Conference Addresses Several Proposals to Cover the Uninsured
Health advocates and professionals on Dec. 11 discussed the benefits and limitations of expanding public programs, broadening employer-sponsored insurance coverage and introducing tax credits as a means to reduce the number of uninsured in America, expressing optimism that such measures could be helpful but cautioning that an incremental and heterogeneous approach was the best strategy. Gathering at a conference in Washington sponsored by the Commonwealth Fund as part of its Task Force on the Future of Health Insurance, state health commissioners, lawmakers and public health experts shared both the successes and the failures they have witnessed in programs designed to provide coverage for the 43 million uninsured Americans. The goal is "to make health insurance a reality for all poor and low-income children," Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured, said, adding, "We [also] have the opportunity by enrolling their parents to cur a big chunk out of the uninsured population."
Expanding CHIP and Medicaid
Conference participants generally praised the success of the Children's Health Insurance Program, and several stated that expanding both this program and Medicaid could significantly lower the number of uninsured. Rowland said that substantial progress has been made in the CHIP program, as 36 states now cover children in families who earn up to 200% of the federal poverty level. In addition for Medicaid and CHIP, 42 states also have eliminated or do not employ asset tests, and 40 do not conduct face-to-face interviews, which has made enrolling children an easier process. The next step, she said, is to expand Medicaid to cover more adults, who constitute 75% of the uninsured population. Extending Medicaid to all low-income parents making up to 200% FPL -- of whom 76% are now not eligible -- would lead to 4.3 million new Medicaid adult beneficiaries at an estimated annual cost of $12.4 billion. And extending the program to all low-income childless adults -- of whom 95% are not eligible - would create 7.4 million new Medicaid beneficiaries at an annual cost of $18.8 billion. "Building on public programs makes the most sense and is the best strategy," Rowland concluded.
State health officials from Wisconsin and New Jersey related their state's success in expanding coverage to both children and adults. BadgerCare, Wisconsin's program for low-income families that commenced last year, has succeeded in covering 91% of the state's previously uninsured children and 57% of previously uninsured adults, Joe Leean, secretary of the Department of Health and Family Services, said. Key to this success was a simplified and streamlined enrollment process that covers both parents and children, in addition to the bipartisan support that the program enjoys. Brian Baxter, deputy chief of policy and planning in the New Jersey Office of the Governor, stated that high income eligibility levels were among the main reasons for the state's success in covering the uninsured through its NJ FamilyCare Program (formerly NJ KidCare). New Jersey now covers children in families with incomes up to 350% of the FPL, and is considering increasing the limit to 500%. In New Jersey, "It's not a question of who's eligible, but what premium they should pay," Baxter said. He and other state officials stressed that flexibility was needed from the federal government in implementing these state/federal government programs.
The Limits of Employer-Sponsored Coverage
The conference participants also discussed employer-sponsored coverage, and speakers emphasized its importance in the American health insurance system while cautioning that its effectiveness in reducing the number of uninsured might be limited. Sixty-six percent of Americans under 65 are covered through their employers, who pay 30% of the nation's $1 trillion in annual health expenditures, Commonwealth Fund President Karen Davis said. Employer-sponsored insurance is attractive because it is affordable and offers easy enrollment. Yet small firms often do not offer coverage because they have to pay high premiums, and low-income workers often cannot afford it. One option for small businesses to provide coverage at an affordable price is to enter an insurance pool with other employers, yet several of these "have floundered, hit a plateau or collapsed," Jack Meyer, president of the Economic and Social Research Institute, said. He added that rising premiums, an increase in the number of part-time, temporary and undocumented workers and the prospect of a slowing economy present obstacles to reducing the rolls of the uninsured through employer-sponsored coverage. Advocating a "heterogeneous approach," Meyer said that "substantial" governmental subsidies and programs can assist employer-sponsored coverage if they are prominently marketed. "If not, no one will know, no one will care, and no one will play," he said.
Tax Credit Possibilities
The issue of tax credits for health insurance is one that surfaced frequently throughout this year's presidential and congressional campaigns, and several speakers at yesterday's conference expressed optimism that credits could serve as a politically appealing, positive incremental step toward reducing the number of uninsured. Tax credits' attractiveness lies in their affordability and the fact that they allow individuals to avoid the stigma of public assistance, Alan Weil, director of the New Federalism project at the Urban Institute, said. Stuart Butler, vice president of domestic and economic policy studies at the Heritage Foundation, called tax credits a "politically astute" idea that still represents government assistance for health care but has gained support from congressional Republicans who view it as a tax cut. Noting that the cost of individual premiums rises as individuals grow older, Davis said that in order to prove successful, tax credits must be age-adjusted. Rep. Harold Ford Jr. (D-Tenn.) was pessimistic about Congress passing legislation to help the uninsured in the near future, but said that a "great will to provide credits" exists on Capitol Hill. However, Meyer cautioned that the leading tax credit proposal in Congress is a tax deduction plan, which will not substantially help those with little or no tax liability.
'Cognitive Dissonance' on the Uninsured
While most Americans want to help the uninsured, the will to take substantive measures to affect a change does not necessarily exist, Robert Blendon, professor of health policy at the Harvard School of Public Health, said. Using survey data he has compiled as director of the Washington Post/Kaiser Family Foundation survey project, Blendon spoke of the "cognitive dissonance" that Americans hold about the uninsured. Sixty-six percent, for instance, believe that the government "should provide health insurance to those without it," but 70% "distrust government to do the right thing." Before the issue of the uninsured really captures the attention of Americans, Blendon said, it must be viewed as a broader social and moral problem. "If the moral issue is going to play out, people are going to have to believe that the uninsured are getting hurt," he said, adding that voters would be more inclined to support efforts to help the uninsured if they knew working people made up most of the uninsured population. Saying that Democrats and Republican voters held differing views on the importance of expanding health coverage, Blendon explained that tax credits and expanding government programs presented the best options for bridging the ideological divide. And any sustained effort to help the uninsured is contingent on an organization or personality taking up the cause. "There is a latent interest [in this issue], but it hasn't shown itself politically," he said (John Kastellec, Kaiser Daily Health Policy Report, 12/12). A Web cast of one of the conference's sessions, "The Electorate's Expectations of a New President and Congress" with Robert Blendon, is available at http://www.kaisernetwork.org/health_cast/hcast_index.cfm?display=detail&hc=89.