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Universal Coverage
                                          Researcher    Published by CQ Press, a division of Congressional Quarterly Inc.


Will all Americans finally get health insurance?

            ome 45 million Americans lacked health insurance in

            2005 — a number that has been climbing for two

            decades. Every month, about 2 million Americans be-

            come uninsured, at least temporarily, as lower-paying

service jobs with minimal benefits replace union-dominated manu-

facturing jobs with health benefits — undercutting the nation’s

employer-based coverage system. Health costs — rising faster than

wages or inflation — also push employers to drop coverage. Past

legislative proposals for universal coverage relied heavily on govern-
                                                                              Uninsured Americans often seek treatment in
ment management, drawing fatal opposition from physicians and               emergency rooms, such as this asthma sufferer at
                                                                          Coney Island Hospital in Brooklyn. While Congress has
                                                                           been expanding coverage for the very poor, students
insurance companies. But now consensus may be forming around              and lower-income workers are losing coverage. Today
                                                                              45 million Americans lack health insurance.
proposals requiring most Americans to buy private insurance with

public assistance. Republican governors in California and Massa-             I
chusetts back such plans, as does former Sen. John Edwards, the             N
                                                                                 THIS REPORT
first presidential hopeful to announce what’s expected to be a                       THE ISSUES ......................267
slew of universal-coverage proposals in the coming 2008 election.                    BACKGROUND ..................274
                                                                                     CHRONOLOGY ..................275
                                                                                     AT ISSUE ..........................281
       CQ Researcher • March 30, 2007 •                         CURRENT SITUATION ..........282
               Volume 17, Number 12 • Pages 265-288
                                                                                     OUTLOOK ........................283
                                                                                     THE NEXT STEP ................287
                                                                                CQ Researcher
                                                                                              March 30, 2007
        THE ISSUES                              SIDEBARS AND GRAPHICS                     Volume 17, Number 12

        • Can America afford uni-
267     versal health coverage?           268   Cost of Premiums Rising
                                                                                      MANAGING EDITOR: Thomas J. Colin
                                                                                   ASSISTANT MANAGING EDITOR: Kathy Koch
        • Should Americans de-                  Employers bear most of the
        pend on states to expand                expense.                                ASSOCIATE EDITOR: Kenneth Jost
        coverage?                                                               STAFF WRITERS: Marcia Clemmitt, Peter Katel
                                                Universal Coverage Faces
        • Should individuals be
        required to buy insurance?
                                          270   Financial Obstacles                 CONTRIBUTING WRITERS: Rachel S. Cox,
                                                Reducing health costs is the           Sarah Glazer, Alan Greenblatt,
                                                                                      Barbara Mantel, Patrick Marshall,
        BACKGROUND                              big challenge.                           Tom Price, Jennifer Weeks
                                                Private Insurance Coverage        DESIGN/PRODUCTION EDITOR: Olu B. Davis
274     America vs. Europe                272   Dropped                             ASSISTANT EDITOR: Darrell Dela Rosa
        U.S. physicians resisted social
                                                Government aid helped
        insurance, fearing govern-              some Americans.
        ment control over medicine.
                                                Wages Lag Behind Increases
277     Sickness Insurance                273   in Premiums
        The first policy was sold               Premiums rose 9 percent vs.                        A Division of
        in 1850 in Massachusetts.               3 percent for wages.                        Congressional Quarterly Inc.

        Workplace Plans                                                                SENIOR VICE PRESIDENT/PUBLISHER:
279     Large unionized companies         275   Chronology
                                                Key events since 1895.                            John A. Jenkins
        led the way in coverage.                                                        DIRECTOR, EDITORIAL OPERATIONS:
                                                Looking Into the Future of
        Coverage Declines
                                          276   Health Coverage
                                                                                                    Ann Davies
279     Higher costs and changing               New proposals offer new                CONGRESSIONAL QUARTERLY INC.
        business practices eroded               approaches.                                  CHAIRMAN: Paul C. Tash
        employer plans.                                                                VICE CHAIRMAN: Andrew P. Corty
                                                Stakeholder Groups May
                                          278   Balk at Changes                 PRESIDENT/EDITOR IN CHIEF: Robert W. Merry
        Clinton Plan
280     Bruising attacks scuttled               They fear paying more, losing
                                                coverage.                       Copyright © 2007 CQ Press, a division of Congres-
        the ambitious 1993 effort.                                              sional Quarterly Inc. (CQ). CQ reserves all copyright
                                                                                and other rights herein, unless previously specified
                                                At Issue
                                          281   Should Congress enact Presi-
                                                                                in writing. No part of this publication may be re-
        CURRENT SITUATION                       dent Bush’s tax proposal for    produced electronically or otherwise, without prior
                                                                                written permission. Unauthorized reproduction or
                                                expanding health care?
        Interest Grows
282     Coalitions of interest groups
                                                                                transmission of CQ copyrighted material is a viola-
                                                                                tion of federal law carrying civil fines of up to
        support universal coverage.             FOR FURTHER RESEARCH            $100,000.

                                                                                CQ Researcher (ISSN 1056-2036) is printed on acid-
        State Steps                             For More Information
283     Many states are considering
                                          285   Organizations to contact.
                                                                                free paper. Published weekly, except March 23, July
                                                                                6, July 13, Aug. 3, Aug. 10, Nov. 23, Dec. 21 and
        expanded coverage.                                                      Dec. 28, by CQ Press, a division of Congressional
                                          286   Selected sources used.
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                                          287   Additional articles.
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        Health Politics
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Cover: Getty Images/Mario Tama

266      CQ Researcher
                                  Universal Coverage
                                                                                                                         BY MARCIA CLEMMITT

THE ISSUES                                                                                      health-care costs skyrocket,
                                                                                                so does the cost of health in-
                                                                                                surance, whether purchased

W             hen Emily, a 24-
              year-old graduate
              student, discov-
ered a lump on her thigh,
her doctor told her to get an
                                                                                                by individuals or by em-
                                                                                                ployers. Between 2000 and
                                                                                                2006, health premiums for
                                                                                                employer-sponsored insur-
                                                                                                ance jumped 87 percent, far
MRI to find out whether it                                                                      outpacing inflation’s 18 per-
was cancerous. But Emily’s                                                                      cent overall increase. 5
student-insurance policy                                                                            “Health insurance expenses
didn’t cover the $2,000 pro-                                                                    are the fastest-growing cost
cedure, so she skipped it. 1                                                                    component for employers,” ac-
   Several weeks later, during                                                                  cording to the National Coali-
outpatient surgery to remove                                                                    tion on Health Care. “Unless
the lump, Emily’s surgeon                                                                       something changes dramatical-
found a rare, invasive cancer                                                                   ly, health insurance costs will

                                                                                              AP Photo/David Kohl
underneath the benign lump                                                                      overtake profits by 2008.” 6
— with only a 20 to 40 per-                                                                         “If there’s one thing that
cent survival rate. The skipped                                                                 can bankrupt America, it’s
MRI could have detected the                                                                     health care,” warns U.S. Comp-
cancer much sooner, improv-                                                                     troller General David Walker,
ing her chances for recovery.                                                                   chief of the Government Ac-
   Emily pieced together          Many working Americans, like Daniel and Mindy Shea,           countability Office, Congress’
payment for her treatment         of Cincinnati, are un- or under-insured. Young workers        nonpartisan auditing arm. And
from her school insurance,         are hit especially hard: In 2004, a third of Americans       in response to those who say
                                       ages 19-24 were uninsured. Only 61 percent of
two state public-aid programs         Americans under age 65 obtain health insurance            the United States can “grow”
and a monthly payment plan            through their employers. As health costs rise and         its way out of uninsurance by
that ate up more than 40 per-      incomes sag, more and more companies are dropping            creating more and better jobs
cent of her take-home income.      coverage, especially restaurants and small businesses.       with coverage benefits, he
But a year later she learned                                                                    states flatly: “Anybody that tells
that annual health premiums for all stu- loss, student status, early retirement or you we are going to grow our way
dents at her school would rise by 19 because they have entry-level jobs or out of this . . . probably isn’t very pro-
percent because a few, like her, had work in a service industry or a small ficient at math.” 7
racked up high expenses. The price business. Only about 40 percent of busi-               While the public often pictures the
hike led many more students to skip nesses employing low-wage or part- uninsured as being unemployed, the
purchasing the coverage altogether.        time workers offer health benefits, and fact is that most un- and under-insured
   Advocates say such stories are a at $11,480 a year, the average family’s Americans have jobs. Only 61 percent
good reason why Congress should health-insurance premium now costs of Americans under age 65 obtain health
enact a universal health-insurance pro- more than a minimum-wage worker insurance through their employers —
gram. While Congress has been ex- makes in a year. Young workers are down from 69 percent in 2000. And
panding public health insurance pro- hit especially hard: In 2004, more than as health costs rise and incomes sag,
grams covering the very poor — a third of Americans between the ages more and more companies are drop-
especially children and their mothers of 19 and 24 were uninsured. 2 And ping coverage, especially very small
— students and lower-income work- in the construction and service indus- businesses. Because insurers raise pre-
ers increasingly are losing coverage or tries, only 80 percent of the managers mium prices for high-cost groups —
are finding, like Emily, that they can’t have health coverage. 3                       as happened with Emily’s grad-school
afford adequate coverage.                     And the situation is only expected coverage — small companies whose
   Today, 45 million Americans — about to get worse. U.S. health spending is employees get seriously ill or injured
15.3 percent of the population — lack expected to double by 2015 — to or pregnant often find themselves priced
health insurance, usually due to job more than $12,300 per person. 4 As out of coverage altogether.

Available online:                                                                              March 30, 2007     267
                                                                                           tify a regular source of medical care and
 Cost of Premiums Rising Rapidly                                                           are less likely to receive preventive ser-
 The average annual cost of family health coverage has risen more                          vices,” he said. 11 And uninsured chil-
                                                                                           dren admitted to a hospital due to an
 than 50 percent since 2001, to $11,500, and is expected to exceed
                                                                                           injury are twice as likely to die and 46
 $18,000 in the next five years. Most of the cost is borne by the                          percent less likely to receive rehabilita-
 employer.                                                                                 tion after hospitalization, according to a
                                                                                           recent study by the consumer advocacy
                    Average Premium Cost for                                               group Families USA. 12
             Employer-Sponsored Family Coverage, 2005                                          The growing number of uninsured
                                                                                           Americans also pushes up the cost of
               Worker              Employer                         Total: $10,880         publicly subsidized health insurance like
             contribution         contribution                                             Medicare, the panel said. Working-age
                                                                                           uninsured patients with uncontrolled
              $2,713                  $8,167                                               diabetes or high blood pressure eventu-
                                                                                           ally enter the health system sicker than
        $0          2,000     4,000         6,000      8,000       10,000      12,000      they would have been had they been
                                                                                           insured. 13 And about 20 percent of those
                                                                                           with schizophrenia and bipolar disorder
       Average Premium Cost for Employer-Sponsored                                         are uninsured and end up in jail or prison
                Family Coverage, 2001-2012                                                 when their untreated conditions trigger
   $20,000                                                                                 illegal behavior, said the panel. 14
                                                                         $18,650               Adding to the problem, manufactur-
                                                                                           ing and unionized jobs were the main-
    10,000                                                $11,500                          stay of job-based coverage, but their
                             $9,068                                                        numbers have been dropping for 20 years.
      5,000      $7,053
                                                                                           “I suspect you’re going to see wholesale
         0                                                                                 withdrawal of employer-sponsored health
                 2001         2003            2005          2006            2012
                                                                                           care” for anyone earning less than twice
                                                                                           federal poverty-level wages, said National
 Sources: Kaiser Family Foundation, National Coalition on Health Care
                                                                                           Governors Association Executive Direc-
                                                                                           tor Ray Scheppach. 15
   Now some states are trying to create       lion Americans are predicted to be unin-         “Economic security, jobs, health care
new sources of affordable coverage.           sured by 2013 — 11 million more than         and retirement security — those are all
Massachusetts is launching a universal-       today, according to a University of Cal-     now one and the same issue,” says Henry
coverage plan in 2007 that has biparti-       ifornia at San Diego study. 8 The increase   Simmons, president of the National Coali-
san support, and Republican California        will cause 4,500 additional unnecessary      tion on Health Care, which includes em-
Gov. Arnold Schwarzenegger hopes to           deaths per year and $16 billion to $32       ployers, unions and academic and other
enact a similar measure. At the feder-        billion in lost economic productivity and    groups advocating universal coverage.
al level, no new initiatives are ex-          other “human capital,” the study says. 9         Pension investment funds have re-
pected this year — except for a prob-             The leading public myth about the        cently realized that skyrocketing health-
able expansion of children’s coverage         uninsured is that “people without health     care costs could bankrupt Americans’
— but many expect universal cover-            insurance get the medical care they need,”   future if they are not checked, says
age to be a major theme in the 2008           said Arthur Kellerman, chairman of Emory     Simmons. Since Medicare covers only
presidential election.                        University’s Department of Emergency         some of the health services needed
   America’s creeping lack of health cov-     Medicine and co-chairman of an Insti-        by retirees, virtually all elderly people
erage constitutes a crisis for the unin-      tute of Medicine (IOM) panel that has        who can afford it also purchase pri-
sured, even as the skyrocketing cost of       called for universal coverage by 2010. 10    vate supplemental insurance to fill the
health care makes it inevitable that even         In fact, the uninsured seldom receive    gaps. But pension-fund investors are
more people will be uninsured in the          appropriate care at the appropriate time,    finding no investments that grow fast
future. If health premiums continue ris-      said Kellerman. “The uninsured are less      enough to allow retirees’ savings in-
ing at their current rate, about 56 mil-      likely to see a doctor or be able to iden-   come to keep up with the anticipated

268          CQ Researcher
soaring cost of future Medicare and
supplemental-coverage premiums.              Americans Without Health Insurance
    While no one expects significant
                                             In 25 states, between 14 percent and 19 percent of the adults ages
action from Congress until after the
2008 presidential election, federal          18-64 did not have health insurance in 2005. States with high levels
policymakers increasingly acknowledge        of uninsured residents typically have minimal state and employer
a need for action. Consensus appears         insurance coverage.
to be growing for some type of hybrid
universal coverage that combines                Percentage of People Ages 18-64 Without Insurance, 2005
public and private insurance.
    “In the past the debate got bogged           Wash.                                N.D.                                                                 N.H.
down because different groups wanted                                                             Minn.                                               Vt.
                                                                                                             Wis.                                              Maine
their first-priority proposal only,” says        Ore.                                 S.D.
                                                              Idaho                                                      Mich.
Ron Pollack, founding executive direc-                                     Wyo.                                                                     N.Y.            Mass.
tor of Families USA. “One group would                                                                                                         Pa.
                                                                                                               Ill.    Ind. Ohio                           Conn.     R.I.
say, ‘Coverage must be financed through                    Nev.   Utah        Colo.
                                                                                                      Mo.                          W.Va.
                                                                                         Kan.                                                                N.J.
public programs,’ while another would             Calif.
                                                                                                                             Ky.             Va.
say, ‘There should be no government                                                          Okla.    Ark.            Tenn.                 N.C.
action in the marketplace,’ And since                             Ariz.
                                                                                                             Miss.                   S.C.          D.C.
everyone’s second-favorite program was                                                                 La.            Ala.     Ga.
the status quo, nothing happened.”
    But that decades-old logjam may                                                                                                                   23% and over
be breaking up, as advocates on all                Alaska                                                                            Fla.
sides of the issue creep closer to one                                                                                                                14-18.9%
another in their proposals. “The very                                     Hawaii                                                                      Under 14%
grand visions on both sides” — a
single-payer government system or            Source: Kaiser Family Foundation,, 2005
relying on individuals saving money
for their own care via Health Savings           So far, every Democrat who has                           Among Republican presidential can-
Accounts (HSAs) — “are both completely      announced he or she will run for pres-                   didates, former Massachusetts Gov. Mitt
impossible in our political system,” says   ident has declared a commitment to                       Romney last year backed legislation
Yale University Professor of Political      universal coverage, tying the issue to                   intended to achieve universal cover-
Science Jacob Hacker.                       the country’s overall economic health,                   age in his state, and former House
    Even President George W. Bush, a        but only former Sen. John Edwards,                       Speaker Newt Gingrich, who has not
longtime proponent of individually          D-N.C., has announced a specific cov-                    yet thrown his hat into the presiden-
purchased HSAs, softened that stance in     erage plan. “The U.S. auto industry is                   tial ring, also has called for systemic
his most recent proposal. Bush’s fiscal     struggling, in part because of the ris-                  reforms in the health-care system.
2008 budget plan would offer similar        ing cost of health care that this ad-                        While a consensus may be devel-
tax breaks to those buying all kinds of     ministration has done nothing to ad-                     oping on the need for some kind of
health insurance, not just HSAs, either     dress,” newly announced Democratic                       universal coverage, many contentious
as individuals or through employers.        candidate Sen. Barack Obama, D-Ill.,                     debates remain. For example, both the
    Paul Ginsburg, president of the non-    said last November. “I have long pro-                    right and the left have criticized the
partisan research group Center for          posed that the government make a                         California and Massachusetts plans for
Studying Health System Change, says         deal with the Big Three automakers                       requiring individuals to buy health in-
critics rightly point out that Bush’s tax   that will pay for a portion of their re-                 surance, just as drivers are required
break doesn’t target lower-income peo-      tiree health costs if they agree to in-                  to carry automobile insurance.
ple who are most in danger of losing        vest those savings in fuel-efficient tech-                   Nevertheless, many believe the
coverage. Nevertheless, “eventually, the    nologies.” Health-care costs account                     country is on the verge of a focused,
Democrats may see that the president        for approximately $1,000 of the cost                     national debate on universal coverage.
has given them something — a revenue        of each car produced by the Ameri-                       “In 2008, universal coverage will be
source” to help pay for expanding           ca’s largest automakers — more than                      up there with Iraq as top election
coverage, he says.                          they spend on steel. 16                                  issues,” says Pollack.

Available online:                                                                                 March 30, 2007                                269

 Universal Coverage Faces Financial Obstacles
 Reducing health-care costs is the big challenge

 N         ow that Americans appear to be reaching some con-              Lawmakers also must figure out how to ensure affordable
           sensus on the need for universal health coverage, major   access to all. Many Republican proposals for expanding cov-
           hidden obstacles — all involving money — must be          erage rely on tax subsidies to help more people buy individ-
 overcome. Among those thorny financial issues are questions         ual health policies. Because such coverage wouldn’t be tied to
 over who is going to pay for the coverage, how can afford-          a job, it would be “portable,” so employees who switch or
 able access be ensured for all and how can overall health-care      lose jobs would not be without insurance.
 costs be reduced.                                                        But buying individual health insurance can be far more ex-
    Perhaps the most controversial issue is who will pay for the     pensive than purchasing through an employer because insurers
 coverage. In 2005, employers paid 75 percent of workers’ health-    don’t “pool” risks the way they do for workers under employer-
 premium costs — about $500 billion compared to the ap-              based policies. So individual purchasers pay based on their fam-
 proximately $170 billion that workers paid. 1 That’s “most of       ily’s health status and age, which makes it the most expensive
 the money outside the government that’s spent on health care,”      way to buy health insurance. Moreover, insurers won’t even sell
 says Stanley Dorn, a senior research associate at the liberal       coverage to some people because the companies themselves con-
 Urban Institute. To work, any universal-coverage plan will have     sider it unaffordable.
 to either continue to use those employer contributions or come           “The words ‘kinda crummy’ come to mind when I think of
 up with a suitable replacement for them.                            the individual market,” said former Maryland Insurance Com-
    That’s why many universal-coverage proposals ask em-             missioner Steve Larsen, now a private attorney. For example,
 ployers for financial contributions. But making those contri-       a case of mononucleosis and a chronic condition like hay fever
 butions both fair and adequate is difficult, mainly because         is enough for some insurers to deem a potential buyer unaf-
 businesses vary so widely in what they pay today: Many              fordable. “And if you have any type of serious mental illness,
 contribute nothing, but others pay hundreds of millions of          forget it,” he said. 2 A study by the Georgetown University In-
 dollars each year.                                                  stitute for Health Care Research and Policy found that a 62-
    Dorn says policymakers may want to consider asking all           year-old overweight moderate smoker with controlled high blood
 employers to pay a set amount into a general pool but vary          pressure was deemed an unaffordable risk 55 percent of the
 the amount by companies’ line of business and their geo-            times he sought individual health coverage. 3
 graphical location. That way, companies that compete with one            Buying an individual policy is more affordable for the young
 another would share the same burden.                                and healthy, says health-care consultant Robert Laszewski. His

   As policymakers gear up for that          shown that universal coverage is not            Institute says that in 2004 universal cov-
debate, here are some of the ques-           financially feasible, he said.                  erage would have added about $48 bil-
tions being asked:                               For example, his home state of Ten-         lion to the $125 billion the nation spent
                                             nessee managed to cover about 93                on health care for uninsured people —
Can America afford universal                 percent of residents — a national high          most of which was paid out of pocket
health coverage?                             — by having Medicaid cover both the             by the uninsured or was delivered with-
   Critics of universal-insurance pro-       uninsured and the uninsurable. But “in          out compensation by doctors and hos-
posals have long argued that while           attempting to do this the state is going        pitals. 21 A proposed universal-coverage
expanding coverage is desirable, cov-        bankrupt,” he said, “and there is a             plan for Maryland would raise that state’s
ering everyone would simply cost             major effort to backtrack.” 19                  health spending by some $2.5 billion
too much. 17 Universal-coverage ad-              Universal-coverage plans generally are      per year, while a Minnesota proposal to
vocates, however, argue that current         “unrealistic,” said former Health and           cover the state’s 383,000 uninsured is
administrative expenses are high             Human Services Secretary Tommy G.               projected to cost an estimated $663-$852
partly because the United States has         Thompson. I just don’t think it’s in the        million in new annual funding. 22
a piecemeal system with many                 cards. . . . “I don’t think that adminis-          Most proposals for universal cov-
uninsured.                                   tratively or legislatively it’s feasible.” 20   erage call for increased government
   “It is impossible to get everybody            While few politicians today will say        spending. And finding those dollars
covered,” former Senate Majority Leader      America cannot afford universal cover-          will be tough, given that the federal
Bill Frist, R-Tenn., a transplant sur-       age, both sides agree that the costs will       budget and many state budgets are
geon, said in 2004. 18 State efforts have    be high. A study by the liberal Urban           facing substantial deficits. 23

270       CQ Researcher
 20-something son found an individual health policy for $150 a              tem could be drastically cut” if insurers had to take all com-
 month several years ago, but “if he was 58 years old, his pre-             ers rather than carefully jiggering their policies, premiums and
 mium would have been $1,500,” he says. “If you’re going to                 marketing strategies to attract only the healthiest, least expen-
 do universal health care, you can’t age-rate premiums or bar               sive buyers, they said.
 people based on pre-existing conditions.”                                      A key is to cut spending on care by “learning more about
     No matter how widely risk is shared, however, behind the high          what works for whom,” says Wilensky. But getting that infor-
 cost of insurance lurks the ever-rising cost of health care. “The          mation requires investment, she says.
 10,000-pound elephant in the room is cost,” says Laszewski.                    In addition to cutting excess services, says Laszewski, making
     Health-care costs have been growing faster than the entire             coverage affordable will ultimately mean sacrificing some of the
 economy or any other sector in it for the past 45 years, says              health-care industry’s high profits and salaries. International com-
 Gail Wilensky, a senior fellow at the nonprofit health-educa-              parisons show that other countries spend less on health care while
 tion foundation Project HOPE and former head of Medicaid                   delivering the same amount or even more services to patients.
 and Medicare. “They can’t go on doing it for the next 30 years”                Americans don’t understand that controlling cost is crucial
 without crippling other parts of the economy, she says.                    to sustaining the health system, let alone expanding coverage,
     U.S. health-care costs are the world’s highest because of in-          says Laszewski. “I’ll bet you if you told consumers that if they
 surers’ high administrative and marketing costs and because Amer-          lost their jobs, replacing their insurance would cost $15,000 or
 ican doctors and medical suppliers enjoy higher profits and salaries       $16,000 a year, they’d understand that,” he says.
 than their counterparts in other industrialized countries. 4
     In today’s fragmented insurance system, insurers’ efforts to attract   1 Aaron Catlin, Cathy Cowan, Stephen Heffler and Benjamin Washington, “Na-

 the healthiest, cheapest customers add extra overall costs, point out      tional Health Spending in 2005: The Slowdown Continues,” Health Affairs,
                                                                            January/February 2007, p. 148.
 Paul Menzel, a philosophy professor at Pacific Lutheran University         2 Quoted in “Reinsurance for Individual Market Pricks Up Many Ears,”
 in Tacoma, Wash., and Donald W. Light, professor of comparative            Medicine & Health, “Perspectives,” Oct. 28, 2002.
 health care at the University of Pennsylvania. 5 For example, they         3 “Hay Fever? Bum Knee? Buying Individual Coverage May Be Dicey,”

 wrote, a Seattle survey found that 2,277 people were covered by            Medicine & Health, June 25, 2001.
                                                                            4 For background, see Marcia Clemmitt, “Rising Health Costs,” CQ Researcher,
 755 different policies linked to 189 different health-care plans.          April 7, 2006, pp. 289-312.
     “The $420 billion (31 percent!) paid [annually] for manag-             5 Paul Menzel and Donald W. Light, “A Conservative Case for Universal Access
 ing, marketing and profiting from the current fragmented sys-              to Health Care,” The Hastings Center Report, July 1, 2006, p. 36.

   “The public sector has fewer re-                  A 2006 Massachusetts law requir-                 ized nations with universal coverage
sources” now compared to when the                 ing every resident to purchase subsi-               spend less per capita on health care
issue was debated previously, says                dized coverage — unless that cover-                 than the United States. In 2004, for in-
Ginsburg, of the Center for Studying              age is “unaffordable” — is already                  stance, the United States spent $6,102
Health System Change. A lack of will-             running into an affordability crisis, said          per capita on health care while Aus-
ingness or ability to commit new rev-             Jonathan Gruber, a professor of eco-                tralia spent $3,120; Denmark, $2,881;
enue has doomed at least one state                nomics at the Massachusetts Institute               Germany, $3,043; Luxembourg,
plan, he adds. When Maine launched                of Technology. 24 The state has said                $5,089; Sweden, $2,825 and Switzer-
a universal-coverage initiative in 2003,          it would subsidize only those who                   land, $4,077. 26
the state “put almost no money in and             earn up to three times the federal                      Not only are Americans paying more
got almost nothing out,” he says.                 poverty level (about $30,000 for an in-             for health care than those in any other
   The Democratic presidential hopefuls           dividual and $60,000 for a family of                industrialized country, but they are get-
who have called for universal coverage            four), said Gruber. But “at three times             ting lower-quality care — by some mea-
“will be desperate for revenues when              poverty, health insurance is still ex-              surements — than consumers in coun-
they put out their plans,” says Robert            pensive. . . . It’s not feasible to have            tries with universal coverage. While new
Blendon, professor of health policy and           someone spend 20, 30 or 40 percent                  drugs and technology have improved
management at the Harvard School of               of income on health insurance.” 25                  longevity and quality of life for many
Public Health. “Money is going to be                 While some say universal coverage                Americans, the United States is ranked
hard to come by. We’ve got defense                is too expensive for America, many                  37th by the World Health Organization
costs that are very, very high.”                  economists point out that industrial-               in overall quality of care, based on adult

Available online:                                                                             March 30, 2007                   271
                                                                                           no doubt that you can have universal
 Private Insurance Coverage Dropped                                                        coverage without substantially raised
                                                                                           costs,” says Simmons, president of the
 The percentage of people with private health insurance dropped by                         National Coalition on Health Care. “Every
 8 percentage points from 1987 to 2005 (right). At the same time,                          other country does it” already, he says.
 the percentage of people insured by either government or private                             Universal coverage is needed to
 insurance dropped 3 percentage points (left). As people lost private                      “get a [health-care] market that works,”
 coverage, government picked up the slack to keep as many people                           he adds. “You can’t fix the issue of
 insured as possible.                                                                      cost” — which affects everyone, in-
                                                                                           sured and uninsured — “without uni-
          Percentage of Uninsured People by Type of Coverage                               versal coverage,” he says. Absent a
 100%                                                                                      universal-coverage requirement, “what
                                                                                           markets do is avoid risk,” such as
    80                                                                            2005     when insurance companies develop
               87.1%          84.1%
                                                   75.5%                                   marketing and risk-assessment proce-
    60                                                            67.7%                    dures to avoid selling policies to sick
    40                                                                                     people. “It’s an open-and-shut case that
                                                                                           universal coverage is cheaper and bet-
    20                                                                                     ter” than the status quo.
      0                                                                                       Getting everyone covered and
            Total Public and Private               Private Insurance                       specifying uniform benefit packages
                                                                                           would create a huge, immediate, one-
 Source: U.S. Census Bureau, “Historical Health Insurance Tables”                          time financial saving, Simmons says.
                                                                                           “Automatically, you’re talking about
and infant mortality rates. The United        the ladder of opportunity . . . the cor-     hundreds of billions of dollars” in sav-
States also ranks 24th among industri-        nerstone of a democratic society, al-        ings that “every other nation has al-
alized nations in life expectancy. 27         lowing people to . . . be productive         ready captured,” partly accounting for
    Those stark realities, coupled with       and to take advantage of the oppor-          lower costs abroad.
the fact that U.S. health-care costs are      tunities of upward mobility.” 30
spiraling out of control, lead a grow-            Others argue that having more than       Should Americans depend on
ing number of analysts to argue that          15 percent of the population unin-           states to expand coverage?
the United States can’t afford not to         sured means that all Americans pay               In recent years, states have been far
have universal coverage.                      more for health care. “The uninsured         more active than the federal government
    “I’ve always believed universal cov-      are one of the inefficiencies” driving       in expanding health coverage. Massa-
erage would carry significant costs and       health costs into the unaffordable range,    chusetts and Vermont passed universal-
would bring daunting . . . economic           says Robert Greenstein, executive di-        coverage laws in 2006, and Illinois
challenges,” said Harold Pollack, asso-       rector of the liberal Center on Budget       created a program to cover all children.
ciate professor at the University of Chica-   and Policy Priorities.                       Other proposals are being discussed in
go School of Social Service Adminis-              “Reining in health-care cost growth”     state legislatures this spring. 31
tration. 28 But recently, he says, he has     — which soared by 7 percent last year            States’ uninsured populations vary
decided “there is no alternative” to          alone — is a prerequisite for universal      widely around the country, so they are
pushing forward with universal insur-         coverage, says Robert Laszewski, an in-      the natural venue for expanding cov-
ance. “The current system is no longer        dependent health-care consultant and a       erage, say some analysts. “All states face
able to accomplish important things we        former health-insurance executive. Health-   different challenges in reducing the num-
expect from our health care.” 29              insurance premiums grow even faster          ber of uninsured residents,” so “im-
    Former Gov. John Kitzhaber, D-            than costs, and neither government sub-      posing a one-size-fits-all program” at
Ore. — an emergency-room physician            sidies nor the incomes of lower-wage         the federal level “will not work,” said
who now heads the Oregon-based                working people can keep up with the          Arthur Garson, dean of the University
Archimedes Project, a health-reform           current growth rate for long, he says.       of Virginia School of Medicine. 32
initiative — agrees. Economic growth              If coverage expansion were accom-            With no national consensus emerg-
depends on good health for all, he            panied by efforts to rein in spending        ing on how to cover the uninsured,
said. Good health “is the first rung on       and improve care, “there’s absolutely        encouraging state action is the only way

272         CQ Researcher
forward, said Stuart M. Butler, vice pres-                                               were uninsured, compared to unin-
ident for domestic and economic pol-          Wages Lagged Behind                        surance rates in other states of 25 per-
icy at the conservative Heritage Foun-        Increases in Premiums                      cent and higher. And the state was al-
dation. “Successful welfare reform started                                               ready spending more than $500
in the states,” and coverage could be         Workers’ wages rose less than              million annually to compensate hos-
expanded by removing federal road-            3 percent from 2004 to 2005                pitals for treating the uninsured. 36
blocks and offering federal incentives        while health-insurance                         “Federal action ultimately [will] be es-
to states “to try proposals currently bot-    premiums jumped 9 percent.                 sential,” said Shoshanna Sofaer, profes-
tled up in Congress.” 33                                                                 sor of health policy at Baruch College
    In California over the past year, the      Comparing Increases in                    in New York City and a member of the
Republican governor, Democratic leg-                                                     IOM insurance panel. States don’t have
                                              Health Insurance Premiums
islators and top executives from the                                                     the steady financing or the legal flexi-
                                                and Workers’ Earnings,
state’s largest private insurer all pro-                                                 bility to expand coverage to all of their
posed universal-coverage plans,                        2004-2005                         residents. One roadblock, she said, is
though none has yet been enacted.             10%       9.2%                             the federal Employee Retirement In-
The California-based Kaiser Foundation                                                   come Security Act (ERISA), which lim-
Health Plan offered a plan that would                                                    its states’ power to control insurance. 37
provide “near-universal coverage” with-          6                                           “The best thing states can do is set
in two years to California’s 5 million           4                      2.7%             up role models,” says Brandeis Univer-
uninsured — who represent a whop-                2                                       sity Professor of Health Policy Stuart Alt-
ping 10 percent of all uninsured Amer-           0                                       man. “You can’t design true national
icans. “Despite the greater dimensions               Premiums        Workers’            health insurance state by state, because
of the problem in California, we be-                                 earnings            you’d get past a few states, then stop.”
lieve that a state-based solution is pos-                                                    While states’ efforts are important,
sible,” wrote Kaiser executives. 34           Sources: Alliance for Health Reform;       says the National Coalition on Health
    While federal laws restrict states’       Kaiser Family Foundation and Health        Care’s Simmons, “we don’t think that
ability to expand Medicaid and set            Research and Educational Trust, 2005       any single state, no matter how large,”
rules for employer-sponsored cover-                                                      can accomplish universal coverage of
age, that hasn’t stopped some states         is supported by both Republicans, who’ve    its residents “without major federal
from expanding coverage, says Stan-          traditionally been skeptical of universal   policy changes.” Many governors agree
ley Dorn, a senior research associate        coverage, and liberal Democrats who         and acted on their own only because
at the liberal Urban Institute. In the       favor a single-payer system, he says.       they’re frustrated with a lack of fed-
early 1990s, for example, Minnesota              The flurry of major state proposals     eral action, he says.
and Washington state both “imple-            shows the nation is ready for change,           Furthermore, even if all states
mented coverage systems that suc-            he says, even though “the federal gov-      achieved universal coverage, the result
ceeded brilliantly,” he says.                ernment has been dysfunctional on do-       would be a cost-increasing nightmare
    Regardless of whether they succeed       mestic issues for many years.” He pre-      — the last thing the health system
completely, state initiatives provide        dicts “a few more states” will expand       needs, says Simmons. “If you think we
models and impetus for future national       coverage soon, but many states are lim-     have administrative complexity now,
efforts, say many analysts. “The state       ited in what they can accomplish.           imagine 50 individual state programs.”
action provides great momentum,” says            All states can’t emulate the Mass-
Dorn.                                        achusetts model, said James J. Mon-         Should individuals be required to
    “States are hugely important,” says      gan, chief executive of the New Eng-        buy health insurance?
Hacker at Yale University. “When two         land-based hospital and physician              At the turn of the new century, few
Republican governors” — Romney and           network Partners HealthCare, because        people were advocating that all Ameri-
Schwarzenegger — “break with the na-         Massachusetts is very different from        cans be required to buy health insur-
tional party to propose universal cov-       most other states. 35                       ance, but in recent years such voices
erage, that’s a huge boost,” he says.            “We started with half the problem       have grown louder. With interest grow-
    Ginsburg, of the Center for Studying     solved,” said Mongan, a former con-         ing in a system that subsidizes the cost
Health System Change, says the 2006          gressional health aide who also worked      of private coverage, advocates say un-
Massachusetts law has been a catalyst        in the Carter administration. Only about    less everyone participates no functioning
— “the answer to political gridlock.” It     10 percent of Massachusetts residents       insurance market can develop. Insurance

Available online:                                                             March 30, 2007               273
is designed to even out annual health         health insurance shouldn’t be any dif-      courages it by imposing a financial
costs for everyone by having everyone         ferent, notes Tanner. But economists        penalty on those who wait to sign
pay similar amounts into an overall pool      say there are some key differences be-      up, he says.
each year, whether they are healthy in        tween the two kinds of coverage. For           The drug benefit “created a huge
that particular year or facing an unex-       example, few people will drive more         pool of people from age 65 to 95,”
pected sickness or injury.                    recklessly just because they have auto      he explains. “And you allowed peo-
    But opponents on the left say man-        insurance. But the prevalence of gen-       ple in at the same rates no matter
dating insurance is unfair to lower-          erous health insurance has been             what their age or pre-existing condi-
income families who can’t afford even         shown to encourage patients to seek         tion, so long as they signed up as
heavily subsidized private insurance.         — and doctors to prescribe — more           soon as they became eligible.”
And conservative critics say a re-            and sometimes unnecessary or unduly            The proof of that approach is in
quirement to purchase is undue gov-           expensive treatments. 40                    the pudding, he says. Private insurers
ernment intrusion into private life.              Nevertheless, policymakers from         have “flooded the market with plans,”
    “You can talk until you’re blue in        both parties increasingly consider          and people are not faced with steeply
the face about risk pools and actuari-        mandating health insurance “an es-          escalating premiums as they age or
al tables and all the green-eyeshade          sential accommodation to limited pub-       their health worsens, he says.
reasons that the health insurers need         lic resources,” explains Ginsburg of
everyone to participate in order to write     the Center for Studying Health System
affordable policies. I understand all that,
and I basically don’t care,” wrote lawyer
and policy blogger David Kravitz about
                                              Change. In 2004, for instance, then-
                                              Senate Majority Leader Frist said “high-
                                              er-income Americans have a societal
Massachusetts’ new buying requirement.        and a personal responsibility to cover
“It is fundamentally wrong to force peo-      in some way themselves and their chil-
ple to buy an expensive product in the        dren.” 41 If those who can afford cov-         America vs. Europe
private market, simply as a condition         erage don’t enroll, the government
of existing in this state,” he wrote on
the Blue Mass Group policy blog. 38
    Monitoring who is obeying the re-
                                              should enroll them automatically in a
                                              high-deductible insurance plan that cov-
                                              ers catastrophic expenses and obtain
                                                                                          F     rom the beginning, America differed
                                                                                                sharply from other industrialized
                                                                                          nations in its approach to health insur-
quirement and determining subsidy             the payment for the premiums at tax         ance. While Europe turned to social in-
sizes creates “one more aspect of citi-       time, Frist said. And the mandate should    surance, in which all residents pay into
zens’ lives” that government would            apply to the “very, very rich” initial-     a common fund that provides popula-
monitor, complains Michael D. Tanner,         ly, then expand over time, he said. 42      tion-wide benefits, American physicians
director of health and welfare studies            Requiring everyone to buy coverage      resisted, fearing such an approach would
at the libertarian Cato Institute. A man-     ensures that those with lower medical       encourage government influence over
date would also be extremely difficult        needs will pay premiums alongside those     the practice of medicine. 43
to enforce, he says.                          with expensive illnesses, analysts point        The development of the American
    “An individual mandate crosses an         out. “If the government says an insur-      workplace-based insurance system
important line: accepting the principle       ance company must take whoever comes        echoed “themes that distinguish the
that it is the government’s responsi-         their way, they couldn’t predict risk and   more general history of the United
bility to ensure that every American          might go broke” if only sicker people       States,” wrote Rosemary A. Stevens,
has health insurance,” said Tanner. “In       enrolled, says Marian R. Mulkey, senior     University of Pennsylvania professor
doing so, it opens the door to wide-          program officer at the California Health-   emeritus of the history of science. So-
spread regulation of the health-care          care Foundation, which funds health-        cial insurance was trumped by “the
industry and political interference in        care research. A mandate like the one       commitment to private solutions to
personal health-care decisions. The re-       Schwarzenegger proposes “relieves this      public needs” and “the belief in local
sult will be a slow but steady spiral         concern of insurers, who are business-      initiatives wherever possible.” 44
downward toward a government-run              es and must be on solid financial foot-         As the 19th century ended, Euro-
national health-care system.” 39              ing to offer benefits.”                     peans leaned more toward “social
    Advocates of a mandate argue that             The Medicare drug benefit works         democracy” — the belief the free mar-
if government can require automobile          similarly, says health-care consultant      ket cannot supply certain human ne-
insurance to ensure that costs are paid       Laszewski. Medicare doesn’t require         cessities, such as a minimum income
when drivers cause accidents, then            seniors to enroll but strongly en-                                 Continued on p. 276

274       CQ Researcher
                                       employer contributions to insurance     1996
Most European countries adopt
                                       income-tax free, enabling companies
                                       to offer health insurance to attract
                                                                               Congress enacts Health Insurance
                                                                               Portability and Accountability Act to
compulsory health insurance.           workers.                                make employer-provided coverage
                                                                               transferable between jobs and more
1895                                                    •                      accessible to the self-employed.
German physicist William Roentgen
discovers the X-ray, ushering in the                                           1997
age of modern medicine and rising
health-care costs.
                                       Health spending and consump-
                                                                               Congress enacts State Children’s
                                                                               Health Insurance Program (SCHIP)
                                       tion rise rapidly, and work-            to help states cover children from
1920                                   place-based health insurance            low-income families.
Public commissions in California,      spreads. Medicare and Medic-
New Jersey, Ohio and New York          aid are enacted for the poor                             •
recommend universal state health       and elderly.

                                                        •                      2000s           As health costs
                                                                               and the ranks of the uninsured
The private Committee on the Cost                                              rise, Congress mulls new tax de-
of Medical Care (CCMC) endorses
developing private health insurance;
                                       Worries grow about health care
                                                                               ductions and credits to help con-
                                                                               sumers buy coverage; interest
American Medical Association           becoming unaffordable. Presi-           grows in compulsory insurance.
(AMA) opposes the idea.                dents Nixon and Carter propose
                                       universal health coverage and           2002
1929                                   health-care price controls. Cost        Congress enacts Health Care Tax
The first hospital prepayment in-      controls reduce federal spending        Credit, available to whose who
surance plan is launched for           on Medicare, but doctors and            lose their jobs due to foreign
school teachers in Dallas, Texas.      hospitals shift their costs to em-      competition.
                 •                                                             2006
                                                        •                      Massachusetts enacts universal-

1930s-1940s                                                                    coverage plan requiring all residents
                                                                               to buy health insurance. . . . Ver-
Private hospital prepayment
insurance spreads around the
                                       1990s           Federal govern-
                                       ment expands Medicaid and en-
                                                                               mont enacts voluntary coverage
                                                                               plan with subsidized insurance
country, as hospitals worry            acts a new children’s health            and medical cost trimming. . . .
they’ll go under when poor             program, but employers begin            Maryland plan to force large em-
patients don’t pay. Congress           dropping health benefits. Wash-         ployers to supply coverage or pay
and legislatures in at least eight     ington lawmakers shy away               into a state insurance pool is
states debate but don’t enact          from large-scale coverage ex-           struck down in federal court.
compulsory health insurance.           pansion after President Clinton’s
                                       ambitious attempt to enact uni-         2007
1935                                   versal coverage fails.                  President Bush proposes replacing
Attempts to include health coverage                                            the tax break received by those
in the new Social Security Act are     Sept. 22, 1993                          with employer-based coverage
unsuccessful.                          Clinton unveils sweeping plan to        with a tax deduction available to
                                       reform U.S. health-care system.         everyone. . . . Gov. Arnold
1943                                                                           Schwarzenegger, R-Calif., proposes
The first measure calling for com-     Sept. 26, 1994                          universal, state-subsidized health
pulsory national health insurance      After a year of fierce debate, Senate   insurance. . . . Advocates press
is introduced in Congress. . . .       leaders declare Clinton’s bill dead.    Congress to expand SCHIP to
National War Labor Board declares                                              more children and parents.

Available online:                                                  March 30, 2007          275

 Looking Into the Future of Health Coverage
 New proposals offer new approaches

  W            ith the number of uninsured Americans creeping          — “as a reasonable premium for their plan,” he laments. “The
               inexorably upward, universal coverage is likely to      chances that the law will ever be implemented are slim.”
               become a hot political issue in the 2008 presiden-          California — In January, Gov. Arnold Schwarzenegger un-
 tial campaign. While former Sen. John Edwards, D-N.C., is the         veiled a universal-coverage plan that also would require all res-
 only candidate to have offered a specific plan so far, the state      idents to buy a minimal level of coverage. Public programs
 and federal plans being considered contain some new wrin-             would be expanded to cover the lowest-income Californians,
 kles that might help policymakers reach a compromise on how           and subsidies would help others buy private insurance.
 to expand coverage.                                                       Insurers would offer policies to all comers, at state-approved
     Massachusetts — A 2006 state law requires all residents to        rates. Employers with 10 or more workers would pay at least 4
 buy insurance, beginning this year, or pay a penalty. Massachu-       percent of payroll for health insurance or pay that amount into
 setts will subsidize premiums for those earning under 300 percent     a state pool. To trim costs, insurers would be required to spend
 of poverty level (about $60,000 for a family of four) and waive       at least 85 percent of every premium dollar on patient care.
 the coverage requirement if no “affordable” policies are available.       To entice more hospitals and doctors to participate in Cal-
     Coverage will be sold through a state-operated market, the        ifornia’s subsidized Medi-Cal program, the state would increase
 Massachusetts Health Insurance Connector, and the state is ne-        payments to participating providers. This would also eliminate
 gotiating with insurers to get affordable premiums for com-           what Schwarzenegger calls the “hidden tax” — low public-pro-
 prehensive policies, something that’s proven to be more of an         gram payments and uncompensated care for uninsured people
 uphill struggle than lawmakers imagined.                              that providers now pass along as higher prices to paying pa-
     “Massachusetts decided consciously not to grapple with rising     tients. The Medi-Cal pay boost would be funded by a tax on
 health-care costs and decided to do it later,” says Paul Ginsburg,    non-participant doctors and hospitals.
 president of the Center for Studying Health System Change, a              Some employers are skeptical of the plan, which must be
 nonpartisan research group. “Now they’re having a problem with        approved by the California legislature. The plan would help
 the bids coming in higher than expected.”                             companies that already provide health benefits because it would
     That decision may have doomed the plan, says Robert               force their competitors to ante up for health care also, said
 Laszewski, a consultant and former insurance executive. An-           Scott Hauge, president of the advocacy group Small Business
 nual health-insurance premiums for the average Massachusetts          California. But that could be perceived as unfair by some com-
 family had already reached $15,000 a few years ago — high-            panies with young workers, whose “invincibility-of-youth syn-
 er than the current national family average of $12,000 — in           drome” means they’d prefer cash to health benefits they be-
 part because of the state’s high-cost academic medical centers        lieve they don’t need, he said. 1
 and plethora of physicians, he points out. “Yet the Massachu-             Insurers are expected to balk at being forced to spend 85
 setts legislature came up with $200 a month” — $2,400 a year          percent of premiums on patient care, says Laszewski. “Wellpoint,

Continued from p. 274                          when people lost their livelihood                  American liberals argued that social in-
to purchase food, clothing, housing            through unemployment, disability or            surance for health would unite the en-
and access to health services. Gov-            retirement. In 1883, Germany added             tire population into a single risk pool and
ernments were seen as necessary to             health care to its social-insurance of-        serve everyone’s long-term interest, ac-
guarantee those needs, explains Thomas         ferings, though with a twist. Unlike           cording to Bodenheimer. Though younger
Bodenheimer, adjunct professor of com-         other programs, health insurance was           people would pay for older people, and
munity medicine at the University of           run by privately operated “sickness            healthy people for sick people, this would
California, San Francisco. 45                  funds.” Social insurance, including            even out in the end, progressives argued,
    In the late 1800s a conservative           for health care, soon became the               since the young will one day be old and
German government enacted the first            European norm.                                 the healthy injured or sick. 46
social-insurance programs in hopes of              In the United States, lawmakers de-            But conservatives answered that it’s
heading off a wholesale movement to-           bated social insurance for decades and         unfair to force young people to sub-
ward more radical socialism with gov-          ultimately used it for a few programs.         sidize health care for older, sicker
ernment ownership of industries. Sup-          But health insurance remained a vol-           neighbors and that people will spend
ported by mandatory contributions from         untary purchase, managed by private            more prudently on medical care if
all citizens, the first programs paid out      companies.                                     they buy their own.

276        CQ Researcher
 California’s biggest [for-profit] insurer,                                                   Bush’s proposed deduction has a much
 puts 80 cents on the dollar toward care,                                                     higher dollar value for higher-income
                                                                                              people. 2

                                                                                         Getty Images/Ethan Miller
 holding on to a full 20 cents for prof-
 its and administration,” he says. Never-                                                         The Edwards plan — The presidential
 theless, “everybody knows that it can                                                        candidate also proposes an individual
 be done for less. In Medicare, 95 cents                                                      mandate, but the requirement would only
 on every dollar goes to patient care.”                                                       kick in once new, affordable coverage
     President George W. Bush — The                                                           options are available and employers are
 president wants to replace the current                                                       either contributing to a general pool or
 unlimited government subsidy for em-                                                         helping their own workers buy coverage
 ployer-sponsored health coverage with                                                        through new, regional nonprofit pur-
 a flat standard deduction available to     Former Sen. John Edwards, D-N.C., is the          chasing pools known as “health markets.”
 everyone who buys at least catastrophic     first presidential candidate to propose a        The federal government would help
                                                detailed universal health-care plan.
 health coverage on their own or through                                                      states or groups of states set up such
 an employer. Federal funds would be available for states to im- health markets, which would offer a choice of competing health
 prove their markets for individual health policies, where people policies. Unlike most current proposals, the health markets would
 would shop for non-workplace coverage.                              offer all buyers — in addition to private coverage — a public-
     Economists praise Bush for proposing to replace the gov- insurance plan modeled on Medicare.
 ernment’s current subsidy for health insurance — the exclu-             “Let’s have real competition between public and private sys-
 sion from taxable wages of employer-sponsored coverage — tems,” says Yale University Professor of Political Science Jacob
 with more widely available assistance. But some critics on both Hacker, who consulted with Edwards on the proposal. “If you
 the left and right agree the proposal doesn’t target the people put a level playing field between the public and private sec-
 most in need of subsidies and doesn’t help create enough af- tors” — as in the health markets — the public programs “might
 fordable coverage for them to buy.                                  turn out to be cheaper. If that happens over time, people would
     “Replacing the current tax treatment with a new standard vote with their feet,” he says.
 deduction is a big step in the right direction,” said Heritage
 Foundation Vice President Stuart M. Butler and Senior Policy 1 Renuka Rayasam, “Schwarzenegger Health Plan Raises Doubts.” U.S. News
 Analyst Nina Owcharenko. Nevertheless, “an even better step & World Report, Jan. 10, 2007,
 would be to replace it with a tax credit,” which would help 2 Stuart M. Butler and Nina Owcharenko, “Making Health Care Affordable:
 lower-income families who are least likely to have insurance, Bush’s Bold Health Tax Reform Plan,” WebMemo No. 1316, Heritage Foun-
 they said. Unlike tax credits, which benefit everyone equally, dation, Jan. 22, 2007.

                                                 The first such policy was sold in                                      The mining, railway, and lumber
  Sickness Insurance                         1850 by the Massachusetts-based                                         industries led the way in establishing
                                             Franklin Health Assurance Company.                                      insurance plans more similar to mod-
                                             For a 15-cent premium, the policy paid                                  ern HMOs (health maintenance or-

T     he private market for what we
      call health insurance today —
policies that pay medical bills — grew
                                             $200 if its holder was injured in a rail-
                                             way or steamboat accident. 47
                                                 Some employers offered sickness
                                                                                                                     ganizations), paying medical costs.
                                                                                                                     Their workers faced serious health
                                                                                                                     risks and labored in remote locations
slowly, mainly because health costs          insurance as a worker benefit. In 1910,                                 where traditional care wasn’t avail-
were low, even in the early 20th cen-        the catalog store Montgomery Ward                                       able. So companies established clin-
tury. Before 1920, there were virtually      and Co. established a group insurance                                   ics that prepaid doctors fixed month-
no antibiotics and few effective drugs,      plan to pay half of an ill or injured                                   ly fees to provide care.
and X-rays had been discovered only          employee’s salary. 48 In 1918, the Dal-                                    Nevertheless, between 1910 and 1920,
in 1895. Most of the financial burden        las, Texas, school system established                                   near the end of the so-called Progres-
from illness was due to lost wages,          sickness insurance to protect teachers                                  sive Era in American politics, “govern-
so insurers sold income-protection           against impoverishment during the great                                 ment-sponsored health insurance
“sickness” or “accident” insurance.          influenza epidemic. 49                                                  seemed a practical possibility in the

Available online:                                                                                        March 30, 2007           277

 Stakeholder Groups May Balk at Changes
 They fear paying more, losing coverage

 A         s costs and the ranks of the uninsured soar, there’s          ance in favor of a government-run universal plan modeled on
           plenty not to like about the current health-care sys-         Medicare are politically impossible today. However, most re-
           tem. Nevertheless, many longtime stakeholders fear            form plans would force insurers to cover potentially sicker ben-
 change. As has often happened in the past, insurance compa-             eficiaries than most do today and would tighten rules for sell-
 nies, health providers, employers and those with expansive              ing and marketing insurance policies.
 work-based health coverage all may balk at the changes uni-                 Many insurers mistrust changes because the current em-
 versal coverage may bring.                                              ployer-based system works well for them by weeding out the
     “You often see interest groups wearing a cloak of ideology,”        sickest populations, said former Rep. William Thomas, R-Calif.,
 saying they oppose a reform plan on economic or philosophical           who chaired the House Ways and Means Committee. Employed
 grounds when they’re really protecting their money, says Stanley        people “have to get up every morning, go to work and carry
 Dorn, a senior research associate at the liberal Urban Institute.       out difficult and complex tasks.” They’re essentially prescreened
     For example, he says, during the bitter debate over President       to be, on average, healthier than the general population and
 Bill Clinton’s universal-coverage plan in the early 1990s, “you had     thus easier to cover and still earn profits, he said. 3
 companies that didn’t provide insurance to their workers and                Insurers also distrust government-run “insurance exchanges”
 knew they could lose money” if the proposal succeeded. “But             in many universal-coverage plans that would establish standard
 they didn’t talk about that. They talked about how evil it would        benefit packages, ensure affordability and replace insurers’ mar-
 be for the government to take over the health system.”                  keting with government-scrutinized plan descriptions. Insurers
     Various employer groups are likely to weigh in on both sides        have “traditionally hated” government limits on their market-
 of the debate. Those who offer health coverage as a benefit today       ing, says Dorn.
 are more likely to embrace the change, although they may still be           Finally, virtually all economists say any health system re-
 hesitant to endorse all universal-coverage proposals, says Paul Gins-   form must include cost cutting, including reining in salaries and
 burg, president of the Center for Studying Health System Change,        profits of doctors, hospitals and drug manufacturers. Some pro-
 a nonpartisan research group. “They’d like to get out of the busi-      posals ask providers to put money in up front to support cov-
 ness of coverage long term, but the issue has always been whether       erage proposals. Providers always push back against such steps.
 they’d end up paying more in taxes” for a new universal cover-              For example, when Democratic Maine Gov. John Baldacci
 age system than they spend now to provide benefits, he says.            unveiled a universal-coverage program in 2003, he included a
     Large, unionized employers like U.S. automakers initially           tax on insurance premiums along with both voluntary and
 supported the Clinton plan in 1993, said Walter Mahan, former           mandatory price caps on many health services, without which
 vice president for public policy of DaimlerChrysler Corp. 1 Em-         the governor said the program could not survive. Maine’s hos-
 ployers who didn’t offer health benefits strongly opposed the           pitals said they couldn’t survive having prices capped.
 Clinton plan, which, like many universal-coverage plans today,              “That cannot happen . . . without irreparably harming Maine’s
 asked all businesses to chip in, including those that didn’t offer      hospitals,” said Warren Kessler, a consultant and former head
 health benefits before.                                                 of the Maine General Medical Center in Augusta. 4
     Caught somewhat off guard by ferocious opposition from busi-            Finally, those who currently have good coverage are sensi-
 nesses that didn’t offer coverage — like restaurants and soda           tive to any proposal that might make their own insurance worse
 manufacturers — architects of the Clinton plan reduced the pay-         or cost more. Interest groups like insurers and doctors who
 ments required from companies that had not previously offered           oppose any new plan “just have to play on the public’s fear
 coverage and hiked the amount asked from employers who of-              of losing what they now have,” says Dorn.
 fered coverage. Complaining of unfairness, unionized employers
 then pulled their support, said Mahan. The bad news for the             1 “Universal Coverage: It Can’t Happen Here . . . Or Can It?” Medicine

 new crop of reformers: More and more companies have been                & Health Perspectives, March 31, 2003.
                                                                         2 Quoted in ibid.
 dropping coverage since then, so the constituency of business-          3 Quoted in “Thomas Takes Aim Again at Tax-Favored Employer Coverage,”
 es not offering coverage “is stronger now,” he said. 2                  Medicine & Health, Feb. 16, 2004.
     Insurers may have the biggest stake in the current system.          4 Quoted in “Baldacci Says Everyone Must Give a Little to Fund Care,”

 Most analysts say proposals that would abolish private insur-           Medicine & Health, May 12, 2003.

United States,” according to the Uni-           New York — recommended universal                 coverage was adopted they would lose
versity of Pennsylvania’s Stevens. In           state-sponsored health insurance. 50             control and cash. The chairman of Ohio’s
1920, expert panels in four large states            However, doctors, hospitals and in-          commission complained about “the con-
— California, New Jersey, Ohio and              surance companies feared if universal            fusion into which the public mind had

278       CQ Researcher
been thrown by the misleading, mali-        munism — inciting to revolution,” wrote         But even in the early days, em-
cious and false statements emanating        Morris Fishbein, editor of the Journal       ployer-provided insurance had limits.
from an interested and active commercial    of the American Medical Association. 57      Many retired people, very low-income
insurance opposition.” 51                                                                families and the disabled never had
   Soon, popular support for govern-                                                     workplace-based insurance and were
ment-sponsored insurance dropped to            Workplace Plans                           too poor to buy individual policies,
a low level again, as financial worry                                                    for which they would be charged pre-
receded in the 1920s economic boom.
In the overall prosperity of that
decade, the medical system flourished,
                                            D      uring the 1930s, as businesses
                                                   folded and millions sank into
                                            poverty, the United States made its
                                                                                         miums based on health status.
                                                                                            After several years of debate, Con-
                                                                                         gress in 1965 enacted a new compul-
and hospitals built new wings in the        largest-ever foray in social insurance.      sory, universal insurance plan — the
mood of general optimism.                      Developed by Democratic Presi-            Medicare program — to provide health
   By 1929, however, more than a            dent Franklin D. Roosevelt and en-           coverage for elderly and some disabled
third of hospital beds were empty,          acted in 1935, Social Security is a          people and Medicaid to provide health
and many hospitals struggled to pay         mandatory, universal system that pro-        care for the poorest mothers with chil-
off the loans that had funded ex-           vides income support for retirees, se-       dren, elderly and the disabled.
pansion. Baylor University Hospital in      verely disabled people, widows and
Dallas, for example, had $1.5 million       under-age bereaved children. During
in overdue loan payments for con-           the debate over passage, activists ar-          Coverage Declines
struction and was behind in other bills.    gued for including health insurance,
“Baylor was just 30 days ahead of the
sheriff,” said one observer. 52 Baylor’s
crisis led to health insurance as we
                                            but the administration declined, in part
                                            because it feared the contentious health
                                            issue might doom the whole plan. 58
                                                                                         W        ith Medicare and Medicaid in
                                                                                                  place, most Americans had ac-
                                                                                         cess to health care.
know it today.                                 Later, members of Congress made               Nevertheless, health spending was
   In search of cash, Baylor made com-      unsuccessful attempts to extend social-      rising sharply, and Presidents Richard
mon cause with local employers. In late     insurance to health in 1943, 1945, 1947,     M. Nixon and Jimmy Carter both pro-
1929, the Dallas school system set up       1949 and 1957. Nevertheless, by 1966,        posed reforms to keep care afford-
a hospital-service prepayment plan that     81 percent of Americans had hospital-        able, including universal coverage. Nei-
operated alongside its sick-benefit fund.   ization insurance — mostly offered           ther plan gained traction, however.
For a monthly premium of 50 cents,          through their workplaces and often as            Gradually, the higher costs and the
teachers would get free hospitalization     a result of labor union demands —            changed nature of American business
for 21 days and a one-third discount        compared to only 9 percent in 1940. 59       began to erode the work-based in-
on additional days. Benefits became ef-        Unlike today, from 1940 to 1966           surance system.
fective on Dec. 20, 1929, less than two     large unionized companies dominated              “Forty years ago, the largest private
months after the stock market crash. 53     the economy. Offered as a worker             employer was AT&T, a regulated mo-
   A few days later, elementary-school      benefit, employer-sponsored health           nopoly with guaranteed profits,” wrote
teacher Alma Dickson slipped on an          plans successfully pooled the risk and       Stanford University Professor Emeritus
icy sidewalk and broke her ankle. 54        contributions of many employees in           Victor Fuchs and Ezekiel Emanuel, chair-
Hospitalized with a cast, Dickson be-       order to keep individuals’ costs low         man of clinical bioethics at the National
came the first patient in the first pre-    and uniform, even in years when they         Institutes of Health. “If health-insurance
paid hospitalization plan, the forerun-     had accidents or illness. And, since the     premiums rose, they could easily be
ner of today’s Blue Cross system. 55        sickest people are unlikely to be em-        passed on to telephone subscribers.” 61
   By 1935, 19 such plans had been          ployed, relying on workplace-based               That changed, however, as union
created in 13 states, as hospitals strug-   plans allowed private insurers to more       membership began declining in the
gled to stay afloat during the Great        easily predict and control costs.            1980s, and manufacturing jobs began
Depression. 56                                 As the primary source of Americans’       migrating overseas and U.S. compa-
   But many influential physicians ar-      health insurance, the still union-domi-      nies had to compete with foreign
gued that “prepayment” threatened pro-      nated U.S. auto industry has evolved         competitors that don’t offer health ben-
fessional independence. Recommenda-         over the years into “a social-insurance      efits. More and more Americans
tions that the nation adopt insurance to    system that sells cars to finance itself,”   ended up working in the largely non-
protect people against the rising cost of   said Princeton University economics          unionized service industry, which of-
care amounted to “socialism and com-        Professor Uwe Reinhardt. 60                  fered few benefits.

Available online:                                                             March 30, 2007             279
    “Today, the largest private employer                                                        Former first lady Clinton — now
is Wal-Mart, which despite its size faces        Clinton Plan                               the Democratic senator from New
intense competition daily from a host                                                       York who is running for president —
of other retail outlets,” Fuchs and Emanuel
wrote. “When they offer health insur-
ance, it must come out of their work-
                                              T     he highest-profile recent effort to
                                                    enact a universal health care plan
                                              was President Bill Clinton’s ambitious
                                                                                            has assured voters she still believes in
                                                                                            universal health coverage, but she has
                                                                                            not yet announced a specific plan. “I
ers’ wages; for minimum-wage em-              proposal to restructure the nation’s          think she’s learned her lesson” and
ployees, this is not possible.” 62            health care system, unveiled on Sept. 22,     likely will propose something “not quite
    Over the past two decades, em-            1993. His Health Security Act was pro-        as big and ambitious” this time, says
ployer-sponsored coverage has grad-           posed at a time when the uninsured            Brandeis’ Altman.
ually waned, along with the number            ranks had swelled to 40 million, and              For the next decade the dramatic
of insured Americans. Government pro-         polls showed that up to two-thirds of         failure of the Clinton plan frightened
grams have grown and picked up some           Americans favored tax-financed na-            lawmakers away from the issue, while
of the slack, however.                        tional health insurance. 64 Yet, within       conservative lawmakers said the boom-
    In 1987, fully 87.1 percent of Amer-      a year Senate Democrats had pro-              ing 1990s economy would enable the
icans were insured, with 75.7 percent         nounced the plan dead, the victim of          United States to “grow its way” out of
insured through private, mostly employer-     bruising attacks by business, insurers        uninsurance by creating more and bet-
sponsored, coverage. By 1999, the per-        and medical providers. 65                     ter jobs with coverage benefits.
centage of insured Americans had                  Five days after his inauguration, Clin-       But that did not turn out to be the
dropped to 85.5.percent, 71.8 percent         ton announced that first lady Hillary         case. From 1997 to 2001, the econo-
through private coverage. In 2005, the        Rodham Clinton would chair a health-          my boomed and jobs were created,
overall percentage had dropped to 84.1        care task force made up of Cabinet            but rates of employer-sponsored
percent — 67.7 percent with private in-       members and White House staffers. It          health insurance did not rise. The late
surance. 63 (See graph, p. 272.)              held hearings for a year and produced         ’90s experience “tells us that relying
    In the face of declining coverage,        a plan to attain universal coverage main-     on economic growth alone to reduce
proposals to expand coverage have             ly through expanded private coverage.         the number of uninsured won’t work,”
been advanced repeatedly by the White         It aimed to offer people a choice of af-      said Ginsburg at the Center for Study-
House, members of Congress, state and         fordable coverage while maintaining the       ing Health System Change. 67
local governments and others. Only            existing private insurance industry and           Since Clinton’s efforts, Congress en-
some small-scale efforts have gone any-       holding down health-cost growth.              acted two coverage expansions. The
where, however.                                   To do that, the Clinton panel pro-        State Children’s Health Insurance Program
    In 1994, Tennessee used federal           posed creating regional government-           (SCHIP) was enacted in 1997. The Clin-
Medicaid dollars and state funding to         managed insurance markets to nego-            ton administration and a bipartisan group
create TennCare. State officials hoped        tiate health-care and premium prices          of lawmakers led by Sens. Edward M.
money-saving HMOs could provide               and insurance-benefit packages and to         Kennedy, D-Mass., and Orrin G. Hatch,
coverage to many lower-income peo-            oversee insurance marketing. It also          R-Utah, gave states federal matching funds
ple and sicker Tennesseans, who were          called for annual caps on health-cov-         to expand coverage for children in low-
ineligible for Medicaid and couldn’t af-      erage cost increases, and a require-          income families. Today, SCHIP operates
ford insurance on their own.                  ment that all employers contribute to         in all states, making nearly all otherwise
    For a few years, the program saved        the cost of coverage.                         uninsured children with family incomes
money and enrolled 500,000 residents              But opposition soon grew from busi-       up to twice the poverty level eligible for
who would otherwise have been unin-           nesses that believed they had more to         public coverage.
sured. But the federal government had         lose than to gain from change. Em-                With Republicans dominating the
agreed to contribute funding for only         ployers who didn’t offer coverage             White House and Congress, most recent
1.5 million people, and when enroll-          balked at proposed fees to help fi-           debate over coverage has focused on
ment exceeded that cap, TennCare re-          nance the plan. Insurers objected to          tax incentives to help Americans buy in-
fused to accept new applicants and            regulations aimed at keeping them from        surance. Criticized by lawmakers of both
struggled financially. For the past sev-      skimming off healthy customers. After         parties for offering too-small tax breaks
eral years, TennCare has fought to sur-       10 months of strenuous campaigns by           in its early proposals, the Bush admin-
vive, plagued by charges of poor care         opponents, public approval had                istration has gradually expanded its plan
at its HMOs and disputes with the fed-        dropped to a lukewarm 40 percent. 66          each year but has seen none enacted.
eral government over funds.                   (See sidebar, p. 278.)                                                Continued on p. 282

280       CQ Researcher
                                                At Issue:
Should Congress enact President Bush’s tax proposal for
expanding health coverage?

                              STUART M. BUTLER,                                      KAREN DAVIS
                              VICE PRESIDENT                                         PRESIDENT, THE COMMONWEALTH FUND
                              NINA OWCHARENKO,                                       FROM THE FUND’S WEB SITE, JANUARY 2007
                              SENIOR POLICY ANALYST
                              THE HERITAGE FOUNDATION

                                                                                    hile it is encouraging that President Bush made

            yes no
          resident Bush’s proposal to reform the tax treatment of                   health care a theme of the State of the Union ad-
          health care takes a bold step toward fixing America’s                     dress, his proposal to offer tax deductions to those
          health system by widening the availability of affordable   who buy health insurance would do little to cover the nation’s
          and “portable” health plans and by defusing some of        45 million uninsured.
the pressure that currently leads to higher health costs.                Under the president’s proposal, Americans with employer-pro-
   Although some Americans would have more of their                  vided health insurance would have the employer contribution
compensation subject to taxes, this proposal is no more a            counted as taxable income. But anyone with health coverage —
tax increase than limiting or ending tax deductions to move          whether provided by an employer or purchased individually —
toward a flatter tax system. It would remove distortions and         would have the first $7,500 of income excluded from income and
inequities and make tax relief for health insurance more             payroll taxes or, in the case of families, the first $15,000 of income.
widely available.                                                        Those purchasing coverage in the individual market would
   While the proposal can be improved in ways that would             get a new tax break, as would those whose employer contri-
further reduce uninsurance, it is a big step toward sound tax        bution currently is less than the new standard deduction for
and health policy. It would treat all Americans equally by           health insurance.
ending the tax discrimination against families who buy their             The proposal would increase taxes on workers whose em-
own health insurance, either because they do not have insur-         ployers contribute more to health insurance than the premium
ance offered by employers or because they prefer other cov-          “cap” allows, such as those that serve a large number of older
erage.                                                               workers. The administration estimates this change would translate
   Ending that discrimination would have the added advantage         into a tax increase for about 20 percent of employees. However,
of stimulating wider choice and greater competition in health        this could rise to more than half of employees by 2013, if in-
coverage, which will help moderate the growth in costs. It           creases in health-insurance premiums continue to outpace gener-
would also make it easier for families to keep their chosen          al inflation. In addition, the president proposes diverting federal
plan from job to job, reducing the loss of coverage that often       funds from public hospitals to state programs for the uninsured.
accompanies job changes.                                                 Although the plan would offer subsidies to people looking
   The president’s proposal could be improved. While replac-         to buy insurance on the private market, it would fail to assist
ing the tax treatment with a new standard deduction is a big         most of the uninsured. Insurance premiums would still be un-
step in the right direction, an even better step would be to         affordable for Americans with modest or low incomes. And the
replace it with a tax credit more like the current child tax         tax increase for employees would likely lead to the erosion of
credit — at least for those buying health coverage outside           employer-sponsored health insurance over time.
their place of work. A tax credit would especially help lower-           The proposal wouldn’t do anything to make individual cov-
income families. With a deduction, many families would still         erage available or affordable for those with modest incomes
be unable to afford basic coverage, but a credit set at a flat       or health problems. The Commonwealth Fund found that one-
dollar amount or a high percentage of premium costs would            fifth of people who had sought coverage in the individual
make coverage more affordable.                                       health-insurance market in the last three years were denied
   A tax credit could be grafted onto the president’s current        coverage because of health problems or were charged a high-
proposal and would strengthen it considerably.                       er premium. The proposal, unlike plans in California and
   By taking this step, Congress can help make the tax treat-        Massachusetts, does not require insurers to cover everyone.
ment of health care more equitable and efficient, help more              Nor would the proposal likely help the currently uninsured.
Americans choose the coverage they want and retain it from           More than 55 percent of the uninsured have such low in-
job to job and begin to reduce the tax-break-induced pressure        comes that they pay no taxes, while another 40 percent are
that is a factor in rising health costs.
                                                                     in the 10-to-15-percent tax bracket and would not benefit
                                                                     substantially from the tax deductions.

Available online:                                                                   March 30, 2007                281
Continued from p. 280                            Meanwhile, outside of legislative              Coalitions of interest groups have
    The only federal health-coverage          chambers advocates increasingly have         come together in 2007 to announce
expansion enacted in this decade was          been calling for universal coverage. In      support for universal coverage. In Jan-
a tax credit to assist workers unem-          2004, a three-year-long Institute of Med-    uary, the Health Coverage Coalition for
ployed due to competition from in-            icine study declared that eroding cov-       the Uninsured (HCCU) advocated a
ternational trade, enacted in 2002            erage poses such a threat that the fed-      phased-in approach to universal cov-
after a long contentious delay. But the       eral government must launch a “firm          erage, beginning with an expansion of
credit has reached only 10 to 20 per-         and explicit” plan to achieve univer-        SCHIP and creation of tax credits for
cent of those eligible for it, says the       sal coverage by 2010. 68                     families with incomes up to about
Urban Institute’s Dorn, which he calls           Many analysts agree that universal        $60,000, and then creating similar pro-
a “tragic” outcome for states like North      coverage has been stalled not because        grams for childless adults. 69
Carolina, where it was intended to            of a lack of knowledge of how to ac-              The coalition includes groups that
help people facing “the largest layoff        complish it but because lawmakers            have traditionally sparred over health
in the state’s history — the closing of       lack the will to demand sacrifices. (See     care, including Families USA, the re-
the textile mills.”                           sidebar, p. 270.)                            tiree organization AARP, the American
    The program failed to catch on be-           There are “at least four ways” to         Medical Association, the American Hos-
cause its premiums are too high, he           get universal coverage, says Simmons         pital Association and the health-insur-
says. “It’s not realistic to ask people to    of the National Coalition on Health          ance lobby America’s Health Insurance
pay 35 percent of premiums when               Care. “This problem is solvable. It does     Plans. “Organizations that have never
they’re not working” when working             not require atomic science.”                 spoken to one another in a friendly
people pay only 15 to 25 percent of                                                        manner are now talking about this,
theirs, he says. In addition, the tax cred-                                                and that has transformed the debate,”
it in most states could only be used for
individual policies, whose premiums           CURRENT                                      says Pollack of Families USA.
                                                                                                Others aren’t convinced. The HCCU’s

generally are based on age and health                                                      “rhetoric was wonderful,” says Altman
status. “Even with a 65 percent sub-                                                       of Brandeis. “But the result shows how
sidy, people were facing an unafford-                                                      little they actually agree on.”
able $1,000 a month premium.”                                                                   But Pollack says the coalition’s
    Over the past decade, some con-                                                        proposal is a “sequential” plan that
gressional Republicans also have pro-            Interest Grows                            will follow expansion of the children’s
posed allowing business and profes-                                                        program — expected to be enacted
sional groups to offer association health
plans (AHPs), which would enable
small businesses and the self-employed
                                              A      few states are moving forward
                                                     with universal-coverage plans, but
                                              little action is expected on Capitol Hill
                                                                                           this year — with a move to universal
                                                                                           coverage after that.
                                                                                                In February the Service Employees
to band together to buy health insur-         this year. Meanwhile, all Democratic         International Union joined with Wal-
ance free from the state regulations          contenders for the 2008 presidential         Mart, an employer whose limited health
that apply to individual and small-           nomination have advocated universal          benefits have been sharply criticized
group insurance plans, which AHP ad-          coverage, although only former Sen.          by the union, to form the Better
vocates say unduly drive up coverage          Edwards has offered a specific plan          Health Care Together group, calling for
costs for small business.                     so far. (See sidebar, p. 276.)               “quality, affordable” universal health care
    In the 1970s Congress waived state             While few expect federal action until   by 2012. The group plans a national
insurance regulation for large employ-        after the next president takes office in     summit this spring to rally support but
ers to encourage them to provide cov-         2009, many Washington hands think            has not announced a proposal, saying
erage for workers. But today both De-         the tide finally may be turning.             only that it supports joint public and
mocratic and some Republican                       “One big difference between now         private-sector efforts. 70
lawmakers staunchly oppose allowing           and several years ago is that there is            But Dana Rezaie, a Wal-Mart shelf
AHPs the same freedom. AHP oppo-              a loss of faith in employer-provided         stocker in Fridley, Minn., says, “any-
nents argue that it is too easy for such      coverage as capable of covering              body can say they support something.
loosely formed groups to skim off work-       everyone, including from unions and          They need to show they really do.”
ers most likely to be healthy and low-        key business groups” who have been           After six years at the store, the widowed
cost, which would raise premium costs         its strongest supporters, says Yale’s        mother of three says she can’t afford
even higher for those left behind.            Hacker.                                      Wal-Mart’s health plan. 71

282        CQ Researcher
    Congress is reviewing President        ance, often with government assistance.     coverage plan, which undoubtedly
Bush’s fiscal 2008 budget, which pro-      A state-operated clearinghouse — the        would shift some resources and bene-
poses a new version of his tax-based       Health Insurance Connector — will           fits away from currently insured people
coverage-expansion proposals. Bush         help consumers comparison-shop for          and health providers.
would ditch the current tax break Amer-    affordable coverage. So far, however,           Some interest groups that helped
icans receive for employer-sponsored       the state is struggling to define bene-     bring down the Clinton plan have
coverage and replace it with a more        fit packages that insurers can sell at      softened their stance, says Ginsburg
general tax break that would apply         “affordable” prices.                        at the Center for Studying Health Sys-
both to employer coverage and to in-           Meanwhile, the California legislature   tem Change. In Massachusetts, he
surance purchased individually.            is considering Gov. Schwarzenegger’s        points out, insurers have accepted
    The plan gets points from Green-       proposal to require individuals to buy      the new state-run insurance market-
stein at the Center on Budget and Pol-     coverage. The plan would be funded          place, even though in the past they
icy Priorities for tackling the unfair-    with contributions from multiple sources,   would have preferred to send out
ness of the current tax treatment of       including government, individuals, em-      their own people to market policies
insurance, which penalizes those who       ployers, insurers and health-care           and avoid head-to-head consumer
purchase insurance on their own. But       providers.                                  comparisons of plans. But insurers
the plan “has an Achilles’ heel,” Green-       Vermont’s new Catamount Health          realize that their long-time bread and
stein says, since it doesn’t encourage     program will focus first on promoting       butter — employer-sponsored cov-
pooling sicker and healthier people to     information technology and other re-        erage — “has topped out,” Ginsburg
spread costs and skews its tax bene-       forms to shave administrative costs         says, so they anticipate no growth
fits toward higher-income people.          and an evidence-based standard of care      unless they embrace government-
    Nevertheless, Pollack does not ex-     “community by community,” says              sponsored expansions.
pect “a serious productive debate on       Emory University’s Thorpe, who con-             “There’s [been] a dramatic change
universal coverage” in 2007, with a        sulted on the program. Then the state       in national political attitudes,” says Sim-
presidential campaign heating up. How-     will turn to expanding coverage.            mons of the National Coalition on Health
ever, he does expect Congress to reau-         In Texas, where more than 25 per-       Care. One “truly remarkable thing is
thorize — and possibly expand — the        cent of the population is uninsured, Re-    that every Democratic and some Re-
10-year-old SCHIP program “before          publican Gov. Rick Perry is looking for     publican candidates now say we have
the end of the calendar year.”             revenue sources to subsidize more cov-      to achieve universal coverage.”
    The Bush budget recommends fund-       erage. In February he proposed selling          But others say the country may still
ing SCHIP leanly, by not offering fed-     off the state lottery and putting part of   not be ready to make the concessions
eral assistance, for example, to the 14    the proceeds in an endowment fund           needed.
states anticipating shortfalls in their    to expand insurance coverage. 73                “It’s not clear to me that life has
2007 SCHIP budgets. But both politi-           Last year, Rhode Island began re-       changed very much,” says Altman of
cal parties strongly support SCHIP and     quiring insurers to develop “wellness       Brandeis. Forces that have resisted
are likely to ride to the rescue. Sen.     benefit” policies to help individuals       change in the past “are stronger
Gordon Smith, R-Ore., has called for       and small businesses afford at least        today,” and “you have very weak
doubling the federal cigarette tax to      basic coverage. 74                          leadership” from the White House
pay for the aid. 72                                                                    and Congress.
                                                                                           Endorsement by Democratic presi-

  State Steps                              OUTLOOK                                     dential hopefuls doesn’t necessarily
                                                                                       mean much, says Harvard’s Blendon.
                                                                                       “Democratic primary voters dispro-
                                                                                       portionately care about this,” he says.

A     s health insurance gains mo-
      mentum as a public issue, many
states are flirting with expanding cov-
                                              Health Politics
                                                                                       But different priorities will prevail in
                                                                                       the general election. “The biggest
                                                                                       thing on everyone’s mind is casualties
erage, and three are struggling to get
universal coverage off the ground.
   Massachusetts was first out of the
                                           C     onsensus has been building
                                                 around proposals that link pub-
                                           lic subsidies to private coverage. But
                                                                                       in Iraq.”
                                                                                           Furthermore, Americans generally
                                                                                       “do not want an alternative health sys-
gate, enacting a plan in 2006 that will    it remains an open question whether         tem,” he continues. “They want to fix
require residents to buy health insur-     Congress will finally enact a universal-    the one they have.”

Available online:                                                           March 30, 2007              283
   Unfortunately for politicians, the sim-          8 Todd Gilmer and Richard Kronick, “It’s the       21 Jack Hadley and John Holahan, “The Cost

plest, catchiest sound bite on health               Premiums, Stupid: Projections of the Unin-         of Care for the Uninsured: What Do We
reform involves covering the uninsured,             sured Through 2013,” Health Affairs, April 5,      Spend, Who Pays, and What Would Full Cov-
but that doesn’t “play politically,” says           2005,                       erage Add to Medical Spending?” The Kaiser
                                                    9 Ibid.                                            Commission on Medicaid and the Uninsured,
Blendon. While people do want every-                10 “Coverage Matters: Insurance and Health         May 10, 2004, p. 5.
one to have access to health care,                                                                     22 “Maryland Universal Coverage Plan Esti-
                                                    Care,” statement of Arthur L. Kellerman, co-
“what they want most is cheaper pre-
                                                    chairman, Consequences of Uninsurance Com-         mated to Cost $2.5 Billion,” Healthcare News,
miums for themselves.”                              mittee, Institute of Medicine, www7.national       News-Medical.Net, Feb. 21, 2007,
                                          ; also see “How Much Would It
                                                    Affordable_Health_Care_Coverage.asp.               Cost to Cover the Uninsured In Minnesota?
    Notes                                           11 Quoted in “IOM Uninsured Report Cites           Preliminary Estimates,” Minnesota Depart-
                                                    Rising Costs, Attacks Myths.” Medicine & Health,   ment of Health, Health Economics program,
1  Jay Himmelstein, “Bleeding-Edge Benefits,”       Oct. 15, 2001.                                     July 2006.
Health Affairs, November/December 2006, p.          12 “The Great Divide: When Kids Get Sick,          23 For background, see Marcia Clemmitt, “Bud-
1656.                                               Insurance Matters,” Families USA, March 1,         get Deficit,” CQ Researcher, Dec. 9, 2005, p.
2 Jeffrey A. Rhoades, “The Uninsured in
                                                    2007,         1029-1052,
America, 2004: Estimates for the U.S. Civil-        great-divide.pdf.                                  24 “Universal Coverage Rx: Tax-Code Changes,
ian Noninstitutionalized Population Under Age       13 “Expanding Coverage Is Worth It for All,        Money, Insurance Pools and a Mandates,” in-
65,” Medical Expenditure Panel Survey Sta-          IOM Panel Insists,” Medicine & Health, June        terview with Jonathan Gruber, “On My Mind:
tistical Brief #83, June 2005, Agency for Health-   30, 2003.                                          Conversations with Economists,” University
care Research and Quality.                          14 Ibid. For background, see Marcia Clem-          of Michigan Economic Research Initiative on
3 Diane Rowland, executive vice president,
                                                    mitt, “Prison Health Care,” CQ Researcher,         the Uninsured,
Henry J. Kaiser Foundation, “Health Care: Squeez-   Jan. 5, 2007, pp. 1-24.                            25 Ibid.
ing the Middle Class With More Costs and Less       15 Quoted in “States Scramble for Ways to          26 “Health Expenditure,” Organization for
Coverage,” testimony before House Ways and          Cover Working Uninsured,” Medicine & Health,       Economic Cooperation and Development,
Means Committee, Jan. 31, 2007; for background,     “Perspectives,” Feb. 8, 2005.            ,2340,en_2649
see Keith Epstein, “Covering the Uninsured,”        16 Barack Obama, “Obama Statement on               _37407_2085200_1_1_1_37407,00.html; also
CQ Researcher, June 14, 2002, pp. 521-544.          President’s Meeting with Big Three Au-             see Rhoades, op. cit.
4 Christine Borger, et al., “Health Spending Pro-                                                      27 See Clemmitt, “Rising Health Costs,” op. cit.
                                                    tomakers,” press release, Nov. 14, 2006,
jections Through 2015: Changes on the Hori-                           28 “Pushed to the Edge: The Added Burdens
zon,” Health Affairs Web site, Feb. 22, 2006.       17 For background, see Marcia Clemmitt, “Ris-      Vulnerable Populations Face When Unin-
5 Rowland testimony, op. cit.
                                                    ing Health Costs,” CQ Researcher, April 7,         sured,” interview with Harold Pollack, “On
6 “Facts on Health Care Costs,” National Coali-
                                                    2006, pp. 289-312.                                 My Mind: Conversations With Economists,”
tion on Health Care,                  18 Quoted in “Frist: 100 Percent Coverage          University of Michigan Economic Research
7 Quoted in Steven Taub and David Cook,
                                                    Impossible, 93 Percent Not Working So Well         Initiative on the Uninsured,
“Health Care Can Bankrupt America,”,        Either,” Medicine & Health, Feb. 9, 2004.          29 Ibid.
March 6, 2007, For background, see Michael          19 Quoted in ibid.                                 30 John Kitzhaber, “Why Start With the Health
E. Chernew, Richard A. Hirth and David M.           20 Quoted in “Who Should Pay for Health            Care Crisis?” The Archimedes Movement,
Cutler, “Increased Spending on Health Care:         Care?” PBS Newshour Extra online, Jan. 19,
How Much Can the United States Afford?”             2004,              31 “Access to Healthcare and the Uninsured,”
Health Affairs, July/August 2003.                   tures/jan-june04/uninsured_1-19.html.              National Conference of States Legislatures,
                                                                                                       32 “Arthur Garson, “Help States Cover the

                                 About the Author                                                      Uninsured,” Roanoke Times, May 26, 2006.
                                                                                                       33 Stuart M. Butler, “The Voinovich-Bingaman

                         Staff writer Marcia Clemmitt is a veteran social-policy                       Bill: Letting the States Take the Lead in Ex-
                         reporter who previously served as editor in chief of Medi-                    tending Health Insurance,” Web Memo No.
                         cine & Health and staff writer for The Scientist. She has                     1128, The Heritage Foundation, June 15, 2006.
                                                                                                       34 George C. Halvorson, Francis J. Crosson
                         also been a high-school math and physics teacher. She
                                                                                                       and Steve Zatkin, “A Proposal to Cover the
                         holds a liberal arts and sciences degree from St. John’s
                                                                                                       Uninsured in California,” Health Affairs, Dec.
                         College, Annapolis, and a master’s degree in English from                     12, 2006,
                         Georgetown University. Her recent reports include “Cli-                       35 Quoted in Christopher Rowland, “Mass.
                         mate Change,” “Health Care Costs,” “Cyber Socializing”                        Health Plan Seems Unlikely to Be U.S.
                         and “Prison Health Care.”                                                     Model,” The Boston Globe, April 14, 2006.
                                                                                                       36 Ibid.

284         CQ Researcher
37  Quoted in “IOM Panel Demands Universal
Coverage by 2010,” Medicine & Health, “Per-
spectives,” Jan. 19, 2004.
                                                      FOR MORE INFORMATION
38 David Kravitz, “The Individual Mandate
                                                    Alliance for Health Reform, 1444 I St., N.W., Suite 910, Washington, DC 20005;
Still Sucks,” Blue Mass Group, Jan. 30, 2007,       (202) 789-2300; Nonpartisan, nonprofit group that disseminates                              information about policy options for expanding coverage.
39 Michael D. Tanner, “Individual Mandates

for Health Insurance: Slippery Slope to Na-         Economic Research Institute on the Uninsured, Re-
tional Health Care,” Policy Analysis No. 565,       searchers at the University of Michigan who conduct economic analyses of the
Cato Institute, April 5, 2006,        hows and whys of uninsurance and coverage-expansion proposals.
40 “Problems of Risk and Uncertainty,” The

Economics of Health Care, Office of Health          Families USA, 1201 New York Ave., N.W., Suite 1100, Washington, DC 20005;
Economics, p. 26,               (202) 628-3030; A nonprofit group that advo-
ohech3pg3.html.                                     cates for large-scale expansion of affordable health coverage.
41 Quoted in “Frist: Limit Tax Exclusion for

Employer-Based Coverage,” Medicine & Health,        The Health Care Blog, Blog published by health-care
                                                    consultant Matthew Holt; analyzes coverage proposals and other insurance issues.
July 19, 2004.
42 Ibid.
43 For background, see Anne-Emmanuel Birn,          Heritage Foundation, 214 Massachusetts Ave., N.E., Washington, DC 20002-4999;
                                                    (202) 546-4400; Conservative think tank that supports state-
Theodore M. Brown, Elizabeth Fee and Wal-           organized purchasing groups for health care.
ter J. Lear, “Struggles for National Health Re-
form in the United States,” American Journal        Kaiser Family Foundation, 1330 G St., N.W., Washington, DC 20005; (202) 347-
of Public Health, January 2003, p. 86; Laura        5270; Nonprofit private foundation that collects data and conducts
A. Scofea, “The Development and Growth of           research on the uninsured.
Employer-Provided Health Insurance,” Month-
ly Labor Review, March 1994, p. 3; Thomas           National Coalition on Health Care, 1200 G St., N.W., Suite 750, Washington, DC
Bodenheimer, “The Political Divide in Health        20005; (202) 638-7151; Nonprofit, nonpartisan group that supports
Care: A Liberal Perspective,” Health Affairs,       universal coverage; made up of labor, business and consumer groups, insurers and
November/December 2005, p. 1426.                    health providers’ associations.
44 Rosemary Stevens, foreword to Robert
                                                    Physicians for a National Health Program, 29 E. Madison, Suite 602, Chicago, IL
Cunningham III and Robert M. Cunningham, Jr.,
                                                    60602; (312) 782-6006; Nonprofit group that advocates for single-
The Blues: A History of the Blue Cross and Blue     payer national health insurance.
Shield System (1997), p. vii.
45 Bodenheimer, op. cit., p. 1426.
46 Ibid., p. 1432.                                 Plus Archive,          sured Boats,” Medicine & Health, Aug. 6, 2002.
47 Scofea, op. cit., p. 3.                         59 Cunningham and Cunningham, op. cit.             68 “IOM Panel Demands Universal Coverage
48 Ibid.                                           60 Quoted in Danny Hakim, ‘Health Costs            by 2010,” op. cit.
49 Cunningham and Cunningham, op. cit., p. 5.      Soaring, Automakers Are to Begin Labor Talks,”     69 “Unprecedented Alliance of Health Care
50 Stevens, op. cit., p. vii.                      The New York Times, July 14, 2003, p. C1.          Leaders Announces Historic Agreement,”
51 Quoted in Scofea, op. cit.                      61 Victor R. Fuchs and Ezekiel J. Emanuel,         Health Coverage Coalition for the Uninsured,
52 Quoted in Cunningham and Cunningham,            “Health Care Reform: Why? What? When?” Health      press release, Jan. 18, 2007, www.coalition-
op. cit., p. 4.                                    Affairs, November/December 2005, p. 1400.
53 Ibid., p. 6.                                    62 Ibid. For background, see Brian Hansen,         70 Dan Caterinicchia, “Rivals Want Health Care
54 “Dallas School Teachers, 1928,”;   “Big-Box Stores,” CQ Researcher, Sept. 10,         for All,” Columbus Dispatch [Ohio], Feb. 8, 2007.     2004, pp. 733-756.                                 71 Quoted in ibid.

teachersdal28.html.                                63 “Historical Health Insurance Tables,” U.S.      72 Alex Wayne, “War Supplemental To In-
55 Cunningham and Cunningham, op. cit., p.         Census Bureau,                     clude Money for Children’s Health Insurance
6. For background, see also “Sickness insur-       64 Bridget Harrison, “A Historical Survey of Na-   Program” Congressional Quarterly Healthbeat,
ance and group hospitalization,” Editorial Re-     tional Health Movements and Public Opinion         Feb. 27, 2007.
search Reports, July 9, 1934, from CQ Researcher   in the United States,” Journal of the American     73 Quoted in The Associated Press, “Texas

Plus Archive,          Medical Association, March 5, 2003, p. 1163.       Governor Has Funding Idea: Sell the Lottery,”
56 Scofea, op. cit.                                65 For background, see “Health-Care Debate         The Washington Post, Feb. 7, 2007, p. A7.
57 Quoted in Cunningham and Cunningham,            Takes Off,” 1993 CQ Almanac, pp. 335-347,          74 “Rhode Island: Making Affordable, Quality-

op. cit., p. 18.                                   and “Clinton’s Health Care Plan Laid to Rest,”     Focused Health Coverage Available to Small
58 For background, see “Federal Assistance         1994 CQ Almanac, pp. 319-353.                      Businesses,” States in Action: A Bimonthly Look
to the Aged,” Nov. 12, 1934, in Editorial Re-      66 Harrison, op. cit.                              at Innovations in Health Policy, The Common-
search Reports, available from CQ Researcher       67 “Rising Tide of Late ’90s Lifted Few Unin-      wealth Fund, January/February 2007.

Available online:                                                                            March 30, 2007                 285
                                                    Selected Sources

Books                                                                States take different approaches to expanding health coverage
                                                                    as worry over lack of insurance grows.
Derickson, Alan, Health Security for All: Dreams of Uni-
versal Health Care in America, Johns Hopkins Univer-                Gladwell, Malcolm, “The Moral Hazard Myth,” The New
sity Press, 2005.                                                   Yorker, Aug. 29, 2005.
  A professor of history at Pennsylvania State University ex-         Some fear that large-scale expansion of health coverage
amines the ideas and advocates behind the numerous 20th-            would encourage patients to rack up higher amounts of use-
century proposals for universal health care in the United States.   less health-care spending.

Funigello, Philip J., Chronic Politics: Health Care Security        Holt, Matthew, “Policy: Why Is Fixing American Health
from FDR to George W. Bush, University Press of Kansas,             Care So Difficult?” The Health Care Blog, Oct. 16, 2006;
  A professor emeritus of history at the College of William         10/abc_news_why_is.html#comment-2418315.
and Mary describes the politics behind a half-century of failed       An independent health-care consultant — along with blog
attempts at major health reform.                                    comments by analysts, businesspeople and members of the
                                                                    public — describes and discusses the interest-group politics
Gordon, Colin, Dead on Arrival: The Politics of Health              that shape the universal-coverage debate.
Care in Twentieth-Century America, Princeton University
Press, 2003.                                                        Holt, Matthew, “Risky Business: Bush’s Health Care Plan,”
 A professor of history at the University of Iowa explains          Spot-On Blog, Jan. 25, 2007;
how numerous private interests — from physicians desiring           holt/2007/01/bush_tax_deductions_and_the_lo.html.
autonomy to employers seeking to cement employer-em-                 An independent health-care consultant explains the concept
ployee relationships — have helped halt development of              of risk-pooling for insurance and the current tax break already
universal health coverage in America.                               enjoyed by workers with employer-sponsored coverage.

Mayes, Rick, Universal Coverage: The Elusive Quest for Na-          Reports and Studies
tional Health Insurance, University of Michigan Press, 2005.
  An assistant professor of public policy at Virginia’s Uni-        “Covering America: Real Remedies for the Uninsured,”
versity of Richmond explains how politics and earlier poli-         Vols. 1 and 2, Economic and Social Research Institute,
cy choices regarding the U.S. health system shape the range         June 2001 and November 2002.
of possibilities available for future reforms.                       Economists assembled by a non-partisan think tank analyze
                                                                    multiple proposals for achieving universal coverage.
Richmond, Julius B., and Rashi Fein, The Health Care
Mess: How We Got Into It and What It Will Take to Get               “Insuring America’s Health: Principles and Recommen-
Out, Harvard University Press, 2005.                                dations,” Institute of Medicine Committee on the Conse-
  Two Harvard Medical School professors recount the histo-          quences of Uninsurance, National Academies Press, 2004.
ry of American medicine and trends in financing health care           In its sixth and final report, an expert panel urges federal
and conclude that the United States could afford universal          lawmakers to create a plan for insuring the entire population
health coverage.                                                    by 2010.

Swartz, Katherine, Reinsuring Health: Why More Mid-                 Burton, Alice, Isabel Friedenzoh and Enrique Martinez-
dle-Class People Are Uninsured and What Government                  Vidal, “State Strategies to Expand Health Insurance Cov-
Can Do, Russell Sage Foundation, 2006.                              erage: Trends and Lessons for Policymakers,” The Com-
  A professor of health policy and economics at the Harvard         monwealth Fund, January 2007.
School of Public Health argues that more people could buy            Analysts summarize recent state initiatives to extend health
insurance and coverage would be cheaper if the federal gov-         coverage to more adults and children.
ernment offered insurance companies financial protection for
the highest-cost illnesses.                                         Haase, Leif Wellington, A New Deal for Health: How to
                                                                    Cover Everyone and Get Medical Costs Under Control,
Articles                                                            The Century Foundation, April 2005.
                                                                      A health analyst for the nonprofit group outlines cost, quality
Appleby, Julie, “Health Coverage Reform Follows State-              and coverage issues that the group says make it necessary for
by-State Path,” USA Today, April 5, 2006.                           the United States to switch to universal coverage.

286        CQ Researcher
                               The Next Step:
                          Additional Articles from Current Periodicals
Federal Solutions                                                 Graham, Judith, “A New Plan to Insure All; Proposal
                                                                  Would Require Illinoisans to Get Health Coverage,”
Harkness, Peter, “No Band-Aid for Medicaid,” CQ Weekly,           Chicago Tribune, Dec. 8, 2006, p. A1.
July 25, 2005, p. 2030.                                             A state task force has endorsed a plan that requires all
  Mike Leavitt and Tommy Thompson, current and former             Illinoisans to obtain health insurance.
secretaries of Health and Human Services, respectively, agree
that Medicaid problems can only be solved through the             Seewer, John, “Colleges Make Health Insurance Mandatory;
broader health-care system.                                       Some Fear Cost May Burden Students,” The Washington
                                                                  Post, March 27, 2005, p. A8.
Miller, Matt, “A Good Idea Inside a Bad One,” Time,                 Many public universities require students to have health
Feb. 5, 2007, p. 25.                                              insurance prior to enrollment.
 To make medical care more affordable, President Bush
wants to create a standard deduction for health insurance.        State Coverage Laws
Porter, Eduardo, “Health Care for All, Just a (Big) Step Away,”   “The Federalist Prescription; Health Care and the States,”
The New York Times, Dec. 18, 2005, p. C4.                         The Economist, Jan. 13, 2007, p. 27.
 The federal government plans to provide $130 billion for           In what could change the terms of the health-care debate,
Americans to buy health insurance.                                Gov. Arnold Schwarzenegger, R-Calif., said he wants to in-
                                                                  troduce universal coverage in his state.
Schuler, Kate, “White House Looks to Price Transparency
to Lower National Health Care Costs,” CQ Today, March 13,         Alonso-Zaldivar, Ricardo, “States Resurrect Topic of Medical
2006.                                                             Care,” Los Angeles Times, Nov. 13, 2005, p. A41.
  President Bush and congressional Republicans are pinning          Governors and legislators in 20 states have reached agreements
their proposals to lower health-insurance costs on consumers’     to expand medical coverage.
responsibility to make informed decisions.
                                                                  Ramer, Holly, “States Try to Extend Health Coverage for Col-
Walters, Jonathan, “SCHIP and Beyond,” Governing, March           lege-Age Young People,” The Associated Press, Jan. 3, 2006.
2007, p. 24.                                                        More states are allowing college-age adults to remain covered
 Congress is set to debate the reauthorization of the State       under the health-insurance plans of their parents.
Children’s Health Insurance Program.
                                                                  Schuler, Kate, “Mandatory Insurance Is Romney’s Big
Insurance Costs                                                   Pitch,” CQ Weekly, June 5, 2006, p. 1538.
                                                                    Republicans and Democrats alike have embraced Massachu-
“Schools Face ‘Death Spiral,’ ” USA Today, Feb. 15, 2006,         setts’ new law — proposed by GOP Gov. Mitt Romney.
p. 12A.
 Los Angeles school officials had thought their unfunded           CITING CQ RESEARCHER
health-care obligation for retirees was $5 billion, but their
                                                                       Sample formats for citing these reports in a bibliography
new estimate of $10 billion is bad news for taxpayers who
have to foot the bill.                                             include the ones listed below. Preferred styles and formats
                                                                   vary, so please check with your instructor or professor.
Agovino, Theresa, “Wealthy Americans Worry that Health
Care Costs Will Eat Their Assets,” The Associated Press,           MLA STYLE
April 7, 2006.                                                        Jost, Kenneth. “Rethinking the Death Penalty.” CQ Researcher
 A majority of 1,500 wealthy Americans surveyed said rising        16 Nov. 2001: 945-68.
medical costs was among their top financial concerns.
                                                                   APA STYLE
Mandatory Insurance                                                  Jost, K. (2001, November 16). Rethinking the death penalty.
Graham, John R., “Filet Mignon, Pinot Noir and an MRI;             CQ Researcher, 11, 945-968.
Compulsory Private Health Insurance Won’t Work,”
The Washington Post, Dec. 21, 2006, p. A29.
                                                                   CHICAGO STYLE
  It is far better to deregulate health insurance than to force      Jost, Kenneth. “Rethinking the Death Penalty.” CQ Researcher,
citizens into a system that does not serve their needs.            November 16, 2001, 945-968.

Available online:                                                             March 30, 2007              287
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