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Executive Summary
Pages 1-14

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From page 1...
... Theframework consists of a set of principles informed by the research and analysis of thefive previous reports in this series. The principles are applied to selected coverage prototypes to demonstrate the extent to which various proposalsfor extending coverage or designing new strategies to eliminate uninsurance would improve the current situation.
From page 2...
... (Short, 2001~. Fewer people have access to coverage at work, more people find the costs of private coverage too expensive, and others lose public coverage because of changed personal circumstances, administrative barriers, and program cutbacks.
From page 3...
... ELIMINATING UNINSU12ANCE: LESSONS FROM THE PAST AND PRESENT Present-day efforts to reduce or eliminate uninsurance build on nearly a century of campaigns to bring about universal health insurance coverage. Past campaigns have yielded both incremental changes and major reforms but not universal coverage, due to the challenges to major structural changes posed by American political arrangements and the lack of political leadership strong and sustained enough to forge a workable consensus on coverage legislation.
From page 4...
... Campaigns for universal coverage in the 1970s and 1990s have been shaped by the tensions between the goals of enrolling greater numbers of people and controlling health care expenditures. Recent Federal Initiatives to Extend Coverage Have Not Closed the Coverage Gap Finding: Federal incremental reforms over the past 20 years have made little progress in reducing overall uninsured rates nationally, although public program expansions have improved coverage for targeted previously uninsured groups.
From page 5...
... Since the mid-1980s, however, major federal initiatives to extend both public and private coverage, many modeled after successful state programs, have improved coverage rates among lower income children (in households earning less than 200 percent of poverty) and boosted the numbers of lower income persons with public coverage.
From page 6...
... The increasingly severe budget crises faced by the states beginning in 2001 have limited state reform and begun to erode coverage, although the prospect of losing federal revenue has motivated states to maintain much of their commitment to public coverage programs that receive federal matching funds (Smith et al., 2002; Boyd, 2003~. State governments' capacity to finance health care and extend coverage tends to be weakest at times when demands for such support are likely to be highest, for example, during an economic recession.
From page 7...
... Universal health insurance coverage will only be achieved when the principle of universality is embodied in federal public policy. A VISION OF UNIVERSAL COVERAGE The Committee's previous reports detailed the negative effects on individuals' health, family stability, community health care institutions and access of residents, and the national economy associated with the existence of a large uninsured population.
From page 8...
... · Uninsured children risk abnormal long-term development if they do not receive routine care; uninsured adults have worse outcomes for chronic conditions such as diabetes, cardiovascular disease, end-stage renal disease, and HIV (Hadley, 2002; IOM, 2002a, b)
From page 9...
... There is no analytically derivable dollar amount of what society can afford; that will be determined through political and economic processes. · The Committee believes that everyone should contribute financially to the national strategy through mechanisms such as taxes, premiums, and cost sharing because all members of society can expect to benefit from universal health insurance coverage.
From page 10...
... USING THE PRINCIPLES The Committee's research on the problems related to uninsurance demonstrates conclusively that there are benefits for the nation and all its residents from eliminating uninsurance and ensuring coverage for everyone. Based on a review of past incremental and disjointed efforts to extend coverage, the limited progress made, and the remaining 43 million uninsured, The Committee concludes that health insurance coverage for everyone in the United States requires major reform initiated as federal policy.
From page 11...
... The Committee is mindful that defining a minimum benefit package for the uninsured would likely also affect some people who currently have a lesser insurance package, increasing their benefits and resulting in additional costs and probably increased access to services and drugs and improved health outcomes. The potential of various models to enhance health through quality care would depend on the design of the benefit packages, the strength of the public programs, and effective consumer demand.
From page 12...
... 12 INSURING AMERICA'S HEALTH TABLE ES. 1 Summary Assessment of Prototypes Based on Committee Principles Prototype 1 Principles Prototyp e Status Quo Major Public Program Expansion and Tax Credit Employer Premium Individual Coverage should be universal Coverage should be continuous Coverage should be affordable for individuals and families Strategy should be affordable and sustainable for society Coverage should enhance health through highquality care Not universal; 43 million uninsured Not continuous; income, age, family, job, and healthrelated gaps in coverage Private coverage unaffordable to many moderate- and low-income persons Not affordable or sustainable for society; uninsurance is growing; cost of poorer health and shorter lives is $65-$130 billion; some participants contribute; no limit on aggregate health expenditures or on tax expenditures spending is higher than other countries; sustainability of current public programs depends on economy and political support Quality of care for the population limited because one in seven is uninsured Would not achieve universality because voluntary, but would reduce uninsured population Family- and job-related gaps in coverage More affordable than current system for those with low or moderate income All participants contribute; aggregate expenditures not controlled; new public expenditures for only the public program expansion and tax credit; sustainability of public program depends on revenue sources and political support; size of credit depends on political support Opportunities to promote quality improvements similar to current system Coverage 1; depends 0 of mandat Brief gaps and j ob tr Yes for wo adequate assistance; designed to all enrolle All partici basic parka,, current ems revenue fi public prc depends 0 for emplo assistance Could desi in expande and basic current er for quality
From page 13...
... ~ S1~1~F ~ ~ , . ~ , oo~ Away fo of Age; dopcnds on cn~rcomcnt of mandates ~e; rewed to h ad job Pardons ; ~, a, Pluming dcqu~tc employer premium mu; ~~ ~ '~' fig 6~ ~~ Or c~oUcos p~dcip~nts con~butc; 6~ ~~ ~ aft ~~" If Oaf revenue Tom pedants in public program; sun dopcnds on revenue sources Or employers' premium P~ P Coca '~" Sniffy fluffs fig ~~'~ ~~m find bloc boncSt package; current c~loycr incondvos -~ raw ~6 find cost of .
From page 14...
... The Committee is concerned that the current and growing economic pressures on state governments as well as at the federal level will have a negative impact on public programs and erode current coverage, making future coverage gains more difficult. Until everyone has financial access to health services through insurance, it is necessary to sustain current public coverage programs.


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