Covering the low-income uninsured: the case for expanding public programs.

In a new administration and Congress, any health insurance coverage initiative will focus on some, rather than all, Americans. Because lack of affordability is the main reason people lack coverage, most observers acknowledge that government-financed subsidies are needed to expand coverage. But there is considerable disagreement about how these subsidies should be provided. Here we argue that priority in expanding coverage should go to the uninsured population that is least able to afford coverage and most likely to have difficulties getting appropriate and timely care. Despite flaws in existing public programs, which can and should be remedied, strengthening these programs establishes a foundation for truly effective health insurance coverage for all low-income Americans. Any initiative to extend health insurance coverage to the forty-three million Americans without it is likely to take an incremental rather than a universal or comprehensive approach. An incremental strategy inevitably requires decisions about whom to provide the financial wherewithal to obtain coverage, as well as how to effectively provide it. In this paper we argue that an incremental initiative should give priority to the uninsured who are least able to afford coverage, and that the most effective way to do this is by expanding publicly provided insurance. Today more than thirty-five million lowincome Americans receive their health coverage through Medicaid, and as many as three million additional children get assistance from the State Children’s Health Insurance Program (SCHIP). Strength©2001 Project HOPE–The People-to-People Health Foundation, Inc. Judith Feder is dean of policy studies, Georgetown University. Larry Levitt is vice-president and director, Changing Health Care Marketplace Project, Kaiser Family Foundation. Ellen O’Brien is assistant research professor, Institute for Health Care Research and Policy, Georgetown University. Diane Rowland is executive vice-president of the Kaiser Family Foundation and executive director, Kaiser Commission on Medicaid and the Uninsured. EXPANDING 27