PERSPECTIVE ON HEALTH-CARE REFORM : The Odd Jargon of the 95% Promise : The new buzzword is <i> trigger, </i> a device to force full coverage at some later date, letting this Congress off the hook.

The health-care reform plan proposed Tuesday by Senate Majority Leader George J. Mitchell reflects Mitchell’s political dilemmas. He knows he can’t muster enough votes in the Senate to approve either the President’s original bill or the bill likely to pass the House of Representatives. And he believes, sadly but accurately, that if he doesn’t get a bill out of the Senate, the reform process will expire for this year or longer.

In response, he has looked for mechanisms that balance his desire for universal coverage and cost containment with political reality--and hopes his package can be strengthened on the Senate floor or in conference with the House.

One of the mechanisms he has turned to is--in the jargon of the moment--a “trigger.” The debate about health care reform has in fact been filled with enough jargon to make a tax lawyer jealous. Lexicological inventions arise, briefly take center stage and then are struck from the script. Recall, for instance, “health insurance purchasing cooperatives” (renamed “health alliances”), “mandatory health alliances” (made voluntary) and “premium caps” (doffed). “Trigger” is the latest term of art, and lurking behind it is an important but little noted paradox.

The basic notion of a trigger is this: If some specified outcome is not achieved by a particular date (for example, health-insurance coverage for 95% of Americans by 2000) as a result of modest steps (say, reforms of insurance practices), then some other measure--presumably with a better chance of achieving the desired outcome--would kick in.

If that measure is tough (imposition of an employer mandate or a payroll tax), the provision is a “hard trigger.” This is a clear decision to do something later, subject to a firm and quantified condition. If carefully crafted, it can be a credible means to a desired end.

If the triggered measure is less forceful (say, the creation of a commission to make some future recommendations to Congress), we are looking at a “soft trigger.” This is the legislative equivalent of a mirage. Of what use is it to say that Congress might decide to do something unspecified five years from now? Such a trigger is a trick that doesn’t bind a future Congress to anything of value.

All sorts of variants have already been invented, leading one congressional aide last week to refer to a provision as a “semi-soft trigger.”

Both bills that will be debated in Congress beginning next week--Mitchell’s in the Senate and Majority Leader Richard Gephardt’s in the House--include triggers of mixed lineage.

Under the Senate bill, if by 2000 a combination of incremental measures and subsidies has not produced 95% coverage, an employer mandate would be triggered--unless Congress approved other steps recommended by a national commission. In the case of the House bill, a trigger would apply to the achievement of cost control. If in the year 2000 spending targets were exceeded in any state, a system of cost containment modeled on current Medicare payment methods would go into effect for that state--unless Congress approved some other strategy conceived by a commission.

No matter what their particulars, triggers generate a political paradox. Consider the Mitchell trigger: If the various reforms and subsidies that the bill envisions were successful in achieving their objective of 95% coverage, there would be no employer mandate. If, on the other hand, coverage did not reach 95%, a mandate could be imposed. Hence, advocates of universal coverage have an incentive to weaken the bill’s initial measures: The less effective they are, the greater the likelihood of a mandate (and universal coverage). Those who oppose an employer mandate could be motivated to pass the strongest possible measures short of a mandate, to reduce the probability that a mandate would be triggered. All of this should make for fascinating political maneuvering in the next fortnight.

Incidentally, why 95%? It is, of course, the level of coverage that President Clinton recently told the governors would satisfy his insistence on universal coverage--even though it falls short of universality. And now it is the level of coverage that is apparently emerging, at least in the Senate, as an acceptable approximation of universality.

Is there any reason to suppose that 95% is about the best we can do? Absolutely not.

When we look at the experience of other advanced industrialized countries that have aimed at universal coverage--which is to say, virtually all of them--what we find is that most of them come so close that the shortfall is little more than a rounding error. Those that come up shorter still achieve coverage of at least 98% (for example 99.5% in France, 98% in Germany, 99.9% in the Netherlands, 99% in Spain, 98% in Switzerland and 99.5% in Belgium.

What these numbers ought to make clear is that the United States, where less than 85% of the population has health coverage, ought to be more ambitious. We ought to try to do at least as well as the least successful of our peers--and if we can do it without the artifice of a trigger, so much the better.