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Guideposts to Universal Coverage Remain Murky

April 9, 2007 – A Monday roundtable discussion sponsored by Georgetown University and featuring some of health policy's leading lights was supposed to help illuminate a path to universal health coverage, but as it turned out, participants at best stumbled across a few guideposts that might point the way.

Among them: It would be wise to play down discord over the relative roles of government and the private sector in expanding coverage.

There was no obvious common ground at the event on how to fund wider coverage or how quickly to move to a universal system. And while a proposal by President Bush to tax lavish health benefits is clearly part of the debate over wider coverage, the big pot of money it could raise over 10 years to fund coverage of the uninsured hasn't generated quite the enthusiasm one might expect among compromise-minded policy wonks.

But, "in many respects we are on the same page," said Jeanne Lambrew, who served as a senior health policy adviser in the Clinton White House and now is an analyst with the left-leaning Center for American Progress. For example, Lambrew said, most health policy analysts agree everyone should be covered, and greater health care quality and efficiency should be top priorities.

Joining Lambrew as principal speakers at the event were Katherine Baicker of the President's Council of Economic Advisers and Stuart Butler of the Heritage Foundation.

Also in attendance were a dozen or so policy veterans, a number of them left-leaning academic types who have served in government but also senior congressional Republican staffers including Mark Hayes of the Senate Finance Committee and Chuck Clapton of the House Ways and Means Committee.

Illustrating the lack of excitement over possible funding approaches was an exchange concerning two ideas floated at the forum, a value-added tax of 3 percent to 5 percent on certain products, and Bush's tax proposal, which according to a revised estimate by the Joint Committee on Taxation would raise revenues of $333 billion over 10 years in creating a standard deduction for health coverage.

When one participant referred to one of the approaches as more politically feasible without making it clear which one he was referring to, virtually all of the participants laughingly pressed him on the matter. It turned out he meant the Bush proposal but that wasn't exactly a hearty endorsement of the administration plan's political viability, given the historic lack of U.S. support for value-added taxes, a form of tax paid on products and services at each stage of production or distribution.

Still, Butler drew no objections when he characterized tax breaks employers now get for health coverage—breaks targeted by the Bush plan—as having gone off the track. "I think the president has done a great service to the nation of opening up that debate," he said.

And Hayes noted several possible uses of the money the Bush plan would raise by taxing higher levels of benefits, including not just tax breaks to buy private coverage but also expansion of government health coverage programs. He said covering uninsured parents with incomes below the poverty level would cost $41 billion over 10 years.

Baicker said the administration firmly believes that private coverage is the better option for covering the uninsured, saying the private market avoids a one-size-fits-all approach and can better meet diverse needs while doing a better job through competition of controlling costs.

However, Alan Weil, executive director of the National Academy for State Health Policy, cautioned that it would be unproductive to emphasize the public–private question in tackling issues involved in achieving universal coverage, suggesting each side would get bogged down in mistrust of the other.

Diane Archer, founder of the Medicare Rights Center, suggested the public–private issue could be defused by making sure Americans have a choice of government-sponsored or privately sponsored coverage. She referred to recent polling in which 80 percent of the public expressed support for a universal coverage system in which individuals would have such a choice.

Butler noted that the lines between public and private coverage aren't necessarily distinct, which could help in reaching agreement on wider coverage. "I think it's very important to kind of bite the bullet and say that there really is an overlap between public and private, and that's actually an opportunity . . . Obfuscation is a great element in terms of getting agreement," he said.

"A lot of people who say it doesn't make any difference tend to use that to expand public programs," Butler added wryly. But he added, there may be ways of expanding the State Children's Health Insurance Program "in ways that are compatible with encouraging private coverage."

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