Americans believe they are facing a crisis in health care marked by rising costs for providing health care along with an increase in the number of people who are either uninsured or under-insured. This problem has long been ignored by policymakers, but recently President Clinton has put the issue in the forefront of political debate and has spurred a flurry of suggestions. The administration has put forward a health care plan, and the Republicans have responded with a health care initiative of their own. An analysis of the issue will lead to a consideration of the forces at work around this issue and the nature of the Republican response.
The problem itself has been well documented. In the last 15 years, the number of uninsured Americans has grown, and most estimates in 1991 place the number lacking public or private coverage at between 31 and 36 million. According to the 1987 National Medical Expenditure Survey, some 47.8 million people lacked insurance for all or part of 1987, and the U.S. Bureau of the Census found that from the first quarter of 1986 to the last quarter of 1988, 63.6 million people lacked coverage for at least one month and 31.5 million lacked it in the final quarter of 1988. In terms of age, those between 19 and 24 years of age are the most likely to be uninsured, and 20.3 percent of this group were uninsured for all of 1987 and another 18.2 percent for part of the year. Children under 18 years of age were the next most likely to be uninsured so that one in four were uninsured either all or part of the year. Of those aged 25 to 54 years, 19.8 percent were uninsured all or part of the year, and among those aged 55 to 64 the figure was 13.6 percent. This was particularly disturbing in that the people in this age group face a higher risk of serious health problems.
Numerous reform proposals have been offered. Among the proposals are a number that have emerged from systems of managed care, including ...