Decision Points and Trade-Offs in Developing Comprehensive Health Coverage Reforms

Approximately 41 million Americans have no form of health insurance. Proposals of many varieties have been put forward to extend health coverage to the uninsured. The differences among them reflect the decisions reformers make with respect to three kinds of judgments. First, the approaches differ because people assign different priorities to particular values. Second, system designers make different assessments about what is politically feasible and about what compromises they are willing to make to enhance their proposal's political acceptability. Third, proposals differ because reformers make different judgments about what mechanisms and structures will actually work best to accomplish the objective of extending coverage.

Of course, these three kinds of judgments are intimately related. It may be necessary, for example, to compromise some values to enhance political feasibility—for instance, accepting some inequities to hold down the budgetary cost. Or, a structure that might work well to achieve the objective of covering everyone—for example, requiring all employers to offer coverage—may conflict with an important value, such as seeking to minimize the level of compulsion. In short, anyone seeking to solve the problems of the uninsured is forced to make many trade-offs. The judgments people bring to bear in making those trade-offs go far to explain the difference in the nature of their proposals. It is useful to make explicit the decision points and the kinds of trade-offs reformers must make in designing policies to cover the uninsured. That is the purpose of this paper, which is the first in a series that will deal with issues that need to be addressed in designing comprehensive coverage expansion. Subsequent papers will address in greater depth some of the issues discussed briefly in this paper, as well as some additional issues.