Health Care Experts Debate Divergent Plans for the Uninsured

With the nation's uninsured emerging as a "top domestic challenge" for President-elect Bush and the new Congress, four leading health care experts discussed the issue during a Monday press briefing sponsored by Health Affairs and the Robert Wood Johnson Foundation. The experts -- Georgetown University Dean of Policy Studies Judy Feder, Wharton School economist Mark Pauly, Families USA Executive Director Ron Pollack and Health Insurance Association of America President Chip Kahn -- each published articles in the January/February edition of Health Affairs dedicated to the issue of the uninsured, offering divergent policy recommendations ranging from providing refundable tax credits to "expanding and strengthening" existing public programs. PBS NewsHour correspondent Susan Dentzer moderated the briefing (Health Affairs release, 1/8).

According to Feder, co-author of "Covering the Low-Income Uninsured: The Case for Expanding Public Programs," proposals to expand health insurance should "help those least able to afford coverage." Although Congress and Bush may favor using tax credits, she called such a plan "giving people who are in a 20-foot hole a 10-foot rope," pointing out that the $1,000 subsidy -- $2,000 for families -- that Bush has proposed would fail to cover the high cost of health insurance premiums (Josh Kotzman, California Healthline, 1/9). "Experience suggests that those with low incomes are unlikely to be willing or able to fill the gap," Feder and her colleagues wrote in the article, adding that tax credits would likely benefit "persons with higher incomes who already have insurance" (Feder et al., Health Affairs, January/February 2001). She also urged the President-elect and Congress to "focus like a laser" on extending public programs, such as Medicaid and CHIP, to cover low-income Americans, especially children.

However, Pauly, co-author of "Expanding Coverage Via Tax Credits: Trade-Offs and Outcomes," argued that refundable tax credits could "substantially" reduce the number of uninsured. He admitted that they would have to exceed $1,000 -- the amount proposed by Bush -- which would only cover about 30% of health insurance premiums. He advised the President-elect and Congress to "get serious" and provide a $1,500 "coupon," which would cover about 50% to 60% of premium costs, to lower middle-income individuals, predicting that Americans would "sign up in droves" (American Health Line, 1/9). "If it takes the form of a proportional credit for a comprehensive policy at less than 50% of the premium, the effect on both coverage and equity could be limited to a small number [of individuals]" Pauly wrote in the article, adding, "A fixed-dollar credit targeted toward a more comprehensive plan could cut the proportion of uninsured by a third to two-thirds" (Pauly/Herring, Health Affairs, January/February 2001). In addition, Pauly pointed out that tax credits, supported by key congressional leaders such as House Majority Leader Dick Armey (R-Tex.) and Rep. Pete Stark (D-Calif.), have "bipartisan interest" and could pass in a tightly divided Congress (California Healthline, 1/9).

Pollack and Kahn, who co-wrote "Building a Consensus for Expanding Health Coverage," back a "reasonable balance," which includes expanding Medicaid and CHIP and providing non-refundable tax credits to businesses to encourage them to offer health insurance to low-income employees. According to Pollack and Kahn, the plan (which they orginally proposed in a November Press Conference) "constitutes the best, and possibly only near term chance" to expand health coverage (Kahn/Pollack, Health Affairs, January/February 2001). Pollack argued that to expand health coverage, "strange bedfellows" must join forces and "transcend ideological, partisan and interest group boundaries." According to Pollack, while Congress may not pass comprehensive legislation, lawmakers should not take "baby steps." He suggested that Congress should target low-income Americans -- a "more politically salient" proposal -- but warned that if plans to provide Americans with health insurance threatened current coverage, support would "wither away." Kahn added that lawmakers should build on current successes, such as the employer-based health insurance system and Medicaid and CHIP, and "go where the ducks are," targeting low-income groups. In addition, Kahn urged Bush to propose a "relatively broad" plan to cover the uninsured that avoids "hot-buttons."

While the problem of America's uninsured persists, the four experts predicted that Congress would likely pass a proposal this year. "It may be easier ultimately to pass coverage for the uninsured than prescription drugs," Pollack said. While Kahn cited a "limit to bipartisan generosity, he suggested that lawmakers could compromise on a plan to cover the uninsured. He also pointed out that legislation to cover the nation's uninsured would likely "get killed" unless lawmakers folded the bill into a larger budget package. Still, with an economic downturn looming and medical inflation rising, Pauly warned that the "window [for passing legislation] is open at the moment, but may not be open much longer." The experts also suggested that HHS Secretary-designate Wisconsin Gov. Tommy Thompson (R) would back efforts to cover the uninsured. Citing Thompson's record in Wisconsin, Pollack said that he has "sympathy" for expanding public programs. Pauly agreed, calling Thompson a "voucher, credit sort of person." However, Pollack concluded that Thompson may not play a prominent role in Bush's tax credit plan, a proposal assembled by the President-elect's tax -- not health -- advisers (California Healthline, 1/9).