"Significant" small steps are no substitute for comprehensive reform
The Commonwealth Fund
January 2003
Small but Significant Steps to Help the Uninsured
By Jeanne M. Lambrew and Arthur Garson, Jr.
This paper suggests a number of low-cost policies that could improve health coverage in this environment by providing discrete groups of people with access to private health insurance, public coverage, or both.
Generally, the policies outlined below would cost less than $1 billion per year-a small amount relative to total spending on Medicare and Medicaid ($260 billion and $270 billion, respectively). Even if all were enacted, they would neither significantly reduce the number of uninsured nor substitute for comprehensive health system reform.
* Extending COBRA continuation coverage to all workers who need it.
* Adding health insurance assistance to unemployment insurance.
* Testing a Federal Employees Health Benefits Program buy-in through a
demonstration.
* Testing an individual insurance tax credit through a demonstration.
* Gradually phasing in public coverage of poor adults.
* Extending private plans' dependent coverage up to age 21.
* Extending Medicaid/CHIP options up to age 21.
* Extending COBRA continuation coverage for early retirees.
* Creating a Medicare buy-in for younger spouses of Medicare beneficiaries.
* Allowing Medicaid to act as a high-risk pool.
* Gradually phasing out Medicare's 24-month waiting period.
* Creating a national health coverage advisory commission.
Conclusion
Small policies cannot cure the myriad problems in the health insurance system in the United States. Solutions will require both significant new funding, since affordability is a major problem, and insurance and delivery system reform, to remove the structural barriers to coverage. The ideas presented in this paper represent a sample of ideas that could be considered in addition to those that have been proposed in Congress and by state officials, researchers, providers, and consumers. They are not incompatible with larger visions for the health system, nor are they intended to substitute or delay action on major reforms. Instead, they aim to break the recent impasse on policy for the uninsured and to make some, albeit limited, progress on reducing the number of uninsured Americans. Success in passing and implementing incremental health policies may, rather than diverting attention away from systemic reform, instill confidence in public policy's ability to take on the larger challenges in improving health insurance coverage in the United States.
http://www.cmwf.org/programs/insurance/lambrew_smallsignificant_585.pdf
Comment: The most important statement in this report: "Even if all were enacted, they would neither significantly reduce the number of uninsured nor substitute for comprehensive health system reform."
The two major pathways to reform include (1) incremental measures, such as those listed, that improve access and equity, and (2) comprehensive reform that assures everyone full, affordable access to health care. To follow one pathway, while publicly opposing the other, constitutes health policy malpractice!
We all need to support modest but politically expedient measures which can be enacted now. But, of much greater importance, we are all ethically mandated to move forward, with all of the forces that we can muster, toward true, comprehensive reform. There can be absolutely no hesitancy nor compromise in this effort.
Those working on modest reforms must continue to do so. But, as we support their efforts, they need to publicly support, in the clearest terms possible, our efforts for comprehensive reform. By unifying our advocacy on behalf of our health care system, we can clarify the confused message that the public is receiving. The public must understand that there is absolutely no substitute for truly comprehensive reform.