A key challenge in covering the uninsured is to fit together in a seamless way a series of reforms that, taken together, will bring affordable health insurance to millions of Americans. These reforms might, for example, include making more lower-income Americans eligible for public programs such as Medicaid, tax credits for lower-income people to help them obtain affordable private health insurance, new purchasing arrangements to gather together people lacking access to affordable insurance and ineligible for public programs, requirements that all individuals obtain health insurance or that employers help fund it, and reforms that limit insurers' ability to set premiums that reflect the risk of each individual or group. Of course, piecing these components together is a bigger challenge under the reform plans that build on our current mixed system of employer coverage, individually purchased insurance and government programs than under a single-payer plan. The Covering America Project includes plans of both varieties. In fact, the various proposals emerging from our project could form a number of points spaced across a broad spectrum representing differing roles for government and the private sector (and differing roles for the states vis a vis the federal government).
A number of very important challenges inherent in reform plans on the table today are seriously addressed in the Covering America papers. Such challenges include how to structure a new insurance "exchange" to provide affordable coverage to low- and moderate-income people outside of government programs without subjecting the exchange to severe "adverse selection, which results if mainly the highest-cost people enter the exchange. Another challenge addressed in our set of papers is how to expand access to government programs without simply encouraging people to switch out of their current private coverage, known as "crowd out." A third feature contained in some of the Covering America plans is the "risk adjustment of premiums" to assure that health plans with good records on serving people with chronic disease and disabilities are not "penalized for their success" when they attract a disproportionate number of such people. An additional challenge is to establish a minimum benefit package that balances the need to cover a full range of important health services while not pricing health insurance out of reach.
There are also important questions relating to mandates. For example, if health insurance is left voluntary for both individuals and employers, the modeling conducted for the Covering America Project shows that it is difficult to get near universal coverage. Yet, requirements on individuals may be unfair if all of the provisions in a reform plan designed to make health insurance affordable for all have not yet been implemented effectively. Smaller firms may struggle with the cost of funding health coverage. If they are exempt from a "pay-or-play" requirement, their concerns will be addressed—but since most non-offering firms are small companies, such an exemption will substantially limit the number of people newly insured.
Of course, the Covering America Project did not take positions on these issues. What we tried to do was to highlight these types of policy challenges and tradeoffs and offer varied approaches to addressing them.
All of the authors were asked to present a specific financing source for new public costs generated by their proposals. They could not rely on sketchy and possible savings that might emerge over long periods of time. We subjected our authors to a kind of "pay-as-you-go" discipline that requires up-front financing of new commitments. There are lessons here for the current debate. Thus, we hope that policy-makers in the legislative and executive branches of government, at the federal and state levels, will make use of our body of work as they continue to assess, refine and burnish their proposals to cover the uninsured. Both Republicans and Democrats will find detailed plans in this diverse set of proposals that form a good fit with their visions for health reform. Further, the authors are among the leading experts in the nation, and we encourage those shaping and amending plans today to consult with them to gain the advantage of their wisdom and creative thinking.