Cost and Coverage: The Impact of Implementing Various State Health Care Reform Proposals Nationally. Conclusion


This analysis included a range of health care reform options with widely varying cost and coverage impacts.  Figure 13 summarizes some of the key data from each, including the net reduction in the uninsured, as well as the cost to the Federal and state governments.  As expected, the most comprehensive reforms, particularly when combined, often result in the greatest reduction in the uninsured and have the highest price tag.  In addition, the details of the reform can have a significant impact on the outcome.  For example, a voluntary subsidy program that includes a provision to reduce the likelihood of crowd-out results in a reduction in the uninsured of 15.5 million at a cost of $81.7 billion; without this provision the same reform only reduces the uninsured by 7.5 million but costs $144.3 billion.  It is evident that the specific design elements greatly influence the return on investment in terms of maximizing coverage based on spending. 

In addition to those analyzed here, there are a variety of other health care reform proposals that we did not discuss.  Indeed, the list of issues to be considered in order to embark on national health care reform is significant.  While states will continue to consider proposals and some may successfully legislate reforms, it remains to be seen if there is enough political will to launch a comprehensive transformation nationally, particularly given the potential cost.


Net Reduction in Uninsured


Federal Cost


State & Local Cost


Figure 13. Summary of Selected Data Elements
Health Insurance Premium Subsidy Programs
With Crowd-Out Rules (Waiting Period) 15.5 >$91.8 ($10.1)
Without Crowd-Out Rules (Waiting Period) 7.5 >$160.9 ($8.3)
Mandatory Section 125 Plans
Firms With 10 or More Workers 4.2 >$26.1 $2.0
All Firms 5.6 >$32.2 $2.5
Employer Mandates
Enforced with Assessment of $295 Per Worker Per Year >.9 ($3.1) ($0.1)
Enforced with Assessment of 4% of Payroll Tax 1.1 > $0.3
Enforced with Assessment of 6% of Payroll Tax 20.2 $176.2 ($11.1)
Enforced with Assessment of 8% of Payroll Tax 20.2 $96.3 ($7.9)
Enforced with Assessment of 10% of Payroll Tax 20.2 >$63.4 ($6.2)
Individual Mandate
Enforced with a Penalty for Being Uninsured 22.3 $70.8 ($8.9)
Enforced with Automatic Enrollment Through the Tax System 36.9 $116.1 ($7.8)
Enforced with Automatic Enrollment Through Other Income Tested Programs 22.1 $96.2 ($6.7)
Enforced with Automatic Enrollment at School 24.6 $97.9 ($7.8)
Enforced with a Combined Approach 38.0 $118.5 ($6.7)
Model Combining Certain Feature of the Massachusetts Plan
Individual Mandate, Insurance Market Reform, Premium Subsidies, Section 125 Plans, Employer Mandates, & Creditable Coverage >39.4 >$155.8 ($2.4)

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