States Take the Initiative in Covering Uninsured


SAN DIEGO — The pressure is building to expand health insurance coverage, and right now the states are taking the lead, Jack Ginsburg said at the annual meeting of the American College of Physicians.

The issue of covering the uninsured is likely to heat up during the 2008 presidential election season, but little is expected at the federal level until after the race is decided, said Mr. Ginsburg, director of health policy analysis and research at the ACP.

“Where the action is really taking place is at the state level,” he said.

There are comprehensive plans aimed at covering the uninsured in Maine, Massachusetts, and Vermont. In Maine, the state offers its residents discounts on premiums and deductibles on a sliding scale. In Massachusetts, the strategy for expanding coverage focuses on individual coverage mandates and income-based subsidies. And in Vermont, the state offers subsidies for the uninsured and employers pay an annual assessment for uninsured workers.

Other states, including Connecticut, Illinois, Pennsylvania, and Tennessee, are offering expanded coverage for children. In Connecticut, for example, families with an income of more than 300% of the federal poverty level can buy into the State Children's Health Insurance Program (SCHIP). More states are considering plans for universal health coverage for children.

In Montana, Rhode Island, Tennessee, and Utah, lawmakers have opted for incremental coverage that relies on public-private partnerships. These programs include combinations of approaches such as limits on insurance premiums, purchasing pools, premium assistance, and tax credits.

Lawmakers in several other states are considering proposals to expand health insurance coverage. For example, in California, Gov. Arnold Schwarzenegger (R) has proposed an individual insurance mandate, an expansion of Medicaid and SCHIP, and the creation of purchasing pools.

There are several legislative proposals circulating at the federal level, starting with the Bush administration plan, which involves tax deductions of $7,500 for individuals and $15,000 for families to offset the cost of purchasing health insurance. The president's plan to expand coverage also relies on health savings accounts, taxing employers' health plan contributions as income, and association health plans.

Other federal legislative proposals include efforts to require employer-sponsored insurance, individual insurance mandates, expanding Medicare coverage to all, expanding Medicaid or SCHIP to cover all children or children and parents, and federal grants for state initiatives.

Most of the 2008 presidential candidates are being cautious about offering details on their health care plans.

On the Democratic side, the most detailed plan so far has come from former Sen. John Edwards (D-N.C.), who favors mandatory coverage for all through an expansion of Medicaid and SCHIP, sliding-scale tax credits, and other initiatives. Two other candidates, Sen. Hillary Clinton (D-N.Y.) and Sen. Barack Obama (D-Ill.), have stated a goal of universal coverage but have released few details, Mr. Ginsburg said.

Among the GOP candidates, most have said that they support “market-driven” approaches, he said.

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