Washington Watch: Universal coverage looms large in U.S.
Universal coverage looms large in U.S.
By Adam Sonfield
Senior Public Policy Associate
Guttmacher Institute
Washington, DC
With high and rising levels of uninsurance and health care costs, federal and state policy-makers have taken note. Three northeastern states — Maine, Massachusetts, and Vermont — have enacted legislation over the past few years, with the goal of achieving near-universal coverage. National leaders, including the presidential candidates, have presented plans to reform the U.S. health insurance system. Democratic and Republican leaders have promoted very different models to that end, with differing implications for coverage and accessibility of reproductive health services.1
For Americans too young to qualify for Medicare, here are the major avenues for coverage:
- Employer-sponsored health insurance, which covers 61% of Americans younger than 65,2 is generally high-quality, yet premiums are most affordable for those working at large employers. Also, coverage has declined steadily for decades.
- Many low-income Americans (13% of Americans younger than 65, including 40% of those who are poor) rely on Medicaid or related public programs. The programs' benefit packages are broad, but eligibility varies widely across states. Large groups, including childless adults and most recent immigrants, typically are excluded.
- Insurance coverage through small employers or the individual market essentially is a last resort. Even when coverage is available, it typically is at a higher cost and with more restrictive terms and benefits than in other sectors.
Publicly funded health clinics are relied upon heavily by Medicaid recipients, by those whose private insurance is limited, and by the 18% of nonelderly Americans who are uninsured.
Most Democratic leaders, as well as bipartisan coalitions in some states, including Massachusetts, have endorsed an approach that seeks to minimize change. This public-private partnership approach would seek to shore up employer-sponsored coverage through subsidies and requirements and to expand the scope of who is covered under Medicaid and State Children's Health Insurance Program (SCHIP). A third component would create an alternative or replacement for the individual and small employer insurance markets by establishing a "connector" or "exchange" that would gather individuals into a large insurance pool and provide them a choice of plans.
Policy-makers have envisioned a range of provisions to make these three components function smoothly as a system and ensure meaningful access to care. These potential reforms include limits on insurers' ability to manipulate premiums and benefits; mechanisms to allow for comparison of competing plans; and subsidies (and perhaps requirements) to ensure that all Americans obtain coverage. Although many experts believe this approach will ultimately save money and most proposals include a series of cost-control provisions, others predict a need for substantial new government investment.
National Republican leaders, in contrast, tout a free-market approach that would emphasize the individual market, on the theory that individual consumers will make better and cheaper decisions than employers or the government. Potential reforms include:
- the expansion of "consumer-directed" plans, combining tax-sheltered health savings accounts with coverage that kicks in only after substantial out-of-pocket payments;
- a revamping of incentives in the tax system to make the individual market more attractive;
- various mechanisms, such as allowing Americans to purchase insurance across state lines, for bypassing or eliminating state and federal regulations such as benefit mandates, that conservatives blame for rising costs.
Opponents of this approach argue that the individual market has inherently high administrative costs that make it prohibitively expensive for many Americans, despite the tax credits included in some proposals. Even if premiums were affordable, high deductibles and cost-sharing may dissuade people from seeking needed care — if they can even figure out what care is truly needed. Consumers in the individual market will struggle to determine what to purchase and how. Without significant government regulation, Americans who are sick may not be able to purchase an insurance plan that includes the services they need, or they may not be able to buy any plan at all.
In part because of government requirements, employer-sponsored insurance and Medicaid typically cover a broad range of reproductive health services, including pregnancy-related care, gynecologic exams, contraception, and testing and treatment for breast and cervical cancer and sexually transmitted infections (STIs). (Coverage of abortion and infertility treatment tends to be more limited.) The public-private partnership approach is not likely to change this coverage, except by drawing more people into the system and, perhaps, by expanding coverage of preventive services.
In contrast, free-market proposals, by undermining benefit mandates, might affect coverage of many reproductive health services. High premiums, deductibles, and copayments might discourage Americans from seeking this care.
With Democratic and Republican leaders touting competing health care philosophies, the 2008 elections may have a substantial impact on the future of reproductive health coverage. Most likely, the political battle will be over broad questions about the shape of the system, the role of government, and how society can afford to expand coverage and contain costs. It is not currently thought likely that Congress will debate the finer points of a benefit package, points that may instead subsequently be left to the quieter, but equally critical, work of regulators.
References
- Sonfield A. Toward universal insurance coverage: A primer for sexual and reproductive health advocates. Guttmacher Policy Review 2008; 11:11-16.
- Urban Institute and Kaiser Commission on Medicaid and the Uninsured Estimates Based on the Census Bureau's March 2006 and 2007 Current Population Survey. Accessed at: www.statehealthfacts.org.
Subscribe Now for Access
You have reached your article limit for the month. We hope you found our articles both enjoyable and insightful. For information on new subscriptions, product trials, alternative billing arrangements or group and site discounts please call 800-688-2421. We look forward to having you as a long-term member of the Relias Media community.