|
Items in cart [4] |
Questions? Call 888-624-8373 |
PAPERBACK + PDF PAPERBACK PDF BOOK PDF CHAPTERS Free Resources |
||||||||||||||||
|
||||||||||||||||
|
|
|||||||||||||||
| ||||||||||||||||||||||||||||||
|
||||||||||||||||||||||||||||||
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 1
Executive Summary
ABSTRACT
The lack of health insurance for tens of millions of Americans has serious negative
consequences and economic costs not only for the uninsured themselves but also for
their families, the communities they live in, and the whole country. The situation
is dire and expected to worsen. The Committee urges Congress and the Admin-
istration to act immediately to eliminate this longstanding problem.
This report offers a framework for the public and policy makers to use as they
weigh the pros and cons of various proposals. The framework consists of a set of
principles informed by the research and analysis of the five previous reports in this
series. The principles are applied to selected coverage prototypes to demonstrate the
extent to which various proposals for extending coverage or designing new strategies
to eliminate uninsurance would improve the current situation.
The lack of health insurance coverage for a substantial number of Americans
has been a public policy problem throughout the past century and particularly
over the past three decades. Three years ago, following a decade of strong eco-
nomic growth but little progress reducing the number of uninsured, the problem
was urgent; 39 million people under age 65 reported having been without insur-
ance during the entire previous year.1 In 2000, the Institute of Medicine (IOM)
1The estimate of the uninsured is based on the Census Bureau’s annual March Current Population
Survey (CPS), as are all annual estimates of the uninsured population of the United States presented in
this report, unless otherwise noted. The CPS may overestimate the number of uninsured for the
entire calendar year and does not account for all who are uninsured for shorter time periods (CBO,
2003). See Chapter 2 for a discussion of who is uninsured, why, and for how long.
1
OCR for page 2
2 INSURING AMERICA’S HEALTH
formed an expert Committee on the Consequences of Uninsurance to study the
issue comprehensively, examining the effects of the lack of health coverage on
individuals, families, communities, and the broader society.2 Now, after a signifi-
cant economic downturn, 17.2 percent of the population under age 65 is unin-
sured and the number has grown to over 43 million. One in three Americans were
uninsured for a month or more during a two-year period (1996-1997) (Short,
2001). Fewer people have access to coverage at work, more people find the costs
of private coverage too expensive, and others lose public coverage because of
changed personal circumstances, administrative barriers, and program cutbacks.
The situation is even more dire now than when the study began and it is expected
to worsen in the foreseeable future because of federal and state budget constraints
limiting public coverage programs, increasing costs of health care and insurance
premiums, and continuing high rates of unemployment.
WHY SHOULD POLICY MAKERS AND THE
PUBLIC CARE ABOUT COVERAGE?
The Committee has conducted an exhaustive review of the scientific evi-
dence on the consequences of uninsurance and finds that having no insurance
decreases access to health services and reduced access to health care among the
uninsured is associated with poorer health. The lack of coverage is not only
associated with negative effects on the uninsured individual but also has implica-
tions for the entire family of the uninsured person and the community in which he
or she lives, and economic costs to society nationally (IOM, 2001a, 2002a, b,
2003a, b). In short, in a series of five reports the Committee concluded that:
• The number of uninsured individuals under age 65 is large, grow-
ing, and has persisted even during periods of strong economic growth.
• Uninsured children and adults do not receive the care they need;
they suffer from poorer health and development, and are more likely to
die early than are those with coverage.
• Even one uninsured person in a family can put the financial
stability and health of the whole family at risk.
• A community’s high uninsured rate can adversely affect the over-
all health status of the community, its health care institutions and pro-
viders, and the access of its residents to certain services.
2In this study, the focus is on people with no health insurance, such as “major medical” coverage
for hospitalization and outpatient medical services, either for short or long periods. The Committee
does not address underinsurance, that is, health plans that offer less than adequate coverage with exces-
sive out-of-pocket payments, maximum benefit limits, or exclusion of specific services, such as mental
health treatment. The problems of underinsurance are generally less severe than those of uninsurance,
involve different policy issues, and require the collection of different types of information. See further
discussion in Chapter 2.
OCR for page 3
3
EXECUTIVE SUMMARY
• The estimated value across the population in healthy years of life
gained by providing health insurance coverage is almost certainly greater
than the additional costs of an “insured” level of services for those who
now lack coverage.3
GUIDING THE DEBATE
In this report, the sixth and last in the series, the Committee presents its
conclusions and recommendations, based on the findings of its previous five
reports. It calls for action on the problems of uninsurance and hopes to stimulate
informed discussion of the various proposals that have been put forth to extend
coverage. By “extend coverage” we mean having more people gain coverage who previously
had had none and reducing the uninsured rate. To guide future discussion, the Com-
mittee offers principles, supported by research, against which proposals for extend-
ing coverage can be assessed.
The Committee’s review of clinical, epidemiological, and economic research
for its earlier reports revealed certain features of health insurance that contribute to
better health outcomes for those who have coverage. These insights into what
accounts for the greater effectiveness of “insured” health care are reflected in the
principles the Committee presents to guide policy makers and the public in
analyzing proposals or developing new strategies. The Committee does not rec-
ommend or reject any specific proposal. Rather it demonstrates, through the use
of the principles, how each of a wide range of proposals would improve the
current situation.
ELIMINATING UNINSURANCE:
LESSONS FROM THE PAST AND PRESENT
Present-day efforts to reduce or eliminate uninsurance build on nearly a
century of campaigns to bring about universal health insurance coverage. Past
campaigns have yielded both incremental changes and major reforms
but not universal coverage, due to the challenges to major structural
changes posed by American political arrangements and the lack of
political leadership strong and sustained enough to forge a workable
consensus on coverage legislation. In addition, the opposition of pro-
vider, insurer, and business groups with economic interests potentially
adversely affected by specific reform proposals has blocked universal
coverage even though many have agreed with the general need for
reform.
3An “insured” level of services reflects the current average benefits under Medicaid or private
health insurance for those under age 65.
OCR for page 4
4 INSURING AMERICA’S HEALTH
In the early 1900s, health insurance was seen initially as a type of social
insurance, justified as a means of protecting workers’ lost income when disabled or
ill (Starr, 1982). By the 1930s it became a way to make health services more
affordable for individuals and thus encourage utilization. Opposition to compul-
sory public insurance at the national level fed the development of private-sector
nonprofit and commercial health coverage organized through the workplace.
Between 1940 and 1960, the proportion of the general population with private
health insurance grew from 9 percent to 68 percent (Bovbjerg et al., 1993).
Reform efforts to extend public coverage to retirees and the poor, two groups
unlikely to purchase private coverage and likely to have difficulty paying for
health care, met with success in 1965 with the enactment of Medicare and Med-
icaid as amendments to the Social Security Act. These two new programs intro-
duced tens of millions of newly insured persons, and billions of new public dollars,
into the health care system. Campaigns for universal coverage in the 1970s and
1990s have been shaped by the tensions between the goals of enrolling greater
numbers of people and controlling health care expenditures.
Recent Federal Initiatives to Extend Coverage Have Not
Closed the Coverage Gap
Finding: Federal incremental reforms over the past 20 years have
made little progress in reducing overall uninsured rates nationally,
although public program expansions have improved coverage for
targeted previously uninsured groups. Federal reforms of employ-
ment-based insurance have not included provisions for assuring
affordability and, thus, have had limited effect.
Finding: Extensions of program eligibility for one group of unin-
sured often affect the coverage status of other population groups
indirectly, for example, when State Children’s Health Insurance
Program enrollment efforts identify children who are eligible for but
not enrolled in Medicaid.
Finding: Public programs fall short of their coverage goals when not
all eligible persons enroll. When outreach and enrollment are made
a priority, coverage levels rise. Public coverage programs some-
times employ administrative barriers to enrollment to contend with
inadequate or unstable funding during periods of economic stress
within states.
Health insurance coverage rates nationally reached their high point in 1980,
when approximately 15 percent of the general population under age 65 was
uninsured (Bovbjerg et al., 1993). The percentage uninsured has not varied widely
since then, but the number of uninsured people has grown substantially, to over
OCR for page 5
5
EXECUTIVE SUMMARY
43 million, reflecting growth in the total population. Reforms since 1980 have
made little progress in reducing the uninsured rate (Levit et al., 1992; Fronstin,
2002; Mills and Bhandari, 2003).
Since the mid-1980s, however, major federal initiatives to extend both public
and private coverage, many modeled after successful state programs, have im-
proved coverage rates among lower income children (in households earning less
than 200 percent of poverty) and boosted the numbers of lower income persons
with public coverage. Between 1984 and 1990, Congress gradually expanded
Medicaid for pregnant women, infants, and young children, delinking coverage
from welfare eligibility. These Medicaid expansions were followed in 1997 by the
creation of the State Children’s Health Insurance Program (SCHIP), a 10-year,
$40 billion allotment in federal matching and capped grants in aid to the states.
This program reduced the number of uninsured children, though more than half
of the remaining uninsured children are eligible but not enrolled (Broaddus and
Ku, 2000; Dubay et al., 2002a; Kenney et al., 2003).
Federal initiatives to extend employment-based coverage have targeted im-
proved portability and continuity of coverage through the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA), the Health Insurance Portability
and Accountability Act of 1996 (HIPAA), and the Trade Act of 2002 (TA). All
three statutes attempt to preserve coverage for specific categories of transitioning
and unemployed workers and their families, yet the lack of authority or resources
under COBRA and HIPAA to make insurance premiums affordable has seriously
limited their usefulness and impact. It remains to be seen whether the subsidized
tax credit to be given to displaced workers and retirees under the TA’s authority
will make premiums affordable enough to increase coverage among the approxi-
mately 260,000 eligible persons (Healthcare Leadership Council, 2003).
State and Local Initiatives to Extend Coverage
Finding: The federal Employee Retirement Income Security Act of
1974 (ERISA) constrains the ability of states to mandate employ-
ment-based coverage, one strategy to extend private coverage within
their boundaries.
Finding: Although some states have made significant progress in
reducing uninsurance, even the states that have led major coverage
reforms have large and persisting uninsured populations.
Finding: States do not have the fiscal resources to implement fully
their existing public coverage programs and are further constrained
from eliminating uninsurance within their boundaries by categorical
limits on eligibility for federally supported public coverage pro-
grams.
OCR for page 6
6 INSURING AMERICA’S HEALTH
Finding: Extensions of public or private coverage at the county level
have focused on increasing coverage among targeted populations
rather than the entire uninsured population locally. Despite the
potential of local programs to fill targeted gaps, the lack of a reliable
funding source limits their scope and effectiveness.
Historically some states have taken the lead in extending coverage, but state
efforts alone have been insufficient to eliminate uninsurance within their bound-
aries and have had little impact on the overall, national uninsured rate. This report
highlights five states—Hawaii, Massachusetts, Minnesota, Oregon, and Tennes-
see—that have invested significant funds since the mid-1980s to expand their
public programs and in some cases have also regulated the small group and
nongroup insurance markets to create more affordable options. In 1994, these
states began using Medicaid Section 1115 waivers, without additional federal
dollars, to broaden eligibility, with all but Tennessee folding in their own separate
coverage programs for persons ineligible for Medicaid. Though all have made
progress in extending coverage, each state still has significant numbers of unin-
sured people.
All states are limited by ERISA, which does not permit direct state regulation
of coverage plans sponsored by private employers.4 States may not tax employer-
sponsored plans directly, require employers to offer coverage, or regulate what
they do offer.
Addressing concerns about the substitution or crowding out of private cover-
age by new public programs has created administrative barriers to full enrollment
of all eligible persons. The increasingly severe budget crises faced by the states
beginning in 2001 have limited state reform and begun to erode coverage, al-
though the prospect of losing federal revenue has motivated states to maintain
much of their commitment to public coverage programs that receive federal
matching funds (Smith et al., 2002; Boyd, 2003). State governments’ capacity to
finance health care and extend coverage tends to be weakest at times when
demands for such support are likely to be highest, for example, during an eco-
nomic recession. Nonetheless, the growing unmet need for health insurance in
recent years has catalyzed reform efforts in many states (IOM, 2003a).
Many states designate their counties as the providers of last resort for the
underserved and uninsured (IOM, 2003a). Across the nation, a handful of counties
has experimented with innovative ways to improve access to care using insurance
or an approach that resembles health insurance to reduce the impact of uninsurance
on their communities. The Committee looked at the experiences of three urban
counties that have led reform, Alameda County (CA), Hillsborough County (FL),
and San Diego (CA). These counties have reformed the organization, financing,
and delivery of local health services, combining outreach and enrollment activities
4In 1983, Hawaii received an exemption from ERISA, under the condition that the provisions of
the state’s employer mandate not be updated.
OCR for page 7
7
EXECUTIVE SUMMARY
with new sources of revenue to support coverage. Serious financial constraints
limit the scope and effectiveness of these programs and keep them from fully
reaching their goals.
Despite gradual expansions of public programs at the federal, state, and local
levels and isolated efforts around the country to move toward the goal of universal
coverage, the lack of political consensus has prevented a substantial reduction in
uninsurance in the United States. Laudable efforts have been hindered by a lack of
resources. The state and county programs described here are noteworthy but
atypical; individual state and local efforts to extend health insurance will not
achieve universal coverage nationally. In some states the size of the uninsured
population is overwhelming and many states lack the resources to extend coverage
substantially. The circumscribed nature of past and present initiatives suggests that
attempts to provide universal coverage without a substantial infusion of new
federal funds are unrealistic. Recognition of the need to treat the elimination of
uninsurance as a national responsibility, as well as a state and local one, is essential
to comprehensive reform of coverage.
Conclusion: The persistence of uninsurance in the United States
requires a national and coherent strategy aimed at covering the
entire population. Federal leadership and federal dollars are neces-
sary to eliminate uninsurance, although not necessarily federal ad-
ministration or a uniform approach throughout the country. Uni-
versal health insurance coverage will only be achieved when the
principle of universality is embodied in federal public policy.
A VISION OF UNIVERSAL COVERAGE
The Committee’s previous reports detailed the negative effects on individu-
als’ health, family stability, community health care institutions and access of resi-
dents, and the national economy associated with the existence of a large uninsured
population. This report reviews a century of efforts aimed at reducing or eliminat-
ing uninsurance. This report also examines various approaches to providing health
insurance because the Committee believes extending insurance coverage is a
worthwhile and feasible endeavor. Imagine what the country would be like if
everyone had coverage—people would be financially able to have a health prob-
lem checked, to seek preventive and primary care promptly, and to receive neces-
sary, appropriate, and effective health services. Hospitals would be able to provide
care without jeopardizing their operating budget and all families would have
security in knowing that they had some protection against the prospect of medical
bills undermining their financial stability or creditworthiness. The Committee
believes that this picture could become reality and that it is an image worth
pursuing because the costs of uninsurance to all of us—financial, societal, and in
terms of health—are so great. The benefits of appropriate and timely health care
are potentially even greater and can help motivate attaining this vision.
OCR for page 8
8 INSURING AMERICA’S HEALTH
VISION STATEMENT
The Committee on the Consequences of Uninsurance envisions an
approach to health insurance that will promote better overall health
for individuals, families, communities, and the nation by providing
financial access for everyone to necessary, appropriate, and effective
health services.
PRINCIPLES TO GUIDE THE EXTENSION OF
COVERAGE
The evidence reviewed and developed by the Committee in its first five
reports contributes to this shared vision and the following five key principles. The
first principle is the most basic and yet most important. The remaining four
principles are not ranked by priority. Selected pieces of evidence are provided in
the following discussion of the principles. (See the Committee’s earlier reports,
Coverage Matters, Care Without Coverage, Health Insurance Is a Family Matter, A
Shared Destiny, and Hidden Costs, Value Lost, and Chapter 2 in the full report,
Insuring America’s Health, for more detailed discussions of the evidence.)
1. Health care coverage should be universal.
• Everyone living in the United States should be covered by health insur-
ance. Being uninsured can damage the health of individuals and families. Unin-
sured children and adults use medical and dental services less often than insured
people and are less likely to receive routine preventive care (Newacheck et al.,
1998b; McCormick et al., 2001; IOM, 2002b). They are also less likely to have a
regular source of care than are insured people (Zuvekas and Weinick, 1999;
Weinick et al., 2000). Insurance coverage is the best mechanism for gaining
financial access to services that may produce better health.
• Uninsured people are less likely to receive high-quality, professionally
recommended care and medications, particularly for preventive services and
chronic conditions (Beckles et al., 1998; Cooper-Patrick et al., 1999; Powell-
Griner et al., 1999; Ayanian et al., 2000; Breen et al., 2001; Goldman et al., 2001).
• Uninsured children risk abnormal long-term development if they do not
receive routine care; uninsured adults have worse outcomes for chronic conditions
such as diabetes, cardiovascular disease, end-stage renal disease, and HIV (Hadley,
2002; IOM, 2002a, b).
• Uninsured adults have a 25 percent greater mortality risk than do insured
adults, accounting for an estimated 18,000 excess deaths annually (Franks et al.,
1993a; Sorlie et al., 1994; IOM, 2002a).
2. Health care coverage should be continuous.
• Continuous coverage is more likely to lead to improved health outcomes;
OCR for page 9
9
EXECUTIVE SUMMARY
breaks in coverage result in diminished health status (Lurie et al., 1984, 1986;
Franks et al., 1993a; Sorlie et al., 1994; Baker et al., 2001).
• Achieving coverage well before the onset of an illness would likely lead to
a better health outcome because the chance of early detection would be enhanced
(Perkins et al., 2001).
• Interruptions in coverage interfere with therapeutic relationships, contrib-
ute to missed preventive services for children, and result in inadequate chronic
care (Rodewald et al., 1997; Beckles et al., 1998; Burstin et al., 1998; Daumit et
al., 1999, 2000; Hoffman et al., 2001).
3. Health care coverage should be affordable to individuals and
families.
• The high cost of health insurance is the main reason people give for being
uninsured (Hoffman and Schlobohm, 2000; IOM, 2001a). Nearly two-thirds of
people with no coverage have incomes that are less than 200 percent of the federal
poverty level (IOM, 2001a). Families in that income group have little leeway for
health expenditures, making some form of financial assistance necessary for ob-
taining coverage (IOM, 2002b).
• Among families with no members insured during the entire year and
incomes below the poverty level, more than a quarter paid out-of-pocket medical
expenses that were more than 5 percent of income (Taylor et al., 2001).
4. The health insurance strategy should be affordable and sustain-
able for society.
• The Committee acknowledges that any health insurance strategy will likely
face budgetary constraints on the benefits as well as on the administrative opera-
tions. Any major reform will need mechanisms to control the rate of growth in
health care spending. There is no analytically derivable dollar amount of what
society can afford; that will be determined through political and economic pro-
cesses.
• The Committee believes that everyone should contribute financially to the
national strategy through mechanisms such as taxes, premiums, and cost sharing
because all members of society can expect to benefit from universal health insur-
ance coverage.
• To help ensure affordability, the reform strategy should strive for efficiency
and simplicity.
5. Health insurance should enhance health and well-being by pro-
moting access to high-quality care that is effective, efficient, safe, timely,
patient-centered, and equitable.
• Insurance should be designed to enhance the quality of the health care
system as specified above and recommended by the IOM’s Committee on Quality
of Health Care in America (IOM, 2001b).
OCR for page 10
10 INSURING AMERICA’S HEALTH
• A benefit package that includes preventive and screening services, outpa-
tient prescription drugs, and specialty mental health care as well as outpatient and
hospital services would enhance receipt of appropriate care (Huttin et al., 2000;
IOM, 2002a).
• Variation in patient cost sharing could be used as an incentive for appropri-
ate service use because it can influence patient behavior (Newhouse and The
Insurance Experiment Group, 1993).
USING THE PRINCIPLES
The Committee’s research on the problems related to uninsurance demon-
strates conclusively that there are benefits for the nation and all its residents from
eliminating uninsurance and ensuring coverage for everyone. Based on a review of
past incremental and disjointed efforts to extend coverage, the limited progress
made, and the remaining 43 million uninsured,
The Committee concludes that health insurance coverage for every-
one in the United States requires major reform initiated as federal
policy.
Achieving universal coverage across the country will require at a minimum
federal policy direction and financial support. The new system would not neces-
sarily be controlled wholly at the federal level or operated solely through a gov-
ernment agency. The Committee presents the preceding set of principles to be
used in clarifying the public debate about approaches to extending coverage. The
principles provide objectives against which to measure various proposals. The
Committee does not endorse or reject any particular approach to solving the
problem of uninsurance, but recognizes that there are many pathways to achieving
its vision.
The Committee recommends that these principles be used to assess
the merits of current proposals and to design future strategies for
extending coverage to everyone.
To illustrate how the principles should be used to evaluate reform proposals,
the Committee sketches four prototypes for major reform in a simplified format so
that the main incentives are clear. It then assesses each prototype against each of
the principles, highlighting the model’s strengths and weaknesses. These models
all include aspects of strategies under discussion in the public debate but are not
detailed legislative proposals or specific strategies favored by particular politicians
or advocacy groups. Brief outlines of the prototypes (discussed fully in Chapter 5
of Insuring America’s Health) are as follows:
1. Major public program extension and new tax credit: No fundamental change in
private insurance, Medicaid and SCHIP merged and expanded, Medicare ex-
tended to 55 year olds, a tax credit for moderate income individuals.
OCR for page 11
11
EXECUTIVE SUMMARY
2. Employer mandate, premium subsidy, and individual mandate: Employers re-
quired to provide coverage and contribute to workers’ premiums, subsidy for
employers of low-wage workers, individuals required to accept employment-
based insurance or obtain it privately, merged public program for those not
covered at work.
3. Individual mandate and tax credit: Each person eligible for an advanceable,
refundable tax credit and required to obtain coverage in the private market,
Medicaid and SCHIP eliminated.
4. Single payer: Administered federally, everyone enrolled, single benefit pack-
age, global budget, no Medicaid, SCHIP, or Medicare.
Each model meets some principles better than others and each principle may
be more fully achieved by one prototype than another. For example, the principle
of universal coverage is more likely to be reached through any of the models with
mandates than by the first prototype, which is entirely voluntary. Prototype 1 was
included for completeness because it is an obvious approach currently under
public consideration, although it would not achieve universality. The single payer
model would most successfully eliminate gaps in coverage. The assessment of each
model is fully discussed in Chapter 5 and summarized in Table ES.1.
The affordability to individuals and families of each prototype would depend
on the size of the subsidies or tax credits and cost-sharing requirements, as well as
eligibility levels for the public programs. The affordability and sustainability for
society of each model would largely depend on the nature of cost controls in the
system, sources of revenues, the amount of cost sharing, and the comprehensive-
ness of the benefit packages. Strong cost and utilization controls could affect access
to services and health outcomes in ways yet to be determined. The Committee is
mindful that defining a minimum benefit package for the uninsured would likely
also affect some people who currently have a lesser insurance package, increasing
their benefits and resulting in additional costs and probably increased access to
services and drugs and improved health outcomes.
The potential of various models to enhance health through quality care would
depend on the design of the benefit packages, the strength of the public programs,
and effective consumer demand. There are some shortcomings of each model, but
each prototype could come closer to achieving the Committee’s vision and be
ameliorated with further refinement, and elements of different models could be
combined to promote particular principles. Most importantly, each prototype
could more nearly achieve each principle than does the current system.
NEXT STEPS
The Committee recognizes that it will take some time to develop, adopt, and
implement a program of universal coverage and that it will require additional
public resources to finance insurance. It will not be quick or easy to implement
the necessary reforms and it will be preferable to phase in the changes according to
a fixed schedule. Implementation should aim for a minimum number of transi-
OCR for page 12
12 INSURING AMERICA’S HEALTH
TABLE ES.1 Summary Assessment of Prototypes Based on Committee
Principles
Prototype 1
Major Public Program
Expansion and
Principles Status Quo Tax Credit
Coverage should be Not universal; Would not achieve universality
universal 43 million uninsured because voluntary, but would
reduce uninsured population
Coverage should be Not continuous; income, age, Family- and job-related
continuous family, job, and health- gaps in coverage
related gaps in coverage
Coverage should be Private coverage unaffordable More affordable than current
affordable for individuals to many moderate- and system for those with low or
and families low-income persons moderate income
Strategy should be Not affordable or sustainable All participants contribute;
affordable and for society; uninsurance is aggregate expenditures not
sustainable for society growing; cost of poorer controlled; new public expenditures
health and shorter lives is for only the public program
$65–$130 billion; some expansion and tax credit;
participants contribute; no sustainability of public program
limit on aggregate health depends on revenue sources
expenditures or on tax and political support; size of
expenditures—spending is credit depends on political
higher than other countries; support
sustainability of current
public programs depends
on economy and political
support
Coverage should enhance Quality of care for the Opportunities to promote
health through high- population limited because quality improvements similar
quality care one in seven is uninsured to current system
OCR for page 13
13
EXECUTIVE SUMMARY
Prototype 2 Prototype 3 Prototype 4
Employer Mandate,
Premium Subsidy, and Individual Mandate
Individual Mandate and Tax Credit Single Payer
Coverage likely to be high; Depends on size of tax credit, Likely to achieve universal
depends on enforcement enforcement, and cost of coverage
of mandates individual insurance
Brief gaps related to life Minimal gaps Continuous until death or age
and job transitions 65
Yes for workers, assuming Subsidy based only on Minimal cost sharing, but could
adequate employer premium income and family size be problem for lowest income
assistance; public program leaves older, less healthy,
designed to be affordable for and those in expensive areas
all enrollees with less affordable coverage
All participants contribute; No limit on aggregate Nearly all participants
basic package less costly than health expenditures or on contribute; aggregate
current employment coverage; tax expenditure, though expenditures controllable,
revenue from patients in federal costs relatively utilization not directly or
public program; sustainability predictable and controllable centrally controlled; high cost to
depends on revenue sources through size of credit; federal budget; administrative
for employers’ premium sustainable through federal savings; sustainability depends
assistance and public program income tax base; size of on revenue source and political
credit depends on political support
support
Could design quality incentives Similar incentives to current Potentially yes; depends on
in expanded public program private insurance system; proper design
and basic benefit package; consumer could choose
current employer incentives quality plans
for quality remain
OCR for page 14
14 INSURING AMERICA’S HEALTH
tional stages, each of which incorporates changes that are as coherent and simple as
possible. Despite a long history of failed attempts to achieve insurance for every-
one, the Committee believes that universal insurance coverage is an important and
achievable goal for the country. Instead of considering the status quo as everyone’s
second choice when consensus on an approach to universal coverage fails to
materialize, we should consider it the last choice. We cannot afford to ignore the
problem of uninsurance.
The Committee recommends that the President and Congress de-
velop a strategy to achieve universal insurance coverage and to
establish a firm and explicit schedule to reach this goal by 2010.
The Committee recommends that, until universal coverage takes
effect, the federal and state governments provide resources sufficient
for Medicaid and SCHIP to cover all persons currently eligible and
prevent the erosion of outreach efforts, eligibility, enrollment, and
coverage.
The Committee is concerned that the current and growing economic pres-
sures on state governments as well as at the federal level will have a negative
impact on public programs and erode current coverage, making future coverage
gains more difficult. Until everyone has financial access to health services through
insurance, it is necessary to sustain current public coverage programs. It is also
important to shore up the current capacity of health care institutions and providers
who take a major responsibility for caring for the uninsured. Continuing support
of service capacity, particularly in medically underserved areas, may be needed.
The Committee appreciates that making a national commitment to achieve
universal insurance coverage will require strong, bipartisan political support as well
as broad-based and deep public support. We all bear the costs of the current
nonsystem that leaves tens of millions without health coverage. Doing nothing
and maintaining the status quo with over 43 million uninsured Americans is
expensive. The nation suffers losses due to ill health, impaired development, early
deaths, and lost productivity. The lack of health insurance is a destabilizing factor
in families and for health care institutions that serve uninsured patients. In fact, the
presence of uninsurance creates insecurity for everyone, even those with health
insurance today, because losing that coverage tomorrow is so easy. Universal
insurance coverage will benefit all Americans, enhance the great promise of our
health care system, and reinforce our values as a democratic society. It is time for
our nation to extend coverage to everyone.
Representative terms from entire chapter:
insurance coverage
