What We Should Have Known All Along about Health Reform

Much handwringing about health care what-ifs

This week’s coverage of the Virginia court decision declaring health reform’s individual mandate unconstitutional was surprisingly thorough and contextual. What a pity the points made in the last few days were not presented during the fifteen months the law wound its way through Congress. Campaign Desk repeatedly urged a more complete discussion of the individual mandate, which essentially forces people to buy insurance from private insurance companies.

In September 2009, we praised The Wall Street Journal for finally looking at what we called “the ignored sine qua non of health reform”—ignored, we said, “largely because the pols—for good reason—have kept voters in the dark about it, perhaps fearing that voters might not be too keen on it.” Perhaps politicians were right to keep mum, but the media were not. In her good story in The Washington Post, Amy Goldstein noted that nearly seven in ten Americans believe the mandate should be repealed. That’s hardly shocking, considering that the public was not told much about the mandate, why it was necessary, what would happen if it weren’t part of the deal, how they would fare under such requirements, and what the alternatives were.

In short, supporters did not make a convincing case to the public about the need for the mandate. And after the law passed, the conventional wisdom reported by the media reflected the reform advocates’ view that the law was constitutional, so there wasn’t much need to worry about that.

Instead, reform’s supporters pushed the peripherals—temporary high-risk pools for sick people to buy coverage right now, which have not been a smashing success so far; keeping young adults on their parents’ policies, which has not be as easy as some thought; and removing annual limits on coverage, from which thousands of people will see no immediate relief. The government has exempted some 220 health plans and employers from that part of the law, at least through next year.

Now that the Virginia decision indicates that the court process may not be the slam dunk some wished for, the focus has shifted to the alternatives. Those should have been discussed during the debate. And yet only this week have the media started to tell us that there might be other, more palatable options that would get more people covered in a system where for-profit insurers rule the roost. Maybe there are other ways to boost the number of people who have coverage.

Jamie Court, president of the California advocacy group Consumer Watchdog, told the Times’s Robert Pear “the health insurance purchase mandate is not necessary for health care reform to work.” John Sheils, vice president of the Lewin Group, told Goldstein that “tweaks” like making it harder for people to sign up for insurance when they get sick, and instead only offering a once-a-year sign up period, might work. The idea of early-bird discounts is floating around, too. Those who sign up early might get a cut in premiums; those who don’t could pay through the nose.

The court’s focus on the mandate brings up another aspect of the law ignored by the press. Former insurance company executive Robert Laszewski, who has resumed his posts on Health Care Policy and Marketplace Review, writes today that the Richmond ruling misses the big picture on health affordability under the law, an issue that Campaign Desk noted was overlooked by the media as much as the mandate was. Laszewski writes:

Many middle class families will not be happy with or be able to afford the fines nor will they be able to afford the much higher cost of health insurance—even after the federal subsidy.

In a table that in that journos should keep for handy reference, Laszewski points out that a family with an income of $65,000 will pay about $6,000 in premiums, even with a government subsidy; a family with an income of $55,000 will still have to pay about $4400; and a family with an income of $90,000 will pay the full cost. In 2010, the average premium cost was nearly $14,000.

If the Supreme Court strikes down the mandate, the affordability question won’t matter much. But if it doesn’t, the media will have some make-up work to do.

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Trudy Lieberman is a longtime contributing editor to the Columbia Journalism Review. She is the lead writer for The Second Opinion, CJR's healthcare desk, which is part of our United States Project on the coverage of politics and policy. She also blogs for Health News Review. Follow her on Twitter @Trudy_Lieberman. Tags: , , ,