Valuable Ideas from the Recent Past for Providing Coverage
The quest to provide universal health insurance in the U.S. is a little over a century old. Both Republican and Democratic Presidents and members of Congress have presented blueprints to achieve universal coverage involving varying combinations of government subsidies, regulations, and private market roles and responsibilities.
With the passage of the Affordable Care Act (ACA) in 2010, the country appeared to have made major progress toward the goal of ensuring that all Americans could have affordable healthcare coverage. But the controversy that preceded the passage of this approach continues to the present. The ACA remains under fire in the executive, legislative, and judicial branches of government.
But it became clear in the 2018 election that the concern about having access to good healthcare is an issue that still has resonance with the American population. The response of some elected leaders is to push for even more encompassing approaches to ensure that everyone has health care coverage, including what some call “Medicare for All.” Others want to end the ACA and replace it with an approach involving much less federal regulation of insurance markets and a curb on ACA’s Medicaid expansion.
The search for alternative approaches to covering the uninsured need not start from scratch. Much work was done in the past to consider alternatives that seem to promise success. One such effort was a four-year project undertaken by the Economic and Social Research Institute, a non-profit research and policy analysis organization that focused on healthcare issues. The work, under the title Covering America: Real Remedies for the Uninsured, produced a three-volume set of proposals to move the U.S. toward universal health coverage. This project was supported by grants from the Robert Wood Johnson Foundation. The first efforts of that project were published in 2001, and other major products were published in subsequent years. In all, seventeen major proposals were published. They are presented in their original form on this website.
A number of years have passed, and surely some of the authors would modify what they wrote in the past, particularly after the passage of and several years of experience with the Affordable Care Act. But we are convinced that these proposals still have relevance and could prove valuable to elected officials trying to think through ways to deal with this problem of ensuring that everyone has access to good healthcare.
In selecting authors to prepare proposals, we at the Economic and Social Research Institute selected individuals whom we knew were very knowledgeable and would bring real intellectual power to the task. We also were determined to present a variety of approaches, representing what would now be considered both more conservative and liberal approaches. We put it this way:
"We have put in place a structure designed to draw the best, most knowledgeable, and most creative policy thinkers and analysts who are concerned with fundamental reform in achieving the ultimate goal of universal coverage. We envision this forum to be a place where innovative thinkers can gather to subject their plans to critique and continuous refinement and where policymakers, the media, interested stakeholders, and, ultimately, the public look for a variety of stimulating, practical proposals for health reform."
The process for preparing proposals was a rigorous one:
"Once the authors had completed a draft, they presented their reform proposals in person to a distinguished and diverse advisory panel of health policy analysts and researchers. These people were chosen for their broad experience, acknowledged expertise, and differing philosophical perspectives. The advisory panel provided feedback, comments, and critiques for each paper."
It seems to us that it could be useful to make the work from this project available again. That is the purpose of this website. We hope that readers find it useful.
Jack A. Meyer, Ph.D.
Elliot K. Wicks, Ph.D.
A Performance-Based Approach to Universal Health Care, by David B. Kendall, Jeff Lemieux, and S. Robert Levine
Tax credits to low- and middle-income individuals and families to be used in either individual or group market. States receive performance-based grants to improve coverage rates, access, quality, and outcomes.
Improving Access to Health Care without Comprehensive Health Insurance Coverage: Incentives, Competition, Choice, and Priorities, by Tom Miller
Tax credits available to all to provide 30% subsidy for high-deductible coverage. Strengthen safety net and establish high-risk pools for the uninsurable. Strong incentives for consumers to economize.
Medicare for All, by James A. Morone
“Single-payer” approach. All legal residents covered by Medicare, with expanded and rationalized benefits package and no copayments. Particular emphasis on community medicine. States could choose to opt out for residents under age 65 by designing their own system under federal guidelines.
The Full Proposals
Clicking on the underlined title opens a downloadable PDF file of the full text of the proposal, which begins with bullet points that summarize the proposal in more detail than is provided in the paragraphs below.
Reforming the Tax Treatment of Health Care to Achieve Universal Coverage, by Stuart M. Butler
Would make refundable tax credits available to working households. States would get grants to expand health coverage to more residents and make insurance more affordable. Coverage obtained at work or from a range of other organizations such as churches or unions.
Assessing the Combination of Public Programs and Tax Credits, by Judith Feder, Larry Levitt, Ellen O’Brien, and Diane Rowland
Expand Medicaid and the State Children’s Health Insurance Program for low-income people. Possible combination with tax credit to small, low-wage firms to expand employer offerings.
A Private/Public Partnership for National Health Insurance, by Jonathan Gruber
Establishment of purchasing pools in every state through which households with incomes up to 300% of the federal poverty level would be eligible for no-cost or reduced-cost coverage on a sliding-scale basis; automatic plan enrollment for lowest-income households.
Medicare Plus: Increasing Health Coverage by Expanding Medicare, by Jacob S. Hacker
A modified “play or pay” approach that creates incentives for workers and employers to buy into “Medicare Plus,” a national program based on Medicare.
Expanding Health Insurance Coverage: A New Federal/State Approach, by John F. Holahan, Len M. Nichols, and Linda J. Blumberg
Extend the type of subsidized coverage that is currently available under S-CHIP to all lower-income people and subsidize insurance for the highest risk.
A State-Based Proposal for Achieving Universal Coverage, by Richard Kronick and Thomas Rice
All non-elderly legal residents would be guaranteed comprehensive health insurance as a “right” (at no direct cost) through a public insurance approach designed by each state and monitored by the federal government.
An Adaptive Credit Plan for Covering the Uninsured, by Mark V. Pauly
A refundable tax credit/voucher system would make some level of coverage affordable to lower-middle-income people who currently have no health insurance. Very-low-income households would initially be eligible for publicly financed zero-premium comprehensive insurance.
Near-Universal Coverage Through Health Plan Competition: An Insurance Exchange Approach, by Sara J. Singer, Alan M. Garber, and Alain C. Enthoven
Combines refundable tax credits and insurance exchanges to promote lower-cost, higher-value health coverage while allowing employers and individuals to continue current arrangements if they desire.
The Medical Security System: A Proposal To Ensure Health Insurance Coverage For All Americans, by Alan R. Weil
A new Medical Security System would be created to provide universal coverage, making coverage a “right.”
A Plan for Achieving Universal Health Coverage Combining the New with the Best of the Past, by Elliot K. Wicks, Jack A. Meyer, and Sharon Silow-Carroll
Tax credits for all households, varying by income. Universal coverage achieved by mandating that everyone have or buy health coverage and having Medicare automatically cover anyone temporarily uninsured. Builds on present system of private health plans and employer-based coverage.
Universal Coverage, Universal Responsibility: A Plan to Make Coverage Mandatory and Affordable for Individuals, by Michael Calabrese
Individual mandate, federal tax credits to limit medical expense, employer pay or play, insurance pools.
Getting to a Single-Payer System Using Market Forces: The CHOICE Program, by Helen Ann Halpin
Incentives to encourage people to enroll in a public plan that would ultimately be a single payer. Employers offer coverage or pay 6.5% payroll tax. Subsidies to limit pre- miums to 2.5% of income.
From Clean Air to a Clean Bill of Health: Using Allowance Trading under the Clean Air Act as a Model for Covering All Private-Sector Employees, by Paul A. Seltman
All employers required to offer coverage, but can postpone deadline by buying government-issued “allowances“ to not cover. Coverage “floors“ rise each year.
A Workable Social Insurance Approach to Expanding Health Insurance Coverage, by C. Eugene Steuerle
Modest, but gradually increasing, tax credit available as an alternative to a capped tax exclusion. Modest tax penalties for those not buying coverage. Employers required to offer but not pay for coverage.