Life can be precarious for the 43 million Americans who lack health insurance. They often go without needed medical and preventive care. If struck by serious illness or injury, they not only face dire health consequences, but financial disaster as well. Most of the uninsured are low-income people without access to public coverage or employer-sponsored insurance. However, they comprise a diverse population, and their complex needs pose unique challenges to policymakers trying to design new options for extending affordable coverage. INQUIRY tackles this pressing matter in a special summer issue, "Strategies to Expand Health Insurance for Working Americans." The 11 papers highlight problems of the uninsured and present detailed suggestions for incrementally expanding insurance to those with no coverage or with unstable coverage. The proposals focus on tax credits and other financial incentives - ideas that have been part of recent congressional debate -- that could help uninsured people purchase health insurance for themselves and their families. They also explore approaches that build on existing public insurance bases or develop new group insurance options. The articles originated as background papers for a December 2000 conference, "Turning Campaign Promises into Reality: Opportunities for a New President and Congress to Expand Health Insurance Coverage," held in Washington, D.C., and sponsored by the Commonwealth Fund's Task Force on the Future of Health Insurance. The strategies discussed in the summer issue are intended to reach the uninsured population with incomes at or above 133% of the federal poverty level - what a full-time worker paid minimum wage earns - and, more generally, to provide more affordable insurance options for the working uninsured. The proposals address the difficulties associated with the uninsured population: its transitory nature; the need for premium assistance; the lack of a natural venue in which to purchase insurance; the significant number with high health risks; and the low rates of participation even when people qualify for public insurance. The options offered fall into four categories: expansions of public coverage, individual purchase incentives, expansions of employer-based programs and proposals designed for specific groups. Examples illustrate how these proposals actually might be applied. "No single incremental approach is likely to meet the needs of all the uninsured. Nor does any approach perfectly balance issues of participation, targeting, and equity. Policymakers will always face trade-offs among these goals," said Sherry Glied, a Columbia University health policy professor and author of the overview article, "Challenges and Options for Increasing the Number of Americans with Health Insurance." "While our fragmented and heterogeneous health insurance system appears to call for innovations that add rationality and order, a more effective incremental approach may be to add further complexity...A mix-and-match approach may work best...It is critical, however, that increased complexity remain at the level of the program and not overwhelm the participant," said Glied. Abstracts are available on Inquiry's Web site (www.inquiryjournal.org) for other articles in the summer issue:
- "A Health Insurance Tax Credit for Uninsured Workers," by Lawrence Zelenak
- "Public Subsidies for Employees' Contributions to Employer-Sponsored Insurance," by Mark Merlis
- "Markets for Individual Health Insurance: Can We Make Them Work with Incentives to Purchase Insurance?" by Katherine Swartz
- "Expanding Access through Public Coverage: Permitting Families to Use Tax Credits to Buy into Medicaid or SCHIP," by Alan Weil
- "Private Purchasing Pools to Harness Individual Tax Credits for Consumers," by Richard E. Curtis, Edward Neuschler, and Rafe Forland
- "Increasing Health Insurance Coverage through an Extended Federal Employees Health Benefits Program," by Beth C. Fuchs
- "Allowing Small Businesses and the Self-Employed to Buy Health Care Coverage through Public Programs," by Sara Rosenbaum, Phyllis C. Borzi, and Vernon Smith
- "A Federal Tax Credit to Encourage Employers to Offer Health Coverage," by Jack A. Meyer and Elliot K. Wicks
- "A Workable Solution for the Pre-Medicare Population," by Pamela Farley Short, Dennis G. Shea, and M. Paige Powell
- "Transitional Subsidies for Health Insurance Coverage," by Jonathan Gruber
