K. Davis, Uninsured in America: Problems and Possible Solutions, BMJ, February 17, 2007 334(7589):3468
The deficiencies in the U.S. health care system are well documented: patients harmed by avoidable medical errors, fragmentation and inefficiency that result in poor-quality care and lost value, consumers forced into debt and bankruptcy to pay for medical bills, and above all, increasing numbers of Americans who go without the security of health insurance coverage. A new article by Commonwealth Fund president Karen Davis, Ph.D., proposes strategies—and examines efforts already under way at the state level—to achieve a health care system that provides affordable, accessible care for every American.
Nearly all the growth in the number of uninsured people (which has swelled from 40 million in 2000 to almost 47 million in 2005) is among those aged 18 to 64, most of whom are working, says Davis in "Uninsured in America: Problems and Possible Solutions" (BMJ, Feb. 17, 2007). Much of the increase is due to employers cutting back on coverage and benefits in response to rising costs and adverse economic circumstances. The consequences of this failure to provide universal coverage are dire: lost lives, decreased economic productivity, underuse of essential services, and inefficient and poorly coordinated care.
Activity on the Federal Front
Despite the fact that public leaders, health care experts, and industry executives say expanding health insurance coverage should be a top priority for the President and Congress, it is unlikely that the federal government will legislate on this issue.
First, uninsured people are not politically organized and do not represent a strong voting bloc, Davis says, and second, the federal budget is in deficit and tax revenues are at their lowest point in 40 years, making funding options scarce. Adding to the political inertia, Congress is deeply divided along party lines. Democrats support comprehensive solutions to expand public programs and employer-based coverage while Republicans favor market-based solutions that encourage consumers to shop around for cheaper health insurance and health care prices.
Davis suggests an alternative way to finance expanded coverage: reinvest savings gained through increased efficiency. Aligning incentives with results by reforming provider payments to reward high-quality, patient-centered, and efficient care is one strategy for achieving this outcome.
States Take the Lead
Encouraging activities are already under way at the state level, Davis says. Strategies include expanding existing programs to cover low-income adults, as well as children; creating an insurance pool for small businesses and the self-employed, with premium assistance for low-wage earners; and requiring employers to either provide health benefits or contribute to a fund to finance coverage for working people.
Moving Toward Success
With the exception of California, these new plans are taking place in states with relatively small uninsured populations and have made use of federal matching funds available under Medicaid. "[I]t will be interesting to follow the recent expansion proposal in California with this state's relatively larger population and higher uninsured rate," Davis says.
Recently, bipartisan bills have emerged in Congress to support demonstrations of state expansion efforts. Given a divided Congress, these bills may have the most realistic chances of success. With the problem worsening, it is clear that policymakers and legislators will have to take action. "If the U.S. hopes to achieve a high performance health system that provides value, it will have to tackle the perplexing problems of access, quality, and cost and overcome considerable political and economic obstacles, as well as institutional resistance to change," Davis says.
Suggested Government Actions to Achieve Universal Health Coverage
Source: K. Davis, "Uninsured in America: Problems and Possible Solutions," BMJ, February 17, 2007 334(7589):346–8.