You'll Be Required to Get a Health Plan?

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In a major development in the push for national health care reform, a diverse coalition of interest groups announced they had agreed to endorse a controversial proposal to mandate that everyone in America obtain health coverage.

Or did they? (No, they didn't.)

The so-called Health Reform Dialogue, an ad hoc coalition of business and health care organizations that had been negotiating for six months with the help of a professional mediator, released a report Friday spelling out their consensus principles for health reform. If you'd read any of the news coverage, you'd be within your rights to be a little confused.

I read the report and some of the supporting materials and, based on that, wrote that the "individual mandate" issue was among those the Dialogue neglected to address, as did a bunch of other news outlets.

But some of my colleagues in the press reported the opposite: that the Health Reform Dialogue had come out in favor of an individual mandate. This would be very significant but it doesn't seem to be true.

This is an important question that policy makers need to answer, so a gang of interest groups choosing one side would be a a big deal. Massachusetts instituted such a requirement in 2006 but it remains a point of passionate disagreement: Is it appropriate for the government to mandate such a thing? How would you enforce it? But how would you get everybody in the insurance risk pool without it? Etc.

My attempts from Friday to Sunday to clear up the confusion illustrated pretty well what happens when lobbying groups come together to try to agree on anything without abandoning their own vested interests. To put it simply, some of these organizations back an individual mandate, some do not, and they couldn't work out an honest compromise. The result was the kind of tortured language you'd expect from such a committee.

My intention isn't to criticize other reporters, I'd like to emphasize. I understand why they reported it the way they did. Trying to get to the bottom of it nearly left me more bewildered than when I started. Allow me to show you the source of our puzzlement.

From the Health Reform Dialogue's report:

Enact reforms necessary so that all individuals will purchase or obtain quality, affordable health insurance

Concentrate your attention on the word "will" here. If they wanted it to say "must," they would've written it that way. A press flack at one of the Dialogue groups, amusingly, read aloud a canned answer to my question when I phoned, then emailed me the text:

There is consensus within the group that there needs to be individual responsibility. We all believe that there needs to be some market reforms that enable those people who need health care the most, to be able to get health care coverage. The best way to achieve that is to get everyone into the system. In doing so, we can enact reforms that would no longer preclude people from getting the care they need.

That's all well and good but it somehow uses more words to say the same thing, only less clearly. "Individual responsibility" doesn't mean the same thing as "You have to buy insurance or we'll fine you or something." The press release isn't much help either, saying the group supports "Reforms aimed at having all Americans purchase or otherwise obtain health insurance." Yes, I'm sure they do support that. Who wouldn't?

The most sincere and enlightening response I got was from an individual who participated in the negotiations: "I think you got it right though there is a bit here of everyone seeing in broad language what they want." That's exactly correct -- and "everyone" doesn't mean just the press. The group's members also get to interpret that language to mean what they want it to mean, as do the lawmakers who read it.

Another one of the participants sent me an email saying, in part: "[W]e never used the 'm' word, but one of the bullets in our document is designed to recognize that we will need to have some reforms that would be designed to get everyone covered, such as with an individual obligation." It seems like that "such as" is being asked to do a lot of work. "None of the 18 groups seem to oppose an individual obligation, but some have not yet worked this through among their memberships," this person tellingly added.

Still another response from someone at one of the groups conceded, "There was a recognition in the group that the word 'mandate' can be a controversial term." This person also said I was "splitting hairs," and wrote, "The group agrees that we need to get everyone in the system and that people have a responsibility to get covered."

Maybe I am splitting hairs but it's a huge policy question: Should people just be vaguely responsible or should they be required to do something? I'm responsible for sorting my recycling but I'm required to pay my taxes, for instance.

In the political sphere, the individual mandate issue is highly contentious. You might recall Hillary Clinton and Barack Obama arguing about it during the Democratic primary last year (she was for it; he was against it). Today, Democrats in Congress are leaning toward making an individual mandate part of their plan but the matter is far from settled.

Despite being a bit mealy mouthed about individual mandates, the Health Reform Dialogue did take stands on some important issues. Their five-page report is a serious contribution to the debate and I encourage you to look it over. It's a fair bet that a lot of its recommendations will be included in the health reform bills moving through Congress. There's also undoubtedly value in having such a diverse group sitting around the same table talking instead of planning multi-million ad campaigns to tear each other down.

[The Health Reform Dialogue's members are the AARP, the Advanced Medical Technology Association, America's Health Insurance Plans, the American Cancer Society Cancer Action Network, the American College of Physicians, the American Hospital Association, the American Medical Association, the American Nurses Association, the American Public Health Association, the Blue Cross and Blue Shield Association, the Business Roundtable, the Catholic Health Association of the United States, Families USA, the Federation of American Hospitals, the Healthcare Leadership Council, the National Federation of Independent Business, the Pharmaceutical Research and Manufacturers of America, and the U.S. Chamber of Commerce. The Service Employees International Union and the American Federation of State, County, and Municipal Employees declined to sign the report because they strongly support creating a new government health program.]

Jeffrey Young is a staff writer at The Hill.

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Jeffrey Young

Jeffrey Young is a staff writer at The Hill, the newspaper for and about Congress, where he covers health care, lobbying, politics, and the intersection thereof for the "Business & Lobbying" section. He's been covering health policy in Washington for a decade and still hasn't heard that one good idea that will fix everything. Email Jeffrey at jeffrey.young.atlanticbusiness@gmail.com
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