NCPA - National Center for Policy Analysis


February 15, 2008

Governments routinely mandate that individuals, employers, and other levels of government behave in specific ways.  But despite mandates' ubiquity, their performance varies greatly, say Sherry A. Glied, Jacob Hartz and Genessa Giorgi, authors of a new study published in Health Affairs.


  • Under an individual health care mandate since 1994, Switzerland now enjoys near-universal coverage -- but this reflects only a minute increase in coverage from the period before the mandate, when 98-100 percent of the population held coverage, most voluntarily.
  • Hawaii has been mandating that certain employers provide health insurance since 1972, yet by 2002, the mandate had only reduced uninsurance by a modest 5-8 percent.
  • Conversely, the Netherlands shifted to a purely private health insurance system and mandated citizens to purchase private insurance in 2005; estimates from the first year of enrollment suggest that only about 1.1 percent of the population failed to enroll.

Similar discrepancies are seen outside of health care:

  • In New Hampshire and Wisconsin, two states that do not mandate auto insurance, the uninsured driver rates of 8 percent and 10 percent, respectively, are well below the national average.
  • Despite an elaborate structure of enforcement and penalties, compliance with nationwide child support is disappointingly low; approximately 30 percent of mothers owed support receive it.
  • On the other hand, child immunization mandates for varicella suggests mandates improved immunization rates; states with mandates average about an 85 percent immunization rate, while those who do not average only a 77 percent rate.

Overall, the authors suggests compliance with mandates can be quite low.  In some cases, however, compliance is nearly perfect.  High-compliance situations share several features:

  • Compliance is easy and relatively inexpensive.
  • Penalties for noncompliance are stiff but not excessive.
  • Enforcement is routine, appropriately timed and frequent.

Enforcement is simplified if all (or nearly all) of those subject to the mandate must purchase coverage at one specified time and if enforcement occurs concurrently with purchasing coverage, says the authors.

Source: Sherry A. Glied, Jacob Hartz and Genessa Giorgi, "Consider It Done? The Likely Efficacy Of Mandates For Health Insurance," Health Affairs, November/December 2007.

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