In the spirit of Mapquest, lets map the way to universal insurance coverage. For too long, prodded by political sound-bites, weve viewed the solution either as a multi-arrowed organizational chart, or a Manichaean battle of Good (liberals, populists, Democratsyou pick the side) versus Bad (insurers, Republicans, conservativesyou pick the enemy). Lets try a different tack.
First, in the jargon of Mapquest, identify your destination. As Cheshire Puss advised Alice, deciding where you want to go determines your route. That holds not just for Wonderland, but for health care in America.
Now plug universal coverage into the system. That means you want to cover all (or nearly all) Americans.
A few nanoseconds later, the GPS will ask: the quickest route? Click yes.
The answer: national health insurance, along the lines of Medicare. Right now everybody older than age 65 has coverage. They receive hospital insurance (Part A) along with Social Security; they pay monthly premiums to cover physicians and other providers (Part B). The government charges deductibles and co-payments; but if your income is low enough, the government waives the premiums.
Critics may fault the costs to enrolleesmost try to buy private medi-gap insurance to supplement Medicare. But the plan covers everybody, with no waiting periods, no pre-existing condition clauses, no premiums tied to a groups or individuals illnesses. The government has 40 years of experience with Medicare. It could plausibly extend Medicare by degrees, first to children, then to young retirees, then to everybody.
The rest of the developed world has universal coverage. Those countries have trod this path through their national governments, which subsidize, and sometimes administer, their insurance systems.
Say you dont want to travel that highway. Mapquest lets you ask for alternate routes no highways, for instance. To reach universal coverage, you dont want to go directly through Washington, D.C.
Type in tax credits. On the GPS screen, the tax credit-route will take you closer to universal coverage, depending on how generous the creditsbut wont get you to your destination. Close, but not there. We as a nation have tried that route.
Type in employers. Most working Americans who are insured are insured via work. But many employers do not offer health coverage, or offer it at such high premiums that the worker declines. Mandates that force employers to cover more employees might get you closer to your destinationbut any legislation for mandates would allow small companies, and barely solvent ones, to bow out. Besides, the mandate route is fraught with political roadblocks. Subsidies that lower costs to employers might get more people insured: the higher the subsidies, the more people covered. But the profusion of part-time, temporary, and contract employees stymies any path to universal coverage that is tied to employers.
Be bold. Discard the employer-based path to universal coverage. Type in individual responsibility. In most states, if you want to drive, you must buy car insurance. Use the same rationale for health insurance: you must have it. (Tying it to income tax refunds will help). With subsidies to help people afford it, this might get you universal coverage. If you apply the money saved from deductions for employer-based insurance to these individual subsidies, you could make premiums affordable for everybody. One downside, for conservatives who dont want to travel through Washington, is that you will still have extensive federal involvement. Indeed, you will need stringent federal regulatory oversight to protect Americans from buying inadequate, if not fraudulent, policies. This route could prove to be lengthy, and bureaucratically horrendous.
Try a federalist tack: type in states. States already have a major role as insurer-of-the-poor, via Medicaid and its extension, States Childrens Health Insurance Program (SCHIP). Give states more money. With a massive influx of federal dollars, states can raise the eligibility level to 300% of poverty (right now poorer states set lower eligibility levels than wealthier ones); cover parents of eligible children; cover all people with disabilities, regardless of income; cover all immigrants. This path still goes through Washington, D.C., but in a circuitous route. It wont get you universal coverage, though.
As any savvy Mapquester knows, you can easily change your destination. Make it 90% coverage. Or 80%. GPS will chart the way.
After this campaign-without-end, in January a new president and a reconstituted Congress will take office. Health insurance will be on their agenda. The first decision will be: Where does the country want to go? Many people, however much they want universal coverage, dont want it enough to travel through Washington, D.C. The advocates for universal coverage will have to persuade their colleagues, their friends, their relatives, and their elected officials, to travel that route. Unless that persuasive conversation succeeds, we will stall in front of Mapquest, as more uninsured Americans pop up on our screen.
Joan Retsinas is a sociologist who writes about health care in Providence, R.I. Email firstname.lastname@example.org.
From The Progressive Populist, July 1-15, 2008
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