By the time the U.S. Census Bureau reported that the numbers of uninsured had topped 41.2 million in 2001, the sheer size of the problem had galvanized old foes throughout the private sector to join forces to find a solution.
Dozens of eclectic coalitions had formed, bringing providers, payers, unions and consumer groups together to build consensus, raise public awareness and promote federal action to tackle the growing access problem.
Yet today, as the nation prepares to kick off its third annual "Cover the Uninsured Week" on May 1, nearly 4 million more Americans are uninsured and researchers are predicting continued increases into the next decade.
Industry observers say national coalitions have played a key role in generating a renewed debate around the uninsured problem. But for all the extra lip service, the nation may be no closer to a workable solution than it was a decade ago, when President Clinton's sweeping healthcare reform plan sank amid skepticism, said professor Richard Kronick, chief of the healthcare-sciences division at the University of California at San Diego.
"There's been very little progress to point to in terms of either market change or policy change," Kronick said. Since 1994, "health insurance has become increasingly unaffordable for the average American, and on the federal level, there's even less political imperative to address the problem than there was back then."
Indeed, for all of the private sector's efforts, the ranks of the uninsured have swelled 13% during the past 10 years, reaching 45 million in 2003 (See chart). And while preliminary data from the Centers for Disease Control and Prevention indicate that coverage rates ticked up slightly last year, the worst may be still to come. According to a study co-authored by Kronick and published earlier this month by the policy journal Health Affairs, the uninsured population is expected to grow another 25% through 2013, to 56 million Americans.
The most substantial drop in coverage this decade is among people insured through their jobs. From 2000 to 2003, the proportion of nonelderly Americans with employer-sponsored health insurance sank from 67.7% to 63.8%, according to the Census Bureau, as rising premiums have forced many small employers to stop offering benefits and workers to forgo increasingly costly coverage.
And were it not for government programs absorbing more low-income workers, the nation's uninsured rate would be even higher. According to CDC data through September 2004, the percentage of nonelderly Americans covered by public programs such as Medicaid rose to 16.1% last year from 12.4% in 1999, while those with private insurance-either employer-sponsored or individually purchased-fell to 68.8% from 73.1%.
But Stuart Schear, director of the Cover the Uninsured Week campaign-an effort sponsored by a diverse group of payer, provider, union and advocacy organizations-doesn't read too deeply into the numbers.
"The uninsured is a problem of historic proportions and people have been trying to solve it for decades," said Schear, a staff member at the Robert Wood Johnson Foundation. "Anyone who is committed to solving a problem of this magnitude knows they're going to have to be in it for the long haul."
Cover the Uninsured Week evolved from a self-proclaimed "strange bedfellows" coalition, which brought together two arch opponents-Families USA, a key backer of the Clinton reform plan, and the former Health Insurance Association of America, which helped torpedo the plan with its "Harry and Louise" TV ads.
Funded by the RWJF, the coalition doesn't endorse specific coverage proposals. But each year since 2003, it has sponsored a weeklong series of meetings, seminars and health fairs across the country to raise national awareness of the uninsured problem. This year, $3.1 million is being spent on the event, on top of roughly $9 million spent in each of the past two years.
"The (political) attention being paid to the uninsured is still disproportionately low for how huge a problem it is," Schear said. "Calling attention to the issue is the most important thing we can be doing at this time."
Chip Kahn, who co-founded the coalition while president of the HIAA, credits Cover the Uninsured Week and other initiatives with propelling the uninsured issue toward the top of the national agenda. But he admits that greater progress toward a solution has been stymied by the changing political climate.
"The amalgam of coalitions out there contributed mightily to the prominent role the uninsured played in the presidential debates in 2004," said Kahn, now president of the Federation of American Hospitals, which represents for-profit hospital operators. "But the fact is, after years of coalition building and consensus building, the number of uninsured has continued to grow dramatically."
Amid much hoopla in 2000, Kahn and his former nemesis Ron Pollack, executive director of Families USA, set out to bridge the partisan divide by pushing a coverage proposal that combined tax credits for employers with the expansion of public programs (Nov. 27, 2000, p. 3). But today, with Medicaid funding cuts looming, Kahn says he has narrowed his focus to "passing what is passable" under the current administration-namely legislation involving tax credits to help workers buy coverage, association health plans and health savings accounts.
Rather than risk allowing the uninsured population to expand, "we need to adapt our approach to reflect political reality," Kahn said. "Instead of pursuing some grand public-policy compromise that's palatable to everyone but has no chance in the current (political) context, let's look at what's already on the table and come together around implementing that."
Meanwhile, a new group of about 60 employers, dubbed the Affordable Health Care Solutions Coalition, isn't waiting around for the government to thin the ranks of the uninsured.
In January, the coalition, which includes IBM Corp., General Electric Co. and Sears, Roebuck & Co., unveiled a program called National Health Access, designed to provide low-cost coverage options to employees who typically don't receive job-based insurance, such as part-time, contract and temporary workers, consultants and certain early retirees (Jan. 31, p. 12). So far, "a fair number" of coalition members have signed up to begin offering the voluntary benefits in September, said Cory Siansky, executive director of National Health Access.
One step at a time
While it's too soon to gauge their success, coalition members estimate they could expand access to 3 million uninsured workers and family members by offering them a variety of health plans at 10% to 30% less than it would cost them to buy individual insurance. Ultimately, the hope is that additional employers will join the coalition or form similar groups to expand access to job-based coverage, Siansky says.
The coalition represents the latest of several efforts by large payers to make coverage more affordable. To reduce their benefits costs, employers have formed regional purchasing groups and lobbied for legislation permitting limited-benefit plans that omit costly state coverage mandates (March 28, p. 30). Meanwhile, insurers have rolled out new consumer-driven products-such as tiered provider networks, high-deductible plans and health savings accounts-designed to reduce costs by making consumers more frugal.
Yet Jack Meyer, president of the Economic and Social Research Institute, contends that such products will likely do little to help the uninsured, two-thirds of whom have annual incomes below the federal poverty level.
Indeed, the study published by Health Affairs projects that more than one in every four workers will lack coverage by 2013 as insurance becomes increasingly unaffordable.
"There has been a pretty steady relationship between rising insurance premiums and the number of uninsured," said Todd Gilmer, an assistant professor at the University of California at San Diego's School of Medicine and co-author of the study, titled It's the Premiums, Stupid. "Until we directly address the reasons behind our rising health expenditures, premiums are going to continue to climb, and so will the number of uninsured."
That's precisely why some coalitions are advocating sweeping, systemwide change. Take the National Coalition on Health Care, another unusual alliance of 100 major corporations, unions, pension funds and trade associations, founded in 1990 to achieve better, more affordable healthcare for all Americans.
Last year, the nonpartisan coalition unveiled what it calls the most comprehensive healthcare reform plan in the nation. The plan outlines several "specifications" designed to achieve mandatory, universal coverage; align healthcare cost increases with growth in per-capita gross domestic product; and boost medical quality and safety while simplifying administration through information technology.
NCHC President Henry Simmons said momentum is building behind more ambitious reforms, as shown by the coalition's membership, which has grown more in the past 18 months than at any time in its 15-year history.
"This is no longer just a healthcare issue; it's become a massive social and economic problem," Simmons said of the uninsured. "And that's going to force us to find a real solution sooner rather than later."
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