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Commentary: The Politics of Reform

The articles on individual health insurance market reform in this issue raise fundamental questions about the role of competitive markets in promoting access to health care. The decision to impose new restrictions on insurers, or conversely, not to regulate insurers’ rating and enrollment practices, rests on certain core assumptions about how the world works (Thompson 1981). In New Jersey, for example, policy makers viewed rating and enrollment reforms in the individual health insurance market as a means to reduce the number of uninsured persons (Garnick, Swartz, and Skwara 1998). This basic policy hypothesis undergirds individual insurance market reforms such as the removal of preexisting-condition clauses, limitations on underwriting practices, and the introduction of community rating. If this assumption is flawed, however, incremental reforms will be ill-equipped to address many of the most significant shortcomings of the marketplace. The articles in this issue return to the familiar “competition versus regulation” debate which dominated the health policy literature in the 1970s and 1980s. First, what lessons can be gleaned from the case studies? Should state government reject insurers’ claims of “actuarial fairness” in enrollment and rating in favor of reforms designed to protect certain groups from discrimination? What are the consequences of doing so? Second, can incremental reforms which regulate the rating and enrollment practices of insurers effectively limit discrimination against chronically ill persons or other high-risk subscribers? Or are regulatory cures worse than the disease? Finally, what are the political dynamics of reforming the individual health insurance market? Under what circumstances are reforms most likely to surface?