Medicaid and the U.S. Path to National Health Insurance (New Eng Jour Med)

[pinto]

The author makes a case for expanding Medicaid, not Medicare. Part of the debate on health care reform - pinto

Medicaid and the U.S. Path to National Health Insurance
Michael Sparer, Ph.D., J.D.

http://content.nejm.org/cgi/content/full/360/4/323?quer...

The 2008 presidential election has rekindled long-simmering hopes for comprehensive health care reform. The policy debate includes references to new government programs (perhaps a federal program for the uninsured to buy into) and vague formulas for cost containment (usually involving overly optimistic assessments of savings to be generated by using health information technology). Ironically, however, the debate generally ignores what I see as the most plausible path toward universal coverage: first, expanding Medicaid to cover the largest portion of the uninsured, Americans with incomes below 350% of the federal poverty level (around $62,000 for a family of three); and second, requiring everyone to carry health insurance and allowing people whose incomes are too high for automatic coverage to buy into Medicaid.

Previous efforts to enact universal coverage have failed in part because opposition from interest groups such as the business community and the insurance industry is far more influential than is organized support for uninsured low-wage workers. Reform opponents also take advantage of the anti–big-government ethos that pervades our political culture. Finally, our political institutions are designed to make it hard to enact comprehensive legislation, since our system of checks and balances provides opponents with numerous opportunities to block legislation.1

Meanwhile, Medicaid, the federal–state program designed to provide health insurance for the poor, has been quietly becoming the most successful program in U.S. history for aiding the uninsured. Since the Reagan administration, program enrollment has more than doubled (surpassing 59 million), softening the impact of the continuing decline in the number of Americans with employer-sponsored coverage.

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I believe that this is the only universal coverage plan with a decent chance of succeeding politically. Employer mandates face treacherous politics: big business doesn't want government telling it what sort of coverage to provide, and small business argues persuasively that many "mom and pop" shops simply cannot afford the bill. Even less likely to fly are Medicare-expansion proposals, given both the cultural opposition to anything that could be labeled a single-payer program and the fierce opposition of the private insurance industry. But the same interest groups that would oppose these alternatives would probably support the Medicaid strategy.

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Source Information

Dr. Sparer is a professor of health policy at the Mailman School of Public Health, Columbia University, New York, and the editor of the Journal of Health Politics, Policy and Law.

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http://content.nejm.org/cgi/content/full/360/4/323?quer...

The New England Journal of Medicine is owned, published, and copyrighted © 2009 Massachusetts Medical Society. All rights reserved.

[bemildred]

1. Medicare for everyone, why fool around? nt