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A national healthcare reform primer

March 02, 2009|Bob Rosenblatt

Most people with health insurance say they like what they have. They trust their doctors, and they are fearful of any change in their policy.

Many of the 47 million uninsured people in this country don't go to the doctor even if they need to because they figure they can't afford it. They skimp on medications or skip them entirely.

President Obama has said that he and Congress will make both groups happy by cutting costs for those who have coverage and by bringing quality care to those who currently have no insurance.

It's a tremendous challenge. And the goal, if accomplished, will affect every American.

On Thursday, Obama's push to expand healthcare coverage began in earnest, with the announcement of his plan to create a $634-billion fund to do just that. The amount was described as a down payment over 10 years; the final price tag would be even larger, perhaps $2 trillion or more.

The president's strategy is starkly different from the approach by the Clinton administration in 1993, when it corralled hundreds of experts and staff people to produce a detailed plan more than 1,000 pages long. The Clinton effort failed, despite Democratic majorities in both houses of Congress. Obama's approach is this: Give me a bunch of money, and we'll figure out the details later how we are going to manage this thing.

Now the wrangling truly begins -- with the administration trying to push its vision through Congress, with Democrats and Republicans trying to shape the effort to their liking and with special interests trying to affect the final outcome, whatever it may be.

The cost of covering the uninsured ultimately will depend on the number of people included, the specific benefits they receive, and the amount of financial help the taxpayers would provide. The only agreement among economists who study the issue is that the tab would be a big one:

* $200 billion to $250 billion a year, says Joe Antos of the conservative American Enterprise Institute.

* $150 billion to $175 billion a year, says Len M. Nichols of the liberal New America Foundation.

The debate over this first proposal and related, still-to-come proposals will boil down to a discussion about the powers and size of the federal government. Do we want the government to have the power to make us buy health insurance, as individuals or businesses? How much power should the government have to control costs? How much do we want to spend to provide health insurance to our fellow citizens who don't have it?

Here is a primer on the big issues to watch as the healthcare debate unfolds:


Regardless of what happens, will I be able to keep the insurance I have now?

Almost certainly. The big lesson from President Clinton's ill-fated attempt at healthcare reform in 1993 and 1994 was that people are terrified of change. They like their doctors, although they don't like insurance companies. An oft-uttered reassurance in the 2008 residential campaign was: If you like what you have, you can keep it. This will likely be a key plank in any plan offered by the Obama administration.

Further, most people get their coverage at work, and this would continue. Despite rising costs, business managers still place high value on insurance as an attractive benefit. The share of the workforce with coverage remains around 70%.


If I don't have health insurance, would I have to buy it if an agreement on reform is reached?

This is the tricky mandate issue. Advocates say you can't cover everyone unless you make everyone buy a policy.

Although nobody from the administration is using the "M" word these days -- a mandate would represent a big expansion of government authority -- many believe it is the logical way to go. So do Democratic leaders in Congress.

Before such a mandate could become law, however, Congress would have to decide the amount of financial subsidies to help people pay for their coverage. Most people without health insurance work full-time and earn less than $30,000 a year. Meanwhile, the average policy for a family of four under job-based coverage cost $12,680 last year, with the employer paying $9,325, according to figures compiled by the Kaiser Family Foundation. Coverage for an individual through work cost $4,704, with the employer paying $3,983.

A decision on a mandate would also involve intense negotiations between the government and the insurance industry over the terms and details of coverage. The industry has indicated it's willing to deliver "guaranteed issue" (nobody gets turned down) in return for a law requiring mandatory purchase of insurance.

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