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March 5, 2003

Incremental Approaches to Increasing Health Care Coverage

JAMA. 2003;289(9):1166. doi:10.1001/jama.289.9.1166

More than 40 million people in the United States, including 10 million children, are without health insurance coverage despite the fact that the United States dedicates a higher proportion of its gross domestic product to health care than any other nation in the world, spending approximately $1.3 trillion in 2000.1 The current system, which has evolved through the past failures to provide universal insurance, now relies on the incremental advances that have created a patchwork of care in which many holes remain.2

Theodore Roosevelt included a social insurance as a major plank of the Progressive Party platform in 1912, making it the first major US political party to call for a national insurance plan. Since that time, the idea of health care for all Americans has been advocated by the Truman, Nixon, Carter, and Clinton administrations, although the proposals that were finally adopted cover only the elderly, the disabled, low-income children, and select low-income adults.2 The consistent failure of sweeping reforms, in conjunction with the success of more incremental measures like Medicare and Medicaid, has done much to shift the direction of health policy research in the last 10 years,2 and many current attempts to increase coverage depend on strategies of incremental change to existing programs.