California's Efforts To Cover The Uninsured: Successes, Building Blocks, And Challenges.

During the last century, California policy makers tried multiple approaches to achieve the goal of affordable health coverage for all: employer and individual requirements, single payer, and hybrids. All failed, primarily because of the amount of financing needed to cover the large numbers of uninsured Californians and the supermajority vote requirements for tax increases. These failures, however, provided important lessons for state and national reform efforts. More immediate success was achieved with incremental reforms, such as child health insurance, Medicaid section 1115 waivers, and the creation of purchasing pools. These reforms, as well as the experience derived from the broader coverage expansion efforts, contributed to the intellectual and policy frameworks that underlay major national reforms and created building blocks for the state's successful implementation of the Affordable Care Act. That act allowed California to meet its greatest need: the financing required to make a truly sizable dent in the numbers of uninsured Californians.

Toward a 21st-century health care system: recommendations for health care reform.

The coverage, cost, and quality problems of the U.S. health care system are evident. Sustainable health care reform must go beyond financing expanded access to care to substantially changing the organization and delivery of care. The FRESH-Thinking Project (www.fresh-thinking.org) held a series of workshops during which physicians, health policy experts, health insurance executives, business leaders, hospital administrators, economists, and others who represent diverse perspectives came together. This group agreed that the following 8 recommendations are fundamental to successful reform: 1. Replace the current fee-for-service payment system with a payment system that encourages and rewards innovation in the efficient delivery of quality care. The new payment system should invest in the development of outcome measures to guide payment. 2. Establish a securely funded, independent agency to sponsor and evaluate research on the comparative effectiveness of drugs, devices, and other medical interventions. 3. Simplify and rationalize federal and state laws and regulations to facilitate organizational innovation, support care coordination, and streamline financial and administrative functions. 4. Develop a health information technology infrastructure with national standards of interoperability to promote data exchange. 5. Create a national health database with the participation of all payers, delivery systems, and others who own health care data. Agree on methods to make de-identified information from this database on clinical interventions, patient outcomes, and costs available to researchers. 6. Identify revenue sources, including a cap on the tax exclusion of employer-based health insurance, to subsidize health care coverage with the goal of insuring all Americans. 7. Create state or regional insurance exchanges to pool risk, so that Americans without access to employer-based or other group insurance could obtain a standard benefits package through these exchanges. Employers should also be allowed to participate in these exchanges for their employees' coverage. 8. Create a health coverage board with broad stakeholder representation to determine and periodically update the affordable standard benefit package available through state or regional insurance exchanges.