Toward Universal Coverage

The New York Times, Editorial

The national debate over health policy, which first occupied the top rungs of the political agenda in the 1992 presidential campaign, shifts focus as the nature of problems shifts. In the mid 1990’s, the focus was on the soaring cost of health insurance. Toward the end of the 90’s, attention shifted to alleged excesses of managed care plans. But one problem never fades away. That is the shameful fact that the United States is the only industrialized power that does not provide some form of universal health coverage for its people. Some 45 million Americans still lack health insurance, and despite a decade of prosperity, the number is growing.

The issue is not just that the uninsured live in constant fear of financial catastrophe. They also suffer medically from the lack of ongoing basic treatment. Studies show that the uninsured are substantially more likely to require hospitalization for festering medical problems like diabetes.

President Clinton proposed in 1993 to achieve universal coverage with a massive overhaul of the entire health care sector. But after the plan self-destructed, the administration did little to attack the problem. The issue flickered momentarily as Bill Bradley posed a thoughtful solution during his presidential campaign. Vice President Al Gore, after he snuffed out Mr. Bradley’s bid in the primaries, also turned away from the issue, and in the general election campaign, he and Gov. George W. Bush have offered piecemeal plans for extending health insurance coverage. But none of their proposals would knock more than a few million off the dreadful 45 million total that includes 10 million children.

Such tentativeness is unwarranted. There is no more important use of the $4.5 trillion surplus expected over the next 10 years than to do what other wealthy countries have proved is affordable.

The straightforward way to reduce the number of uninsured Americans is to provide them refundable tax credits to help pay for their health coverage. Tax credits lower a family’s tax bill dollar-for- dollar to offset the cost of insurance premiums. By making credits refundable, families too poor to owe much tax receive the offset as cash.

Mr. Bradley proposed tax credits of up to $5,000 per family to buy coverage from private plans, including those that cover federal employees. The plan would not have reached everyone – perhaps leaving 5 percent or more of the population uninsured. Yet the plan would still have cost perhaps $50 billion a year, a price tag that at one time paralyzed debate. But burgeoning surpluses – estimates of which have risen by trillions of dollars since Mr. Bradley proposed his idea – make a Bradley-like program affordable.

Governor Bush, by contrast, proposes a tax credit of up to $2,000, costing about $60 billion over 10 years. He would also spend $8 billion to build community health centers. But the tax credit is too skimpy to draw many uninsured families to policies that could cost them thousands of dollars a year more than the Bush credit would cover. Nor does the Bush proposal include requirements that parents buy coverage for children or strong penalties for states that fail to drive down the number of uninsured residents.

Mr. Gore’s platform calls for spending about $140 billion over 10 years to raise coverage among the uninsured. He proposes a refundable tax credit for individuals equal to 25 percent of the cost of their coverage. For a $2,000 premium, that would amount to a credit of only about $500.

Mr. Gore fears that tax credits large enough to attract the uninsured would encourage employers to drop coverage for workers. So he would also make more low-income children eligible for the Children’s Health Insurance Program, an existing state-run program, and open that program to the parents of eligible children. The Gore plan would permit children from families that earn too much to qualify for the program to buy coverage at an unsubsidized premium. But state programs have been slow to soak up many uninsured children, so Mr. Gore’s proposal, though over all a more effective approach than Mr. Bush’s, offers little prospect of making a giant step toward universal coverage.

Though it is unconscionable that the richest country in the world refuses to cover the insurance needs of all its residents, neither candidate proposes to do much about the problem anytime soon. True, they have plans to spend the surplus on other purposes, some of which are worthy in their own right. But if this moment – a moment of unprecedented economic prosperity and looming budget surpluses – is the wrong one for an aggressive move toward universal health insurance, when will it be right?


Grace-Marie Arnett is president of the Galen Institute, a health policy research organization based in Alexandria, VA. Readers may write her at, or P.O. Box 19080, Alexandria, VA, 22320.

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