March 17, 2009
12:01 a.m. Eastern Time
What Are The Lessons Of SCHIP For The New Round Of Health Reform?
Incrementalism Can Be Alluring, But Bolder Reforms Are Needed For Universal Coverage, Say Oberlander And Lyons
Bethesda, MD - Given the enormous fiscal and political obstacles to achieving universal coverage, some have argued for following an incremental reform model, exemplified by the creation of the State Children's Health Insurance Program. In a paper published today on the Health Affairs Web site, two leading health policy analysts examine the incremental approach through the experience of SCHIP and discuss the lessons for policymakers contemplating how to achieve comprehensive health reform. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399
"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 health care is an individual responsibility or a social good. Those issues are far from resolved," write Jonathan Oberlander, an associate professor, social medicine and health policy and management, at the University of North Carolina at Chapel Hill, and Barbara Lyons, a vice president of the Kaiser Family Foundation and deputy director of the foundation's Commission on Medicaid and the Uninsured.
Oberlander and Lyons trace the history of SCHIP, from its creation in 1997 through its reauthorization and expansion early this year. The authors point out that SCHIP's narrow focus on expanding coverage for children enabled it to avoid the political opposition that doomed the Clintons' comprehensive reform efforts, and they note the coverage gains SCHIP has achieved during its decade of operation.
However, SCHIP also illustrates the "real limits to incremental health reform," Oberlander and Lyons write. Almost nine 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 health care system. Moreover, there are also 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 point out.
What Does The SCHIP Reauthorization Experience
Say About The Coming Health Reform Debate?
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, Oberlander and Lyons observe. 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."
However, Oberlander and Lyons also find reason for caution in the ideological divides once again 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 write. "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."
Finally, of course, 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. Comprehensive 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 note.
After the embargo lifts, you can read the paper by Oberlander and Lyons at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.28.3.w399
ABOUT HEALTH AFFAIRS:
Health Affairs, published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. Web Exclusives are supported in part by a grant from the Commonwealth Fund.
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