WASHINGTON — Lawmakers are brimming with ideas about what to do for the nation's 47 million uninsured, but it is not clear whether any single proposal has enough support to overcome political obstacles.
Just months into the start of this session of Congress, several bipartisan bills have been introduced and sweeping reforms have been proposed, including some that would expand health coverage to most—if not all—Americans. Lawmakers are also proposing incremental approaches that would build on ongoing state efforts.
Although those proposals would require increased federal spending, they would also bring about administrative savings within the health care system. Reductions in the amount of paperwork and in uncompensated care could yield savings of between $4.5 billion and $60.7 billion, according to a new report from the Commonwealth Fund.
The report, with cost estimates produced by the Lewin Group, contains analyses of recent proposals, including the tax reforms that President Bush described in his January state of the union address. In that speech, the president proposed a health insurance tax break to everyone who purchases coverage, rather than only for those who get it through their employers.
Under the proposal, anyone covered by a private plan would get the standard deduction of $7,500 for individuals and $15,000 for families.
The implementation of this tax change would help 9 million uninsured Americans get coverage at a cost of $70.4 billion in federal subsidies in the first year, according to the report.
The goal of this or any reform should be to make health insurance more affordable and efficient, explained Katherine Baicker, Ph.D., a member of the president's Council of Economic Advisers, at a recent briefing sponsored by the Alliance for Health Reform.
“The parts of the country where we spend the most on health care are not the parts where people end up with the highest quality health care, they're not the parts where people are sickest,” Dr. Baicker said.
There is evidence “that we could get more for our money,” she added.
Proposals in Congress tend to have more ambitious aims. Legislation introduced last year by Rep. Pete Stark (D-Calif.) would open both Medicare and the Federal Employees Health Benefits Program to all Americans. It would cover almost all of those who are currently insured and uninsured and increase federal health care spending by $154.5 billion in the first year.
Another proposal from Sen. Ron Wyden (D-Ore.) would extend coverage to 95% of the uninsured through large, regional risk pools whereby individuals and families could purchase private plans. Because it requires employers to buy into the plan, this approach would cost the federal government only $24.3 billion in the first year.
More modest proposals have also been circulating on Capitol Hill and are receiving bipartisan support. Among these are calls to ensure that all children are covered, which is likely to arise during discussions on the reauthorization of the State Children's Health Insurance Program. Other lawmakers would like to see more federal government support for state experiments with sweeping reforms.
However, there are more fundamental differences in the philosophies that undergird many of these proposals.
Some are rooted in the belief that the health care system cannot be fixed until everyone is brought into it.
“As long as coverage is incomplete, efforts to achieve cost control with respect to the insured population will generate social and health consequences that none of us would find tolerable,” said Henry Aaron, Ph.D., an economist and senior fellow at the Brookings Institution in Washington.
He explained that in a situation in which some patients are insured and others are not, physicians and other providers are forced to prioritize by attending to patients who can pay so that they can subsidize those who can't.
But as increasingly fewer people can afford coverage, it will become more difficult for physicians to accept patients without insurance. “Cross-subsidies that the uninsured now enjoy would be squeezed, and it would give the state of being uninsured a whole new and terrifying meaning.”
Others argue that covering everyone without first dealing with the rising cost of health care would aggravate existing problems. “Getting the fundamental cost drivers under control is a necessary precondition for covering the uninsured. If we don't do that, no system we design today will be affordable tomorrow,” Dr. Baicker said.
Dr. Aaron pointed out that such differences in perspective are reflected in the diversity of proposals that are on the table, which is why it may be necessary to try reforms at the state rather than the national level.