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College unveils new seven-year plan to expand access

From the June ACP-ASIM Observer, copyright © 2002 by the American College of Physicians-American Society of Internal Medicine.

By Deborah Gesensway

In its latest effort to expand access to health care, ACP-ASIM has proposed a comprehensive plan that would help bring health care coverage to all Americans within seven years.

The College's new plan would achieve that goal by building on the nation's public and private health care systems. The proposal calls for a combination of measures: expanding Medicaid and the State Children's Health Insurance Program (S-CHIP); providing government-sponsored premium subsidies; and establishing new state programs.

College leaders


At an Annual Session press conference, College leaders explain how ACP-ASIM's plan to expand existing government programs and change the private insurance market would make universal coverage possible by the end of the decade.


ACP-ASIM leadership unveiled the plan, "Achieving Affordable Health Insurance Coverage for All Within Seven Years: A Proposal from America's Internists," at an Annual Session press conference in April. The College also held a briefing on Capitol Hill in late April to present the plan to members of Congress. Attending the briefing were Reps. James McCrery (R-La.) and James McDermott, MD (D-Wash.), both members of the House Ways and Means Committee.

College President Sara E. Walker, MACP, told attendees at the Hill briefing that the nation can reach the goal of universal access to health insurance in a matter of years—not decades—by building on the current health care system. She emphasized that the plan does not seek to replace the current system with a single-payer model like that used in Canada or Great Britain.

"America is simply too different to adopt their approach," Dr. Walker explained at the briefing. "We propose to preserve what is best about the American approach to health care and expand programs that are already in place and functioning." At the Annual Session briefing, Robert B. Doherty, the College's Senior Vice President for Governmental Affairs and Public Policy, put it even more simply: "This is not a one-size-fits-all country, and this is not a one-size-fits-all plan."

Expanding existing programs

Dr. Walker told attendees at the Hill briefing that public support for universal access has been undermined by myths about the uninsured. One myth holds that the uninsured can readily get adequate health care through emergency rooms and free clinics, a misperception the College dispelled in its "No Health Insurance? It's Enough to Make You Sick" reports issued in 1999. (The reports are online at www.acponline.org/uninsured/index.html.)

The second myth is that uninsured Americans are homeless or on welfare. "The fact is," Dr. Walker said, "more than 80% of the uninsured are working families."

To meet the health care needs of all Americans, including those who are employed but often ineligible for benefits, the College plan would broaden existing programs while restructuring their financing and eligibility requirements. ACP-ASIM is calling on the government to take the following steps:

  • Expand—and standardize—income requirements for Medicaid. The College plan would expand the Medicaid program to cover everyone with incomes up to 100% of the federal poverty level. Currently, states set the program's income eligibility requirements, resulting in considerable variation among states in the level of income and other factors to qualify for coverage.

  • Convert S-CHIP to a federal-state entitlement program. This part of the ACP-ASIM plan would divorce funding for S-CHIP from discretionary appropriations by the states. When states face revenue shortfalls, S-CHIP has been vulnerable to deep funding cuts and a reduction in the number of individuals covered by the program.

  • Create premium subsidies to help people buy into public programs or private insurance. People with incomes between 100% and 200% of the poverty level would receive subsidies to buy insurance through either the S-CHIP program or the private insurance market. According to the College's proposal, subsidies must cover 90% of the cost of premiums for lower-income individuals, and they should be given in the form of a refundable tax credit or voucher. The amount of the subsidy would decline as income increases.

College officials estimate that by providing coverage for all Americans who earn up to 200% of the poverty level, the new program would cover two-thirds of currently uninsured Americans by 2005.

The premium subsidy program would later be expanded to uninsured individuals with incomes above 200% of the poverty level, making coverage affordable for up to an additional 34% of the uninsured by 2007.

Any remaining uninsured would be covered by 2009 through automatic enrollment in public programs or other measures to be recommended by an independent advisory commission. The same independent commission would recommend a basic benefits package for all participating insurers and monitor the effectiveness of each program in reducing the number of uninsured persons.

Health plans and state options

Another key element of the College plan calls for changes in the private insurance market. ACP-ASIM believes that any private health plans that want to participate in the premium subsidy program should be required to agree to basic reforms to make coverage more affordable and uniform throughout the country.

For example, the College wants to require participating insurers to offer an evidence-based basic benefits package, as recommended by the independent commission, that would include proven preventive and screening procedures. At the Annual Session press conference, Dr. Walker said this solution is the only effective way to deal with the growing problem of "underinsurance."

Under the ACP-ASIM plan, participating health plans would have to offer coverage through purchasing groups, either on a state or regional level. These groups would give individual members more buying clout. They would also ensure that health plans conform to other requirements, such as premiums based on the health risks of the overall insured community, rather than of the individual, as well as guaranteed renewability, regardless of changes in a patient's health status.

These kinds of safeguards would allow uninsured individuals to obtain affordable coverage regardless of where they live, their health status or their place of employment.

The College's plan maintains a role for employer-based coverage and includes measures to make such coverage more affordable for small employers. Small businesses would be permitted to purchase coverage through purchasing groups, and the premium subsidy could be applied to an employee's contribution to employer-provided coverage.

The College plan would also allow states to opt out of any national coverage framework and establish their own coverage programs with federal funding, as long as that coverage meets federal guidelines. (For full text of the College's seven-year plan, see www.acponline.org/hpp/afford_7years.pdf.)

Mr. Doherty said that the seven-year goal is "partly symbolic and partly practical." Symbolically, he explained, the plan makes the point that universal access can be achieved by the end of the decade—as long as the nation is committed to providing coverage for the uninsured.

The proposal is practical, he noted, because it provides a detailed analysis complete with a timetable of how long it would take to create the infrastructure to meet that goal of universal coverage.

Mr. Doherty also explained that ACP-ASIM has intentionally refrained from calculating the cost of such a program. The goal, he said, is to focus the discussion less on the cost of insuring everyone and more on the cost-both financial and to society in general-of not insuring everyone.

As Dr. Walker explained at Annual Session, "We want to move the debate to 'how,' not 'why.' "

Deborah Gesensway is a freelance writer in Glenside, Pa.

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