A Word from Jacob Hacker

Jacob Hacker is professor of Political Science at the University of California, Berkeley. He authored a proposal for Covering America, "Medicare Plus: Increasing Health Coverage by Expanding Medicare."

The Covering America project was one of the most productive and collegial collaborations in which I have had the pleasure of participating. It brought together an all-star cast of health policy experts from a variety of perspectives. And it gave this group the opportunity to think about an issue that was not currently in the legislative spotlight: how to cover the nation's then-around 40 million uninsured in a cost-effective way that would improve American health care. Perhaps because the issue was not actively under debate in Congress, participants felt unusually free to put aside acrimony and accusations and address the issue creatively and constructively, bringing new ideas and new mixes of ideas to bear. I can think of few groups that better combined policy expertise with practical thinking about how to break the logjam that had stymied action for so long.

For my part, I served as both a member of the advisory group and prepared a proposal of my own, which the Economic and Social Research Institute published in 2001 as part of the first compendium of proposal to emerge from the project. That proposal—then titled "Medicare Plus" and later slightly retooled and re-released by the Economic Policy Institute as "Health Care for America"—has had far more imprint on the national reform debate than I could have guessed at the time. The essential goal of the proposal was to build on the existing foundation of coverage in American health insurance, but to broaden that foundation by creating a new source of coverage at the national level: a new public framework modeled after Medicare that would provide a choice of public or private insurance. I saw this as an opportunity to place a floor under existing benefits, preventing their continued erosion; to provide good coverage to the millions who did not receive secure insurance at their place of work; and to create effective pressure for greater cost-containment, improved health care quality and more rational financing down the road.

I was not sanguine about the prospects for my ideas at the time. I closed my 2001 proposal by noting that "the prospect that the current President and Congress will follow the map outlined here is nil, and, in fact, there is little prospect that they will make substantial steps toward universal coverage by any means." Yet, I continued:

In the long term, the tides of American politics are more difficult to foretell.... Historically, health reform has become a major issue about every 15 years, after a period of dormancy during which politicians and private leaders celebrated private market solutions. If the past is prelude to the future, the next big tide of health policy ferment is set to roll into Washington sometime near the end of this decade....

If the economy continues to weaken, if the cost of private health insurance returns to the high growth rates of the past (as it has over the past few years), and if the states began to face new fiscal pressures (as they already have started to), the interest of employers and the states in strict cost containment may revive once again. Yet it will do so after a decade during which both players have used nearly all the managerial and administrative tools at their disposal, in the process prompting a public backlash against some of the most restrictive of their practices. The alternatives left will be much less attractive: for the states, cutting Medicaid benefits for the very poor to retain or expand coverage for the near-poor; for employers, switching to so-called defined contribution arrangements in which workers are given a fixed amount for medical costs that is pegged to inflation or company revenues rather than health costs. Judged against these options, Medicare Plus may become not simply a viable alternative, but an attractive solution for many key stakeholders—not least the American public.

Well, here we are at the end of that decade, and the "next big tide of health policy ferment" is certainly upon us. What is more, key elements of reform that I and others proposed as part of the Covering America project back in 2001 are very much part of the debate. President Obama promised during his campaign an approach that built on employment-based insurance yet would create a new "national insurance exchange" for those without workplace coverage—an exchange that, crucially, includes the choice of a public plan modeled after Medicare. This basic blueprint was also supported by other Presidential contenders during the primaries and received the endorsement of the chairman of the Senate Finance Committee, Max Baucus. As a result, despite continuing principled support for a national insurance program among the most fervent advocates of reform, there is far greater consensus among those who favor comprehensive reform than there was in the early 1990s.

Yet that broad agreement is certainly not enough to actually "cover America." As Jack Meyer and Elliot Wicks note in their thoughtful reprise of the deliberations and discoveries of the project, all of the participants in "Covering America" learned that coming up with blueprints to expand coverage, challenging as it was, represented the easy part. The hard part was figuring out how to fund these proposals and to gain political support for them in a nation whose public life has too long been marked by polarization and paralysis on the most crucial issues of the day. So while I feel grateful I was asked to think about how we as a nation could overcome this stalemate, we will need more than such thinking today. We will need action, and quick action at that. If we move rapidly to build on what we have learned from projects like "Covering America," then perhaps, as I hoped at the end of my 2001 proposal, "the next big step in American health politics will lead not to another political dead end but to the beginning of the difficult yet necessary journey toward universal health insurance in the United States."