SCHIP - a lesson on demographic incrementalism
Beyond Incrementalism? SCHIP And The Politics Of Health Reform
by Jonathan B. Oberlander and Barbara Lyons
Health Affairs
March 17, 2009
Given the enormous political and fiscal barriers to adopting legislation that aims for universal or near-universal coverage, it could be tempting for Congress and the Obama administration to follow the expansion of children’s health insurance with further incremental measures. The political appeal of such a strategy is understandable: maximizing consensus on incremental policies while avoiding harder, more polarizing, and more expensive reforms is a time-tested strategy in U.S. health policy. Indeed, it is the exact political formula that produced SCHIP’s enactment in 1997. Advocates of incrementalism have long recognized that political constraints mean that the alternative to imperfect, limited reforms is, alas, often to do nothing. In that context, incrementalism looks quite appealing—a fallback position seemingly validated by the repeated failure of big-bang reform.
Yet there are real limits to incremental health reform. After all, despite gains in Medicaid and SCHIP, almost nine million children remain uninsured. The insurance system for children, notwithstanding their sympathetic status, is beset by the same problems that plague the rest of the U.S. health care system: fragmentation, inequality, and alarming coverage gaps. It is a sobering reminder of just how far the country has to go in health reform that we have not been able to secure universal coverage even for children.
There are also limits to a health reform strategy premised on demographic incrementalism that insures Americans group by group. Unlike children or the elderly, most uninsured Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs. The SCHIP formula can only take us so far, since “all the ‘good’ (that is, politically attractive) populations are taken.” To make significant progress toward covering all Americans, we will have to adopt insurance expansions that don’t simply target politically attractive populations.
If the past decade has proved anything in American health policy, it is that incrementalism is not enough. A decade of incrementalism and inaction has left us with higher costs and rising numbers of uninsured Americans; absent decisive action, those trends will only worsen in coming years. It is encouraging, then, that both the Obama administration and key players in Congress are now pursuing bolder reforms. Perhaps we are entering a new era where U.S. health policy will finally move beyond incrementalism.
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399v1
Comment:
By Don McCanne, MD
Incrementalism: the crossroads of policy and politics.
When each attempt at comprehensive reform fails, the usual response is for everyone to walk away. A few come back to try to retrieve whatever little bit that seems to be politically feasible.
The path of incrementalism has failed to slow the increase in costs and has resulted in increases in the numbers of uninsured and now greater increases in the underinsured. Lauding the mini-successes rings hollow when the health care system continues to have “fragmentation, inequality, and alarming coverage gaps.” By any reasonable standard, incrementalism has been a miserable policy failure.
The incrementalists tell us that the Children’s Health Insurance Program (CHIP) shows us that incrementalism can be a very successful approach to reform. There is no question that this program has been beneficial at least for those children covered. The primary detriment is that it reduced the political pressure for more comprehensive reform.
As the authors point out, children are perhaps the most attractive group for demographic incrementalism. It passes the test of politics, but fails on policy. The CHIP program that “covers all children” has left 9 million children without coverage, perpetuating “fragmentation, inequality, and alarming coverage gaps” for children! The very best incremental program that we have enacted in the past four decades has fallen far short of our goals for reform because beneficial policies were traded away in the politics of reform.
We are now at a rare moment in time when the politics seem aligned so that we can set aside incremental approaches for the time being and seriously consider comprehensive reform. The difficulty is that those leading the reform process are already abandoning important beneficial policies in what they believe will be a successful strategy to keep the politics aligned.
Let’s look at one important example. In their article, Oberlander and Lyons describe the fight over “crowd out,” the concept that, as you raise the qualifying income level for a government children’s insurance program, you increase the number of children that will move from private health plans to the public program that provides a better value. The qualifying income level is very problematic because it is middle-income families that have incomes too high to qualify for the program yet too low to readily afford private insurance. Although the opposition to crowd out could be perceived as an attempt to protect the private insurance industry, the policy principle is much more fundamental.
As the authors explain, “The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether health care is an individual responsibility or social good. Those issues are far from resolved.”
So… the intersection of policy and politics. Those who are leading the reform process and who should believe that health care is a social good are supporting policies that will leave the private insurers in charge, invoking the politics of appeasement to satisfy those who believe that health care is an individual responsibility.
If we are going to achieve our goals of affordable, high quality health care for everyone, it is absolutely imperative that we adopt policies that advance health care as a social good. Policies that shift the responsibility to the individual will further increase our problems with fragmentation, inequality, and alarming coverage gaps.
Whether following a path of incrementalism or the enactment of comprehensive reform, this political divide will never go away. Appeasement politics will always be ruinous for the social good of health care.
The bottom line: The politics must support the policies of health care as a social good, with no compromise. The battle must continue until it is successfully executed. Perceptions of defeat are only perceptions. That is not the time to walk away and eventually crawl back on the ragged path of incrementalism. We must continue the charge, no matter the battle scars, until we achieve health care justice for all. Our finances, our health, and our lives depend on it.