and it summarized those approaches, “generally presented in the order of frequency with which they were proposed by the experts for consideration” (though it noted that the approaches were not endorsed by GAO, nor necessarily by any particular experts interviewed, or the organizations they represent):

  • Modify open enrollment periods and impose late enrollment penalties.
  • Expand employers’ roles in autoenrolling and facilitating employees’ health insurance enrollment.
  • Conduct a public education and outreach campaign.
  • Provide broad access to personalized assistance for health coverage enrollment.
  • Impose a tax to pay for uncompensated care.
  • Allow greater variation in premium rates based on enrollee age.
  • Condition the receipt of certain government services upon proof of health insurance coverage.
  • Use health insurance agents and brokers differently.
  • Require or encourage credit rating agencies to use health insurance status as a factor in determining credit ratings.

In discussing these approaches, GAO said that four key themes emerged. First, the report said that experts emphasized that most people would prefer to purchase health insurance coverage; “however, to the extent that high cost is a barrier, the use of financial incentives is key”. Secondly, the report said that the experts interviewed stated that, “regardless of the particular approach taken to increase voluntary enrollment in the absence of an individual mandate, the availability of affordable, high-quality health care plans with a basic set of benefits, and full coverage of preventive care services is essential to encouraging voluntary enrollment in the coverage. Third, experts told GAO that strong marketing and public education from trusted, community-based sources informing people about their health care choices, their costs, and the consequences of not enrolling in a timely manner are important. And fourth, they said convenient access to the health insurance system through multiple access points staffed by knowledgeable individuals would further facilitate enrollment.

However, in presenting its findings, GAO noted that not all the experts concurred that any particular approach merited consideration, and those who proposed an approach for consideration did not necessarily suggest its impact would be significant or comparable to that of an individual mandate.  “Experts noted that various approaches would have different impacts on encouraging voluntary enrollment, and that a combination of multiple approaches holds more potential to encourage voluntary enrollment than any single approach,” according to GAO.

The report is available online at