Expanding Health Coverage to the Uninsured: Research Analyses

Alliance for Health Reform. April 2008. Lessons Learned: The Health Reform Debate of 1993-94.
This issue brief summarizes briefings convened by the Alliance for Health Reform in December 2007 and January 2008 with support from the Robert Wood Johnson Foundation. These briefings looked at lessons learned from the failure of health reform during the Clinton Administration. Panelists were seven experts who were active in health issues on Capitol Hill during 1993 and 1994, representing both sides of the political aisle and the administration.

Blumberg L and J Holahan, Urban Institute. Jan 2008. Do Individual Mandates Matter?.
The authors address whether an individual mandate is necessary to achieve universal coverage.

Blumberg L. Mar 2007. Expanding Health Insurance to the Uninsured: Rationale, Recent Proposals, and Key Considerations, Testimony before the Subcommittee on Health, Education, Labor, and Pensions (HELP), House Education and Labor Committee.
This Congressional testimony discusses the problems faced by those without health insurance and shares the author’s thoughts on strategies for expanding coverage to them.

Burton A, et al, Commonwealth Fund. Jan 2007. State Strategies to Expand Health Insurance Coverage: Trends and Lessons for Policymakers.
The authors discuss state reforms, most of them enacted or proposed in 2006, that present a variety of approaches to covering the uninsured, including new mechanisms to subsidize coverage for low-income families, new variations on employer and personal responsibility for insurance coverage, and new strategies to facilitate the purchase of health insurance for small businesses and for individuals without access to employer-sponsored insurance.

Butler SM, The Heritage Foundation. Mar 2003. Laying the Groundwork for Universal Coverage.
Stuart Butler testified before the Special Committee on Aging in the U.S. Senate about the challenges and gaps in coverage in the U.S. health care and suggests what actions need to be taken in order to begin a difficult path toward universal health care.

Collins S, et al, The Commonwealth Fund. Oct 2007. A Roadmap to Health Insurance for All: Principles for Reform.
This report, prepared for The Commonwealth Fund Commission on a High Performance Health System, explores the different health reform options and how each may not only increase coverage for the uninsured, but also improve quality and efficiency and gain control over spiraling health care costs.

Dorn S and J Holahan, Urban Institute. April 2008. Are We Heading Toward Socialized Medicine?
With health reform at the forefront of the 2008 national campaign, some charge that proposals to restructure our health care system represent dangerous steps moving the country towards government-run health care and socialized medicine. The authors explore the concept of socialized medicine and find the rhetoric inapplicable to both the SCHIP bill and proposals from most presidential candidates. The core issues in health reform involve, not the size of government, but proposals' effect on the number of uninsured, access to quality care, cost growth, and consumers' health care choices.

Dorn S, Urban Institute. Feb 2008. Health Coverage Tax Credits: A Small Program Offering Big Policy Lessons.
The author describes the Health Coverage Tax Credit (HCTC), which pays 65 percent of health insurance premiums for 16,000 trade-displaced workers and others. This credit is the only use of federal income tax credits to cover the otherwise uninsured. This report describes the lessons about how to structure tax credits serving a larger group of uninsured, such as credits proposed by Republican and Democratic Presidential candidates.

Economic and Social Research Institute. Covering America: Real Remedies for the Uninsured, Vol. 1 (June 2001), Vol. 2 (November 2002), and Vol. 3 (December 2003).
These three reports detail a set of comprehensive health coverage proposals from a philosophically diverse group of respected health care analysts and scholars that seek to move the country toward universal health coverage. The proposals include a number that are broad in scope and go beyond incremental reform. Included are new approaches to using federal income tax credits, expanding Medicaid and the State Children's Health Insurance Program, implementing Medicare buy-ins, and organizing insurance purchasing.

Feder J and S Burke, Eds. The Kaiser Project on Incremental Health Reform, The Kaiser Family Foundation. Oct 1999. Options for Expanding Health Insurance Coverage: A Report on a Policy Roundtable.
This report summarizes proceedings from a February 1999 roundtable discussion among policymakers and researchers from across the political and policy spectrum. The conference report uses four approaches when comparing options to cover the uninsured: 1) a comparison of the predicted impact of alternative strategies on coverage of the uninsured; 2) consideration of the policy and political issues of federal entitlements vs. state discretion; 3) assessment of relative strengths and weaknesses of tax credits and direct subsides; 4) analysis of potential "crowd-out."

Hadley J and JD Reschovsky, Center for Studying Health System Change. July 2002. Tax Credits and the Affordability of Individual Health Insurance.
This issue brief is an analysis of two leading proposals—one by President Bush and the other by a bipartisan group of senators—indicates tax credits would make individual coverage affordable for many people but are unlikely to offer much help to those who are older or in imperfect health.

Institute of Medicine, National Academy of Sciences. Jan 2004. Insuring America’s Health: Principles and Recommendations.
This report is the culmination of a series of six from the Institute of Medicine's Committee on the Consequences of Uninsurance on the problems of uninsurance in America. The report presents guiding principles for evaluating proposals to extend health insurance coverage and demonstrates how the principles can be used to assess policy options.

Klain K, S Glied, and D Ferry, The Commonwealth Fund. Sept 2005. Entrances and Exits: Health Insurance Churning, 1998-2000.
Analysis of 1998-2000 health insurance data from the Medical Expenditure Panel Survey shows large numbers of people with unstable health insurance coverage. Policies should target high-risk groups such as Hispanics, people with low levels of education, those who transition into and out of poverty, and those with private non-group insurance in order to provide them with stable health insurance coverage.

Kaiser Commission on Medicaid and the Uninsured. Oct 2007. The Uninsured: A Primer.
This report reviews the basic profile of the uninsured population, how they receive care, and the options for increasing coverage.

Lav I, Center on Budget and Policy Priorities. Feb 2002. Health Care Tax Credits to Decrease the Number of Uninsured.
Iris Lav from the Center on Budget and Policy Priorities testified before the House Committee on Ways and Means on the Bush Administration’s health insurance coverage initiative. This testimony discusses the weaknesses to using a tax credit approach to decreasing the number of the uninsured.

Moffit R and N Owcharenko, The Heritage Foundation. Mar 2003. Covering the Uninsured: How States Can Expand and Improve Health Coverage.
This policy brief discusses the key steps states need to take to address the issues of the uninsured.

Rowland D, Kaiser Family Foundation. Apr 2008. Health Care Affordability and the Uninsured, Testimony before the U.S. Congress Committee on Ways and Means, Subcommittee on Health.
Diane Rowland, Executive Vice President of the Kaiser Family Foundation and Executive Director of the Kaiser Commission on Medicaid and the Uninsured, testified before Congress on gaps on the inadequacy of health coverage in the United States.

Rowland D, Kaiser Family Foundation. Jan 2007. Health Care--Squeezing the Middle Class with More Costs and Less Coverage, Testimony before the U.S. Congress Committee on Ways and Means.
Diane Rowland, Executive Vice President of the Foundation and Executive Director of the Foundation's Commission on Medicaid and the Uninsured, testified to the U.S. House Committee on Ways and Means about the economic challenges of rising health care costs and growing gaps in health coverage facing middle class families.

Lambrew J and A Garson, The Commonwealth Fund. Jan 2003. Small But Significant Steps To Help The Uninsured.
This report outlines a dozen policy options that, for less than $1 billion each, would provide uninsured and underinsured Americans with access to private health coverage, public coverage, or both.

Academic Literature

Aaron HJ and SM Butler. Mar 2004. How Federalism Could Spur Bipartisan Action on the Uninsured. Health Affairs Web Exclusive W-4:168–178.
This paper explores federalism, specifically federally supported state experimentation, as an approach to make progress on covering uninsured Americans.

Bilheimer L and D Colby. 2001. Expanding Coverage: Reflections on Recent Efforts. Health Affairs 20(1):83–95.
This paper focuses on the major health care initiatives and proposals to expand health insurance coverage that policymakers have enacted or considered since 1980 and describes what can be learned from these efforts to expand coverage.

Blendon R, J Benson, and C DesRoches. Aug 2003. Americans' Views of the Uninsured: An Era for Hybrid Proposals. Health Affairs Web Exclusive.
This paper draws on data from 10 recent public opinion polls and concludes that the issue of the uninsured is likely to become more visible however, not as prominent as the early 1990s. The authors also found that there was no public consensus on any single approach but a hybrid of public and private policy options offers the best possibility of reform.

Davis K and C Schoen. April 2003. Creating Consequences on Coverage Choices. Health Affairs Web Exclusive.
This paper outlines a framework for reaching near-universal health insurance coverage combining tax credits for private insurance and public program expansions. The paper also provides coverage and cost estimates and identifies potential sources of revenue to finance coverage.

Feder J, et al. 2001. Covering the Low-Income Uninsured: The Case for Expanding Public Programs. Health Affairs 20(1):27–39.
This paper argues for strengthening public programs as an approach to expand health insurance coverage and that the priority in expanding coverage should go to the uninsured population that is least likely able to afford coverage and most likely to have difficulties getting appropriate and timely care.

Glied S. April 2008. Universal Coverage One Head at a Time--The Risks and Benefits of Individual Health Insurance Mandates. New England Journal of Medicine 358(15):1540-1542
The author examines the benefits and challenges associated with implementing an individual health insurance mandate to achieve universal coverage.

Glied S and S Little. 2003. The Uninsured and the Benefits of Medical Progress. Health Affairs 22(4):210–219.
This paper analyzes medical technology access problems among the uninsured. Using the research findings of David Cutler and Mark McClellan on the benefits of medical technology, the authors estimate the extent to which uninsured Americans ages 22-64 use certain medical technologies; estimate the differential in rates of technology use by insurance status; and calculate the welfare lost due to the lack of access to new

Glied S. 2001. Challenges and Options for Increasing the Number of Americans with Health Insurance. Inquiry 38(2):90–115.
This paper provides an overview of the issues confronting policymakers who want to develop programs to help working Americans obtain health insurance. The authors examine the challenges to covering the uninsured, describe principles that should be used in assessing policy proposals aimed at this purpose, and evaluate the main strategies for coverage expansions.

Gruber J and L Levitt. 2000. Tax Subsidies for Health Insurance: Costs and Benefits. Health Affairs 19(1):72–85.
This paper assesses the potential implications of tax-based approaches to increase health insurance coverage using a microsimulation model. The paper examines how the characteristics of these types of proposals are likely to affect the overall cost to the federal government, the number of uninsured who would gain coverage, and how those who now have employer-sponsored coverage would be affected.

Haber S, G Khantutsky, and J Mitchell. 2000. Covering Uninsured Adults Through Medicaid: Lessons from the Oregon Plan. Health Care Financing Review 22(2):119–135.
The Oregon Health Plan, Oregon’s section 1115 Medicaid waiver, expanded eligibility to all state residents living below poverty. This paper profiles the expansion population and provides lessons for other states considering similar programs.

Hadley J. March 2007. Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition. Journal of the American Medical Association 297(10): 1073-1084.
The author compares medical care use and short-term health changes among US uninsured individuals and insured nonelderly individuals following a health shock caused by either an unintentional injury or the onset of a chronic condition.

Hadley J. June 2003. The Consequences of Being Uninsured. Medical Care Research and Review Supplemental Issue 60(2).
A June 2003 supplement of Medical Care Research and Review presents a compelling case that health insurance does lead to improved health and better access to care. The supplement, with Thomas Rice as guest editor, includes four commentaries on the topic by John Ayanian, Stuart Butler, Karen Davis, and Richard Kronick.

Hadley J and P Cunningham. Oct 2004. Availability of Safety Net Providers and Access to Care of Uninsured Persons. Health Services Research 39(5):1527–1546.
This study examines how proximity to safety net clinics and hospitals affects a variety of measures of access to care and service use by uninsured persons.

Hadley J and J Holahan. June 2003. Covering the Uninsured: How Much Would It Cost? Health Affairs Web Exclusive.
To provide benchmarks for evaluating the costs of alternative proposals to expand health insurance coverage to the uninsured, this analysis estimates the cost of increased medical care use by the uninsured if all were to gain coverage comparable to lower to middle-income people covered by private insurance and public insurance policies.

Himmelstein D and S Woolhandler. 2003. National Health Insurance or Incremental Reform: Aim High Or At Our Feet? American Journal of Public Health 93(1):102–105.
This paper presents a case for a single-payer national health insurance system, outlines the key features of such a system, and discusses the limits of incrementalism.

Kahn C and R Pollack. 2001. Building A Consensus for Expanding Health Coverage. Health Affairs 20(1):40–48.
The authors argue that to win broad-based support for expanding health insurance coverage, a meaningful health insurance expansion proposal should achieve a balance between public and private sector approaches, focus attention on those who are most in need of assistance, and build on systems that work today. This paper also presents a proposal for expanding insurance coverage.

Meyer J and S Silow-Carroll. Aug 2003. Building on the Job-Based Health Care System: What Would It Take? Health Affairs Web Exclusive.
The authors present a blueprint for health insurance reform including design choices and their implications that would improve access, cost control and quality. The authors conclude that requiring employers to provide coverage or at least help employees obtain group insurance combined with income-based premium subsides, expanded public programs, and backup “insurance exchanges” would make affordable coverage available to nearly everyone.

Mitchell J and D Osber. 2002. Using Medicaid/SCHIP to Insure Working Families: The Massachusetts Experience. Health Care Financing Review 23(3):35–45.
Massachusetts was the first state to implement a premium subsidy program for employer-sponsored health insurance, using both Medicaid and the SCHIP funding. This article reviews the mechanisms states may use to provide premium assistance through either Medicaid or SCHIP and describes the Massachusetts program.

Neuschler E and R Curtis. May 2003. Use of Subsidies to Low-Income People For Coverage Through Small Employers. Health Affairs Web Exclusive.
This paper investigates how public subsidies targeted to low-income people might also be applied in ways that broaden employment-based coverage for low-income workers and their families and lessen the risk of erosion in employer coverage.

Oberlander J. Oct 2007. Learning from Failure in Health Reform. New England Journal of Medicine 357(17): 1677-1679.
In this Perspective article, the author highlights lessons from the attempt at health care from in the 1990s.

Pauly M and B Herring. 2001. Expanding Coverage Via Tax Credits: Tradeoffs and Outcomes. Health Affairs 20(1):9–26.
This paper discusses various options for using refundable tax credits to reduce the number of uninsured, the issues surrounding the "costs" of tax credit strategies, and the policy issues raised by the uncertainty of the effects of tax credits.

Pauly M. 1994. Making the Case for Employer-Enforced Individual Mandates. Health Affairs 13(2):21–33.
This paper discusses and evaluates individual mandates as a strategy to expand health insurance coverage.

Reinhardt U. Aug 2003. Is There Hope for the Uninsured? Health Affairs Web Exclusive.
The author discusses the prospects for universal coverage in the United States. He concludes that the U.S. will probably not achieve universal coverage anytime soon, if ever, but not for lack of good ideas and sound policy reasoning.

Reschovsky J and J Hadley. Feb 2004. The Effect of Tax Credits For Nongroup Insurance on Health Spending by the Uninsured. Health Affairs Web Exclusive.
The authors compare health care out-of-pocket spending for lower-income uninsured people with their spending if they participated in one of three hypothetical tax credits. The authors conclude that because of the nongroup policies’ high cost and low benefits, nearly all of the uninsured would spend considerably more under a tax credit similar to that proposed by the Bush Administration. The authors conclude that to have sizeable reductions in the uninsured, the tax credits would require more generous tax credits than those currently being proposed.

Schroeder S. 2001. Prospects for Expanding Coverage. New England Journal of Medicine 344(11):847–852.
This paper discusses the uninsured population, the obstacles to health insurance expansion and strategies considered in the 106th Congress to expand health insurance coverage to more Americans.

Swartz, K. 2001. Markets for Individual Health Insurance: Can We Make Them Work with Incentives to Purchase Insurance? Inquiry 38(2):133–145.
This paper addresses how the markets for individual health insurance could be reformed to gain some of the advantages of large groups if incentives to purchase insurance were implemented.

Vladeck, Bruce. 2003. Universal Health Insurance in the United States: Reflections on the Past, the Present, and the Future. American Journal of Public Health 93(1):16–19.
This editorial presents 10 explanations for why the United States does not have a national health insurance system, including historical-cultural and political-structural explanations. The author also examines how political change occurs and offers strategic suggestions to consider when contemplating health insurance reform.