It’s a mandate! It’s a tax! How word choice effects Obamacare enrollment.

March 25, 2013

Welcome to Health Reform Watch, Sarah Kliff’s regular look at how the Affordable Care Act is changing the American health-care system — and being changed by it. You can reach Sarah with questions, comments and suggestions here. Check back every Monday, Wednesday and Friday afternoon for the latest edition — and read all previous columns here.

It was this week, one year ago, that the Affordable Care Act had its day in court—the Supreme Court, that is.

The health care care law had the longest oral arguments of any case the high court has heard; supporters lined up for a seat in the courthouse four days in advance.

Obamacare's mandated purchase of health coverage survived the challenge. It may not, however, have gotten off scot free: New research suggests the controversy over the mandate may been a blow to its credibility—and Americans' willingness to comply.

That's the takeaway from a new paper, authored by Boston University's Keith Marzilli Ericson and University of Pennsylvania's Judd Kessler that looks at the difference beween describing the health law's penalty for not carrying insurance as a "mandate" or a "tax."

The two are, as Ericson describes it, "logically identical." Beginning in 2014, a person who fails to purchase health insurance will pay a $95 fine, regardless of whether they consider that a tax penalty or a fee for non-compliance with the mandate.

Ericson, whose research focuses on the intersection of health insurance and behavioral economics, had an inkling that the description would matter. He has researched the Massachusetts health reform effort, where a mandate helped the state achieve the highest rate of insurance in the country.

"We expected that the mandate would encourage insurance purchase more than a tax," he says. "We thought that it establishes a social norm, and a sense of obligation."

Ericson and Kessler conducted research before and after the Supreme Court decision on the health law, in the four waves outlined below.

In the first two waves of the research, before and during the Supreme Court hearing, survey participants were more likely to say they would comply with a mandate to buy insurance than a tax penalty for going without. More specifically, the mandate condition increased a willingness to buy insurance by 10 to 11 percentage points.

That was all before the individual mandate was in the news—a lot. Right around the second wave of research, there was a slew of news articles about the required purchase of health insurance.

While this paper doesn't get into the details of each article, it's likely a fair assumption that many of these articles dealt with the question of whether the mandate was constitutional. It was, after all, the question at the heart of the Supreme Court case: Could the federal government require citizens to buy a private product?

Ericson and Kessler measured, for a second time, willingness to comply with the required purchase of health insurance after all of that controversy. They found that the gap between describing it as a "mandate" or a "tax" disappeared: Each was equally persuasive to Americans weighing whether they would comply with the provision. The mandate lost its upper hand.

"Having seen how this all developed, it does make sense," Ericson says. "People might be less inclined to comply with a law that they've heard is illegitimate or unconstitutional."

One other hypothesis that Ericson and Kessler advance is that, in all the talk of the Supreme Court decision the mandate and the tax could have been made "equivalent in the minds of individuals." That could have a lot do with the decision itself, where Chief Justice John Roberts specifically upheld the health law's mandate as a tax provision.

I asked Ericson whether there was anything that the mandate could do to get its mojo back. Would the Supreme Court decision mute its efficacy for years to come, or could it somehow get back to pre-controversy levels?

"I would speculate that, if this kind of discussion can remove it, similarly a different discussion could increase its effectiveness," he said. "If people understand it as important, that it helps extend access, that could change things. If it had a lot of political actors talking about that, we might see a change."

KLIFF NOTES: Top health policy reads from around the Web.

Inside Tennessee's very competitive Medicaid lottery. "Two nights a year, Tennessee holds a health care lottery of sorts, giving the medically desperate a chance to get help. State residents who have high medical bills but would not normally qualify for Medicaid, the government health care program for the poor, can call a state phone line and request an application. But the window is tight — the line shuts down after 2,500 calls, typically within an hour — and the demand is so high that it is difficult to get through." Abby Goodnough in the New York Times.

Elsewhere in Tennessee: Republican Gov. Bill Haslam is still weighing the Medicaid expansion.

Repealing Obamacare's medical device tax faces a tough road. "Because Thursday's measure was an amendment to the Senate Democrats' budget—a partisan blueprint that stands little chance of passing the GOP-led House—the vote to repeal the tax was largely symbolic. Lawmakers are unlikely to bring forward the measure as a stand-alone bill on the Senate floor and will push instead to have it considered in broader discussions to overhaul the tax code and reduce the deficit, a Democratic Senate aide said." Kristina Peterson and Christopher Weaver in the Wall Street Journal

Covered California, the state health exchange, will build a 500-person call center to support enrollment. "The Covered California call center is expected to open in August. Its 500 employees, including call center agents, managers and technology specialists, will work in a city that is already home to call centers for Dignity Health, Sutter Health, Delta Dental and Vision Service Plan. The nearly 60,000-square-foot Rancho Cordova site will be one of two statewide call centers for Covered California." Peter Hecht in the Sacramento Bee.

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