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Small but Significant Steps to Help the Uninsured

Even in the present economic and fiscal environment, there are a number of low-cost policies that could ensure coverage for at least some Americans who currently lack access to affordable health insurance, a new report finds. While not a substitute for comprehensive health system reform, together these policies would, at a very modest cost, provide badly needed insurance access to workers changing jobs, small business employees, and others for whom health coverage is unaffordable.

In the new Commonwealth Fund report, Small but Significant Steps to Help the Uninsured, George Washington University associate professor Jeanne M. Lambrew and University of Virginia Medical School dean Arthur Garson, Jr., M.D., outline a dozen policy options that, for less than roughly $1 billion each, would provide uninsured and underinsured Americans with access to private health coverage, public coverage, or both.

One of the groups that could benefit under Lambrew and Garson's proposed policies is workers losing or changing jobs, who are twice as likely to experience gaps in health coverage as those who remain in the same job all year. Under one of the authors' options, COBRA continuation coverage would be offered to all workers who lose their job, including employees of small businesses (firms with fewer than 20 workers) that are not currently eligible under federal rules. Such an extension, which some states have already enacted, would allow people who are temporarily unemployed to buy into their former company's health plan for up to 18 months in most circumstances.

To assist uninsured employees working in small businesses, the report suggests allowing them to participate in the insurance program now open only to federal employees--at least on a limited basis to start. In a demonstration project, selected employers would buy into the Federal Employees Health Benefits Program by paying the same share of the premium paid by the federal government. The addition of a tax credit could make this coverage more affordable for lower-wage employees, the authors note.

More Ways to Expand Access to Affordable Health Coverage

  • Provide Medicaid or CHIP coverage to low-income adults who sign up for unemployment insurance.
  • Test a system of refundable tax credits for self-employed people and workers in small firms who lack access to group health coverage.
  • Gradually phase in Medicaid coverage of all adults living below the poverty level.
  • Require all private insurers that offer health coverage to dependents to insure children up to age 21.
  • Allow workers age 60 and older who retire without health benefits to purchase COBRA continuation coverage until they enroll in Medicare.
  • Allow Medicaid to act as a high-risk pool for adults with chronic health conditions who are priced out of the private market but are ineligible for public coverage.

Publication Details



Small but Significant Steps to Help the Uninsured, Jeanne M. Lambrew and Arthur Garson, Jr., The Commonwealth Fund, January 2003