Every Christmas, through the miracle to which we bear witness, we are reminded of life’s infinite possibilities. In this context, we enter each new year with a sense of renewed hope and opportunity. We see afresh the potential for achieving good and righting wrongs in our lives, in our communities and in the life of our broader society.
This year, 2001, also brings with it the opportunity for a fresh start in our national polity as we inaugurate a new president and seat a new Congress. Those in the health care field are particularly focused on the possibilities for national action to expand health insurance coverage to significant numbers of the more than 40 million Americans who are without it. In addition, the Catholic Health Association will be advocating other important national policy objectives. These include responsible Medicare reform that provides a prescription drug benefit and adequate payment levels for providers; conscience protection for Catholic and other faith-based health care providers who choose not to provide abortion or other objectionable services; legislation to prohibit assisted suicide; and steps to improve palliative care. These goals support and enhance the goal of a fairer, more inclusive health care system.
Political prognostications, especially regarding health care issues, are perilous at best. Yet I believe that the conversation about expanding health insurance coverage, in which people in the Catholic health ministry and others have engaged over the past several years, may begin to move to center stage. Why do I think there may be hope for progress? First, because the alternative, the status quo, is simply unacceptable. Second, because recent proposals for sequential, rather than wholesale, reformsincluding those developed by C.H.A.have greater viability. Finally, there are signs of a growing interest in sequential reforms.
The Imperative for Change
My perspective, and that of C.H.A., on the challenge of the uninsured is not only that of representatives of a major sector of the health care community, but is also that of active representatives of our community of faith. As participants in the Catholic health ministry, we believe there is a human right to health care and that society has a special duty to care for the poor and vulnerable.
This country would not accept a public policy that turned a blind eye to discrimination, that denied a child access to a public education or allowed a defendant to stand trial without legal counsel. Yet every day almost 43 million Americans are without the basic human right to health care. Forty-three million is a big, abstract number that is perhaps difficult to relate to. Let me put it in more concrete terms. The number of uninsured people equals the entire population of the states of Florida, Georgia, Alabama, Mississippi, Louisiana, South Carolina and Tennesseecombined. Or, to draw on an example from the recent election, try to imagine how long it would take the Palm Beach County election commission to count not ballots, but the number of uninsured. At the rate of 462,000 ballots in six days, it would take one year and nine months to count this nation’s uninsured.
We are faced with a silent national policy that, by default, countenances the disenfranchisement of 15 percent of our population from the health care system. If Congress were to pass, or even consider, legislation denying health insurance coverage to the residents of seven states, the result would be national outrage. We need to stimulate similar concern regarding governmental inaction in the area of health coverage.
To this end, in February 1999 the C.H.A. board of trustees once again reaffirmed its commitment to health care reform. Informed by the church’s teaching on human dignity and social justice, the C.H.A. board decided that C.H.A. should serve as a catalyst for accessible and affordable health care for all in a just and compassionate health care system. In pursuing this catalytic role, C.H.A. has adopted eight guiding principles for health care reform. These principles call for a health care system that:
makes health care available to all, regardless of employment, age, income or health status;
makes a defined set of basic benefits available to all;
shares responsibility for health among allindividuals, families, health care providers, employers and government;
bases health care spending on appropriate and efficient use of resources;
shares responsibility for financing among government, employers and individuals;
promotes the continuous improvement of health care services;
encourages effective participation in decision making by patients and their families.
As an eighth principle, we have adopted the concept of a sequential strategy for transforming the health care system. We recognize that systemic change is likely to be a gradual rather than a sudden process. With these principles in mind, C.H.A. has offered a working proposal for health care reform.
Building an Infrastructure
While maintaining the goal of universal coverage, C.H.A. has chosen to pursue a strategy that works toward our ultimate goal in deliberate and sequential steps. It extends, over a three-year period, health insurance coverage to about 19 million persons, almost one-half of those currently uninsured. Our proposal places special emphasis on low-income and other vulnerable populations. Of critical importance, the C.H.A. proposal creates an infrastructure capable of supporting future expansion of insurance coverage.
The five essential components of the C.H.A. proposal are:
An expansion of Medicaid and the State Children’s Health Insurance Program (S-CHIP). We would expand eligibility to these two programs to all persons below 150 percent of the federal poverty level, including non-U.S. citizens who are legally in this country. Individual states could choose to implement this expanded coverage either as an extension of the existing Medicaid program or as a separate program with a private insurance benefits package, but states would be required to increase their income eligibility levels to 150 percent of the federal poverty level.
A program of premium subsidies. We would provide subsidies equaling up to two-thirds of the premium for the purchase of private insurance for low- and middle-income persons, that is, those with income below $35,000 for single individuals and $50,000 for families. For income-eligible individuals with employer-sponsored coverage, the program would pay two-thirds of the employee premium contribution. For eligible individuals without employer coverage, the program would pay two-thirds of the premium, but only if they purchase their coverage through an expanded Federal Employee Health Benefits Program.
An expansion of the Federal Employee Health Benefits Program. We would expand the existing F.E.H.B.P. to create a marketplace for individuals without employer-based insurance. The program would be required to cover eligible individuals regardless of health status. Premiums would be permitted to vary by age within limits, but no variation in premiums would be permitted by sex and health status. Restricting the subsidies to those who participate in F.E.H.B.P. would encourage all eligible persons to obtain their coverage through the program. This would prevent adverse selection into the program by attracting both low- and high-cost individuals. Coverage provided to these individuals would be at least as comprehensive as that received by federal workers.
An outreach and enrollment initiative for Medicaid/S-CHIP coverage. We would increase enrollment of those already eligible for health insurance, particularly low-income children eligible for Medicaid and S-CHIP. Our proposal includes targeted measures to expand outreach to childrenmaking it easier for parents to enroll their children and maintain coverage. And we would allow states to cover legal immigrants, children and pregnant women. The Catholic health ministry, working with Catholic Charities and others in the community, is already engaged in these efforts, but policy changes are needed at the federal level.
An initiative to strengthen the health care safety net. Even with significant expansions in health coverage, a stronger health care delivery safety net will be needed for those who remain uninsured, particularly vulnerable populations such as the homeless. We would include $500 million annually in grants to enhance collaboration and cooperation among safety net hospitals and clinics, helping to produce a more efficient and seamless health care system for the uninsured.
Our proposal is both a recognition of today’s political realities and an example of the policy choices and strategy needed to build an infrastructure for universal coverage consistent with our sense of moral responsibility.
A New Opportunity?
The C.H.A. is not alone in its efforts to craft an effective and viable proposal for expanding health insurance coverage. In recent years, numerous bills have been introduced in Congress by members of both parties that would provide some degree of subsidy for insurance premiums, often in the form of tax credits. There is wide variation in the size of proposed subsidies and the degree to which a basic benefit is specified.
Recently, the Health Insurance Association of America (H.I.A.A.) and Families USA have come together to develop a joint proposal for broader insurance coverage. The fact that two organizations that are often on opposite sides of health care debates have agreed on a proposal for reform is an encouraging sign in itself. While the proposal by H.I.A.A./Families USA is similar to the C.H.A. proposal, in that it relies in part on increasing eligibility for Medicaid and S-CHIP, there are also significant differences in the amount and scope of public investment and in the use of tax credits to employers rather than premium subsidies for individuals.
There are also some similarities between the C.H.A. proposal and health care reform proposals made by President Bush in the recent election campaign. As a candidate, President Bush proposed a refundable tax credit of up to $2,000 for families and $1,000 for individuals to assist them in purchasing a basic health insurance plan. Also, when he was governor of Texas, President Bush signed legislation creating the S-CHIP program in Texas, as well as an optional, parallel program for immigrant children. It is also noteworthy that President Bush’s secretary of health and human services, Wisconsin’s former governor Tommy Thompson, implemented a program of significant Medicaid expansion in that state. Medicaid coverage was extended to families with incomes of up to 185 percent of the federal poverty level.
Even with those hopeful signs, there are, of course, no guarantees of progress on health care reform. The evenly divided Senate and the almost evenly divided House of Representatives could produce a period of unprecedented gridlock. At the same time, the two parties will be forced to cooperate in order to transact any business of significance. The evolution of health care reform proposals away from the comprehensive toward the incremental may well offer an opportunity for bipartisanship that Congressional and administration leaders will find attractive. We should keep in mind that the most important health care legislation of the 1990’sS-CHIP and the Health Insurance Portability and Accountability Actwere both incremental steps that depended on broad bipartisan support.
In sum, I believe that the present equation in Washington offers a new opportunity to expand health insurance coverage. Whether this opportunity will be converted into significant accomplishment depends in large measure on maintaining our vision of comprehensive reform, while advocating the adoption of sequential steppingstones that will take us to that goal.