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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.

Probably the most common of these involves building on and expanding the previously created programs of Medicaid and the State Children's Health Insurance programs.3,4 Proponents of these plans claim that they have established administrative systems, mutually beneficial provider and managed care plan contracts, and reliable mechanisms for federal fund handling. In addition, these programs already provide comprehensive benefits with no or minimal cost-sharing, and neither has reached its full enrollment potential. Finally, because most working poor adults do not have access to employer-sponsored insurance, there is little chance that these programs would be replaced by commercial plans. Rather than questioning the basic organization of Medicare and Medicaid, then, the debate here is largely over standards for eligibility. For instance, it has been estimated that a modest change in current eligibility structure could allow these programs to reach more than 27 million additional low-income uninsured people.4

A second approach relies on the provision of tax credits for employers, deductions for employers and individuals delivered via the federal income tax system, thus allowing for the subsidization of private health insurance.3,5 Tax credits are advantageous because they would not require any changes in the current health care regulatory structure, delivery system organization, or current medical treatment philosophy. Depending on their level of use, tax credit or deduction policies might assist both the uninsured and those already purchasing individual coverage. The number of those receiving help would thus remain income-dependent and would be re-established with each yearly tax filing.

The third idea involves providing subsidies or vouchers to those with low incomes to use either toward the direct purchase of insurance or the supplementation of employer-sponsored coverage, their provision being independent of the federal income tax system.3,6 Some states, for example, use revenues from tobacco and alcohol taxes, hospital services, or other sources to create new insurance options for people who can contribute to premiums on a sliding scale based on income and family size.2

However, because research has shown that those with low and modest incomes are unlikely to take advantage of subsidies that do not cover the full costs of insurance, more generous subsidies would likely be required to effect any meaningful increase in coverage among poor people. In addition to the size of the subsidy, the structure of the private insurance market would also affect the number ultimately covered.

Although all 3 approaches have undoubtedly helped increase coverage to some degree, none of them alone is sufficient to produce significant declines in the number of uninsured.3 The vast majority of recent federal plans combine one or more of these approaches with myriad other, smaller ideas.7 Such programs, however, risk becoming so complex that they fail to gain public support.8 Their variety and complexity also tend to complicate the delivery of health care services.9 Finally, by imposing arbitrary boundaries on eligibility and services, this incremental approach always runs the risk of marginalizing subgroups within the population.

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