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3 Eliminating Uninsurance: Lessons from the Past and Present Despite nearly a century of efforts and incremental reforms to extend cover- age, the nation’s multiple sources of coverage leave 15 percent of the total popu- lation uninsured. This chapter develops the historical context of national reform efforts to reduce or eliminate uninsurance in the United States. It then looks at relatively recent federal initiatives to broaden coverage substantially and extension of coverage by some states and counties that have taken leadership roles. Past efforts offer useful lessons for reforming health care financing today. Federal, state, and county reforms have not eliminated uninsurance, although some initiatives have improved access to health services or resulted in better health outcomes for populations who had lacked coverage. Some reforms have affected the basic structure of health care finance, while others have had a more limited focus, building on existing public programs or private insurance. The Committee’s principles for assessing coverage proposals derive from the historical record as well as from its examination of the consequences of uninsurance. NATIONAL EFFORTS TO BROADEN COVERAGE, 1916–1984 The lack of universal health insurance in the United States is in part a legacy of early twentieth-century precedents in the organization and financing of health services in the United States. It also reflects the absence of political leadership strong, broad, and sustained enough to forge a consensus in favor of universal coverage, despite public support, in the face of opposition from overlapping yet at times incompatible economic interests forged within the constraints of American political institutions and processes (Oberlander, 2003). Our government’s federal 66
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67 LESSONS FROM THE PAST AND PRESENT structure and the independence of the legislative and executive branches place a relatively great burden on proponents of change. Coverage reform first became a national issue in the early 1900s, when relatively few people had health insurance and most health care was purchased out of pocket or provided charitably. Over the next 70 years, a series of campaigns attempted to bring about greater coverage nationally. Early campaigns to create mandatory coverage were opposed by the medical profession, commercial insur- ers, and the business community. From the 1930s through the 1970s, the House Ways and Means Committee of the U.S. Congress determined the fate of most federal legislation to extend coverage, and most proposed reforms were prevented from coming before the full House for a vote. In the context of the lack of federal legislation for more widespread public coverage, consumer demand fueled the rapid growth of private-sector coverage, starting in the mid-1930s. The nonprofit Blue Cross and Blue Shield plans, and subsequent plans from commercial insurers, enrolled millions of subscribers and by the early 1960s most Americans were insured through employment-based cover- age. The enactment of the Medicare and Medicaid amendments to the Social Security Act in 1965 filled some of the gaps left by the emerging employment- based approach to financing care. Medicare extended coverage to most of the population over age 65 as well as to smaller groups of eligible persons (the perma- nently disabled). State implementation of the Medicaid program increased cover- age significantly among categories of the low-income population. By the 1970s, the growth in total health care spending facilitated by the creation of Medicare made the issue of controlling health care spending and inflation central to universal coverage reform proposals. The early 1980s marked a high point for coverage levels nationally. Since that time, there has been a gradual increase in the number, and in most years the proportion, of uninsured persons under age 65. See Box 3.1 for a timeline of these efforts. The sections that follow briefly review this history in order to illustrate important issues and basic tensions in the political sphere that have shaped more recent reform efforts. It is organized roughly chronologically, with diversions from the timeline to allow focus on specific topics. Early Efforts: From Protecting the Income of Industrial Workers to Social Insurance for Improving Access to Care Social insurance programs in late nineteenth-century Europe (for example, Germany, 1883) and Great Britain (1911) that included health insurance, and experience with the limited prepaid medical services available to fraternal or mutual benefit society members, spurred interest in universal coverage in the United States (Numbers, 1978). Initial organized efforts to extend coverage broadly occurred during the years around World War I (Starr, 1982). Early twentieth- century America was in the throes of rapid industrial and urban growth, with a booming population of low-income working families. With an eye toward allevi-
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68 INSURING AMERICA’S HEALTH BOX 3.1 Landmarks in the History of Coverage 1916–1920 American Association for Labor Legislation campaigns for publicly administered, private-sector sickness insurance to protect the lost income of workers and their families 1932 Committee on the Costs of Medical Care final report calls for group organization and payment of health services on voluntary basis 1935 Social Security Act 1939 First of series of Wagner-Murray-Dingell bills in U.S. Congress that propose universal health insurance as social insurance 1942 War Labor Board ruling permits employers to exclude employment- based coverage from taxable income 1945 President Truman’s “Fair Deal” proposal includes publicly financed and administered universal coverage 1948 U.S. Supreme Court ruling (Inland Steel) permits collective bar- gaining for employment-based coverage 1960 Social Security Act Amendments including Kerr-Mills program cre- ating federal grants to the states to finance health services for poor persons at least 65 years of age (seniors) 1965 Social Security Act Amendments that create Medicare and Medic- aid, nearly universal publicly and privately financed coverage for seniors and federally guaranteed eligibility for public coverage for specific categories of the poor 1971–1974 President Nixon and U.S. Congress introduce and debate propos- als for universal coverage through a mix of public and private sourc- es, fail to reach a vote in Congress ating the economic burden of illness, a relatively small group of elite reformers, organized as the American Association for Labor Legislation (AALL), campaigned for mandatory workplace-based “sickness insurance.” Sickness insurance, often called health insurance after the English precedent, was modeled after recently created state workmen’s compensation programs (Numbers, 1978).1 It targeted 1For example, former President Theodore Roosevelt made sickness insurance one of the planks in his ultimately unsuccessful campaign against Woodrow Wilson in 1912 on the Progressive ticket (Numbers, 1985).
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69 LESSONS FROM THE PAST AND PRESENT 1974 Employee Retirement Income Security Act, prohibiting state regu- lation of self-insured employer health plans. 1981 President Reagan’s proposals to turn Medicaid into block grants to the states, in the Omnibus Budget Reconciliation Act of 1981 1984–1990 Expansions of Medicaid to pregnant women, infants, and children at higher income levels and delinking from eligibility for (state) in- come support 1985 Consolidated Omnibus Budget Reconciliation Act of 1985, with pro- vision to improve continuity of employment-based coverage. 1993–1994 President Clinton’s Health Security Act proposal for universal cov- erage through publicly administered, publicly and privately financed regional purchasing alliances created and debated, fails to reach a vote in Congress 1996 Federal welfare reform delinks Medicaid from income support pro- grams, bars legal immigrants from Medicaid eligibility for first five years of residency 1996 Health Insurance Portabilitiy and Accountability Act, with provisions to improve continuity of coverage 1997 State Children’s Health Insurance Program, extending public insur- ance eligibility to children in families earning between 100 and 200 percent of federal poverty level, expansions to their parents 2002 Trade Act, with provision for health insurance premium tax credit for groups of workers displaced by international commerce and retirees industrial workers and their families and included a cash benefit to replace lost income, access to free health care, and a death benefit; premiums would be paid by employers, workers, and the state (Starr, 1982; Hoffman, 2001). The plan was not universal, for it excluded most African Americans and other ethnic minorities by not including agricultural, domestic, and temporary workers. In addition, it re- stricted eligibility to employed men and women earning less than $1,200 annually (low income but not poor), assuming that the poor could rely on charity and that the middle class could afford to purchase their own care (Hoffman, 2001). Between 1916 and 1920, the AALL’s model sickness insurance bill was de-
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70 INSURING AMERICA’S HEALTH bated in a number of state legislatures in more urban and industrial parts of the United States, most notably California and New York, with support from many governors and state-level fact-finding commissions (Numbers, 1978; Hoffman, 2001). Ultimately, these bills were defeated. Key opponents included: • the American Medical Association (AMA), an early supporter that became an outspoken opponent as rank-and-file members (county medical societies), gaining experience with contract practice under the new workmen’s compensa- tion programs, grew concerned that insurance would interfere with the practice of medicine and threaten the economic viability of solo practice; • employers who did not welcome broadened financial responsibility for the health of their workforce and who predicted higher costs passed along to consum- ers and the loss of jobs; • commercial insurers who stood to lose their lucrative business selling death benefits (industrial insurance) to low-income workers and who were excluded from the proposed state-level administration of sickness insurance; and • organized labor, principally Samuel Gompers of the American Federation of Labor, to whom mandatory coverage was a threat to the organizing ability of unions (Numbers, 1978; Starr, 1982; Hoffman, 2001). Proposals for state sickness insurance programs were abandoned by 1920, felled by the lack of political leadership, the difficulties of enacting mandatory policies on a state-by-state basis, and the AALL’s inability to build coalitions and fashion workable political compromises with the economic interests that opposed its model for expanding health insur- ance (Numbers, 1985). In addition, a harmful legacy of this first political battle was the framing of mandated coverage as counter to American values, with coverage proposals attacked in newspapers and speeches as fundamentally Germanic, and, after the close of World War One and the onset of the Red Scare, as expressions of Bolshevism (Hoffman, 2001). Starting in the 1920s, demand for health care services by the middle class, fed by the improved effectiveness of hospital-based care and the increasing risk of high-cost medical expenses, reinvigorated public debate about extending coverage (Starr, 1982; Stevens, 1989). Unlike the sickness insurance proposals of the 1910s, the goals of reform were to increase utilization, and health care spending, by making care and coverage more affordable to all Americans universally, not only low-income workers and their dependents (Starr, 1982; Derickson, 2002). During the 1930s and into the 1940s, proposals to extend public coverage significantly took the form of social insurance for all Americans, resembling the system of federal pensions created by the Social Security Act of 1935. Proposed reforms drew on the work of an independent group of scholars and physicians, the Committee on the Costs of Medical Care, that advocated both group practice and financing for care, to rationalize health services delivery and make health care
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71 LESSONS FROM THE PAST AND PRESENT more affordable (Starr, 1982). Because much domestic policy making for the nation now took place at the federal rather than the state level, health finance reformers faced a number of new challenges, including the separation of powers (so that Presidential support would not necessarily be matched by congressional support); a lack of party discipline within the two houses of Congress; powerful regional voting blocks and interest group lobbies; and the ideological constraints of single-party reform efforts (Marmor, 1973; Maioni, 1998). In the 1930s, organized labor supported a publicly mandated extension of coverage, but the medical profession, insurance industry, and business interests continued to resist such proposals. The AMA in particular was a strong political presence in Washington, and its vigorous lobbying of Congress and the public in favor of voluntary rather than mandatory coverage threatened the passage of New Deal legislation, and the President’s bid for reelection. In response, President Franklin Roosevelt’s Administration cut a provision for health insurance from what became the Social Security Act of 1935 (Marmor, 1973; Starr, 1982; Maioni, 1998). In an effort to revive universal coverage proposals, which many perceived as the “missing piece” of the New Deal, in 1939 reform-minded members of Congress began introducing universal coverage bills each year (labeled Wagner- Murray-Dingell bills, after their key sponsors) that framed coverage as a means to lower financial barriers, made eligibility universal (not only for persons in the Social Security system), and included grants-in-aid to the states to support indigent care (Maioni, 1998). None of these bills was reported out of the Ways and Means Committee, undone by the lack of leadership by President Roosevelt and the slim voting majority of the Democrats in Congress that was insufficient to pass contro- versial reform (Marmor, 1973; Maioni, 1998). Universal coverage bills stalled in Congress, but consumer demand for health insurance grew. While commercial insurers were slow to enter the market for group policies organized through the workplace, nonprofit and independent orga- nizations created prepayment plans for hospital services, indemnity and service benefit plans for physician care, and sites for the direct delivery of services that gave fundamental shape to the organization and financing of health services in subsequent decades. The locally organized and directed Blue Cross hospitalization plans and Blue Shield physician plans expanded rapidly from their origins in the early 1930s to become the single largest source of coverage by the 1950s (Cunningham and Cunningham, 1997). Community organizations such as Group Health Cooperative of Puget Sound, consumer cooperatives and private clinics, and health plans organized around industries, such as Kaiser Permanente, extended both coverage and services (Somers and Somers, 1961; Starr, 1982). Enrollment of workers and their dependents in private coverage soared: between 1940 and 1960, the proportion of the general population with private coverage grew from 9.1 percent (about 12 million people) to 67.8 percent (about 122 million people) (Etheredge, 1990; Bovbjerg et al., 1993). Offering health insurance as a benefit was attractive to employers, given the exemption from federal taxes of the em-
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72 INSURING AMERICA’S HEALTH ployers’ contributions to health insurance premiums (codified in the Internal Review Code of 1954) (Starr, 1982).2 Although private-sector coverage grew quickly, there was continued public and legislative interest in universal health insurance. After World War II, the federal government’s role in many aspects of health policy expanded, for example, in the funding of biomedical research and hospital construction, but congressional resistance, bolstered by the lobbying of reform opponents, blocked public man- dates for coverage (Marmor, 1973; Fox, 1986). The first president to champion universal coverage, Harry Truman revisited this issue in the late 1940s, fighting a contentious political battle against the AMA, commercial insurers, and the busi- ness community in a failed bid to convince the 80th and 81st Congresses to enact Wagner-Murray-Dingell legislation (Starr, 1982).3 President Truman added the key ingredient of political leadership but lacked sufficient votes in Congress, facing a hostile reception in Congress from Southern Democrats committed to reversing New Deal policies and opposed to his Administration’s civil rights policies (Poen, 1979; Maioni, 1998). The only public coverage to be expanded would be federal grants-in-aid to the states to support indigent care, in the 1950 Amendments to the Social Security Act (Stevens, 1989). In the 1950s enrollment in commercial policies outgrew that of nonprofits (Somers and Somers, 1961; Starr, 1982; Cunningham and Cunningham 1997). One advantage that commercial insurers could offer purchasers of group policies was a less expensive alternative to nonprofit “community rating” (where actuarial risk was spread broadly through uniform premiums) in the form of “experience- rating,” or charging premiums according to the claims experience of the employer’s workforce. Experience rating made policies less expensive for healthier employee groups and more expensive or unavailable for individuals, particularly ill or dis- abled persons, who tried to purchase coverage outside the workplace (Starr, 1982). The growing centrality of health insurance revenue to the fiscal health of the health care system created interest on the part of providers (physicians, hospitals) in seeing greater numbers of the general population covered by insurance, albeit on a voluntary basis (IOM, 2003a). For persons without coverage, the price of being uninsured was growing, as the increasingly widespread coverage fueled higher costs for health care and doubled hospital prices during the 1950s (Starr, 1982). Following the defeat of President Truman’s campaign for universal coverage 2In 1942, a War Labor Board ruling made health coverage an attractive fringe benefit for employ- ers to offer workers, whose salaries were restricted due to wartime wage controls; between 1942 and 1945, there was more than a fourfold increase in group hospitalization enrollment (Starr, 1982). A 1948 U.S. Supreme Court decision allowed unions to collectively bargain for health insurance, and enrollment jumped (Starr, 1982; Gabel, 1999). 3The Truman Administration’s proposal included medical and hospital benefits and federal grants- in-aid to the states to finance premiums for the poor, with national administration and financing through a 3 percent payroll tax split between firms and workers (Marmor, 1973).
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73 LESSONS FROM THE PAST AND PRESENT in the late 1940s, proposals to extend health insurance by means of public policies focused on incremental change. In 1951, the handful of public officials who had worked for universal coverage shifted tactics, proposing a new 60-day hospitaliza- tion benefit for Social Security beneficiaries. This benefit would be funded off- budget, using Social Security trust dollars to lessen the economic burden of health services already used by the over-65 population (rather than to increase access to care) who were less likely to carry private insurance (Maioni, 1998). Their pro- posal aided the perception that the middle class (i.e., those who had paid Social Security taxes) had earned such coverage. They sidestepped AMA criticism by not including physician services (Marmor, 1973).4 The proposed reform brought out traditional allies and opponents of mandatory coverage extensions, pitting the AMA against organized labor (the AFL-CIO) (Starr, 1982). Annual hearings on hospitalization proposals failed to advance reform, although the 1960 Kerr-Mills Act amending Social Security did acknowledge the interest in financing care for low-income seniors, increasing grants-in-aid to the states that raised sufficient matching funds (Marmor, 1973). An Incremental Compromise for Universal Coverage: Medicare and Medicaid In the late 1950s, the level of health insurance coverage was at an all-time high, although only about 8 percent of the population had coverage that could be called comprehensive (i.e., insurance that covered hospital stays and physician services) (Somers and Somers, 1961). Employment-based coverage was becoming the norm, with gaps of uninsured populations growing among those who did not or could not receive an employer’s offer of group coverage. A crescendo of political and legislative activity on hospital insurance in the early 1960s led to the first significant extension of publicly mandated coverage (Medicare and Medicaid) after the 1964 elections returned President Lyndon B. Johnson to the White House and brought large Democratic majorities favoring passage to Congress. In the years immediately before, President John F. Kennedy had campaigned for a Social Security hospitalization benefit, a scaled-down ap- proach compared with President Truman’s universal coverage proposals. Despite annual hearings, the garnering of public support by the Administra- tion, and the strategic building of votes on the Hill, House Ways and Means Chair Wilbur Mills released a coverage bill only after legislative developments in 1964 and the elections threatened his continued leadership on health insurance (Marmor, 1973; Maioni, 1998). When the 89th Congress convened in 1965, Medicare was 4Proposals tied to the Social Security system were not for universal coverage; in 1952, only 7 million of the roughly 12.5 million persons over age 65 would have been covered by the proposed reform (Marmor, 1973).
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74 INSURING AMERICA’S HEALTH at the top of the agenda and was signed into law later that year, together with Medicaid, as amendments to the Social Security Act (Fox, 1986; Hacker, 1997). Medicare and Medicaid passed because of the unique legislative alignments of 1965 and also because of Chairman Mills’ leadership in crafting a political com- promise acceptable to interest groups, especially the AMA, which continued to lobby against the Administration’s plans (Marmor, 1973; Maioni, 1998). He de- scribed the amendments as a “three-layer cake” with something for everyone: • Medicare—consisting of Part A, hospitalization, for which there is auto- matic and permanent enrollment and financing through Social Security, and Part B, coverage for physician visits, with voluntary one-time enrollment and a monthly premium payment—provided nearly universal coverage for persons ages 65 and older.5 Part A achieved the goal of social insurance advocates and the Johnson Administration, while Part B accommodated the AMA’s objections to a manda- tory program. • Medicaid, the third layer of the cake, covers certain categories of low- income persons and makes existing grants-in-aid to state programs more uniform in terms of eligibility and benefits (Marmor, 1973).6 Medicaid addressed the interest of the hospital industry in alleviating the burden of uncompensated care. To win support for passage from provider groups, the new law essentially adopted the reimbursement approaches of Blue Shield (for physicians) and Blue Cross (for hospitals), including few limits on reimbursement for physicians, and added favor- able provisions to pay hospitals for capital depreciation. However, these two aspects of the 1965 statute laid the groundwork for significant growth in health care inflation and spending (Starr, 1982).7 The Medicare and Medicaid Amendments represented a limited extension of health insurance coverage. Medicare also augured for improved access to care for African Americans, as certification for a hospital to participate in the program was conditioned on its desegregated status (Reynolds, 1997). While social insurance advocates saw the amendments as an opening wedge for future growth in coverage levels, more pragmatic observers interpreted their design as a way to fend off 5Amendments have added Medicare coverage for persons certified to be permanently and totally disabled and persons with end-stage renal disease (IOM, 2001a). 6Eligibility to enroll in Medicaid involves fulfilling requirements related to income and assets (making it a so-called means-tested program) and being a member of a specific group or category that is eligible for benefits, for example, a minor child. Those who meet economic and categorical criteria must also meet immigration status and state residency requirements. Eligibility standards vary by state and have changed from year to year, with general oversight provided by the federal government (IOM, 2001a). 7The Hill Burton Act of 1946 substantially expanded hospital capacity across the nation in the years before implementation of Medicare, contributing to the availability and utilization of health services nationally.
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75 LESSONS FROM THE PAST AND PRESENT further broadening of the public mandate. For example, financing Medicare phy- sician services with general tax revenues and beneficiary contributions, and using Medicaid to fill coverage gaps for persons under age 65, extended coverage while reinforcing existing approaches (i.e., voluntary coverage for the services most often used, and means-testing for benefits for the poor) (Marmor, 1973). Implementation of Medicare and Medicaid introduced tens of millions of newly insured persons, and billions of new public dollars, into the health care system. By 1970, 20.5 million people were enrolled in Medicare and 18 million people in Medicaid (Bovbjerg et al., 1993). Between 1965 and 1975, annual federal spending on health care jumped from less than $10 billion to more than $40 billion (Hacker, 1997). There was a dramatic increase in utilization; within a year of implementation, 20 percent of all persons 65 years and older had used Medicare for hospital services and 12 million had used Part B coverage for physi- cian services (Marmor, 1973). Nevertheless, gaps in coverage and financial protec- tion remained. Medicaid covered only an estimated one-third of those considered poor, and Medicare reimbursed less than half of seniors’ spending on health and long-term care services (Starr, 1982). Paying for Reform: Cost Containment Joins Access as a Focus for Reform in the Years Since 1965 With federal taxes supporting coverage for a large segment of the population, and with the country in an economic recession, the rapidly increasing costs of health care to society overall and interest in improving the efficiency (including financing) of the health care system motivated reform (Starr, 1982; Lewis, 1983; Steinmo and Watts, 1995; Hacker, 1997). Public officials, insurers, and employers were united in the widely shared belief that a poorly organized and inefficient health care system fueled health care inflation and that universally mandated coverage could bring cost savings (Starr, 1982).8 A combination of factors defeated efforts to extend coverage further. Some were unique to the political circum- stances of the day (i.e., the impeachment proceedings against President Nixon and Wilbur Mills’ fall from power in 1974). Others, such as the inability to fashion a workable consensus on a congressional bill and opposition from commercial insur- ers and employers, were familiar from earlier efforts to achieve broad-based re- forms. As analyst Stuart Altman has observed of the era, which leads up to the present, many policy actors who previously opposed reform altogether have joined the call for change, but they have often been unwilling to compromise their own vision of reform and the absence of change has been the second-best or fallback option (Kahn and Pollack, 2001). During the early 1970s, members of Congress and the Nixon Administration 8Such interest in improving the design and efficiency of the health care system was reflected in the Health Maintenance Organization Act of 1973, for example.
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76 INSURING AMERICA’S HEALTH generated a number of bills to extend coverage and constrain costs, either by filling gaps in the existing mix of public and private coverage (the Nixon Administration’s proposed employer mandate funded by a payroll tax, paired with expanded public coverage and regulation of payment rates) or by replacing privately purchased policies with a federally administered system under a national budget (e.g., Senator Edward Kennedy’s Health Security Act of 1970) (Starr, 1982; Etheredge, 1990; Hacker, 1997; Maioni, 1998). Despite the resistance of providers, employers (especially small businesses), insurers, and the states to the regulatory aspects of proposed reform, passage of a universal coverage bill came close in 1974 (Starr, 1982; Etheredge, 1990; Steinmo and Watts, 1995; Hacker, 1997). President Nixon’s February message to Congress laid out a Comprehensive Health Insur- ance Plan that combined Medicare, Medicaid, and an employer mandate (Davis, 2001). The lack of political leadership to forge a consensus on one of the many proposed plans in Congress by the summer of 1974, however, combined with the turmoil of President Nixon’s August resignation and the decision of organized labor to withhold its support from reform until after the November elections, resulted in the disintegration of what bipartisan agreement existed (Starr, 1982; Maioni, 1998). After 1974, ongoing economic recession and price inflation, par- ticularly in health care, sank any further serious debate about reforming health care financing to extend coverage. Cost controls became the key emphasis during the Ford and Carter Administrations.9 By the late 1970s, health insurance coverage reached its highest level yet; in 1980, roughly 15 percent of the general population under age 65 was uninsured, about 29.6 million people (Bovbjerg et al., 1993). From 1970 to 1980, aggregate spending on health care had continued to grow, from $69 billion to $230 billion and from 7.2 percent to 9.4 percent of the gross domestic product (Starr, 1982). For employers, health insurance premiums were becoming more expensive, lead- ing them to increase deductibles, decrease dependent coverage, and, as the 1980s wore on, turn to commercial managed care contracting to restrain health care cost increases (Hacker, 1997). In an effort to restrain the continued growth of health care spending under Medicare, federal officials replaced fee-for-service reimburse- ment with capitation. During the 1980s, there would be incremental public expansions, particularly through the Medicaid program, which will be discussed later in this chapter. Absent major reforms of health care financing to extend coverage in the future, the stage was set for the major increases in the number of uninsured seen during the 1980s (Lewis, 1983; Hacker, 1997). Interest in comprehensive national reform of health care financing surfaced again in the early 1990s. Economic recession and continuing health care inflation renewed interest among middle-class voters (Hacker, 1997). During President 9The Carter Administration did develop a universal coverage proposal, never introduced in Con- gress, called the National Health Plan, which divided coverage between private sources (employer mandate) and public sources (a federal program to replace Medicare and Medicaid and expand eligi- bility to all lower income persons) (Congressional Quarterly, 1977; Davis, 2001).
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99 LESSONS FROM THE PAST AND PRESENT In the first two years of the waiver, there was a 14 percentage point increase in public coverage and greater than a 7 percentage point drop in the uninsured rate for low-income children; for low-income adults, there was an 8 percentage point increase in public coverage and an 11 percentage point drop in the unin- sured rate (Bovbjerg and Ullman, 2002). Three years into the waiver, enrollment in public coverage had grown from about 700,000 to 926,000 (Bovbjerg and Ullman, 2002). MassHealth consists of two programs that offer eligibility to the disabled and Medicare-eligible persons and four programs that extend coverage to the noninstitutionalized, nondisabled population (Bovbjerg and Ullman, 2002). These programs extend eligibility to • pregnant women and infants in families earning up to twice the poverty level; • children up to 150 percent of FPL, and parents up to 133 percent of FPL (Standard); • unemployed low-income adults and their families earning up to four times the poverty level (Basic); • children in families earning between 150 and 200 percent of poverty, adults earning up to 200 percent of poverty through an employer premium subsidy, and persons living with HIV (but not with active AIDS) earning less than 200 percent of poverty (Family Assistance); and • emergency services (through MassHealth Limited) for low-income per- sons ineligible for other programs (e.g., undocumented immigrants) (Rosenbaum et al., 2002). MassHealth is funded by state revenues and from federal matching funds from both Medicaid and SCHIP. Massachusetts’ uninsured rate of 11.3 percent (2002) is lower than the na- tional average for the population under age 65. Nonetheless, there are approxi- mately 637,000 uninsured under age 65 in the state (U.S. Census Bureau, 2003d). High levels of both employment-based and public coverage contribute to the relatively low uninsured rate (Bovbjerg and Ullman, 2002). Six percent of the state’s children under age 18 are uninsured (approximately 88,000 uninsured children), and the rest of the uninsured are adults under age 65 (U.S. Census Bureau, 2003d). Minnesota A total of about 4.9 million people live in Minnesota, and 22 percent of them live in households that earn less than 200 percent of FPL (KCMU, 2003f). Min- nesota has extended public coverage gradually, through a step-by-step or phased- in incremental approach of filling in private coverage gaps using the availability of federal matching funds through Medicaid to maximize the eligibility levels it can
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100 INSURING AMERICA’S HEALTH offer state residents (Chollet and Achman, 2003). In 1994, Minnesota inaugurated its own public coverage program, MinnesotaCare, intended to achieve universal coverage in ten years by expanding eligibility to all members of low- and moder- ate-income families ineligible for Medicaid (Gold et al., 2001). A year later, the state folded MinnesotaCare into a Section 1115 Medicaid waiver, together with the state’s Medicaid program and other state-supported public coverage (Gold et al., 2001). Minnesota’s public coverage programs extend eligibility through a small group purchasing pool for county, town, and school district employees and their families; to childless adults earning less than 70 percent of FPL who are ineligible for Medicaid (e.g., noncitizen immigrants, persons in mental institutions) (General Assistance Medical Care); pregnant women and infants under two years at nearly three times the poverty level, families with children earning less than 275 percent of FPL, and childless adults earning less than 175 percent of FPL (Medical Assis- tance, MinnesotaCare); and a high-risk pool (Chollet and Achman, 2003). Be- cause the state’s public programs made children eligible well above 200 percent of FPL before the enactment of SCHIP and SCHIP funds can be used only to extend coverage to newly eligible populations, Minnesota’s SCHIP program covers only a few hundred children (Chollet and Achman, 2003). Public coverage is financed with a mix of federal, state, county, and private dollars, including enrollee premi- ums and a tax on health care providers; about half of the state’s spending is matched by federal dollars, for the most part Medicaid (Chollet and Achman, 2003). The state is at a relative disadvantage financially compared with other states because it cannot reap the full benefit of new federal funds for SCHIP that are matched at a higher rate than is Medicaid spending. Changes in enrollment have reflected welfare reform and growth in earnings among the poor, for example, a dip in public programs (Medical Assistance and General Assistance Medical Care) after the delinking of welfare from Medicaid (Chollet and Achman, 2003). Over the decade from 1991 to 2001, both of these programs have declined somewhat in enrollment overall (although the numbers of enrollees outside of the welfare system grew), while there has been steady growth for MinnesotaCare (Chollet and Achman, 2003). The state’s low uninsured rate of 8.8 percent (2002) for the population under age 65 reflects high levels of both employment-based and public coverage (U.S. Census Bureau, 2003d). In 2000, public programs enrolled nearly all uninsured low-income persons under age 65 in the state (Chollet and Achman, 2003). Yet there are still an estimated 397,000 uninsured persons under age 65 (U.S. Census Bureau, 2003d). Most (325,000) are adults. About two-thirds of this uninsured population (including 91 percent of uninsured children) are believed to be eligible for but not enrolled in some type of coverage. If all eligible persons were enrolled, the state’s uninsured rate, it is estimated, would stand at 2.7 percent (Chollet and Achman, 2003).
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101 LESSONS FROM THE PAST AND PRESENT Oregon There are approximately 3.4 million persons of all ages in Oregon, one-third of whom live in households earning less than twice the poverty line (KCMU, 2003g). Since the 1980s, health reformers have attempted to implement universal coverage in the state in coordinated phases. The most widely known of these reforms is the Oregon Health Plan, enacted in 1994, which expanded Medicaid (through a Section 1115 Medicaid waiver), imposed an employer mandate (never implemented because the state did not receive the exemption it sought from ERISA), provided a public subsidy for workers to purchase employment-based coverage, and created a state high-risk pool (Gold et al., 2001). The Medicaid expansion received national attention for its innovative benefits package (initially intended to be applicable to the employer mandate and other parts of the Oregon Health Plan), which ranked conditions by priority for coverage, given the budget- ary constraints imposed by the Medicaid waiver obtained to implement the ex- pansion (Conviser, n.d.; Skeels, 1994; Jacobs et al., 1999). Conditions for which treatment would be covered under the expansion have been ranked in order of priority (reflecting cost effectiveness, the number of people potentially affected, and other factors) and funding decisions made on the basis of the prioritized list. A series of working groups and meetings across the state engaged, and continue to engage in, public and legislative discussion about the scope of health insurance benefits. Currently, the Oregon Health Plan extends Medicaid eligibility to pregnant women and children under age 12 with incomes up to 170 percent of FPL and other residents earning up to the poverty line (Gold et al., 2001). Through the Family Health Insurance Assistance Program, subsidized coverage is available for persons ineligible for Medicaid who earn up to 170 percent of FPL (Gold et al., 2001). The Health Plan is financed by cost savings achieved through mandatory managed care participation by enrollees and state revenues including income taxes and a sales tax on cigarettes, a funding base vulnerable to change with the changing economic fortunes of the state. As a result, enrollment barriers have been raised to slow growth of the public expansion, through income and assets tests and premi- ums (Gold et al., 2001). In 1993, before the Oregon Health Plan was implemented, the state’s unin- sured rate was 14.7 percent, or about 453,000 persons under age 65 (Gold et al., 2001). In the first year, there was an unanticipated groundswell of participation, with approximately 100,000 persons newly enrolled (the initial goal was to extend coverage to an additional 130,000 persons), of whom roughly 75,000 were new to public coverage (Leichter, 1999; Gold et al., 2001). Since the first year, growth in public coverage has been more modest, covering in total an estimated additional 130,000 low-income persons who would otherwise be uninsured (Leichter, 1999). Four years into the Health Plan, roughly two-thirds of the 1993 low-income uninsured population was enrolled (Gold et al., 2001).
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102 INSURING AMERICA’S HEALTH Current coverage gaps include uninsured adults earning more than 100 per- cent of FPL, including those with incomes below 170 percent of FPL who, while eligible for the public subsidy, either may not be able to enroll because of fiscal limits on the coverage programs or may be unable to find affordable coverage (Gold et al., 2001). The state’s uninsured rate of 16.5 percent (2002) for the population under age 65 is barely lower than the national average, and an esti- mated 511,000 persons under age 65 lack coverage (U.S. Census Bureau, 2003d). More than eleven percent of the state’s children under age 18 are uninsured (roughly 95,000 uninsured children) (U.S. Census Bureau, 2003d). Tennessee Tennessee is home to about 5.6 million people of all ages, nearly 40 percent of whom live in households earning less than twice the poverty level (KCMU, 2003h). Although the state’s insurance expansion was not expected to bring about universal coverage, it did broaden public coverage dramatically and significantly in 1994, through reform of its Medicaid program (Gold et al., 2001). A few years earlier, Congress had restricted the use of provider taxes to raise state matching funds for Medicaid, throwing Tennessee’s publicly financed health care into fiscal crisis. State officials responded by obtaining a Section 1115 waiver that allowed the state to extend public coverage to greater numbers of uninsured persons and recapture federal Medicaid dollars that would no longer be available through the DSH program. The waiver created a new program, TennCare, that implemented mandatory managed care for all enrollees and doubled the number of enrollees within its first year. TennCare extends eligibility for coverage to 400 percent of FPL. However, since January 1995, enrollment has been capped at 1.3 million persons because of limited public dollars to support further enrollment. Although TennCare is funded by federal, state, and local funds, including Medicaid DSH payments to hospitals and annual insurer assessments, support has been insufficient to cover all who are eligible to enroll and has also constrained provider reimbursements. One study estimates that, during TennCare’s first five years, the federal and state governments spent about $700 million less than would have been predicted for the Medicaid program without the waiver. At the same time, TennCare’s expansion of eligibil- ity cost approximately $3.8 billion more (net new costs of $3.1 billion) from all payers than would have been predicted when anticipated changes in charity care, patients’ cost sharing, and local government spending were considered (Conover and Davies, 2000). At present, no new eligible persons may enroll unless they are members of groups required to be covered by Medicaid, dislocated workers, children in fami- lies earning less than 200 percent of FPL, and children in families earning between twice and four times the poverty limit who do not have access to employment- based coverage (Conover and Davies, 2000; Gold et al., 2001). In the year before TennCare (1993), Tennessee’s uninsured rate was 13.2 percent (about 673,000 persons under age 65) (Gold et al., 2001). In the first year after TennCare began,
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103 LESSONS FROM THE PAST AND PRESENT the state’s uninsured rate shrank by one-third to one-half, putting the state well below the national average uninsured rate. Four years into the program, nearly 400,000 persons have left the ranks of the uninsured and enrolled (Gold et al., 2001). Currently about 12.0 percent (606,000 persons) of the state’s residents under age 65 are uninsured (2002) (U.S. Census Bureau, 2003d). Most are adults, al- though nearly one in six are children under age 18 (U.S. Census Bureau, 2003d). LOCAL INITIATIVES TO EXTEND COVERAGE In many states across the country, counties are the providers of last resort for the underserved and uninsured (IOM, 2003a). Counties have responded to this charge in a variety of ways. The three counties reviewed in this section are among the few jurisdictions that have programs devoted explicitly to increasing the level of insurance coverage significantly and reducing uninsurance. Each takes a differ- ent approach, tailored to the characteristics of the local population, the resources available to deliver and pay for care that would otherwise go uncompensated or not be received at all, and local leadership. At each site, state or local conversion foundations, created as part of changes in the ownership status of health plans or hospitals, have contributed financing for coverage initiatives. From the following discussion of local extensions, the Committee draws the following observation. 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 address targeted gaps, the lack of a reliable funding source limits their scope and effectiveness. San Diego, CA In 2001, there were nearly 365,000 uninsured children and adults under age 65 in San Diego County, or about 15.1 percent of the county’s 2.4 million residents (Brown et al., 2002).23 There is a sizable coverage gap among low- income workers. In 1997, two local organizations—the Sharp Health Plan (a nonprofit insurer) and the Alliance Healthcare Foundation (a conversion founda- tion)—created a small-scale demonstration program to reduce uninsured rates 23This is a point-in-time estimate (e.g., the survey respondent reported his or her coverage status at the time of participation in the survey). Analysts evaluating the county’s uninsured problem devel- oped a much higher estimate of the number of uninsured in the county, 537,000 persons, based on a three-year moving average of national Census data (the March Current Population Survey 1998– 2000) that estimates uninsured status over a one-year period of time (the calendar year preceding the year of the survey) rather than a point-in-time estimate (Kronick, 2002). This higher estimate of the number of uninsured persons yields a higher county uninsured rate of 21.7 percent.
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104 INSURING AMERICA’S HEALTH among low-income workers by offering employer premium assistance to small firms that do not offer employment-based coverage (Silow-Carroll et al., 2001). The program, abbreviated FOCUS (for Financially Obtainable Coverage for Un- insured San Diegans), targeted firms with 50 or fewer workers and formally began in April 1999. Firms are eligible to participate if they have not offered coverage in the previous year, and they are given a two-year commitment of support (Silow- Carroll et al., 2000). Employees may enroll if they work full-time, earn up to 300 percent of FPL, and have been uninsured for the past year, with the requirement that all dependents be enrolled as well; however, dependents may also be eligible for public coverage (Silow-Carroll et al., 2000). Both employers and employees contribute to the premium, which is subsidized by private dollars from Sharp Health and two foundations (the California Endowment and the California Health Care Foundation) established when Blue Cross of California converted to for- profit ownership status (personal communication, Jeffrey Lazenby, Sharp Health Care, April 29, 2003). Providers are paid on a fee-for-service basis, and the benefit package is comparable to that of other local commercial benefits, with copayments but no deductibles (Silow-Carroll et al., 2001; personal communication, Jeffrey Lazenby, Sharp Health Care, April 29, 2003). Although outreach has been an important part of FOCUS and the business community has offered much interest and support, enrollment has been limited by the availability of funding. To date, FOCUS has obtained roughly $3 million in private support (personal communication, Jeffrey Lazenby, Sharp Health Care, April 29, 2003). The target population initially identified was the approximately 49,000 adult workers employed by firms that did not offer coverage and the initial goal of FOCUS was to enroll 1,000 workers. As of mid-2000, nearly 2,000 workers and dependents were estimated to be enrolled, representing 232 busi- nesses; participating employers are more likely than average to have uninsured owners who are also more likely to be foreign born and to have a very low-waged workforce (Kronick, 2002). An estimated 55,000 to 80,000 uninsured workers and dependents would be eligible to enroll if the program were expanded (per- sonal communication, Jeffrey Lazenby, Sharp Health Care, April 29, 2003). At present, enrollment is closed to new firms but open to new employees and their dependents that join firms already participating in FOCUS. Alameda County, CA About 1.3 million people live in Alameda County, situated in the Bay Area and including the cities of Oakland, Berkeley, and Hayward. The county has an uninsured rate of about 8.4 percent, or roughly 109,000 uninsured under age 65 (Brown et al., 2002).24 More than half of the uninsured adults are in the workforce, 24In 2000, the county supported its own survey of sources of coverage status over a 3-month
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105 LESSONS FROM THE PAST AND PRESENT with 28 percent earning less than the poverty level and another 37 percent earning between 100 and 250 percent of FPL (Ponce et al., 2001). In 1996, the county health department began a collaboration with local providers, screening low- income people for Medi-Cal (the state’s Medicaid program) for enrollment in a managed care plan (personal communication, Nina Maruyama, Alameda Alliance, May 29, 2003). The program, known as the Alameda Alliance for Health, has evolved into a private, nonprofit managed care health plan that receives a core of public funding and builds programming around its private-sector and foundation fundraising. Its goal has been to provide or coordinate seamless, continuous cov- erage for all members of families earning up to 300 percent of FPL who are county residents, considered as a unit rather than as individually eligible, regardless of eligibility for other public programs or immigration status (Ibarra, 2002). The Alliance’s strategy has been to gather stakeholders and to participate in coalitions devoted to improving access to care. Alliance coverage programs emphasize primary and preventive services while offering a comprehensive benefit package. Care is provided by a network of providers. Enrollees pay part of their premiums, with the Alliance supporting premiums that are not covered through public programs such as Medi-Cal or SCHIP. Copayments are tied to the type of service, with none for primary and preventive services to encourage utilization and a copay for emergency depart- ment visits to discourage nonurgent use. In addition, the Alliance takes a culturally sensitive approach to outreach among the county’s diverse population, translating materials into a number of languages and working with community-based groups. More than half of the enrollees in its Family Care program are Spanish speaking and 19 percent speak Cantonese. The Alliance offers subsidized coverage to all members of families earning no more than 300 percent of FPL (Medi-Cal, an SCHIP program called Healthy Families, and Family Care) and unsubsidized coverage (through the First Care program) for those with higher incomes (Ibarra, 2002). For Family Care, which has nearly 5,200 enrollees, family members may qualify under different programs, for example, Family Care program eligibility is extended to family members (parents, siblings) of those who qualify for Medi-Cal or Healthy Families. As of spring 2002, approximately 81,000 persons were enrolled through the Alliance, most of whom (68,000) received coverage through Medi-Cal. In addition, the Alliance Group Care program begun in 2002 offers subsidized coverage to full- time home supportive services workers (about half of whom were previously uninsured). Financing comes from a combination of public and private sources. The period, arriving at an estimate that roughly 16 percent of the county’s adults, or 140,000 persons, were uninsured (Ponce et al., 2001). While this survey’s estimated uninsured rate is about double the estimate given by a statewide survey that included a sample of county residents questioned about their coverage status over the course of a year, both surveys arrive at estimated numbers of uninsured persons that are surprisingly similar (Brown et al., 2002).
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106 INSURING AMERICA’S HEALTH nonprofit’s endowment is supported by grants from the California Endowment, the California Health Care Foundation, and tobacco settlement dollars from the county. Coverage programs have been added as new funding streams have be- come available, for example, through the federal SCHIP program (1998). Hillsborough County, FL In 2000, roughly 40,000 of the county’s 1 million residents were uninsured and living below the poverty line (personal communication, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003).25 Like other Florida counties, Hillsborough (which includes the city of Tampa) serves as a provider or payer of last resort for the county’s medically indigent population. In the early 1990s, rising health care costs, especially uncompensated care costs at the county public hospital’s emergency department, motivated county officials to devise a health care plan for the portion of its uninsured population below the poverty line. The Hillsborough Health Plan is intended to promote the use of primary and preventive services, targeting low-income families and coordinating the provision of coverage with other public services in the county (personal communication, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003). Eligibility is restricted to persons earning no more than 100 percent of FPL; for persons earning up to 125 percent of FPL, catastrophic coverage is available with an income-based sliding scale premium (Hillsborough County, 2003). En- rollees obtain care on a fee-for-service basis through one of four networks of providers that have contracts with the county (personal communication, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003). Since its inception, the plan has been supported by county revenues from property and a dedicated sales tax, as well as premiums for the catastrophic care plan (Hillsborough County, 2003). The county made a concerted outreach effort through its neighborhood service centers and with assistance from local community-based groups, reaching an initial enrollment of 15,000 out of the 40,000 eligible (personal communica- tion, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003). In 2002, nearly 28,000 persons were enrolled in the Health Plan, divided between indi- vidual members (61 percent) and families (39 percent) (personal communication, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003). In addition to extending coverage, the Health Plan has been estimated to have saved more than $11 million in hospital emergency department costs (personal communication, Toni Beddingfield, Hillsborough Health Plan, April 30, 2003). Like many other states and counties, however, Hillsborough has faced budget shortfalls over the past few years that have led County Commissioners to make difficult decisions. In 25A state-level survey in 2000 estimated the county’s uninsured rate at 14 percent, with 117,000 uninsured persons under age 65 out of a general population of 839,000 (Lazarus et al., 2000).
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107 LESSONS FROM THE PAST AND PRESENT 2003, cost-saving measures have been geared toward decreasing enrollment (by requiring more frequent reenrollment). SUMMARY None of the reform campaigns or public initiatives discussed in this chapter has achieved universal health insurance coverage. Economic and demographic changes over time have influenced the level of private coverage (employment- based coverage), with larger public insurance programs such as Medicaid and SCHIP modestly lowering the proportion of uninsured persons by filling in some of the many gaps in coverage created by the employment-based system. As illus- trated in Figure 3.1, however, given the absence of major federal reform targeting the general population since the mid-1960s, there has been little variation in the sources of coverage and in the uninsured rate over the past 25 years. Those pursuing extended coverage in recent years have grappled with con- cerns and obstacles shared by reformers before them. During the era before Medi- care and Medicaid, reformers sought health care financing arrangements that would apply universally (covering all members of society), be affordable to those seeking coverage, and be adequate in benefits to sustain health and well-being (making accessible the demonstrated and perceived advantages of medical care). The boom in private coverage between the mid-1930s and the 1960s, through Blue Cross and Blue Shield and independent plans initially, then by commercial insurers in the group market, made employment-based coverage the norm for most Americans. Implementation of Medicare and Medicaid in the 1960s filled in some of the gaps left open by employment-based coverage, for persons aged 65 and over and for categories of the poor and medically indigent. The two programs, which today cover nearly a quarter of the U.S. population, grew to be much more expensive than initially anticipated. After the federal government became a major insurer and purchaser of health care, reform campaigns shifted their focus to controlling costs, stressing the need for insurance schemes to be affordable to society, administra- tively efficient, and transparent to political stakeholders. Over the decades, there has been moderate public sympathy for the general idea of universal coverage, yet no groundswell of public interest in a particular strategy to reach this goal (indeed, polls report a drop in support for universal coverage when couched in terms of specific provisions or financing requirements) (Marmor, 1973), and the spillover effects of a large uninsured population on persons other than the uninsured them- selves have gone largely unacknowledged by the public (IOM, 2003a). Even though most uninsured persons are members of families with at least one worker, government efforts to reduce uninsurance since Medicare and Med- icaid continue to focus on public coverage to fill gaps. Since the mid-1980s, major federal initiatives to extend both public and private coverage have lowered unin- sured rates among children and raised the numbers with public coverage, although the number of uninsured overall has continued to grow. Between 1984 and 1990,
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108 INSURING AMERICA’S HEALTH Congress gradually expanded Medicaid eligibility for pregnant women, infants, and young children, delinking coverage from welfare eligibility. These Medicaid expansions were followed in 1997 by the creation of SCHIP grants-in-aid to the states. SCHIP appears to have reduced the number of uninsured children recently, but millions of children remain uncovered, more than half of whom are eligible (Broaddus and Ku, 2000; Dubay et al., 2002a,c; Kenney et al., 2003). Federal initiatives to extend employment-based coverage have targeted improved port- ability and continuity of coverage through the COBRA, HIPAA, and TA statutes, yet the lack of authority or resources under COBRA and HIPAA to make insurance premiums affordable has seriously limited their usefulness and impact. With the exception of Tennessee, the states discussed in this chapter have relied on relatively high levels of employment-based coverage, plus generous public coverage for their low-income populations using Medicaid waivers and additional state funds to keep uninsured rates below the national average. Con- straints on federal dollars, for example, due to the budget-neutrality requirement of Medicaid waivers, and the shortcomings of the federal matching formula (FMAP) to compensate adequately for the effects of economic recessions, contrib- ute to the difficulties experienced by the states in extending coverage (Corrigan et al., 2003; IOM, 2003a). The federal ERISA also narrows state options to reform their private insurance markets, through which most of their residents obtain coverage. However, it is mainly the lack of sufficient or sufficiently stable public dollars that has checked broad access reforms, despite the willingness, albeit lim- ited, of taxpayers in these states and others to tax themselves in order to raise funds to extend coverage, for example, through tobacco taxes (Marquis and Long, 1997; IOM, 2003a). Hawaii’s inability to update provisions of its employer mandate to meet newer needs for coverage and failure to enforce the mandate contribute to an ongoing population of uninsured low-income workers, while limited resources have constrained public programs intended to fill coverage gaps. The breadth of Massachusetts’ reforms is comprehensive, yet implementation of its “pay or play” law for employment-based coverage was delayed and eventually repealed due to waning political support, limiting the state’s ability to boost private-sector cover- age. Budget shortfalls have limited public coverage programs (MassHealth). In Minnesota, the uninsured rate is nearly the lowest in the nation, but gaps in coverage remain, jeopardizing its goal of universal coverage. The inability to obtain an ERISA exemption kept Oregon from using its innovative Medicaid expansion to broaden employment-based coverage in the state, and reliance on tax revenues has left the Oregon Health Plan underfunded. Finally, Tennessee’s am- bitious efforts to use existing Medicaid dollars and managed care contracting to markedly extend the program to its uninsured population with low and moderate incomes resulted in increased enrollment among the poorest segment of this group in the first year, followed by closed enrollments to all but those required under law to be covered. Localities, whose economic resources are more limited than those of the states (which can cross-subsidize among communities), may come close to
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109 LESSONS FROM THE PAST AND PRESENT filling a particular local gap in coverage but remain even more constrained than are the states by a lack of sustainable revenues for public coverage. Despite gradual extensions 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 national political consensus has hindered a substantial reduc- tion, if not elimination, of the problem of uninsurance in the United States. Laudable state- and county-level efforts to extend coverage have been constrained by a lack of resources. The circumscribed nature of these past and present initia- tives suggests that attempts to provide universal coverage through state or local efforts without a substantial infusion of additional federal funds, and federal lead- ership, are unrealistic. 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. In the chapters that follow, the Committee builds on this base of knowledge about past and present efforts to reduce uninsurance to formulate its set of prin- ciples to guide a universal approach to insuring all Americans. These principles will be used to assess comprehensive models that describe “pure” or ideal ap- proaches to universal coverage (for example, an employer mandate) in order to reach conclusions and recommendations about how the United States can defi- nitely and successfully eliminate uninsurance among its population.
Representative terms from entire chapter: