Required coverage for all: The pressures are increasing whether discussed or not

Issue: July 2006

Douglas W. Jackson [photo] --- Douglas W. Jackson, Chief Medical Editor

Some states are now considering required health care coverage. They are proposing it as a solution for the large and growing number of uninsured and under-insured in the existing system. Wrapped into it is the concern that many currently insured individuals who have long depended on employer-subsidized health insurance now feel squeezed by actual or looming subsidy cuts.

Federal and state financing of medical coverage continues to be challenged by rising costs. Government agencies are having more difficulty maintaining programs for patients that provide access to quality medical care and new technology. This is a manifestation of what appears to be a widening discrepancy in the access to quality health care between upper and lower income levels.

Politicians are starting to feel more pressure to bring forward some type of meaningful legislation to address these concerns. However, they have been unwilling to seriously discuss, debate or propose health care reform. They see any discussion that includes Medicare reform as a no-win situation for them — a threat to electability.

Cost pressures force change

The pressure of future funding of health care may become the basis for a change. There are hints that we may see some meaningful health care discussions in the upcoming presidential election. One potential presidential candidate has been working with bipartisan support in proposing a health care experiment in the state of Massachusetts. This program involves providing and/or “requiring health care coverage” for everyone in that state. Next door, in Vermont, another experiment is under way (see related story for details on these programs on p. 52).

The nation is watching these provincial attempts to reform health care financing. The details are sketchy and slow in coming forth. There are many questions from skeptics and interested observers on the ultimate costs, enforcement and workability of these plans. And even if the programs in Massachusetts or Vermont succeed in those states, many wonder whether similar models could work elsewhere. These two states are unique in size and demographics, and have a population that may accept the taxation necessary to support such programs. Massachusetts does not currently rank among states with relatively low per capita medical costs, and many predict that added costs for this new program will drive overall costs there up significantly. One problem intrinsic in required health care coverage: how the social engineers distribute the risks and costs among the funding population.

Devil in the details

The new system will have to continually cost shift a disproportionate expense to those with healthy and disciplined lifestyles. Covering the costs of social problems such as drug, cigarette and alcohol abuse, and addiction, as well as costs related to violence and similar problems will challenge the system. Lifestyles that include obesity and associated health-related issues must be paid for by others. The working class and income generators will most likely continue to contribute through higher health care insurance premiums and taxes.

Can you conceive of a more cost-effective health care system that involves more government bureaucracy for administration? Imagine, in addition, another layer that will be necessary to police mandatory coverage. Medicare has instituted price controls in health care to try and balance their budget. Price controls have not worked well in other sectors of the marketplace but will continue to be used in health care.

Proponents of required health care coverage say it will function like the car insurance model where all drivers must carry insurance. While that model has resulted in more of the responsible individuals carrying proof of coverage, many of us still feel we have to carry uninsured motor insurance for those who choose not to buy insurance for themselves. Imagine the challenges of enforcing health insurance payments for those who do not want to buy it or discipline themselves to make payments.

The time has come to place health care reform on the national agenda as a priority issue. The upcoming presidential race should stimulate new proposals and meaningful debate. This debate should consider what coverage would be basic for all, who gets covered, and how we work out who pays for it and subsidizes it.

It will only become a priority issue when enough voters make it so. More people (voters) need to become involved and require candidates to address the ongoing and increasing medical care funding crisis.