The resources below explore the important link between the market reforms included the Affordable Care Act (ACA) and the mandate.

"The Link" Infographic
Studies from independent experts—the Congressional Budget Office (CBO), Center for American Progress (CAP), Urban Institute, Lewin Group, and RAND Corporation—have examined the impact of severing the individual mandate but retaining ACA market reforms. While the studies differ on the magnitude of the impact of severing the mandate, they all find that doing so would result in a dramatic rise in the uninsured population and increases in health insurance premiums compared to health reform with a mandate.

What They Are Saying

What You Need to Know: The Link Between Market Reforms and the Individual Mandate

Fact Check: State Experience with Health Insurance Reforms Highlights Need for Broad Participation

Explore a running list of quotes from policy experts, political leaders and editorial pages across the ideological spectrum who all agree that there is an inextricable link between the guarantee issue and community rating provisions in the ACA and the personal coverage requirement.


A number of studies have been conducted that show the impact of delinking market reforms from the personal coverage requirement. While the studies differ on the magnitude of the impact, the conclusion of all the studies is clear: more uninsured, higher premiums and less choice for individuals and families.


  • Wrong Rx for healthcare website
    Los Angeles Times
    "Suspending the penalties is tantamount to delaying the mandate. And if there's no enforceable requirement to buy insurance, many Americans who don't need healthcare immediately won't do so. That's because, under the 2010 law, they can still get coverage after they're sick. There's already a risk that the penalties in the law aren't stiff enough to guard insurers from being saddled with an ever-sicker, costlier pool of customers, which would cause premiums to spiral upward. Suspending those penalties would only make that result more likely."
  • Delaying the individual mandate is a bad idea
    Washington Post
    "Attacking the so-called individual mandate makes for great politics but following through on the delay would destabilize the new and vulnerable insurance market. Next year, the law will oblige insurance companies to accept pretty much anyone, regardless of age or health. The trade-off is that everyone will be required to buy into the system so that insurance companies can have enough healthy customers to keep premiums for everyone reasonable. The penalty against individuals lacking health-care coverage is a crucial tool in the effort to drive people into the new system. Delay it, and you’ll get fewer people signing up in the first part of next year, and insurance companies will demand, with good reason, to renege on the rates they are offering for next year’s coverage. At present, lawmakers do not need and should not attempt to make that outcome any more likely."
  • Analysis: N.Y. Insurance Market Called 'Poster Child' For Individual Mandate
    Kaiser Health News
    "New York is like the poster child for why you need an individual mandate,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reform. “They implemented all the reforms without the individual mandate, and premiums just went through the roof."
  • "Washington state provides case study on effects of heath-care reform"
    The Washington Post
  • "The Lesson of State Health-Care Reforms"
    The Wall Street Journal
  • "Health Care After the Supreme Court Ruling"
    The New York Times
    “’States that have tried community rating and guaranteed issue without a mandate and without subsidies saw a “death spiral,”’ Dr. Lischko said, in which more sick people and fewer healthy people enter the insurance pool.”
  • "Even with a High Court win, Obamacare won't work"
    "A new study shows that the basic requirements of President Obama's health care plan have been tried, and failed, in many states in the past two decades."
  • "Why Washington state’s health reform faltered after loss of mandates"
    The Seattle Times
    "Washington state is no stranger to the debate about the individual mandate now under way in the U.S. Supreme Court. In the early 1990s, the state created a comprehensive package using mandates and incentives to get all state residents insured. But when the package was dismantled, a spiral began that led insurers to stop selling individual policies."
  • "The New Jersey Experience: Do Insurance Reforms Unravel Without An Individual Mandate?"
    Kaiser Health News
    "The Obama administration has told the court that if it invalidates the mandate it should also invalidate two key insurance reforms that would prevent discrimination because of preexisting conditions. On this, the administration has a somewhat unusual ally: The insurance industry. Although insurers have fought many parts of the health law, they have long favored the establishment of a mandate, which requires almost everyone who can afford it to buy health insurance or pay a fee, saying the reformed market cannot function without it… But is the administration's claim correct? For some clues, the justices could examine what happened in New Jersey, a state that tried to reform its insurance markets without a mandate -- and failed pretty miserably."
  • "Would Premiums Without A Mandate Really Only Be 2.4% Higher Than With A Mandate?"
    Colorado Health Insurance Insider
    "A lot could happen between now and 2014 when the main provisions of the ACA are scheduled to take effect. But if all continues as currently planned but with the individual mandate eliminated, I would expect premiums – in the long run – to be significantly higher than they would be with the individual mandate in place."
  • "The Importance Of The Individual Mandate: A Response To Sheils And Haught"
    Health Affairs Blog
    "The likelihood of crippling market effects is also suggested by experiences in every state that has attempted to implement guaranteed issue and community rating in the individual market without a purchase mandate… But this we do know: with a mandate, all models predict stable markets. Without a mandate, there is at least great uncertainty about whether the reform structures would survive intact, and a real risk they would crumble. Without a mandate, perhaps the individual market would stumble along somehow, but at least it would deteriorate: coverage would drop, and prices would increase, forcing government to subsidize higher premiums in order to cover fewer people. That is all one needs to know to conclude that the mandate is an essential lynchpin for the ACA’s success."
  • "Liberals go off on a mandate"
    The Economist
    "If you don't oblige everyone to buy health insurance, then many young and healthy people will bet on not needing insurance, and will decline to buy it. That shrinks the remaining pool such that it is made up of older, sicker people with higher medical costs, and thus premiums will rise. That in turn will cause more healthy people to leave the system. This is the phenomenon of ‘adverse selection’. Ultimately you're left only with rich old sick people, and nobody else can afford insurance. This is known as an insurance death spiral. If you want affordable, universal health insurance, then everyone has to buy in."
  • "Maine Finds a Health Care Fix Elusive"
    The New York Times
    "...the state is one of 17 that limit how much insurers can charge people for being older, and it does not allow exclusions for previous illnesses — both policies that are part of national reform proposals. But one result is that premiums for younger people are relatively high. Although national proposals would require that nearly everyone get coverage or pay a penalty, Maine’s Legislature rejected such a mandate so many young people do not or cannot buy insurance — further skewing the insured pool to sicker and older people and making premiums that much higher."