Reflections from Alice Rivlin

Covering America-Still Relevant and Insightful in 2009

Director of the Office of Management and Budget under President Clinton, Alice Rivlin is now a senior fellow at The Brookings Institution. She served as a member of the advisory committee to the Covering America project.

For at least two decades millions of Americans have complained about the inadequacies of their health delivery system for at least three reasons. First, the quality of care, while sometimes excellent, is variable and frequently poor. Many patients receive ineffective and sometimes harmful treatment. Second, health spending is greater in the US than in other countries and rising rapidly. On the current trajectory health care will soon equal 20 percent of total spending in a very few years. Third, millions of Americans have no health care coverage or very inadequate coverage. They often go without treatment or seek it late (and expensively) in emergency departments.

In the early 1990s many people thought the time had come for a comprehensive reform of health care delivery to improve quality and access and slow the growth of costs. But President Clinton's reform effort failed and the issue dropped from the national agenda for over a decade. Now in 2009, the time is right for another attempt and hopes are high that this one might succeed. The economic crisis is dramatizing the need for reform as unemployment rises, workers lose coverage, and rising health costs put pressure on family, company and public budgets. Scholars and politicians are again coming forward with health reform proposals.

Fortunately, the job of understanding and comparing these reform proposals is made easier by the accumulation of good policy analysis in the years since the last reform attempt in the 1990s. In particular, a major project called Covering America, funding by the Robert Wood Johnson Foundation between 2000 and 2004, produced a rich trove of analysis that can help today's policy-makers. A well-selected group of health policy professionals with diverse approaches and viewpoints were invited to work out detailed proposals for comprehensive health reform. Some emphasized government action and others relied heavily on market forces. Some would have replaced the whole health delivery system with a different one and others would have reformed the existing system incrementally.

These proposals were intensively reviewed and discussed by an advisory panel of a dozen people—a mix of academic experts and people who had held important policy positions in government. This panel asked hard questions, demanded evidence of feasibility and subjected the proposals to cost analysis. The resulting revised proposals were published in readable form with accompanying critiques. The participants in the process benefited greatly and sharpened their thinking about the pros and cons of different approaches to health reform. (I know because I was one of them!) The publications were widely read and used as teaching materials.

As the political process once again focuses on comprehensive health reform, the findings of Covering America have become highly relevant once more. The issues have not changed, although the short-comings of the current system have worsened. The range of solutions is much the same, and the analytical framework designed by the Advisory Panel still brings clarity to the debate.

Fortunately, the Robert Wood Johnson Foundation is resurfacing the work and reissuing the publications of Covering America. This time they may contribute to decisions that will result in comprehensive health reform.