It looks like the glimmer of a compromise on health reform: the "trigger." The notion is to revamp the health insurance marketplace to extend protection to far more Americans -- from the current 85 percent who have health coverage to more like 95 or 97 percent. If that target isn't achieved several years from now, one of several triggers would go off: Employers could be compelled to contribute to workers' health insurance, individuals could be required to buy it or still other steps could be undertaken to extend coverage. In effect, the trigger is a mechanism to postpone the contentious issue of imposing these employer or individual "mandates" upfront. But when lawmakers confront the substantive and technical problems, both Democrats and Republicans will conclude that triggers alone won't work. Unless they find the money to fund health reform, that grim realization could kill sweeping health legislation this year.
As politicians struggle to salvage a health bill, they're toying with more types of fancy triggers than cowboys in the old Wild West did. A number of Democrats prefer a "hard" trigger: Under one version, failing to cover perhaps 97 percent of the population after several years would prompt a mandate on employers to contribute to workers' coverage. Then there's the "soft" trigger, the brainchild of moderate Republicans and conservative Democrats, under which failing to achieve the target would result in less-clear-cut actions. The president or a commission could then be required to recommend additional steps to spread insurance, such as giving uninsured people hefty subsidies; Congress would then have to vote these measures up or down.
Cash and carry. The crucial test of any health reform plan that aims to spread coverage is whether it's backed up with cold, hard cash -- in other words, with the tens of billions of dollars needed to subsidize coverage for many of the uninsured. Clinton's plan was designed to do so in large part through its employer mandate -- but the evidence suggests that most trigger proponents aren't willing to put their money where their mouths are. Indeed, most reform plans that could mesh with a trigger are drastically underfunded because politicians don't want to propose massive tax hikes or other ways to pay for the plan. Consider the reform proposal advanced by Rep. Jim Cooper, a Tennessee Democrat. An analysis by the Congressional Budget Office concluded that the program would extend coverage to about 91 percent of the population after four years. But getting that far would cost the government a net $190 billion more in subsidies than Cooper has proposed, assuming that Congress chose to guarantee a moderately generous package of insurance benefits. Bumping up the target to something close to universal coverage -- or about 97 percent of the population would cost an additional $142 billion, according to the health policy research firm Lewin/VHI.
That suggests a Catch-22. Unless Congress voted to raise money for these massive subsidies upfront, even a relatively low target of covering 91 percent of the population wouldn't be achieved. Thus, the trigger would automatically go off in several years. The hard trigger would then lead to an employer mandate, which Republicans and conservative Democrats don't want now and undoubtedly wouldn't tolerate in the future. And a soft trigger might lead to a recommendation by a commission to create the same huge subsidies that Congress balks at creating now.
Dozens of daunting technical problems also arise with triggers, since Congress would have to devise two new health insurance systems -- one that would prevail before most of the population was covered and a second thereafter. Consider one insurance- market change that almost all lawmakers would like to make: banning "pre-existing condition" restrictions, which prevent many people from obtaining coverage if they are already afflicted with a disease. Yet under a system where everyone isn't required to buy insurance, some of these restrictions would have to be maintained; otherwise, many people would put off buying coverage until they got sick, when the costs would bankrupt insurance companies. The restrictions could only be lifted when almost everyone was covered, either because Congress had ponied up the money or because mandates kicked in.
Recognizing many of these problems, Republican senators have signaled that they're opposed to a hard trigger out of fear that it would lead to the dreaded employer mandate. Clinton, meanwhile, is open to discussing the hard trigger but views its soft sister as merely an escape hatch for Congress to duck the issue of universal coverage. That portends an ongoing stalemate - - and it is why health reform will die this year unless Congress faces up to the true costs. If the goal is universal coverage or something close to it, the money has to be collected somewhere, either directly from taxpayers or indirectly through the employer mandate. That is, of course, unless Congress ditches the trigger and moves on to the next gimmick -- like a magic wand.
