Should reducing the uninsured rate by half be our goal?
The Commonwealth Fund
March 8, 2005
News Release
New Health Care Opinion Leaders Survey: Uninsured Rate Could Be Reduced
by Half in Ten Years
The proportion of Americans without health insurance can and should be reduced to 8 percent in ten years, less than half the current rate, according to the Commonwealth Fund Health Care Opinion Leaders survey, an online survey of widely-recognized experts in health care practice and policy.
Three-quarters (75%) of respondents say that employer-sponsored insurance should not be permitted to decline. There was also wide support from respondents for a range of policy efforts to improve coverage. About four-fifths (82%) favor incentives for employers to provide insurance that meets minimum standards, and tax credits or other subsidies for low-wage workers (79%). Other popular policy options included requiring employers who do not provide health benefits to pay into a fund to insure workers and their families (70%), allowing employers to buy into Medicaid or CHIP for their employees (60%), and employer mandates to help finance benefits (52%).
Respondents expressed lower rates of support for replacing employer coverage with a single-payer plan, with about two-fifths supporting (42%) or opposing (40%) this policy.
In contrast, three-fifths (62%) of respondents oppose making HSAs the centerpiece of efforts to cut health care costs (combined with making high- deductible plan coverage more widely available).
http://www.cmwf.org/usr_doc/HCOL_survey2_release.pdf
The survey questions and results:
http://www.cmwf.org/usr_doc/HCOL_survey2_topline.pdf
Comment: The good news about this survey is that health care opinion leaders support protecting the coverage that we do have, and they support improving coverage. The bad news is that this survey was designed to support the current path of incrementalism, an approach that has been ineffective in expanding coverage.
As an example, the very first question: “Health care costs, market pressures, and public and private policies are changing insurance coverage in the U.S. For each of the following, please indicate what you would see as both an achievable and a desirable target or goal for policy action for the next ten years: (1) The proportion of under-65 population that has no health insurance (now about 18%).”
The median answer given was a goal of 8% without insurance. Thus the survey begins with a concession on the part of the respondents that 100% coverage is not an achievable goal. Obviously that makes it very easy to reject 100% solutions as lacking political feasibility.
The third question: “About 160 million Americans get health insurance coverage through their employers who spend more than $400 billion on such benefits. Would you favor or oppose each of the following options for such coverage in the future? Please consider each option in isolation.” (Seven options are offered, in randomized order.) One option: “Employer coverage should be replaced with a single-payer plan, with current employer premium contributions redirected to help pay for coverage.”
Results: 42% in favor, 40% opposed, and 17% not sure. But this was not a question about abolishing the current fragmented system of funding care, including employer-sponsored coverage, and replacing it with a single,
publicly-administered program. Instead, this was a question about preference for a universal insurance program in which employers must bear much of the burden of the funding of health care for everyone. It makes the assumption that employer sponsorship would continue to be the mainstay of health care funding, thereby losing the support that much of the business community would have for a single payer system.
The political consequences of rejecting a 100% solution before beginning negotiations are exemplified by the comments of Charles Kahn in an accompanying commentary. He is the president of the Federation of American Hospitals, an advocacy organization for investor-owned hospitals. He is also the “strange bedfellow” of Ron Pollack, the executive director of Families USA. Although of different ideological persuasions, they had joined together to drive consensus on the development of public policy to address the problem of the uninsured.
Kahn’s comments:
“Up to this point, it has been my belief that the best way to proceed on this front is to bring together people with varying ideas about health policy and to work within the current context.”
“I still have great hope for this approach… But after many years of coalition building and consensus development, the number of uninsured Americans continues to grow, dramatically. Rather than risk inactivity and allow this number to escalate, perhaps we should adapt this approach to better reflect current political reality.”
“Republicans, who control the White House and both Houses of Congress, dominate the current political landscape. Therefore, if health policy advocates want to see progress on the uninsured, we have to look to President Bush and the GOP majority to take the lead.”
“Rather than trying to achieve a sufficiently broad consensus, there is a compelling argument to be made that, to begin reducing the number of uninsured Americans, we instead ought to reach for what is already within our grasp.”
“I recognize that tax credits and expanded health savings accounts are not the preferred policy approaches for some members of our ‘strange bedfellows’ coalition. However, these are the approaches most likely to be approved by Congress. Given the rising number of uninsured Americans, we owe it to them, and to ourselves, to work to pass what can be passed, and then allow these approaches sufficient time to work.”
http://www.cmwf.org/publications/publications_show.htm?doc_id=262376
Further comment: When you wake up in the morning and find your bedfellow gone, you suddenly realize that your self-esteem left with him. But all is not lost. There is no better way to recover your self-respect than to pick yourself up, reject the siren song of incrementalism, and move forward with great certitude toward a fully achievable 100% solution in health care.
Fortunately, we can find more inspirational guidance in another commentary by Michael Rodgers, interim president of the Catholic Health Association:
“Most important, those working to amplify the voice of the uninsured and the marginalized are well served to remember that the cause for which they fight is nothing short of a moral imperative.
“We are a fortunate nation with plentiful resources and a community spirit rooted in equality and fairness. Now it is our monumental but unavoidable task to express the need for change, to mobilize the nation behind it, and to once and for all meet our obligation not just to the sick specifically, but to one another generally.”
http://www.cmwf.org/publications/publications_show.htm?doc_id=260394