Expanding Medicare and employer plans to achieve universal health insurance.

This article presents a proposal for expanding Medicare and employer-based health insurance plans to achieve universal health insurance. Under this proposed health care financing system, employees would provide basic health insurance coverage to workers and dependents, or pay a payroll tax contribution toward the cost of their coverage under Medicare. States would have the option of buying all Medicaid beneficiaries and other poor individuals into Medicare by paying the Medicare premiums and cost sharing. Other uninsured individuals would be automatically covered by Medicare. Employer plans would incorporate Medicare's provider payment methods. This proposal would result in incremental federal governmental outlays on the order of $25 billion annually. These new federal budgetary costs would be met through a combination of premiums, employer payroll tax, income tax, and general tax revenues. The principal advantage of this plan is that it draws on the strengths of the current system while simplifying the benefit and provider payment structure and instituting innovations to promote efficiency.

Universal health insurance through incentives reform.

Roughly 35 million Americans have no health care coverage. Health care expenditures are out of control. The problems of access and cost are inextricably related. Important correctable causes include cost-unconscious demand, a system not organized for quality and economy, market failure, and public funds not distributed equitably or effectively to motivate widespread coverage. We propose Public Sponsor agencies to offer subsidized coverage to those otherwise uninsured, mandated employer-provided health insurance, premium contributions from all employers and employees, a limit on tax-free employer contributions to employee health insurance, and "managed competition". Our proposed new government revenues equal proposed new outlays. We believe our proposal will work because efficient managed care does exist and can provide satisfactory care for a cost far below that of the traditional fee-for-service third-party payment system. Presented with an opportunity to make an economically responsible choice, people choose value for money; the dynamic created by these individual choices will give providers strong incentives to render high-quality, economical care. We believe that providers will respond to these incentives.

A framework for reform of the US Health Care Financing and Provision System. The Kansas Employer Coalition on Health, Task Force on long-term solutions.

KIE: Thirty million Americans lack health insurance, and despite soaring costs and a leading U.S. role in world health spending, American health statistics remain below the standards of industrialized democracies. Based on principles of universal coverage and responsibility, the Kansas Employer coalition proposes a restructuring of the American health insurance system with minimal reliance on regulation and maximum utilization of current structures. The proposed system would require coverage of every citizen by either an employer's plan or, by default, a tax-supported public plan. The long-term proposal also urges a community, not experience, rating basis for determining insurance premiums; health care cost containment through government dictation of maximum plan increases; government monitoring of health care quality; and individual responsibility for paying some fraction of the cost of each episode of care.^ieng

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

KIE: To meet the need for expanded health care coverage in America, Holahan, et al. of the Urban Institute, incorporate aspects of the Canadian health care system and the Pepper Commission's proposals in the design of what they propose as a cost effective and politically acceptable health care reform package. Medicare would be unchanged. Employers would provide basic coverage for their workers, or pay a tax in support of state-administrated public health insurance programs. This public program would replace Medicaid, and would be utilized by three groups: those whose employers opted to pay a tax, the poor, and citizens who buy into the program. Strong incentives for states to control health care costs would be provided by requiring states to bear the burden of cost increases exceeding the rate of growth in GNP.

A tax reform strategy to deal with the uninsured.

The high level of ininsurance in the United States is due in large measure to the tax treatment of health care, which is based on the tax exclusion for company-provided plans. Correcting the perverse incentives for providers and patients resulting from this tax treatment is the crucial step to creating a national health care system that is affordable and efficient. The Heritage Foundation proposal calls for the elimination of the current tax exclusion and its replacement with a system of refundable tax credits for the purchase of health insurance and medical services.

Liberal benefits, conservative spending. The Physicians for a National Health Program proposal.

The Physicians for a National Health Program proposes to cover all Americans under a single, comprehensive public insurance program without copayments or deductibles and with free choice of provider. Such a national health program could reap tens of billions dollars in administrative savings in the initial years, enough to fund generous increases in health care services not only for the uninsured, but for the underinsured as well. We delineate a transitional national health program budget that would hold overall health spending at current levels while accommodating increases in hospital and physician utilization. Future national health program spending would be indexed to the growth in gross national product adjusted for demographic, epidemiologic, and technologic shifts. Financing for the national health program would transfer funds into the public program without disrupting the general pattern of current revenue sources. We suggest a funding package that would augment existing government health spending with earmarked health care taxes. Because these new taxes would replace employer-employee insurance premiums and substantial portions of current out-of-pocket expenditures, they would not increase health costs for the average American.

The Health Security Partnership. A federal-state universal insurance and cost-containment program.

The Health Security Partnership attempts to assure (1) that all Americans have insurance coverage for a set of comprehensive health care benefits, (2) that cost-containment issues are addressed in a manner that does not impinge negatively on the quality of care, and (3) that provider freedom to deliver appropriate clinical care is strengthened. It assigns important responsibilities to the federal government (eg, specification of benefits, review of proposed state health care budgets), while permitting states to select, develop, and administer specific program design features they deem appropriate (eg, states could build on and expand the existing health system infrastructure, including private insurance, and/or extend the role of tax-supported programs). It is estimated that in its first year the program would add about 5% to America's health expenditures, but within a few years, cost-containment efforts and administrative efficiencies would reduce overall expenditures below what they otherwise would be.

Universal access to health care. A comprehensive tax-based approach.

More than 30 million Americans lack health insurance, and millions more are "underinsured." Meanwhile, the cost of health care in the United States is escalating, and some of our care is of questionable value. This article presents a health care reform strategy that addresses these three fundamental problems in the US health care system. The strategy, designed to empower consumers to make cost-conscious health care choices, combines a universal tax credit that enables all Americans to purchase basic health coverage; insurance reforms including pooling and reinsurance mechanisms; requirements that all employers make insurance available to their employees and that all consumers purchase coverage; and efforts to measure and improve the quality and efficiency of health care services. This strategy would help us to achieve universal health insurance coverage, while creating the proper incentives for cost control. In addition, it can be largely internally financed through savings automatically triggered by its implementation.

Can we learn health care lessons from Germany?

While Americans are unlikely to import a foreign health care financing system lock, stock and barrel, the country could learn from Germany's checks and balances that maintain fairness, economy and professional freedom, says this well-known congressional adviser.

The U.S. healthcare system after NHI: financial ramifications for providers and personnel.

Although much attention has been paid to the general structure and possible implementation of a U.S. national health-insurance program, there remains the brass-tacks question of how such a plan would specifically affect today's providers and payers. Here the author outlines some of NHI's financial and organizational implications for patients, facilities, and staff.