This is big!  Color me amazed: The principal association of U.S. health plans, America's Health Insurance Plans (AHIP) has announced that it will support healthcare reform that would lead to insuring all Americans, on one condition: That all Americans be mandated to buy health insurance. (Yahoo article)  Here's what is going on.

The health plans have been painted into a corner. They are the least popular sector of health care, and one of the least popular sectors of American life, period. They are the bad guys of the system in pretty much everyone's eyes, facing not only horrible PR numbers, but actual civil and criminal proceedings in a number of jurisdictions across the country for what they consider normal business practices, such as rescinding contracts on people who run up big medical bills. They are facing a Democratic Congress and a Democratic president – and even the recent Republican nominee campaigned on radical healthcare insurance reform. And many Republicans in Congress have come on board with fairly sweeping proposals. So they know something serious is coming down the pike and they are afraid it will be completely out of their control.

If they succeed once again in thwarting healthcare reform, they will go even further down the "bad guys" road, fighting a rear-guard action in state after state. If they try to thwart it and fail, they may well be stuck with a bill mandating that they take all comers, regardless of pre-existing conditions. If they are forced to take all comers, who will fill their rolls? All the people whom they denied before based on existing conditions – all the customers they don't want. So they are saying, "Give us all the customers we do want, as well, all the people who opt out of healthcare insurance because they think they are too healthy for it to be worth it for them."

That is, you need to have everyone in the system so that the premiums paid by people who use the system the least help pay for the people who use it the most. That's the whole idea of an insurance pool: spreading the risk. And that's how the relatively successful Massachusetts plan works.

Of course, this leaves out: How expensive will the insurance be? Will there be subsidies of some kind? How much will it really cover?  Will it have such high co-pays and deductibles as to be useless on a less-than-catastrophic basis? Will preventive and maintenance services be fully covered?  And – a big detail – will the government offer a plan of its own in competition, as President-elect Obama has suggested? If so, will the government plan be allowed to be truly competitive or will it be politically hobbled so as not to discomfit the insurance plans?

But it it is a big step forward. We are far more likely now to have healthcare reform that covers all Americans in some way.