Mandates Are Go

There were three major issue silos that Barack Obama called for major progress on in last night's speech. On only one issue did he provide a guarantee that we'll work on it in this calendar year, and that's health care. Now Harry Reid is putting calendar dates to that request, calling for a start to the process in the summer before the August recess.

As for what form any bill will take, as I mentioned briefly, the Obama team is softening their resistance to an individual mandate.

Here's how it will work, according to the officials I've spoken to. The budget's health care section is not a detailed plan. Rather, it offers financing -- though not all -- and principles meant to guide the plan that Congress will author. The details will be decided by Congress in consultation with the administration.

One of those details is "universal" health care coverage [...]

The budget -- and I was cautioned that the wording "is changing hourly" -- will direct Congress to "aim for universality." That is a bolder goal than simple affordability, which can be achieved, at least in theory, through subsidies. Universality means everyone has coverage, not just the ability to access it. And that requires a mechanism to ensure that they seek it.

Administration officials have been very clear on what the inclusion of "universality" is meant to communicate to Congress. As one senior member of the health team said to me, "[The plan] will cover everybody. And I don't see how you cover everybody without an individual mandate." That language almost precisely echoes what Senate Finance Chairman Max Baucus said in an interview last summer. "I don’t see how you can get meaningful universal coverage without a mandate," he told me. Last fall, he included an individual mandate in the first draft of his health care plan.

The mandates argument during the Clinton/Obama primary took on a kind of mythic importance because it was among the few major differences between the candidates. Only it was not a giant difference at all, really. There was always room for mandates down the road in Obama's plan, if other approaches to get to universality didn't work. If this is the way for Congress to put their stamp on the policy, I don't think it's the worst idea.

However, I think an individual mandate would have to be carefully described. It would have to include guaranteed issue, ending the ability for insurers to deny a customer for a pre-existing condition. And it should have community rating, which would allow a flat rate of care for everyone in a community regardless of medical condition. There also must be a public option so that insurers would have to compete for this forced market on quality and price, and not have an incentive not to provide care. Finally, there has to be a focus on both prevention and overall population health, which includes nutrition and exercise and a recognition that income inequality contributes massively to poor health outcomes.

My preference would be single payer, but with all those crucial elements, an individual mandate can work.

There is a way forward with this plan, and if it includes these elements, Americans will support it. 7 in 10 “would favor a proposal that would increase the government’s influence over the health-care system in an attempt to reduce costs and expand coverage,” and most find it the number one pressing need after the economy. Of course, the two are linked. A rational health care system will increase global competitiveness and provide for worker security. This is a legacy builder. Health care is on the fast track to a solution.

SEIU and Health Care for America Now have a good action that will keep the pressure on.