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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

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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.

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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.

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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

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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.

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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.

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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.

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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;

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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).

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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.

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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-

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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

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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

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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.