Recharging the Individual Mandate as Part of Health Reform

Les Masterson, for HealthLeaders Media, March 31, 2009

Just when single-payer advocates thought the individual mandate idea was nearing its demise, Washington lawmakers placed defibrillation pads on the patient and shocked it back to life.

As the major cog of the Massachusetts healthcare reform effort, the individual mandate requires residents to purchase health insurance. The result has been miniscule uninsured numbers in the Bay State, but healthcare costs continue to spiral. I'm surprised that the individual mandate is now being considered a healthcare reform option. It's not that I don't like the concept—it's that only seven months ago the idea seemed dead.

At that time, I wrote a column about how Sen. Hillary Clinton's withdrawal from the presidential race ended the individual mandate as part of a comprehensive healthcare reform plan because neither the Democrat nor Republican nominee supported the idea.

Now, the individual mandate idea is back—and the single-payer option is the idea on the outs. As part of its healthcare reform plan, America's Health Insurance Plans included the individual mandate as well as agreeing to accept all members and not charging sicker individuals more for their coverage.

The biggest boost to the individual mandate since the Clinton campaign came Friday when the Health Reform Dialogue included the concept in its report as a path to healthcare reform. The group, comprised of 18 organizations, including AARP, AHIP, the American College of Physicians, American Hospital Association, American Medical Association, American Nurses Association, Blue Cross and Blue Shield Association, Business Roundtable, and the U.S. Chamber of Commerce, could not find consensus on the most difficult healthcare issues, but it agreed on a two-pronged approach: Build on employer-sponsored insurance and expand public safety-net programs for low-income people and families.

The groups suggest three areas in which to focus: increasing coverage and access, strengthening wellness and prevention, and ensuring quality and value.

The first of these three is the easiest because it requires money and expanding/creating programs to cover most or all of the 46 million uninsured Americans. Expanding coverage is costly, but it's easier than controlling costs and improving quality—Massachusetts leaders have learned.

Strengthening wellness and prevention, and ensuring quality and value are where reform will face its hardest obstacles.

It's not easy to get people to take better care of themselves—just ask a health coach. The Centers for Disease Control and Prevention estimates that eliminating three risk factors—poor diet, inactivity, and tobacco use—would prevent 80% of heart disease and stroke, 80% of Type 2 diabetes, and 40% of cancer. I wrote an article for the September 2008 HealthLeaders magazine that was part of a package of stories called the 10 Events that Could Change Healthcare. My contribution was "What if People Actually Start Taking Care of Themselves?"

I spoke to David B. Nash, MD, MBA, one of the leaders in population health, who is chair of the department of health policy at Jefferson Medical College of Thomas Jefferson University in Philadelphia. He said only 3% of the American population follow four basic wellness goals: Don't smoke, stay close to their ideal body weight, exercise three times a week for at least 20 minutes, and eat fruits and vegetables regularly.

If that percentage increased to a mere 9% of the population, he suggested, hospital admissions would plummet for bronchitis and upper respiratory problems, heart attacks and strokes, and diabetes.

Getting Americans to follow through on better health is not easy. If they won't take better care of themselves for loved ones, you can't expect the argument that their health affects the U.S. economy will work.

And then we come to the issue of cost and quality. Controlling costs will require changing the way we pay for care. Rather than pay strictly for services, the feds will need to develop a way to pay for care coordination and raise compensation levels for primary care, while creating incentives for physicians to accept sicker patients. That's not easy. Changing payment should improve quality, but we also need to test what works and improve cost and quality transparency, so individuals can visit physicians who are providing the best services.

True healthcare reform is going to take a long time, and I still don't expect a major bill will get through Congress this year. One only needs to look at the Health Reform Dialogue. The coalition of groups couldn't come to a consensus on the issues of the employer's role in healthcare reform or whether to create a public insurance option to compete with private insurers, and it lost two unions from its coalition, the American Federation of State, County and Municipal Employees and the Service Employees, because they couldn't support the final report.

Most agree that healthcare reform is needed, but what primary care doctors think is required is not the same as specialists, health insurers, employers, Democratic lawmakers, Republication lawmakers, or hospitals.

Though some have bashed the Health Reform Dialogue for its report, and I admit I was hoping for greater consensus, this is a nice first step in what will be a lengthy healthcare reform debate.

The industry should realize that any reform package that comes from Washington will have something for everyone, but no one will love it. In other words, prepare for disappointment.

Les Masterson is senior editor of Health Plan Insider. He can be reached at

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