Cut the uninsured to 8%? Yes, but opinions on how are varied
A Commonwealth Fund survey of health care opinion leaders shows the proportion of Americans without health insurance can be cut to 8% over 10 years, less than half the current rate. But the way the experts say that goal can be accomplished sometimes is far different from the direction currently being taken.
Most of the experts said employer-sponsored coverage should continue to cover about two-thirds of people younger than 65, and 84% said a plan like the Federal Employees Health Benefits program (FEHB) would be the most effective way to help small employers and the self-employed obtain affordable coverage. In contrast, one-third favored association health plans as a policy option.
There was consensus that the proportion of individuals with Health Savings Accounts (HSAs) will increase in the next 10 years, but only to 5%, a projection far different from what is heard from those promoting HSAs. Some 22% of those surveyed support HSAs as a policy option for expanding coverage.
"It is encouraging that health care leaders are optimistic about our ability to find solutions to the crisis of millions of Americans without health insurance coverage," says Karen Davis, Commonwealth Fund president. "There also appears to be a great deal of consensus among leaders across health care sectors — academia, health care delivery, business, and insurance, as well as government, labor, and consumer groups — about actions we can take that will reduce the number of uninsured. We expect some of our results to be a prime topic for lively debate, even criticism. And that’s fine. The goal is to offer a forum for such professional discussions and present a wide range of points of view on crucial issues."
In the survey results, 75% of respondents said employer-sponsored insurance should not decline. Respondents also gave wide support to a range of policy options to improve coverage. Thus, 82% favored incentives for employers to provide insurance that meets minimum standards, and 79% approved of tax credits or other subsidies for low-wage workers.
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 SCHIP 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 (42% in favor and 40% opposed). Even more of the experts (62%) opposed making HSAs the centerpiece of efforts to cut health care costs combined with making high-deductible health plan coverage more widely available, although at least one expert contends HSAs may be the place to start since there is administration and congressional support for them.
The survey also asked whether association health plans or an FEHB-type plan would be more effective in improving coverage and reducing costs. Some 48% said a federal employee benefits-styled program would be more effective in expanding coverage to the uninsured, while 10% said AHPs would be more effective for coverage expansion.
Likewise, 57% said the FEHB option would be a better way to avoid risk segmentation; while only 4% thought AHPs could better avoid risk segmentation. And 59% said an FEHB-type program would provide greater value for premium dollars for employers and employees and would provide more essential benefits, while 5% saw better value in AHPs.
About three-fifths said the FEHB option would be more effective in expanding health plan choices, and 8% said AHPs would do better at expanding choices. Interestingly, 32% of respondents felt that FEHB would be more effective than AHPs in cutting costs to employers and employees, another 32% thought neither option would cut costs, and 11% favored AHPs as a cost-cutting option.
Other responses included:
- When asked about the maximum percentage of income a consumer should spend for out-of-pocket health care expenses and premiums, the median response was 9%.
- A majority of respondents (57%) supported a mandate to require individuals to buy health insurance, with federal premium assistance available for those with low incomes.
- Two-thirds (68%) supported expanding state Medicaid and SCHIP programs to low-income adults and families.
- Respondents said that a small fraction of the population should have high-deductible health plans and HSAs; median responses were 11% and 5% respectively.
- When asked about health expenditures, respondents said they believe they will need to increase somewhat as a percentage of gross domestic product.
National wellness at stake
In response to the survey findings, Michael Rodgers, Catholic Health Association interim president and CEO, says ensuring access to quality affordable health care services "is not merely a matter of system reform. It is a matter of human dignity and of national wellness. We must remind ourselves of that at every turn of the debate."
He adds that no one really knows what should be done to solve the problem of the uninsured and thus the starting point should be to "collectively acknowledge that the necessary national dialogue must take on new urgency and solicit the views of everyone affected by the health system. . . . I would hope that the national discussion could result in an agreement that quality, affordable health care is a fundamental building block for a free society."
According to Mr. Rodgers, health care has always posed policy conundrums, but recently greater division and political considerations have overtaken wise policy recommendations. "Solutions are usually characterized as having obvious winners and losers," he said, "rather than as potential remedies that can improve the lives of people and the health of families. Stakeholders find it easier to choose the status quo than to select an option where not everyone comes out ahead. In the meantime, the number of uninsured continues to grow. It is time to seek common ground. We can and must put aside partisan political differences to build consensus toward viable, common-sense solutions."
Getting started
Arguing in favor of starting where the political power base may be willing to work is Charles Kahn III, president of the Federation of American Hospitals, the association representing for-profit, investor-owned hospitals.
Mr. Kahn says that in the last few years, as representatives of disparate stakeholder groups have come together to search for consensus on how to address the problem of the uninsured, he has believed that the best way to move forward is to bring together people with varying ideas about health policy and to work within the current context.
"Within this scenario, people with different perspectives but with similar goals can compromise on some policy principles, avoid the perfect becoming the enemy of the good, and achieve consensus about developing policy to cover more uninsured Americans."
While he says he still has great hope for such an approach, the reality is that after many years of coalition building and consensus development, the number of uninsured Americans continues to grow dramatically.
"Building coalitions and achieving consensus is eminently worthwhile, but to make progress, we must also consider political reality," Mr. Kahn adds. "If we want to be effective and implement public policy, we who are involved with building coalitions and achieving consensus cannot afford the luxury of being prisoners of process. Rather than working toward a grand public policy compromise intended to be palatable to all but with no political legs at this time, let us instead look at the policy items already on the table and work to implement them and thereby help reduce the number of uninsured Americans."
(The survey report and commentaries are available on-line at www.cmwf.org.)
A Commonwealth Fund survey of health care opinion leaders shows the proportion of Americans without health insurance can be cut to 8% over 10 years, less than half the current rate. But the way the experts say that goal can be accomplished sometimes is far different from the direction currently being taken.
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