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Universal health care surging in popularity with policy-makers.

Universal health care--once dismissed by policy-makers--has landed a starring role on the U.S. policy agenda, with a range of state, federal and private leaders now embracing the issue as a way to target the nation's growing health care woes.

Responding to rising uninsurance rates and health costs, more and more state and federal policy-makers are laying out plans for curbing the problems. Most recently at the state level, California and Pennsylvania debuted plans fashioned after a 2006 Massachusetts health care law, which requires all residents to have health insurance and expands the state's Medicaid eligibility standards. Ideas at the national level include a proposal from Sen. Edward Kennedy, D-Mass., to expand the Medicare program to people younger than 65 and give enrollees the option of choosing any of the plans offered to members of Congress, the president and federal employees. Congressional legislators have come together to propose expanding eligibility requirements under the State Children's Health Insurance Program and allowing employers to buy coverage through SCHIP for employees' children. President Bush also outlined a new health care proposal in his State of the Union address, calling for tax incentives that would help people afford health coverage, and universal health care plans are popping up on the platforms of numerous presidential hopefuls.

"We've seen a rising number of uninsured in this country and that's a huge factor," said Elise Gould, PhD, a health economist at the Economic Policy Institute in Washington, D.C. "Second and perhaps even more importantly, we're seeing people becoming afraid of losing the benefits they already have. There's rising insecurity: Lots of people uninsured, businesses dropping retirement coverage, more burden on the individual--it's not just coming from one camp, it's coming from all over the place."

Almost 47 million Americans are currently living without health insurance, according to the latest U.S. Census Bureau figures, and the rate of people who receive health coverage via their employers is decreasing. Coinciding with rising uninsurance rates are skyrocketing health care costs: A January study in Health Affairs found that while health care spending growth has slowed, total spending continues to increase. Health care spending accounted for 16 percent of the nation's gross domestic product in 2005, topping off at a total of $2 trillion, the study reported. Funding and resources for safety net programs such as Medicaid and SCHIP, which together provide health care for millions of low-income families, are being stretched dangerously thin, and segments of the American population many thought were buffered against uninsurance, such as those with employer-sponsored coverage, are beginning to feel the strain of a fragmented health care system.

However, the convergence of so many issues is bringing some new and innovative ideas to the table--especially from state policy-makers--and creating an atmosphere in which not taking action may no longer be an option.

One model that policymakers could use to create a more inclusive and universal health system is Medicare, which boasts low administrative costs and a large purchasing pool, Gould said. While there's been an unraveling of the employer-based market, the system works for those who can take part, Gould said, and to address the uninsured, "you don't want to erode that market more, you want to build upon it."

Bush's plan, which Gould said provides no incentive for employers to provide insurance and instead encourages people to seek less expensive coverage outside of their employment, could lead to an erosion of employer-based health coverage. In other words, enticing healthy people to pull out of their employers' overall "risk pool" would leave behind the employees with the highest health costs, such as people with chronic illnesses, and make it harder for employers to provide coverage, Gould said. Instead, the goal should be to "keep healthy, young people in the employer pool because it keeps it stable--the risk pool is a key form of social insurance," she noted.

"Piecemeal plans that do a little bit here and there aren't going to tackle the problem in a big way," Gould told The Nation's Health. "You need a more large-scale change if you're really going to tackle the problem of health care."

Setting the foundation for such change is exactly what a group of self-described "strange bedfellows" said they hope to achieve through the new Health Coverage Coalition for the Uninsured. Consisting of 16 major national organizations, including APHA, Families USA, the American Hospital Association, AARP and America's Health Insurance Plans, the coalition announced a proposal at a Jan. 18 news conference in Washington, D.C., that would "significantly expand health coverage" for the uninsured. The proposal, agreed to during the course of two years of meetings, consists of two phases.

The first is a "Kids First Initiative," which calls for a "one-stop" shopping system in which low-income families could enroll their children in SCHIP or Medicaid at the same time they apply for other public assistance programs. The initiative also calls for increased funding to help states enroll additional children in SCHIP. The second phase focuses on uninsured adults and advocates giving states the flexibility to expand Medicaid eligibility to cover adults with incomes below the federal poverty level. The Kids First Initiative would cost $45 billion over the next five years and if successful, up to 98 percent of U.S. children would have health coverage, said Ron Pollack, executive director of Families USA, at the news conference. The coalition has yet to come to a consensus on how to finance the Kids First Initiative, but member groups said they are committed to "sticking together."

"In the 21st century in the United States, no one should have to live without health coverage," said Kevin Lofton, chairman of the Board of Trustees for the American Hospital Association, at the news conference.

The new coalition isn't the only group of unlikely stakeholders coming together to face the nation's uninsurance problems. Other coalitions attempting to tackle the problem include insurers, religious groups, business leaders and union workers--a signal that the nation's health care problems are leaving no segment of the population untouched.

Regardless of what health care proposals come out of the national debate, APHA will be working to support universal coverage for everyone in the United States, said APHA Executive Director Georges Benjamin, MD, FACP. APHA supports universal health care that is comprehensive, eliminates financial barriers to care and includes disease prevention and health promotion components, among other measures.

States lead the charge on insurance plans

While many health experts agree that at some point the nation's uninsurance problem will have to be addressed at the national level, states aren't waiting around. In early January, California Gov. Arnold Schwarzenegger unveiled a proposal to bring universal coverage to his state. Similar to a 2006 Massachusetts law, the California plan would require all residents to have a minimum level of coverage, provide subsidies to low-income families, expand Medi-Cal, the state's Medicaid program, and require certain employers who don't offer insurance to contribute 4 percent of payroll toward the cost of employees' coverage. However, with 6.5 million uninsured people in California--a substantially higher percentage than Massachusetts' uninsurance rate--the road to success is steeper.

"It's very intriguing," said Michael Miller, policy director at Community Catalyst, a national support center for state health policy. "You can say a lot of things about the weaknesses of Gov. Schwarzenegger's plan, but he put out a serious effort. It may not be exactly right in all of its particulars, but you have to say that this is a serious effort."

States often act as laboratories for innovation and if California is successful in addressing its uninsurance rates, it could be a major tipping point in moving the health care debate forward on the federal level, Miller told The Nation's Health.

While there is skepticism as to whether a Massachusetts-like plan could work in California, the "dirty little secret is that there aren't that many options out there--there really aren't that many levers to pull, so any state is looking at the same levers, but just may be pulling them in a different combination," said Alan Weil, executive director of the National Academy for State Health Policy. Weil said states are proposing more ambitious health plans than the nation has seen in a decade, but it's wrong to think that states are doing so on their own. Existing Medicaid and SCHIP programs--which rely heavily on federal funds--are the platforms on which every state proposal is being built, and while the states are taking health care reform further than the federal government is currently willing to go, "no state wants to do this alone," he said.

"I'm an eternal optimist," Weil told The Nation's Health. "But I do worry that it's a lot easier to talk about this issue than to really make headway. Let's not declare victory too soon."

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Title Annotation:States taking lead
Author:Krisberg, Kim
Publication:The Nation's Health
Geographic Code:1USA
Date:Mar 1, 2007
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