As these pressures have converged, the share of Americans who receive coverage at work has fallen in each of the last five years -- from nearly 64% in 2000 to just under 60% in 2004. Most experts project continued declines. Stern sees in these trends the writing on the wall.
"We have to recognize that employer-based healthcare is ending; it is dying before our very eyes," he said at a recent forum sponsored by the Brookings Institution think tank.
Stern didn't endorse a specific plan to replace employer-provided coverage. But he flagged the obvious two options: a government-run, single-payer healthcare regime versus a system that would require individuals to purchase insurance with subsidies from government and, perhaps, mandated contributions from employers.
McCrery, not surprisingly, prefers the latter option, minus the employer mandate.
In an essay published this month in the new journal Democracy, Jason Furman, a visiting scholar at New York University and former economic policy aide to President Clinton, said that tax policy would be the key to any shift away from the employer-based healthcare system.
The existing tax subsidy for insurance, Furman said, perversely benefits upper-income workers more than lower-income ones. The reason is that under the progressive income tax, the affluent pay higher tax rates on their income. So it would cost them more than low-income workers if government taxed the value of employer-provided insurance.
Furman wants to reverse that equation. He says that if government eliminated the current tax subsidy for employer-provided coverage (which costs Washington about $200 billion a year), the savings could fund a tax credit that would help all Americans purchase basic health insurance. That structure, he said, would provide the biggest subsidy to the least affluent.
"We should spend less subsidizing more expensive insurance ... for higher-income people and spend more to help moderate-income families obtain the health insurance they lack," Furman wrote.
A first step, he said, might be to limit the amount of insurance employers could provide tax-free, and to use the savings to fund coverage for some of the nearly 46 million uninsured.
Any system that affects as many people as employer-based health coverage won't be changed quickly, nor should it be.
"We have to work incrementally toward getting to a point where we can slowly shift insurance from the workplace," McCrery said.
Likewise, most big-business executives aren't clamoring to jettison their role.
"We're not giving up on this system and saying it needs to be thrown out," said John J. Castellani, president of the Business Roundtable, which represents the nation's largest companies. "We think it can be improved from both a cost and quality standpoint, and that's what we are focusing on."
The critics haven't assembled an irrefutable case against the employer-based system; refurbishing it might well make more sense than dismantling it. Any replacement system would need to guarantee affordability and preserve the sharing of risk.
But the tough, thoughtful questions from such voices as Stern, McCrery and Furman are an encouraging sign that the nation finally may be ready to reexamine a healthcare system that costs too much and covers too few.
Ronald Brownstein begins a book leave this week. His column will resume Sept. 10.
