That, they say, would be a step toward a good mix of sick and healthy people that will keep the plans profitable. Ideas include creating high-risk pools to keep the very sick in a separate market and offering low prices to the young and healthy.

Without a punishment for not buying insurance that is like the individual mandate, the market can't survive, according to Dr. J. Mario Molina, Chief Executive Officer of Molina Healthcare Inc., a company that provides Medicaid for the poor and individual insurance plans on the exchanges.


“It probably needs to be a combination of both an incentive and a penalty,” Molina said.

Insurers also want to keep the cost-sharing subsidies that have made health care costs affordable for millions of people as well as the premium subsidies that help to reduce the monthly cost for people with low incomes. Those subsidies are part of a court case filed last year that is on hold.

"If it's free or close to free, you are more likely to sign up in the absence of the mandate," said Dan Mendelson, CEO of Avalere Health, a research group and consultant that advises health insurers and is part of Inovalon Holdings.

Insurers also want continued premium subsidies, skewed to keep up enrollment of younger people.

"I think if you don't have the subsidies, then the whole thing falls apart," said Molina.


(Reporting by Caroline Humer; additional reporting by Susan Cornwell in Washington D.C.; editing by Edward Tobin)


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