An incremental healthcare reform model, exemplified by the creation of the State Children's Health Insurance Program, is not bold enough for broad-based reform that would create universal coverage, according to a new paper in the journal Health Affairs.
Jonathan Oberlander, an associate professor at the University of North Carolina at Chapel Hill, and Barbara Lyons, a vice president of the Kaiser Family Foundation, examined the incremental approach through the experience of SCHIP and discussed lessons for policymakers contemplating how to achieve comprehensive health reform.
"The SCHIP debate revolved around the same boundary issues that will determine the fate of comprehensive reform in 2009 and beyond: the balance between public and private insurance, who should be eligible for government subsidies and at what income level, whether healthcare is an individual responsibility or a social good. Those issues are far from resolved," Oberlander and Lyons wrote.
The authors traced the history of SCHIP, from its creation in 1997 through its reauthorization and expansion early this year. They pointed out that SCHIP's narrow focus on expanding coverage for children enables it to avoid the political opposition that doomed President Bill Clinton's comprehensive reform efforts, and they noted the coverage gains SCHIP has achieved during its decade of operation.
Nevertheless, SCHIP also illustrates the "real limits to incremental health reform," Oberlander and Lyons wrote.
Almost 9 million children remain uninsured, and the insurance system for children is marked by the same fragmentation, inequality and coverage gaps that affect the rest of the nation's healthcare system. Thus, there are political limits on a "demographic incrementalism" that insures Americans group-by-group, as Medicare did for the elderly and SCHIP did for children.
"Unlike children or the elderly, most Americans do not fit into sympathetic population subgroups that can be neatly matched to public programs," the authors noted.
Oberlander and Lyons say the sizable majorities with which Congress quickly passed the 2009 Children's Health Insurance Program Reauthorization Act, or CHIPRA, are a hopeful sign for the prospects of comprehensive health reform under the Obama administration.
CHIPRA also drew strong support from the public, businesses, providers and the insurance industry, offering "a glimpse of exactly the type of coalition reformers hope to build for universal coverage during the Obama administration," they wrote.
However, Oberlander and Lyons also find reason for caution in the ideological divides revealed in the SCHIP reauthorization fight. The CHIPRA majorities largely reflected Democratic election gains in 2008 and contained limited numbers of House and Senate Republicans.
"Most Democrats and Republicans come to health reform with different public philosophies, different reform priorities and different solutions," the authors wrote. "As health policy moves away from children's health insurance and onto more controversial terrain, such as whether to impose employer mandates or adopt a new national health plan, that partisan divide will grow."
The bill for universal coverage will dwarf the relatively modest price tag for SCHIP expansion. Congress paid for CHIPRA through an increase in the cigarette tax.
In contrast, comprehensive healthcare reform will require tapping more controversial revenue sources or suspending Congressional "PAYGO" budget rules that require new spending to be paid for through cutting other spending or increasing revenues, Oberlander and Lyons noted.