The Link

The Supreme Court’s ruling preserved the link between the market reforms and universal coverage. The disastrous experience in states that tried to implement similar market reforms in the absence of universal coverage will not be repeated nationally.  However more must be done to get as many people into the system as possible.

State Case Studies

Experience in eight states that enacted various forms of guarantee issue and community rating in the 1990s all showed what happens when these market reforms are not linked to a mandate – higher premiums, no reduction in the uninsured and loss of consumer choice.



This case study examines Washington state’s experience with enacting market reforms without achieving universal coverage and the impact this had on premiums, consumer choice and the number of uninsured.





In 1994, Kentucky attempted health insurance reforms without a mandate. Costs skyrocketed for consumers, and the number of uninsured increased.




Independent experts, policymakers and elected officials have all recognized the inextricable link between the mandate and market reforms such as guarantee issue and community rating.