care providers, and those financers of care. Some would put a single national purchaser—the federal government—in charge. Others would put the cost-conscious individual consumer at the helm. Yet others would mix strong government regulations with market competition among certified health plans. Most of these proposals would leave employers with a more limited role than they have now.

The debate over health care reform raises many controversial questions involving the obligations of richer or healthier individuals to help poorer or sicker individuals, the role of the private versus the public sector in ensuring access to needed health care, the virtues of voluntary versus compulsory insurance, and the effectiveness of market versus regulatory strategies to contain costs and ensure value. Regardless of the stance taken in such debates, the central position of employment-based health benefits is a major factor to be reckoned with in considering the feasibility and specifics of proposals for change.

This report explores the following questions: How did the current system of voluntary employment-based health benefits develop? How does it relate to the overall structure of health care delivery and financing in the United States? What are its basic characteristics, strengths, and limitations? What might be done about the limitations? The committee believes that the results of this exploration will be informative and thought-provoking for both those who favor the continuation of a voluntary employment-based health benefit system and those who favor its replacement by other arrangements.

The findings and recommendations presented here do not constitute a blueprint for health care reform, even for reform that seeks to build on voluntary employment-based health benefits. In particular, the findings do not address the most effective means to limit the rapid escalation in health care costs and to define the appropriate role of advanced medical technologies, two issues that trouble all economically developed countries regardless of their system of financing medical expenses. Furthermore, the discussion here does not touch directly on the problems facing Medicare, Medicaid, and other public programs, although the committee recognizes that efforts to resolve those problems cannot go forward in isolation from the system examined here.

Rather, this report sets forth some steps that government, business, individuals, and health care practitioners and providers could take to alleviate certain problems related to the current link between the workplace and health benefits. These steps are grouped into two divisions: one that assumes the preservation of a voluntary system of employment-based health benefits and a second that assumes that a voluntary system cannot significantly extend access, control biased risk selection, or manage costs. This discussion does not constitute a general committee endorsement or rejection of either a voluntary or a compulsory system of employment-based health benefits.

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