The Kaiser Project on Incremental Health Reform

In November 1996, the Kaiser Family Foundation initiated a project to examine different strategies for expanding health insurance coverage to America’s growing uninsured population. The Foundation asked two leading health policy experts with experience in Democratic and Republican leadership roles, Judith Feder and Sheila Burke, to direct the project’s work in considering and evaluating the potential for, and likely impact of, alternative incremental reform options. This continuing effort has made important contributions to the public and policy dialogue about covering the uninsured. With new proposals emerging across political parties as we head into the 2000 election, the project’s analysis of tax-based reform options along with direct subsidy or government expansion options is directly relevant and useful to the debate.

Project Description

Project Publications

Phase I

The project began by soliciting the development of alternative proposals for incremental expansions from experts with diverse points of view: Linda Blumberg, Stuart Butler, Rick Curtis, John Holahan, Pamela Loprest, Mark Merlis, Marilyn Moon, Mark Pauly, Wendell Primus, Tom Rice and Gail Wilensky.

Experts were asked to identify a population on whom to target coverage, specify a mechanism for providing that coverage, and lay out both the rationale for and the operational details of their approach. The next step was to systematically estimate and compare the impacts of these proposals on coverage and costs, using a common set of assumptions about incentives, disincentives and individual behavior. In addition, a number of analysts were commissioned to explore a variety of issues related to incremental reforms from a variety of perspectives ethical, political, and empirical.

February 1999 Conference

At a February 1999 conference, more than 60 individuals representing diverse points of view were invited to present papers and engage in a discussion of the policy, politics and likely impacts of alternative coverage proposals. An overview of the results of the Incremental Health Reform Project was presented to open the conference and presentations and discussions then focused on issues related to: (1) federal entitlements vs. state discretion; (2) tax preferences vs. direct subsidies; and (3) causes, costs and consequences of crowd out.

Phase II

The Foundation is supporting continuing efforts to evaluate the impact of alternative reform options. With renewed discussion about tax-based reform options on Capitol Hill and proposals to expand coverage from the Health Insurance Association of America and other interest groups across the ideological spectrum, this continuation project will enable us to take advantage of the current environment to monitor the debate over options and provide new analyses on the relative impacts of different approaches.

This project will pull together work on incremental reforms, including both direct coverage approaches, such as direct subsidies and Medicaid expansions, with tax reform options.

Products of the Kaiser Project on Incremental Health Reform

Conference Report
Options for Expanding Health Insurance Coverage. A Report on a Policy Roundtable
Judith Feder and Sheila Burke

Overview Paper
The Difference Different Approaches Make: Comparing Proposals to Expand Health Insurance
Judith Feder, Cori Uccello, Ellen O’Brien

Expert Proposals
Extending Health Insurance Through Insurance Credits
Mark Pauly

Analysis of a Specific Tax/Health Credit that Provides Insurance to All Children
Wendell Primus

Children’s Health Insurance Coverage: Tax Credit and Publicly Sponsored Children’s Insurance Pool
Linda Blumberg

A Premium Subsidy Program for Modest Income Children
Mark Merlis and Richard E. Curtis

Children’s Health Insurance: The Difference Policy Choices Make
John Holahan, Cori Uccello and Judith Feder

Expanding Health Insurance Through Tax Reform
Stuart Butler

Extending Health Insurance Through Incremental Reform
Gail Wilensky

Subsidizing COBRA: An Option for Expanding Health Insurance Coverage
Thomas Rice

Medicare Buy-In Proposal
Pamela Loprest and Marilyn Moon

Issue Papers
An Assessment of Strategies for Expanding Health Insurance Coverage
Sherry Glied

Incrementalism: Ethical Implications of Policy Choices
Ruth Faden and Madison Powers

The New Child Health Insurance Program: A Carefully Crafted Compromise
Alan Weil

Expansions in Public Health Insurance and Crowd-Out: What the Evidence Says
Lisa Dubay

Public Subsidies and Private Markets: Coverage Expansions in the Current Insurance Environment
Mark Merlis

Insurance Market Reforms and the Individual Insurance Marketplace: Implications for Coverage Expansions
Nicole Tapay and Judith Feder


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