A call for action. The Pepper Commission's blueprint for health care reform.

After a year of deliberation and investigation, the Pepper Commission recommended action to ensure that all Americans would have health insurance protection in an efficient, effective health care system. Because it believes that action is urgent, the commission would build universal coverage by securing, improving, and extending the combination of job-based and public coverage we now have. Reform would entail the following elements: a combination of incentives and requirements that would guarantee all workers (with their nonworking dependents) insurance coverage through their jobs; replacement of Medicaid with a new federal program that would cover all those not covered through the workplace and workers whose employers find public coverage more affordable; guaranteed affordable coverage for employers--through reform of private insurance, tax credits for small employers, and the opportunity to purchase public coverage; a minimum benefit standard for private and public plans that would cover preventive and primary services as well as catastrophic care and would include cost sharing, subject to ability to pay; and a combination of public and private sector initiatives to promote quality and contain costs.

Restructuring health care in the United States. A proposal for the 1990s.

KIE: Nutter, et al. present proposals, developed by the Medical Schools Section of the A.M.A., for reform of the U.S. health care system. The goals of this plan include the definition of appropriate roles for business, government, and the individual; responsible cost containment; simplified administration; quality assurance linked to effective methods of technology assessment; continued public and private support for biomedical research; greater responsiveness by academic medicine to national health care needs in the areas of primary care and geographic distribution; health care payers' shared responsibility for the support of graduate medical education; and the measurement of the restructured system's effectiveness against changes in citizens' health status. Supportive of the Pepper Commission's proposed replacement of Medicaid with a public health plan, the authors also urge the continuation of Medicare, the provision of health benefits by all employers, and subsidized, regional insurance pools for those not covered by other means.^ieng

An American approach to health system reform.

In terms of the major objectives one would have for health system reform, this plan makes the following choices: 1. It would cover everyone, through Medicare (the elderly), employer-based coverage (some workers and dependents) or a state-level public program that would replace Medicaid (the poor, unemployed, and other workers and dependents). 2. There would be a standard minimum package of required benefits for employer-based and public programs, with legislative requirements on maximum cost-sharing. Choice of provider might be restricted in some states. 3. Administration of the private programs would be the responsibility, as now, of the employers and/or insurance companies. Administration of the public program would be the responsibility of the states, with the objective of maximizing responsiveness to local needs and conditions. 4. It would control costs through giving the states a substantial financial stake in ensuring that the public program costs did not grow faster than nominal GNP. State control would also allow the testing of different mechanisms for cost control, with the ultimate objective of identifying the most effective cost-containment strategies. 5. The cost would be borne by employers, employees, and taxpayers. Employers would be protected from exorbitant costs by being allowed the option of paying into a public plan rather than providing health insurance themselves. The poor and unemployed would be protected by having their coverage under the public program subsidized on a sliding scale. 6. The political feasibility test would be met by retaining a major role for insurance companies and by retaining the role of employer-based coverage--thus reducing the tax increase needed to ensure universal coverage. By allowing flexibility in design of cost-containment strategy, some of the controversy over this issue would also be deflected. Our proposal is also not without problems. First, our approach would still have adverse effects on the profitability of small businesses and on the employment prospects for low-wage workers--although these effects would be less than under conventional mandates and less than under proposals with higher tax rates. Second, some states may not want the responsibility we envision or have the capacity to carry it out. But several Canadian provinces are relatively small and are able to perform the same administrative functions within the Canadian national health system. In addition, since the federal government would continue to administer the Medicare program, states would have the option of tying their policies for hospital and physician payment and utilization control to those of Medicare.(ABSTRACT TRUNCATED AT 400 WORDS)

KIE: To meet the need for expanded health care coverage in America, Holahan, et al. of the Urban Institute, incorporate aspects of the Canadian health care system and the Pepper Commission's proposals in the design of what they propose as a cost effective and politically acceptable health care reform package. Medicare would be unchanged. Employers would provide basic coverage for their workers, or pay a tax in support of state-administrated public health insurance programs. This public program would replace Medicaid, and would be utilized by three groups: those whose employers opted to pay a tax, the poor, and citizens who buy into the program. Strong incentives for states to control health care costs would be provided by requiring states to bear the burden of cost increases exceeding the rate of growth in GNP.