|
| |
In Health Care,
Incremental Reform
Is Not Piecemeal
by Ken Frisof
unedited and by permission
and read the EINO critique of this essay
Haunted by Clinton’s debacle in ’93 - 94, mainstream
politicians have been reluctant to consider proposals for comprehensive health
care reform. In its place, they talk about "piecemeal" or
"incremental" reform as if the two are interchangeable. But they
are not.
An incremental reform definitively and permanently provides health
coverage to a part of the population. A piecemeal reform allows for both
increments and decrements of coverage. The health care reform discussions now
beginning anew bear a striking resemblance to the debates of 40 years ago. In
the late 1950s, in the aftermath of President Truman’s 1949 defeat on national
health insurance, leading liberal reformers proposed an incremental strategy –
provide permanent insurance to the most needy group, the elderly. Republicans
and conservatives countered with a piecemeal strategy – provide hospital
insurance only to the poor elderly.
When comprehensive health care reform was finally enacted in 1965, both
incremental and piecemeal measures were included. Medicare, an incremental
program, provides coverage to all who meet its simple eligibility requirements
of age or permanent disability. Medicaid is a piecemeal reform. Since
eligibility is based on income, it adds patients who fall into poverty, but
subtracts those whose income rises or who fail to follow complex
eligibility-determination rules. Currently, despite the Child Health Insurance
Program (CHIP), the number of people on Medicaid has not changed because of
declining welfare rolls and bureaucratic failures to inform people of
eligibility.
Piecemeal reform has a superficial political allure. It is seen as easier to
pass and less likely to threaten budgetary targets. But since piecemeal
measures, by definition, have no way to protect against decrements of coverage,
they are a poor basis on which to build a lasting solution to America’s
national disgrace of uninsurance.
True incremental reform can follow one of two paths. Age-based
incrementalism would add age groups to Medicare, America’s only guaranteed
health insurance program. Five years ago, some advocacy groups were considering
an incremental Medicare for children, but that constituency was hijacked into
the piecemeal means-tested CHIP (Child Health Insurance Program).
The other approach to true incrementalism is geographical incrementalism.
The federal government could provide financial incentives to states to develop
plans to cover, not just some more, but all of their residents. The Health
Security for All Americans Act of 2000 (Wellstone/Baldwin/Obey) utilizes this
approach. Devolution of authority to the states appears to be popular on Capitol
Hill nowadays. For a problem that has eluded a national solution for a whole
century, turning to states as "laboratories of democracy" might indeed
make sense.
Meaningful incremental reform to provide coverage for the working age
population will not be easy to achieve. Large businesses fear losing the
leverage they have over the health care system through paying their workers’
premiums. Small businesses, especially those not providing coverage, will fight
any new costs. Insurance companies will object to reforms that could reduce
their number of potential paying customers. Universal coverage through a single
piece of federal legislation is not likely in the near future. It is important
to build towards it through solid increments rather than through unreliable
piecemeal measures.
|
|
|
|
|
|
|
