The looming demise of Obamacare’s individual mandate is spurring talks in a handful of blue states about enacting their own coverage requirements, as state officials and health care advocates fear repeal will roil their insurance markets.

Republicans in Congress are poised to kill off the individual mandate in their sweeping tax overhaul, knocking out one of Obamacare's most unpopular features — but one that health experts have said is essential to making the law's insurance marketplaces function.


Blue state officials, who have been working to protect their insurance markets from the Trump administration's efforts to dismantle the health law, are beginning to grapple with strategies for preserving coverage. Those officials — in California, Connecticut, New Jersey and elsewhere — aren't ruling out a state-level requirement that residents must obtain health insurance.

But even in the most Obamacare-friendly states, trying to implement an individual mandate could be politically risky, particularly in an election year.

In Maryland, the co-chair of a key health care commission said an individual mandate may be the most effective way of saving the state's insurance market from collapse.

“That’s the one that seems the most clearly in the cards,” said Maryland state Sen. Brian Feldman, a Democrat whose commission will soon issue a report to the Legislature on how to protect coverage. "I’m fairly confident there will be a bill if the tax plan results in a repeal of the individual mandate."

Feldman acknowledged the Legislature could pursue other, potentially less controversial methods, for tamping down insurance premiums and preserving coverage. However, he said a state mandate would have one clear benefit — Maryland wouldn't need federal permission to enact one.

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“In this climate, I would gravitate toward the things that we have control of in the state of Maryland rather than floating options that the Trump administration would have to approve,” he said.

A state-level mandate "has been high on our list ever since the threat began to the Affordable Care Act in Washington," said Vincent DeMarco, president of the Maryland Citizens Health Initiative, a consumer advocacy group.

Supporters of the Affordable Care Act insisted the individual mandate — no matter how unpopular — was necessary to nudge healthy people into buying insurance, helping insurers offset the costs of sick patients who could no longer be denied coverage. Though the mandate's relatively low tax penalty has proved weaker than expected, insurers still see it as a key tool and could flee the marketplaces without it.

Repealing the Obamacare mandate would lead to 13 million more uninsured people in a decade and increase average individual premiums by 10 percent, a recent analysis from the CBO concluded.

“If you get rid of the individual mandate, it’s bad for everything,” said Connecticut Lt. Gov. Nancy Wyman, a Democrat who chairs the board of the state’s Obamacare exchange.

Wyman earlier this year convened a group with four state legislators to study how Connecticut could prevent people from losing coverage if Congress gutted Obamacare. She said they haven't thoroughly deliberated a state-level mandate, but she believes they'll consider the option.

“Everybody is looking at ways to see ... how we could come up with a plan for ourselves,” she said.

States most likely to explore a coverage requirement are the nearly dozen running their own Obamacare marketplaces, which tend to have Democratic governors. They have a greater stake in ensuring their markets function properly, said Rosemarie Day, a Massachusetts health consultant who more than a decade ago helped launch the state's insurance marketplace — the model for Obamacare.

Still, another former Massachusetts health official was skeptical that Democrats would push for state coverage requirements.

“I doubt it,” said Jon Kingsdale, who led the Massachusetts insurance marketplace. “It’s the single most unpopular piece in Massachusetts.”

Washington state, which operates its own exchange, would struggle to find a coverage mechanism since the state doesn’t have an income tax, Insurance Commissioner Mike Kreidler said in an interview. Still, he said officials are exploring whether the state would implement something to compel people to get coverage.

“We’re very engaged in discussion as to what our options would be," Kreidler said, noting the state's history of dealing with Obamacare-style insurance rules without an individual mandate in the 1990s. Insurance premiums skyrocketed when healthy people avoided buying coverage, and the state's insurance market collapsed.

"We have the advantage of having the discussions we went through in the early '90s,” Kreidler said.

In California, the head of the state's Obamacare exchange recently raised the possibility of a state mandate as one of several options to stabilize its market. But even blue states can have fraught politics when it comes to raising taxes. Measures to raise revenue in California require a two-thirds majority of both legislative chambers, and Democrats have temporarily lost a supermajority in the Assembly after two lawmakers resigned over sexual harassment allegations.

Officials in New Jersey, where Democrats will fully control state government next year, also wouldn’t rule out a state-level mandate.

“Everything's got to be on the table," said New Jersey Gov.-elect Phil Murphy earlier this week when asked about the possibility of enacting a statewide mandate.

Democratic state Sen. Joe Vitale, who chairs a health care committee, said he would consider it, adding that he is evaluating several options with a working group.

“There’s a lot to think about in terms of how we would do it, what it would cost and could it be successful,” he said.

There's at least one state that would have an individual mandate if Congress repeals Obamacare's coverage requirement. Massachusetts, which pioneered the idea in 2006, never canceled its mandate, even after Obamacare instituted one nationally in 2010.

Katie Jennings, Victoria Colliver and Joanne Kenen contributed to this report.