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Hard or Soft Trigger? Cracking the Health Debate Code


Washington. -- Hard trigger. Soft trigger. Roy Rogers and Trigger. The debate over restructuring the nation's health care system is beginning to sound like the shootout at the OK Corral.

Which it sort of is, politically speaking. The stakes are very high for President Clinton, the members of Congress and virtually every American. All will be affected by whatever legislation emerges -- or fails to -- before the matter is resolved this year.

Still to be answered are such difficult questions as whether health insurance coverage will be provided for everyone, by what date, and who will pay for it. Looming large over the process are the concerns of those already covered by insurance who fear they will wind up worse off.

Thus, the inevitable Washington jargon that has been coined as the common tongue of health care reform serves two purposes: It provides a short-hand means of expressing complicated concepts, and it puts a political slant on certain tactics to suit the needs of the user.

For example, Mr. Clinton likes to call his proposal that employers be required to help their workers buy health insurance "shared responsibility." Senate Republican leader Bob Dole of Kansas likes to call it a "tax increase."

For most of this month, Senate Majority Leader George J. Mitchell of Maine and House Majority Leader Richard A. Gephardt of Missouri will be engaged in the toughest job either of them has ever faced. They are trying to combine competing health care reform proposals passed by four separate Senate and House committees into a form they believe can be passed by their respective chambers.

Mr. Mitchell will bring his plan to the Senate floor to face the prospect of unlimited amendments and a possible filibuster. Mr. Gephardt has the advantage of more structure and time limits, but he needs to find 218 votes from a pool of only 256 Democrats.

Herewith is a glossary of some of jargon likely to be tossed about as each house of Congress struggles to pass a version of the health care legislation by the mid-August recess.

* UNIVERSAL COVERAGE -- This sounds so simple: everybody covered. But universal coverage has become the slipperiest phrase in the entire debate because Mr. Clinton has threatened to veto a bill that does not provide for it. Mr. Clinton has had to adjust his own definition several times already to keep his bluff from being called.

Just last week, Mr. Clinton appeared to lower the bar again by suggesting that guaranteeing health insurance to 95 percent of the population might still be considered "universal" coverage -- at least in the short run. About 85 percent of Americans have health insurance today.

But after liberal Democrats and some party leaders protested the president was caving in too soon, Mr. Clinton abruptly reversed course. Stay tuned.

* UNIVERSAL ACCESS -- This is an alternative goal invoked by opponents of the Clinton plan who don't want to force anyone to buy health insurance but hope to make it more affordable and thus easier to obtain. Hillary Rodham Clinton notes that Americans have universal access to Mercedes automobiles, yet that doesn't put them in the driver's seat.

* SINGLE PAYER -- The simplest and probably most effective means of providing universal coverage, this proposal calls for enrolling all Americans in a government-run program financed by a substantial new tax. Mr. Clinton rejected this approach, similar to the Canadian health system, because he didn't consider it "feasible." Strong advocates of this approach remain, however, among the most liberal ranks of the Democrats. They are digging furiously to prevent a total capitulation by Mr. Clinton to moderates and conservatives.

* EMPLOYER MANDATE -- A lesser-of-the-evils option Mr. Clinton decided was a more practical means than direct taxes to finance universal coverage: making firms pay 80 percent of the cost for their workers. Though polls show most Americans support the idea, small business lobbyists have waged a highly effective campaign, claiming that the "mandate" would force their clients to lay off workers or go out of business altogether. No Republicans are supporting the concept.

* INDIVIDUAL MANDATE -- A third financing option that would require individuals to buy their own insurance if employers do not provide it. Mr. Clinton included this in his proposal to apply to the self-employed and others not covered by the employer mandate.

One Republican plan included individual mandate -- instead of, rather than as a supplement to, an employer mandate -- on the theory that, like automobile insurance, every citizen has a responsibility to obtain health coverage. That concept also came under sharp attack as a "tax increase." But some requirement is considered necessary to guarantee that young, healthy people remain in the pool of insured to offset the greater expenses of the ill and elderly.

* HARD TRIGGER -- A political device intended to soften the appearance of passing an employer mandate that is likely to be used by House leaders when their version of the bill comes to the floor next month. Under this approach, the employer requirement would automatically take effect if universal coverage has not been achieved by a certain date. The tentative target is the year 2000.

* SOFT TRIGGER -- A political device intended to postpone making the tough decision on employer mandates while still giving Mr. Clinton something he can claim will lead to universal coverage. This approach, already adopted by the Senate Finance Committee, calls for the creation of a commission to recommend steps to Congress if universal coverage has not been achieved by a certain date. This may be the farthest the Senate will go when its version of the bill comes up next month.

* GOLDILOCKS TRIGGER -- Not too hard, not too soft, but "just right," says Sen. John B. Breaux, a Louisiana Democrat promoting this potential compromise. It would require Congress to act on the commission recommendations if universal coverage is not achieved.

* CONFERENCE COMMITTEE -- The joint meeting of House and Senate leaders where the competing versions of the bill passed by the House and Senate will be melded into one for a final vote before Congress adjourns in October.

Republicans fear Democratic leaders will use their greater clout at this meeting to fashion a stronger bill than what comes out of the Senate, and then challenge the GOP to filibuster it weeks before the midterm elections.

* BASIC BENEFIT PACKAGE -- The standard package of benefits that must be

available to all. Every medical specialty wants its service in this package, but the big fight will be over abortion.

* CHOICE -- Whatever bill emerges is almost certain to provide that individuals have a choice of at least three types of insurance plan, and the freedom to pick their own doctors -- though some doctors might cost extra.

* INSURANCE MARKET REFORMS -- The minimum changes in the system on which nearly everyone agrees. These would end current discriminatory practices, such as cutting off or refusing insurance coverage to people who become sick. The catch is that insurers say they can't afford to do this without universal coverage to spread the cost around. Otherwise premiums would be too high.

* COMMUNITY RATING -- An insurance reform that balances out premium costs between the young and old, healthy and sick. This is another concept that only works with universal coverage, insurance industry lobbyists say.

* MANDATORY ALLIANCES -- A major element of Mr. Clinton's original bill that was half-dead-on-arrival, and finished off by the "Harry and Louise" television ads. The idea was to group everyone into regional alliances that would negotiate for them to get the best rates from insurance companies.

* VOLUNTARY PURCHASING GROUPS -- The same idea, only voluntary. These groups will almost certainly survive because they provide a means for individuals and small businesses to band together to negotiate for cheaper insurance rates. Purchasing groups will also be needed to allow workers to carry their insurance from job to job: the single remaining reform now advocated by Mr. Dole.

* COST CONTROLS -- A mechanism to control medical inflation by requiring insurance companies to keep their spending within certain limits. Mr. Clinton proposed premium caps.

Some Republicans favor limiting the tax deductions for insurance benefits. The Senate Finance Committee adopted a tax on the most expensive insurance plans.

* RATIONING HEALTH CARE -- This is what the insurance industry claims will happen if their spending is controlled. This concept is even more frightening to voters than "employer mandates." If any form of cost controls is adopted, those cost controls are also likely to take effect after some kind of trigger.

* CLINTON BILL -- Whatever passes.

Karen Hosler covers Congress from the Washington Bureau of The Baltimore Sun.

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