Thorpe K E
Department of Health Systems Management, Tulane University School of Public Health and Tropical Medicine, New Orleans, La 70112, USA.
JAMA. 1997;278(4):329-33.
To present several incremental strategies for extending health insurance coverage for segments of an estimated 40.6 million uninsured persons in the United States. Along with these strategies, the federal costs and estimates of the number of newly insured are presented.
Using data from the Congressional Budget Office and the federal government, the number of newly insured persons in the United States under options designed to increase coverage among uninsured children, their parents, and workers between jobs are simulated. The federal costs and coverage implications of these options are estimated for federal fiscal years 1998 through 2002.
Three distinct incremental approaches for covering the uninsured are explored. The first approach would expand coverage through the current Medicaid program. The second approach would provide financial incentives for parents of children eligible for Medicaid to purchase coverage, and the final approach provides time-limited subsidies allowing workers and their families to purchase insurance when they are between jobs.
The federal costs of these approaches range from $2 billion to $3 billion per year (enrollment outreach approach) to $5 billion to $7 billion per year (enrolling parents of Medicaid-eligible children approach). If pursued simultaneously, the incremental strategies under investigation could extend health insurance to more than 7 million uninsured persons in the United States. The cost of these options could be financed through Medicaid savings, restructuring the current disproportionate share payments made through Medicare and Medicaid, increasing excise taxes on tobacco, or all of the above.
The incremental strategies would build on the current US health care delivery system by providing targeted financial assistance to specific populations. By their nature, such reforms could provide a political means for compromise and agreement between Congress and the president. Though the reforms do not, by design, provide a comprehensive solution to the problems facing the uninsured, they would address the severe problems facing many low- and middle-income families unable to purchase health insurance today.
提出几种渐进策略，以扩大美国约4060万未参保人群的医疗保险覆盖范围。同时，还列出了这些策略的联邦成本以及新增参保人数的估计值。
利用国会预算办公室和联邦政府的数据，模拟了旨在增加未参保儿童、其父母以及失业工人医保覆盖范围的方案下，美国新增参保人数的情况。对1998年至2002年联邦财政年度这些方案的联邦成本和覆盖范围影响进行了估计。
探索了三种不同的渐进式覆盖未参保人群的方法。第一种方法是通过现行医疗补助计划扩大覆盖范围。第二种方法是为符合医疗补助条件的儿童的父母提供购买保险的经济激励，最后一种方法是提供限时补贴，使工人及其家人在失业期间能够购买保险。
这些方法的联邦成本从每年20亿美元到30亿美元（参保推广方法）到每年50亿美元到70亿美元（为符合医疗补助条件的儿童的父母参保方法）不等。如果同时推行，所研究的渐进策略可将医疗保险覆盖范围扩大到美国700多万未参保人群。这些方案的成本可通过医疗补助节省、调整现行通过医疗保险和医疗补助进行的不均衡份额支付、提高烟草消费税或上述所有方式来筹集资金。
渐进策略将在当前美国医疗保健提供系统的基础上，为特定人群提供有针对性的财政援助。从本质上讲，此类改革可为国会和总统之间达成妥协与共识提供一种政治手段。尽管这些改革并非旨在全面解决未参保人群面临的问题，但它们将解决许多中低收入家庭目前无法购买医疗保险所面临的严峻问题。
