Covering America: A Timely Reprise

In a 2009 essay, Meyer and Wicks reintroduce Covering America Project with the hope that it will provide some timely guidance in the struggle to find a political consensus around a plan to cover the uninsured.

Jack Meyer and Elliot Wicks work for Health Management Associates, an independent national research and consulting firm specializing in complex health care program and policy issues. Meyer is a principal with HMA, and Wicks is a senior economist. Meyer led the RWJF-funded Covering America Project, with Wicks, from 2000-2003. They also co-authored a Covering America proposal, with Sharon Silow-Carroll, "A Plan for Achieving Universal Health Coverage: Combining the New with the Best of the Past," as well as several other papers.

The United States is seriously considering comprehensive reform proposals to cover the uninsured.

President Obama and the Congress are debating and assessing a range of blueprints to move the nation toward universal coverage. All plans on the table try to bring more people into our health care system while at the same time reforming it to improve quality and decelerate the growth in health care spending.

From 2000 until 2004, the Economic and Social Research Institute (ESRI), a nonprofit group, conducted the Covering America Project, with support from the Robert Wood Johnson Foundation. When we began this undertaking, hope for comprehensive health reform had faded and interest in covering the uninsured had waned. A major purpose of this project was to rekindle interest in covering the uninsured and to create, assemble and objectively analyze a range of detailed proposals across a wide spectrum of thinking. As we wrote in the preface to the first of three volumes containing a total of seventeen proposals to cover the uninsured, we found it necessary to "create some intellectual ferment around the need for serious reforms" and to establish "a forum where new and creative ideas can be developed, dissected, debated and reconfigured."

Since the Covering America Project was completed, the problem of the uninsured has worsened. Millions more people have lost coverage, and the proportion of Americans considered under-insured has risen sharply. The deep recession that the nation now endures is exacerbating the problem, as people losing jobs frequently lose health insurance as well. Moreover, while health care spending increases have moderated in recent years, they continue to outpace the growth in wages and salaries, putting a squeeze on the real incomes of working Americans.

Despite these trends, there are some hopeful signs. In 2006 Massachusetts enacted comprehensive health reform, whose major design elements seem to have provided a model for many people contemplating state and national reform. This program has already covered well more than half of the uninsured in that state. While some challenges remain, the state continues to make progress in enrolling the uninsured in employer coverage, the "Connector," and public programs. Vermont has also implemented a promising health reform program, and other states are considering important reforms (some on hold due to the current economic situation).

Further, Congress recently reauthorized the SCHIP program, which is expected to provide some 4 million additional children with coverage.

Against this backdrop, we now reintroduce people to the Covering America Project with the hope that it will provide some timely guidance to our leaders as they struggle to find a political consensus around a plan to cover the uninsured.

The Covering America Project was guided by an Advisory Panel of 12 individuals who participated actively in meetings held about five times a year over the four-year period. This panel was comprised of people who had held leadership positions in government under both Republican and Democratic administrations and leading experts from the academic and foundation communities. These advisors helped ESRI select the proposals in a national competitive process, reviewed drafts of each one and offered constructive criticism at meetings in which all the authors presented first drafts of their plans. None of the panel members tried to dissuade an author from taking a certain approach to covering the uninsured. Instead, their stance was, "given your approach, here are some ways to strengthen your case and make the various moving parts of your plan fit together in a workable fashion."

RWJF also commissioned the Lewin Group to provide cost and coverage estimates for 10 of the proposals. Based on the microsimulation model used, this exercise provided projections of the number of people newly insured by each plan, the net cost per newly insured person, and a clear understanding of how various key parties in the system—households, employers, the federal government, states, and so on—would fare under each reform plan. The Lewin Group's findings can be found in their report, Cost and Coverage Analysis of Ten Proposals To Expand Health Insurance Coverage, published in October 2003.

The purpose of this document is to rejuvenate interest in the Covering America Project by mapping the array of proposals it produced into the current debate. Two important cautionary notes should be sounded. First, the authors wrote these proposals several years ago. What we report here is their best thinking and recommendations at that time. Clearly, the positions and blueprints favored by some of the authors are likely to have evolved since then. Second, various reform plans produced under the Covering America banner will differ, some slightly, some in major respects, from the ones under serious consideration today. Nevertheless, many of the Covering America reform designs contain key elements that are strikingly similar to those now under review in Congress. Indeed, a major purpose of this report is to focus attention on the "architecture" of health reform. A proposal need not be identical to the plans on the table today to inform those considering them. Many of the issues and challenges are the same.

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