How Democratic Candidates For The Presidency In 2020 Could Choose Among Public Health Insurance Plans.

Democratic candidates for president in 2020 will likely include some type of public plan in their health care reform platforms. Existing public plans take many forms and often incorporate private elements, as do most proposals to extend such plans. We review the types of public plans in the current system. We describe and assess the range of proposals to extend these plans or elements of them to additional populations. We suggest questions that candidates could use to guide their decisions about the scope and content of their health policy proposals. Developmental work during campaigns will contribute to success in turning candidates' promises into accomplishments.

Money and mandates: relative effects of key policy levers in expanding health insurance coverage to all Americans.

This study examines the relative effects of three policy levers on health coverage and costs in plans aimed at covering all Americans. Specifically, using microsimulation analysis and hypothetical proposals, it assesses how the generosity of financial assistance, an employer mandate, and an individual mandate affect the level of uninsurance, distribution of coverage, and federal costs, holding delivery system and benefits constant. The results suggest that only an individual mandate would cover all the uninsured; neither an employer mandate nor generous subsidies alone would be sufficient. The distribution of coverage would be least disrupted by an employer mandate, while 7.3% of people could lose employer coverage with generous subsidies and a voluntary purchasing pool. Federal costs would be highest under a combined individual and employer mandate since there would be costs to minimize disruption. Although less generous subsidies coupled with an individual mandate could yield universal coverage at a low federal cost, doing so would require large, new payments by individuals. Other key trade-offs are discussed.

"Choice" in health care: what do people really want?

Proposals to expand the individual health insurance market and promote health savings accounts are intended to provide consumers with more "choice." The types of choices people prefer, however, are not well understood. This analysis of survey data finds that having a choice of health care providers matters more to people than having a choice of health plans. Dissatisfaction among adults with no choice of providers was more than twice as high as among those with no choice of plan. Moreover, a large majority of Americans who have had experience with employer-based health insurance believe that employers do a good job of selecting quality plans. Two of three preferred an employer-selected set of plans over an employer-funded account that they would use to find coverage on their own. Thus, policymakers should be cautious about embracing the individual market and health savings accounts as a way to improve satisfaction in the system.

Making Medicaid a block grant program: an analysis of the implications of past proposals.

In 2003, President Bush proposed converting Medicaid from an entitlement to a block grant program. Similar ideas from President Reagan in 1981 and Congress in 1995 were introduced but not enacted. Block grants aim to provide greater federal budget certainty and a stronger state incentive to contain program costs. This paper compares the preestablished funding levels proposed in 1981 and 1995 with what actually happened to federal Medicaid spending. Its results show that previous block grant proposals' funding levels at the national and state levels were quite different from what was anticipated and what occurred. As a result, Medicaid probably could not--and cannot--maintain existing health coverage under a block grant financing structure.

Change in challenging times: a plan for extending and improving health coverage.

Some speculate that Americans are neither politically capable of nor morally committed to solving the health system problems. We disagree. We propose a plan that insures all and improves the value and cost-effectiveness of health care by knitting together employer-sponsored insurance and Medicaid; promoting prevention, research, and information technology; and financing its investments through a dedicated value-added tax. By prioritizing practicality, fairness, and responsibility, the plan aims to avoid ideological battles and prevent fear of major change. By emphasizing the moral imperative for change, especially relative to other options on the policy agenda, it aims to create momentum for expanding and improving health coverage for all.