Health system reform debate returns to national spotlight

Several strategies for improving access to health insurance have been proposed, but what would they cost and who would pay?

By Joel B. Finkelstein, AMNews staff. Nov. 17, 2003.

Washington -- With the presidential election campaign getting off the ground, comprehensive health system reform is back on the radar screen.

A report from the Robert Wood Johnson Foundation's Covering the Uninsured project offers estimates on the scope and cost of 10 proposals that use a handful of different strategies to expand access to coverage.

The plans include some combination of Medicare and/or Medicaid expansion, tax credits or other tax-based incentives, premium subsidies, employer mandates, managed competition arrangements, and subsidized or government-run insurance pools.

Overall, the cost of the proposals are a mere drop in the bucket compared with the $1.6 trillion that Americans already spend on health care every year, but the question remains: Who will foot the bill?

"Are we ready to pay for our fellow man, today?" asked Len Nichols, PhD, vice president of the Center for Studying Health System Change. "We weren't in 1990."

Incremental proposals promise more limited impact but cost much less to implement than more comprehensive plans.

Tax credits are the basis of most incremental approaches. The main instrument preferred by the Bush administration is tax credits, along with the liberalization of markets to make more affordable health insurance products available.

Other proposals call for tax credits to be used in conjunction with a buy-in option to Medicaid to ensure individuals have an insurance option they can afford. Tax credits could also be used to replace the current employer-based system of tax incentives to create a more equitable system for the individual health insurance market. Such proposals include expanded access either through Medicaid or government-run purchasing pools.