Managed Care - February 2008 - (Page 17) LEGISLATION & REGULATION Move to Mandatory Coverage Wouldn’t Ensure Universality Compared to the existing state of affairs, there’s a lot to like in mandatory coverage, but the Massachusetts experiment is a lesson to not expect miracles By John Carroll I nside the Democratic party, it’s axiomatic that health care insurance reform is crucial to unlocking the door at 1600 Pennsylvania Ave. In poll after poll, a majority of voters gives the party a decided edge over Republicans in dealing with the country’s 47 million uninsured. But while universal coverage is every candidate’s goal, each of the keys being offered by the leading contenders is being cut to a different size. The biggest difference is focusing the debate on one central issue: Should individuals and some companies be required to buy insurance, with subsidies and tax cuts offered to make premiums more affordable? Hillary Clinton has been forced to defend her stance on mandatory coverage, and she has launched a series of counterattacks on her closest competitor in the primaries — Barack Obama — who is concentrating on a plan that is designed to expand federal health programs, make insurance for children and employees at all but small companies compulsory, make coverage for adults more affordable, but not mandatory, and help cover the cost of catastrophic cases. Outside of a single payer system, achieving full coverage isn’t really possible, according to many analysts. Even Clinton’s mandatory plan will leave some without health insurance. But the Democrats’ competing plans for universal coverage have the potential to broaden the base of insurers’ covered lives — while fixing a harsh spotlight on future premium hikes. “The only way to cover nearly everyone is to have an individual mandate that is strongly enforced,” says Marylou Buyse, MD, a practicing physician and CEO of the Massachusetts Association of Health Plans, a state been a contributJohn Carroll, a freelance writer, has where insurers are at the of MANAGED CARE for six years. ing editor epicenter of the universal coverage de- bate. The commonwealth is well into an experiment that offers a few lessons on how a mandatory program could affect health plans if a federal program ever takes effect. Uncharted waters In early December, officials in Massachusetts trumpeted a key milestone, noting that about 300,000 of the estimated 550,000 or so of the state’s uninsured had been provided coverage under a public health program or bought insurance rather than run the risk of being penalized. But inside the state, even supporters of the initiative are wary of suggesting the same approach for the country. No matter how confident candidates may sound, even the reform advocates know they’re in largely uncharted waters. “It’s great to hear John Edwards and Clinton talk about a national mandate, but we haven’t proven that it can work in Massachusetts,” says John McDonough, executive director of Health Care for All, a consumer advocacy group. “I think that the people supporting it and opposing it don’t know what they’re talking about because we don’t know what we’re talking about.” As for insurers, he adds, not all plans are likely to benefit equally in the state. “Blue Cross Blue Shield of Massachusetts supported the measure and Harvard Pilgrim Health Care opposed it” largely because of Blue Cross’s sizable position in the individual insurance market and Harvard Pilgrim’s smaller share, says McDonough. To keep coverage affordable, rates in the lowcost plans created to help cover the uninsured have to be kept down. And in Massachusetts, there is an intense focus on premiums as another year rolls around for a health care indus- FEBRUARY 2008 / MANAGED CARE 17
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