Why can't the richest nation in the world provide health-care coverage to all its people? It's the question that hangs over all debates about medical care and insurance -- particularly in an election year when jobs -- and the employer-based health system that ties insurance to work -- are a key voter concern.
The answer: It's not that Americans don't want to cover the 41 million uninsured. And the cost, pegged by Kaiser Commission on Medicaid & the Uninsured at less than $69 billion a year, isn't insurmountable, adding just 6 percent to annual health spending.
It's just that no consensus exists -- in the public, among politicians, or in the health industries -- about how best to get the job done. And because the vast majority of voters have health insurance (85 percent of the population is insured, but 92 percent of those who participated in the 2000 election were covered), political leaders have little incentive to overcome that impasse.
Turning to hybrids
"Most Americans think that the wealthiest nation in the world should wipe this problem out," says Robert J. Blendon, an expert on polling and public attitudes on health care at the Harvard University School of Public Health. "But there's no single plan for universal coverage that more than one-quarter of the nation thinks is a good idea." And each of the leading alternatives has substantial and obvious trade-offs -- in cost, freedom, quality, and economic growth -- that make it hard for voters and politicians to rally around a second-choice plan.
So the most likely course toward expanded coverage will involve what Blendon calls "hybrid plans" -- a mix of state-run Medicaid programs to extend coverage to currently uninsured groups, enhanced incentives for employers to make insurance affordable for low-wage workers, and personal tax breaks to encourage individuals to buy coverage.
The truth is, Americans have long rejected sweeping attempts to solve the problems of health coverage by creating a single seamless system. President Harry S. Truman proposed a universal health plan in the late 1940s, only to be soundly beaten. The next steps were incremental: Lyndon B. Johnson won government-run coverage for the elderly (Medicare) and poor (Medicaid).
A simpler past
The last Democratic attempt to overhaul the entire system -- President Bill Clinton's reform drive in 1993 -- was shot down in partisan warfare that led to Republican control of Congress in the 1994 election. In the decade since, changes have once again been incremental -- adding more children to Medicaid, offering prescription-drug coverage through Medicare, and pursuing the conservative vision of individual insurance through tax-favored Medical Savings Accounts.
"In most countries, one political party had a vision for a health system, and when they took power, they put it in place," Blendon notes. But that was a lot easier in parliamentary systems, where the same party controls the legislature and the executive, and in post-World War II boom days, when health care was simpler, costs and expectations were much lower, and voters were willing to redirect their heavy tax burden from warfare to health care.
Now, most Americans have a strong vested interest in their employer-based insurance, even though they complain about cutbacks in coverage and higher costs. And when only a small, politically inactive slice of the public is uninsured, it takes an economic upheaval to raise enough fear about losing coverage to prompt political action.
Compare public concerns today with the fears following the 1991 recession -- the first "jobless recovery." Back then, more than 50 percent of respondents told Harris pollsters that health care was one of the two most important issues for government to address. But last December, in the midst of a seven-month string of weak employment reports, only 16 percent of respondents ranked health care in that league, far behind the economy and jobs (40 percent) and war and defense (32 percent). [One explanation: The jobs figures have been weak because of a lack of new hiring, rather than layoffs, which have remained low. So, current workers have less reason to fear losing their insurance.]
That's not to say Americans don't wish that health care was available to all. Some 62 percent support universal coverage, according to an October, 2003, Washington Post/ABC News Poll. But that's not their top concern: A poll for the Harvard School of Public Health and the Robert Wood Johnson Foundation last December found that dealing with the uninsured was only the third-most important health-related issue. The cost of health care (36 percent) and Medicare's problems (26 percent) outstripped helping the uninsured, which tied with prescription-drug costs at 21 percent.
As Blendon noted, none of the major alternatives for reaching universal coverage commands anything close to universal support. The leading choice is further expansion of Medicaid, favored as a top pick by a mere 22 percent of respondents in the Harvard/Johnson poll. That's closely followed by a mandate on employers requiring them to offer insurance, the top pick of 21 percent. But after that, none of the likely ideas -- mandates for families to buy insurance, tax breaks for individual coverage, universal Medicare, or its close cousin, a government-run single-payer plan -- is the clear choice of more than 14 percent of the public.
Furthermore, when the drawbacks are pointed out, support for any alternative drops sharply. A separate 2003 Harvard School of Public Health poll of Massachusetts adults found that 82 percent of the public generally supports expanded Medicaid -- but only 55 percent like the idea when they're told taxes might rise to pay for it. Similarly, support for an employer mandate falls by more than half, from 76 percent to 35 percent, when respondents are told that the cost of insurance might force businesses to lay off workers.
Blendon sees little on the health-care or political scene that's likely to change this picture. "There's no American Association of Uninsured Persons issuing report cards on candidates or holding feet to the fire," he notes. "President [George W.] Bush knew he couldn't run for reelection without passing a drug plan for the elderly. No one thinks he faces that same urgency on taking care of the uninsured." Until that changes, America will at best nibble away at the problem of ensuring that all its people are covered.