Health care reform is once again at the top of the nation's policy agenda. In addition to public officials, business leaders and consumers are concerned about health insurance coverage, and all for similar reasons—affordability. Corporate leaders place reducing health care costs at the top of their priority list. For the public, growing debt levels, high energy prices, and eroding housing values combine to make the personal cost of health care and the fear of losing health insurance rallying cries for change. Survey after survey reveals that the cost and precariousness of health care lie at the root of the public's economic concerns.

The re-emergence of coverage as a policy issue offers the Robert Wood Johnson Foundation an opportunity to build on more than 30 years' experience working to increase access to health care and, over the past decade, specifically to reduce the number of uninsured. The first three chapters of this year's Anthology examine that experience, providing a framework from which to consider the options for expanding health insurance coverage to all Americans.

In looking at the Foundation's history and how it bears on our current and future programming, a number of thoughts come to mind. The first is that although health care reform is a highly partisan issue, the Foundation has always been agnostic about the specifics of reform as long as they lead to high-quality care for all Americans at a reasonable cost. We have developed a set of principles that we believe are fundamental to any coverage approach and that guide our efforts to expand health insurance coverage. A second observation, closely related to the first: to reach the point where Americans have high-quality care at an affordable cost, we must have bipartisanship and consensus in the policy-making process; maintain our role as a source of objective, trusted, and timely information; and promote advocacy based on such information. Third, the states represent real-world sites for innovation and testing of both policy and political will. We will continue using our resources to catalyze, nurture, and evaluate state-based approaches because of the tremendous potential to learn from these efforts, and to create greater momentum for expansion nationally. Fourth, effective implementation of existing policies is critical. The State Children's Health Insurance Program (SCHIP) and Medicaid provide evidence of this point. Simplification of eligibility requirements and better coordination between the programs has helped to facilitate initial enrollment and enrollment renewal, particularly of children. Maximizing enrollment of eligible individuals in Medicaid and SCHIP has been and remains a Foundation priority.

RWJF Coverage Principles.

The meaning of the term health insurance coverage raises a complex array of questions, each of which provokes some level of controversy. We do not intend to express a position on every facet of the issue; however, we do wish to establish a set of principles we believe are fundamental to any health care system extending health insurance coverage to all Americans.

Our commitment to achieving health insurance coverage for all Americans is based on the following basic concepts:

  • Good health is necessary for all Americans to participate fully in ­society, and a healthy population is vital to the productivity and ­economic and social well-being of our nation.
  • Health care is critical to good health and should be available to all regardless of race/ethnicity, age, gender, geography or income.
  • Health insurance coverage* is essential for access to necessary and appropriate health care and should be available to all Americans.

Therefore, we believe that:

  • Health insurance coverage should be affordable. Individuals should contribute to the cost of their care; however, the cost of health insurance and the out-of-pocket costs incurred in accessing care should not force individuals to choose between health care and other basic necessities of life.
  • Health insurance coverage should include necessary, appro­priate, and effective health care services.
  • Health insurance coverage should be continuous and portable, bridging life span, employment and geographic relocation.
  • Health insurance coverage should promote high-quality and cost-effective health care.
  • Health insurance coverage should be based on shared responsibilities between the public and private sectors and individuals. These ­responsibilities include the oversight, management, and financing of the health care system.

* The term health insurance coverage throughout this document is intended to include both private commercial health insurance plans, as well as public programs, such as Medicaid and Medicare.

A last observation: Our nation's experience over the past 30-plus years has taught us that no one and no interest group is likely to see their first policy choice for expanding coverage adopted in toto and that the status quo cannot be our default option. Therefore, it is important to support those who have or can develop a backup plan—one that is an acceptable alternative to a wide range of people who will not get their first choice. Our role is to help to build the bridges and trust needed to reach the kind of compromise that can be the basis for reform.