What's "universal" health coverage? It means insuring 100 percent of Americans, "less what you lose in the normal confusion of life," says New York Democratic Sen. Daniel Patrick Moynihan. That is about as succinct a definition as the American public has gotten of a phrase that conjures up visions of health insurance for extraterrestrials. Although President Clinton threatened to veto any health reform plan that lacked universal coverage, he has not adequately defined the term or fully explained why it is important. Doing so sooner might have rallied more support for comprehensive health reform -- but now the goal of truly universal coverage seems to be slipping from Clinton's grasp.
Few countries with universal health systems manage to provide insurance to literally everybody, and Clinton's reform plan would not have done so, either. The president's bill, built on a requirement that employers help pay for covering their workers, omitted insurance for an estimated 3 million to 4 million undocumented immigrants and roughly 800,000 convicts serving prison sentences. The best guess is that the plan would have covered 98 percent of the population when fully phased in by 1998.
In fact, there is no way to know how many would be insured under most reform plans because of the normal slippage to which Moynihan refers. Many Americans eligible for public health insurance do not sign up for it -- including an estimated 25 percent of those qualified for Medicaid who do not enroll in the health program for the poor. Clinton's plan probably would have eliminated most gaps through penalties on employers who did not provide coverage or on individuals who failed to obtain it. But almost no other plan likely to pass Congress has similar enforcement features.
In fact, many plans getting serious consideration from Congress set their sights considerably lower, aiming to cover anywhere from 91 percent to 95 percent of Americans, up from roughly 85 percent now. But some of these numbers have been pulled out of a hat -- and no one really knows how many more people would actually become insured. Consider the 91 percent solution, a plan proposed by Tennessee Democratic Rep. Jim Cooper. The Congressional Budget Office came up with that percentage after estimating that the proposal would add 15 million mostly poor Americans to insurance rolls -- leaving another 24 million better-off people still unable to afford insurance. Yet CBO also calculated that 4 million of the poor would still forgo coverage even if Uncle Sam paid for all of it. That's a guess, based on the number of people who currently qualify for public benefit programs but do not participate.
No numbers game. All these numbers matter far less than the real test of universal coverage: whether guaranteed sources of insurance and adequate funding exist to extend coverage to nearly all Americans. Many plans now in Congress spell out how various uncovered groups could get insurance, but may fall drastically short on money. An example is a bipartisan plan backed by centrists on the Senate Finance Committee. Devoid of any mandate that employers contribute to coverage or that individuals buy it, it aims to make insurance more affordable and accessible through various reforms and provides subsidies to help millions of the uninsured buy coverage. The stated goal is to cover 95 percent of Americans by 2002, a target that by then would still leave 14 million uninsured. Yet the evolving plan could fall tens of billions of dollars a year short of the money needed to extend coverage that far.
Why would failing to achieve universal coverage matter? Clinton has not explained clearly enough that something close to it is needed to banish aspects of health insurance that really plague people. Examples are "pre-existing condition" restrictions -- typical features of individual and small-business health policies -- that bar coverage for illnesses people already have when they apply for insurance. In a system where not everybody has to have coverage, these restrictions make perverse economic sense; otherwise, people would sign up for insurance only when they got sick, bankrupting insurance companies in the process. In fact, most reform plans that aim for less than universal coverage retain these restrictions in some form. But if almost everyone was always insured, the restrictions could be dismantled.
Health reform is a bazaar of trade-offs, yet the White House has not adequately framed the choices for the public. In a system free of pitfalls over pre-existing conditions, is it worth requiring employers to contribute to workers' coverage? Would it be worth higher taxes to fund subsidies for millions of the uninsured? We'll probably never know how the public might have answered that, since a tax-averse Congress is likely to produce a health reform plan -- if any -- that will fall far short of Clinton's universal coverage goal. The president will have no choice but to sign it if he wants a health bill -- in large part because so many Americans never had a clue about what he meant.
