In an earlier post, we discussed my appreciation that the Democratic legislative leaders were being intellectually honest that their plan was “near-universal,” and not fully “universal,” even though they do dramatically expand group coverage to millions of Californians, and provide more security to millions who have it but are concerned it won’t be there for them when they need it.

Universal is the ultimate goal, but let’s be clear that it is hard to get there. The closest way is through a Medicare-like system, where enrollment is simple and required just once in a lifetime, and which is financed through taxes (based on ability to pay). Medicare comes very close, but still falls just short. At the state level, the only bill that can be called “universal” is Senator Kuehl’s SB840.

This has come up on the presidential campaign trail, as some critique presidential candidate Barack Obama’s plan for *not* being universal, and while for some that means not being single-payer, for many others that means not having an individual mandate.

I disagree that an “individual mandate” gets you “universal.” Without a truly automatic enrollment and affordable coverage, the enforcement mechanism would have to be pretty punitive, and the publicly-financed subsidies very generous. And even presidential candidate John Edwards’ plan, which does include an individual mandate, has exemptions for those who aren’t able to afford it. However good it is (and I think there are many good things in it), it is not universal either.

Governor Schwarzenegger’s doesn’t have any exemptions to his individual mandate, and the enforcement remains a troubling discussion. He trumpets his proposal as universal, but it is not. The modeling suggests that about a million undocumented adults, and slices of other populations, will remain uninsured.

Yet from some reporters’ point of view, his plan is supposedly more “comprehensive” than the others, yet it really doesn’t help more people. Even though roughly a half-million more people are said to be “insured” under the Governor’s plan than the Nunez or Perata plan, those people would not necessarily be better off. These are folks that are not getting coverage on the job, not eligible for public programs, yet are forced to buy individual coverage.

Without any exemption for affordability, many of these folks will be required to pay for a premium, but will only be able to afford a high-deductible product that requires them to spend thousands of dollars out of pocket before care is covered. Is it better for these people to be required to pay a premium for a product many of them won’t be able to afford to use?

So maybe we shouldn’t call these folks newly insured, because that would imply they got a benefit, as opposed to a burden. Here’s where I need your help. What should we call people who are forced to buy a plan that is more than 5% of their income? Forced to buy a high-deductible plan?

The Unafffordables?
The Burdened?
The Forced Underinsured?
TOUGHs? (Tough Option: Uninsured Greater than High-deductibles?)

Defining this group will allow for better apple-to-apples comparisons between the various plans, between the truly insured, and those who are being made to buy a product that doesn’t make sense for them. E-mail your suggestions to I look forward to your replies.

Health Access California promotes quality, affordable health care for all Californians.
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