DURHAM, N.C. -- When President Clinton proposed in January a significant expansion of Medicare, he said it would allow hundreds of thousands of early retirees, laid-off workers and uninsured Americans between the ages of 55 and 65 to get health care coverage.
But like-minded efforts by state governments in the 1990s to increase the percentage of "near elderly" people with health insurance have been largely ineffective, according to a study by two Duke University researchers. They reported their findings in the February issue of the journal Medical Care.
"The one reason why these state programs were probably ineffective was that they still relied on out-of-pocket payments for premiums from families, and families without coverage often just don't have the money for that," said Frank Sloan, one of the study's two authors, in an interview. "They're just taking their chances that when they get an illness, either they'll be treated on a charity basis or they'll get on Medicaid."
"And that's the same reason that the Clinton proposal to cover the near elderly is not likely to cover that many people," added co-author Chris Conover in the interview, "because at the end of the day there aren't going to be that many people who can afford to pay $300 or $400 a month in premiums to get that coverage."
Sloan, director of the Center for Health Policy, Law & Management at Duke, and Conover, an assistant research professor at the center, used data from the 1992 and 1994 Health and Retirement Study to analyze health care coverage among adults ages 51 to 64. The 1994 data represent the latest information available at the time the authors did their study.
Their findings include:
- Eleven percent of the people (or about 3.6 million out of 33 million) in the 51-64 age group had no insurance coverage in 1992 and 1994. Many of the same people had no insurance in both 1992 and 1994, although some people did obtain either private insurance or Medicare or Medicaid in that time frame while others lost coverage, "sort of a musical-chairs phenomenon," Conover said. Overall, about 40 million people are uninsured in the United States.
- One-in-five near-elderly persons experienced a change in insurance coverage from 1992 to 1994, yet there was no significant change in the overall percentage of people with coverage.
- Individuals whose health deteriorated significantly were no more likely than others to lose coverage. In addition, people who became permanently work-disabled were more likely to get coverage, through Medicare, than others, "so that is a group for which the public safety net appears to be working," Conover said.
- Those most likely to be uninsured were non-white, less educated, and less wealthy.
- Various state policies implemented during the early 1990s to improve the affordability of coverage and to help people in poor health get coverage were generally not effective.
Sloan said that piecemeal approaches, like those tried by the states, usually are ineffectual in solving large-scale problems. "Often in the public policy arena we think that just because we implement a policy, it's going to work," said Sloan, who is also the J. Alexander McMahon professor of health policy and management and a professor of economics at Duke.
State policy makers "need to understand that much of what they're doing is tinkering at the margins, and if they're really serious and want to do something more extensive, then they're going to have to resort to other initiatives," Conover said.
"I think part of the reason that states adopted these policies in the first place is because it wasn't popular to talk about mandates or expensive increases in taxes to subsidize the coverage, so the hope was maybe we can get this done through voluntary efforts," Conover added. "And this study is pretty much saying, "No, you don't get very much mileage out of those voluntary efforts at the end of the day.'"
The same is true of Clinton's Medicare proposal, the two Duke researchers said. Clinton's proposal, they said, is either going to end up costing taxpayers a lot of money if it wants to dent the uninsured problem, or it won't have much of an impact if recipients pay premiums that would allow the plan to pay for itself, as Clinton has said it would.
Sloan said other developed countries do not have the uninsured problem that the United States faces because they have some sort of guaranteed universal coverage, which Clinton unsuccessfully proposed earlier in his presidency.
"Most other countries have a single system sort of designed to catch everyone," Sloan said. "We have a system where you have different types of insurance working quasi-independently, and it's only as an accident that people find themselves in one of these groups. So there's no concerted effort to take the whole population and develop a scheme for covering everybody."
"We've taken the segments that are most in need, the poor and the elderly, and tried to target coverage at them, but it leaves a lot of other people, who don't fit those characteristics, without coverage," Conover added.
Another danger of the Clinton proposal, the researchers said, is that those small companies with older workers may opt to drop their private insurance coverage and encourage their workers to sign up for Medicare, especially if some of those workers are in poor health.
"The immediate downside is where you think you're doing something to solve an uninsured problem and you inadvertently end up covering people who were insured anyway," Sloan said.
"I think the problem is in defining what the problem is," Conover concluded. "That is, what do you care about in this group? Is it the fact that on any given day 11 percent are uninsured? As we've seen, this is a group that turns over constantly. So it's not like you could say, "Let's just give that group a voucher to get coverage,' because there are a whole lot of people who have coverage who might feel, "Hey, I've been digging into my own pocket. Why does this individual without coverage deserve any more help than I would?"
"So it comes down to what is your policy objective. Is the goal to get universal coverage in this group, and how do you do that without creating some perverse incentives given that such large numbers in this population currently are covered by the private system?"