Four leading options for health care reform are under discussion by the
Obama administration and leaders in Congress, although many advocates said the
final plan that is expected to emerge from months of negotiation may include
components of each approach.
A version of the plan advocated by President Obama may garner the greatest
public support, but some health reform advocates worry about its bottom line
since it also offers the least ability to control the rapid rise in health
Among the four options that have drawn the most attention in Congress are a
single-payer plan (HR 676), an approach that increases the competitive market
for health insurance, and two plans that would expand the current mixed public
and private insurance system.
Many reform proponents maintain that a single-payer system supported by
taxes and providing universal access is among the most straightforward."
This is probably the only approach that's actually going to get us to
having no uninsured left," said Jack Ebeler, an independent consultant
on federal health policy, during a Washington, D.C., roundtable discussion in
This approach offers the largest reductions in administrative costs, based
on estimates that Medicare spends up to 3 percent on administration, while
private insurers average about 14 percent to 15 percent.
However, it is also the least likely to succeed, according to some health
policy experts, because it may require large increases in taxes and greatly
increase government control of health
A major drawback for physicians is that this approach is likely to result
in lower payments for care. Based on Medicare Payment Advisory Commission
(Med-Pac) data, private-system reimbursements are about 20 percent greater
than those in public systems.
Another option not likely to succeed, according to Ebeler, is the one
advocated by the Republican minority in Congress, which involves tax reform,
individual markets, and cross-state purchasing.
"The theory is that increased competition might result in a
competitive market for health insurance," Ebeler said, thus driving down
the cost of buying it.
Many Congressional leaders, however, oppose this approach because it could
discriminate against sicker people by allowing companies to either charge them
higher premiums or deny them coverage.
Also, this approach could relegate many chronically ill
people—prominent among them people with co-occurring serious mental
illness—to expensive or under-funded high-risk pools for coverage.
More widely known is the proposal outlined by Obama during the election
campaign, which is similar to an approach advocated by Sen. Max Baucus
(D-Mont.) (Psychiatric News, December 19, 2008). Their approaches
build on the current system, which is likely to appeal to many in the public
who are wary of drastic change.
"It's very easy for the public to get scared away from the concept of
coverage if they think their own coverage is vulnerable," said Diane
Rowland, executive director of the Kaiser Commission on Medicaid and the
The Obama and Baucus approaches use a national insurance exchange, which
would allow people to comparison shop for policies nationwide.
The more-detailed Baucus plan would create a mandate for all Americans to
have insurance—as was done in Massachusetts—and create a
government-run insurance option while allowing the private insurance system
and employer-provided insurance to continue.
His plan would bar exclusion of people from insurance coverage based on
preexisting conditions and allow those aged 55 and older to "buy
in" to Medicare. Medicare is restricted to people aged 65 and older.
But this approach also has its detractors. A highly contentious aspect of
it is the inclusion of a federal health insurance option that would compete
with plans sold by private insurers. Republicans consider this a"
Another potential complication of building on the system in which employers
provide insurance for a substantial number of Americans is the lack of
subsidies for workers who earn relatively low wages, whose employers do not
offer insurance, and who cannot afford to buy individual insurance.
Brad Herring, Ph.D., an economist at the Bloomberg School of Public Health
at Johns Hopkins University, said that such an approach will struggle
politically because many Democrats prefer a single-payer system, while
conservative Democrats also may oppose the federal insurance option because of
their concern that it could undercut private insurers and eventually lead to a
Another leading option is the only one that has so far gained broad
The Healthy Americans Act (S 391), sponsored by Sen. Ron Wyden (D-Ore.),
also would build on the existing mix of public and private insurance systems
through the use of state-based "exchanges" in which buyers could
comparison shop for plans. The key difference from the plans advocated by
Obama and Baucus is the continued state-specific limitation of insurance
plans, which the insurance industry has advocated. Wyden recently updated this
legislation to allow workers insured through their employers to retain their
The Wyden legislation has 13 cosponsors, including six Republicans. This
bipartisan option has drawn some fire from liberal legislators because it
would move the "vulnerable" Medicaid population into private
insurance plans. "That could be problematic for many advocates,"
Although this legislation is seen by some as the best bipartisan compromise
possible, it generally remains congressional leaders' second preferred plan,
or even a third plan behind retaining the status quo.
"That may not bode so well for us all," Ebeler said about the
continuing preference for no action if a favored option fails.
Regardless of which option eventually becomes the focus of legislative
action, the final plan is likely to include some version with rigorous
cost-control approaches and perhaps the use of allied health professionals to
expand into physicians' traditional scope of practice.
Rep. Parker Griffith (D-Ala.) signaled this possibility, noting that any
system that provides broad-based health care access will immediately confront
the challenge of an insufficient number of physicians to meet the need,
especially in rural and some urban areas. "So the question is who are
[patients] going to see, and are we willing to step outside the box and say
that nurse practitioners, clinical pharmacists, nutritionists, in conjunction
with physicians, must deliver primary care?" Griffith said.
Herring, of Johns Hopkins, said an eventual national health plan may
address the physician shortage through expanded subsidies for physicians who
practice in underserved areas and increased tuition support for students going
into medical fields in which there are shortages.
The text of health care reform bills can be accessed at<http://thomas.loc.gov>
by searching on bill numbers, S 391 and HR 676. ▪