American Journal of Nursing 2000 April Volume 100, Issue 4

Spotlight on the Uninsured

In January, several major health care stakeholders gathered at a Washington, DC, conference, entitled Health Coverage 2000: Meeting the Challenge of the Uninsured, to address the issue of health insurance for the 44 million Americans currently without coverage. Released later that month, President Clinton’s budget proposal included a major expansion of coverage for poor children. It seems policy makers have begun yet another serious debate on the plight of the uninsured.

In this round, several proposals to secure health care coverage for all Americans have been put forth. Most are similar to past attempts—they offer incremental changes rather than the sweeping reforms advocated by the ANA. The ANA, in keeping with the position adopted by its 1999 House of Delegates in support of a single-payer system, recommends expanding the Medicare system, with appropriate improvements and accommodations of scope, to cover the entire U.S. population.

Incremental Reforms

The proposed incremental reforms emphasize reaching those Americans, especially children, who have fallen through the cracks in the current public and private programs. President Clinton followed this strategy, proposing that coverage through existing private and public programs be expanded. His program, which would cost an estimated $110 billion over 10 years, would:

• offer a new health insurance option for families by providing higher federal matching payments to states to cover the parents of children eligible for Medicaid and the Children’s Health Insurance Program (CHIP). It could also provide a state pool of funds to help families purchase plans through their employers.

• accelerate enrollment of uninsured children eligible for Medicaid and CHIP through new outreach initiatives.

• require states to simplify Medicaid and CHIP enrollment procedures.

• expand health insurance options for adults who face barriers to affordable coverage; this would include a Medicare buy-in option for persons between ages 55 and 65, coupled with a tax credit to make it more affordable.

• provide a 25% tax credit to those using the COBRA benefit, which allows continuation of coverage under a former employer’s plan.

• give a tax credit to small businesses that offer to their employees for the first time health benefits obtained through purchasing coalitions.

• allow states to offer Medicaid coverage to people ages 19 and 20, to those leaving the welfare program, and to legal immigrants.

• create additional funding for programs that provide health care directly to the uninsured, including community health centers.

Similar proposals were made by several organizations participating in the January conference, which was sponsored by the Robert Wood Johnson Foundation. Participants included the American Hospital Association, the American Medical Association, the Catholic Health Association, Families USA Foundation, the Health Insurance Association of America, Service Employees International Union, and the U.S. Chamber of Commerce, as well as the ANA, which recommended its proposal for a universal Medicare program.

“Over the past few years, incrementalism has become the popular approach to addressing the problem of the un- and underinsured,” said ANA president Mary Foley, MS, RN, at the meeting. “We believe that we must look more broadly at the extent of the problem and develop a comprehensive solution. When a person is sick, you must first diagnose the problem before you can develop an effective treatment plan. It’s the same for a sick system. If we limit ourselves to plugging gaps, the goal of universal coverage will not be met.”

The ANA Proposes Universal Medicare

While pledging to support efforts to expand the current system, the ANA made clear in its conference proposal its belief that a hodgepodge approach won’t bring about universal coverage.

“We need to be clear,” said Foley. “Targeted, ‘incremental’ proposals and programs may effectively expand access for some of the uninsured, but they are not intended to and cannot provide universal access to health care. To the extent that they can provide some relief for some of the uninsured, especially uninsured children, they are important—and valuable—and the ANA will continue to support them enthusiastically. But the expansion and creation of more partial and incremental programs is not a strategy for achieving universal coverage.”

The ANA’s program is based on expanding Medicare into a universal, seamless program of health coverage for all Americans. The ANA decided on this approach for a number of reasons:

• Medicare is an American institution, and the ANA believes that a U.S.-style system of seamless, universal health care coverage would be the most successful.

• It provides a way to build on Medicare’s success as an efficient and effective means of providing coverage to a large segment of the population that has diverse health care needs.

• Covering the entire population will help stabilize Medicare financially by providing a large influx of younger, healthier beneficiaries into the program.

• By basing the program on Medicare’s experience and its understanding of our nation’s health care needs, we can build on a well-established foundation, rather than invent a new one.

• Medicare beneficiaries are entitled to specific health care services based on the program’s benefits structure and on the beneficiary’s need of specific services—not on the limitations of a set contribution amount. The ANA recognizes that, in order to provide the most effective and efficient system of health care coverage, some changes will need to be made in the Medicare benefits structure, including an outpatient prescription drug benefit within the Medicare program. In addition, the ANA plan would expand the availability of mental health services through a reduction in the copayment for outpatient services and an elimination of the 190-day limit on inpatient mental health care.

• A universal Medicare program would emphasize primary, preventive, and early intervention services. It would also necessitate the elimination of inappropriate restrictions on nursing practice, to allow for the full use of registered nurses and advanced practice registered nurses in the provision of care.

Business Community Wants Tax Benefits

Plans developed by the business community, reflected in legislation proposed by Republican leaders in Congress, focus largely on tax incentives that make it easier for businesses to provide health insurance to their employees or for individuals to buy insurance.

One proposal would expand the current ERISA system used by many large employers to include multiemployer group health plan sponsors. This would allow small businesses, the self-employed, and individuals to join purchasing pools free from state regulation. The ANA disagrees with this approach. Already concerned that ERISA is too loosely regulated, the ANA believes the system’s expansion would push health plan regulation in the wrong direction. This proposed federal exemption from state laws could undermine the most volatile segment of the insurance market—the individual and small-group insurance pools—by siphoning off the healthy. Those remaining could face significant and unaffordable premium increases that would ultimately leave them uninsured.

Other tax proposals, such as the one offered by the U.S. Chamber of Commerce at the Health Coverage 2000 conference, include increased individual tax deductions for purchasing health insurance, tax credits for low- and middle-income individuals, more liberal rules for flexible spending accounts, and removing restrictions on medical savings accounts. The ANA believes some of these tax measures could have merit if they were part of comprehensive health care system reform and if appropriate measures were taken to ensure that access to and quality of care in vulnerable populations weren’t adversely affected.

“Medicare has served American seniors well for almost 35 years,” commented Foley. “The ANA believes that a restructured and enhanced Medicare program would offer a solid basis from which to ensure that no American goes without health care.”