The United States has considered proposals to achieve universal coverage for almost a century.⁽³³⁾ Other countries have achieved that goal by covering their citizens under some form of automatic coverage, either through public programs or a mix of public and private insurance. Their citizens do not move in and out of coverage or experience gaps in coverage, and administrative costs are therefore markedly lower.⁽³⁴⁾ More important, no one is denied access to essential health services because of an inability to afford care.

A bold strategy for change would be to establish the capacity to enroll all Americans automatically in some form of health insurance. The general principle would be to cover everyone under one of four private or public group insurance options: a new pool modeled on the Federal Employees Health Benefits Program (FEHBP), employer coverage, Medicare, or the Children's Health Insurance Program (CHIP). Individuals would have a choice of coverage, and default criteria would assign those not exercising an active choice to a plan best fitting their circumstances. Enrollment could be checked through the federal income tax system⁽³⁵⁾ or by state-level clearinghouses when people seek medical care.⁽³⁶⁾

A new insurance pool for uninsured individuals and small businesses could be modeled on plans participating in FEHBP. A large pool, coupled with reinsurance, would enable small businesses to obtain lower premiums and provide their employees with a wider range of insurance options. For individuals, tax credits could subsidize premiums in excess of a given percent of income.

For people covered under employer-sponsored plans, changing jobs is a major cause of insurance loss. Of those leaving employer coverage, 53 percent become uninsured.⁽³⁷⁾ Attempts to provide advanceable tax credits for workers displaced by international trade have reached only a tiny fraction of eligible workers.⁽³⁸⁾ A better strategy would be to cover all unemployed workers automatically through their former employers under so-called COBRA plans, with premium assistance to ensure affordability. Two small steps to increase continuity of coverage would be to require employers to cover former workers for at least two months following termination, and to require employers to enroll newly hired employees automatically within two months.

Medicare already provides automatic, permanent coverage for most elderly and disabled Americans. Stable coverage—coverage that does not change and is easy to understand—is one reason why beneficiaries tend to be very satisfied with Medicare, and one reason for the program's low administrative costs.⁽³⁹⁾ By expanding Medicare in two major ways—enabling older adults to become eligible earlier, and eliminating the two-year waiting period for people who become disabled⁽⁴⁰⁾ —important gaps in coverage could be closed. Spouses of disabled or elderly beneficiaries who are not currently eligible could also be given the option to buy in to Medicare, with premiums varying according to income.

The CHIP program provides coverage to low-income children, but many more could be covered if enrollment were made automatic and extended to their parents. CHIP could also be used to cover all uninsured school children. Medicaid, rather than disenrolling young adults on their 19th birthday, could continue their coverage until they get a job and qualify for their own benefits.⁽⁴¹⁾ College students could be enrolled automatically in either their university health plans or CHIP.

CHIP might also be used to extend coverage to low-wage workers, either through premium assistance to allow employees to receive coverage under their own employers' health plans, or by giving employers the option of purchasing employee coverage through CHIP.

Another strategy for reducing the number of people without insurance is to prevent loss of Medicaid/CHIP coverage. Of the one million people who go off Medicaid each month, 65 percent become uninsured.⁽⁴²⁾ A study in New York showed that most people who lose Medicaid coverage continue to be eligible but are unable to overcome the administrative barriers to reenrollment.⁽⁴³⁾ Rather than require people to reenroll, a simpler strategy would be to sustain their coverage under Medicaid or CHIP until other coverage—such as employer-sponsored insurance—kicks in. CHIP beneficiaries could be assessed a premium through the income tax system, thus ensuring that people whose incomes rise make appropriate contributions toward their coverage.

Helping people hold onto their coverage would go a long way toward solving the uninsured problem. A Fund-supported study estimates that guaranteeing coverage for even one year would reduce the uninsured rates for low-income children by 40 percent and for low-income adults by about 30 percent.⁽⁴⁴⁾