HSR editorial: oversimplifying health reform discussions.

Far too often, debates over the best approaches to dealing with the large number of uninsured people in America oversimplify the problem and the solutions, undermining our opportunity to have the kind of useful public conversations about a complex issue that could help us toward the formation of needed sensible health care system policy. The problem and solutions to it are nuanced. Some people who are observed to be uninsured on a given day have only been uninsured for a short time and may easily regain insurance before too long. But others – data show many others – uninsured at a given point in time have been uninsured for a long period leading up to that point. People end up uninsured for a variety of reasons. Among the 40-plus million people lacking insurance at any given point in time are some who had a reasonable opportunity to obtain insurance, but elected not to. Young and healthy workers, offered health insurance by their employer in return for a non-trivial explicit financial contribution, may elect not to enroll, a choice that to some people may in fact be economically rational. Other people may make a principled choice to go it alone with respect to health care costs, or at least promise themselves at the point of deciding not to obtain insurance that they would go it alone if they ever came to need medical care (a stance that may not actually stand the test of time and illness). But for all of those who make a choice against insurance, there are many who would like to obtain insurance and even make serious efforts to do so, but who end up without it. Some may have health histories that render them uninsurable, or that lead insurance companies to offer them coverage only at prohibitively high premium quotes. Others may have lower incomes or significant other obligations that make the purchase of health insurance even at typical average premiums a questionable proposition. Estimates of the affordability of insurance vary, but by most accounts there are substantial groups of the uninsured for whom affordability is unclear at best. People who are uninsured differ in their ability to get themselves care if they end up in need of it. Some, one way or another, manage to get access to reasonable care. Perhaps they can pay out of pocket, or live in an area with strong and accessible safety net providers. But these methods don't work for others, who can end up in much more difficult circumstances, relying on increasingly frayed structures and emergency services and ending up without valuable care. The public debate over health reform and insurance frequently glosses over the multi-dimensionality of the problem, the participants spinning in one direction or another to justify policy points or to create and exploit wedge issues with an eye toward short-term electoral strategies. Some uninsured do lack insurance for only a short time, because of choices they themselves made, and will get perfectly fine care if they end up needing it. Others are uninsured for long periods of time, because of noticeable failings of the health insurance structures now in place, and end up in worse health because of it. With the problem portrayed in simple terms, the policy debate can be too easily framed around simplified options that address a stylized view of the problem. Though there are some possible solutions that could significantly simplify the health care financing structures and expand insurance coverage, the current political climate seems to require solutions that leave large parts of the status quo intact but with modifications that can improve coverage and access to care. These will necessarily have complexities that will need thoughtful consideration. Health services researchers have offered many useful insights into possibly approaches, and we hope will continue to do so. Several articles in this issue of Health Services Research emphasize ways in which policies, individual choices, and the environments in different places come together to both create the problem of people without insurance and can be harnessed to begin to deal with it. Policies may need to be flexible across areas. The work in this issue by Atherly and colleagues looks at “Health Insurance Flexibility and Accountabillity” (HIFA) waivers, which allowed states to work with their Medicaid programs, with flexibility in the design of new approaches to expanding insurance coverage through Medicaid itself, the State Children's Health Insurance Programs, and new public-private partnerships (Atherly et al, 2012). Fifteen states got waivers, though not all of them were actually implemented. The overall effect in places that used the waivers was a net increase in coverage. But, importantly, the approaches taken and the effects showed variations across states. In the current environment, health reforms that aim to expand coverage may well benefit from efforts to allow enough flexibility across states in approaches to populations and challenges that vary from place to place. As long as employer-provided health insurance remains a central part of the U.S. health care system, policies need to recognize and respond to both variations across employers in their actions and variations in the responses of individuals to employer policies. Work in this issue by Vistness and colleagues studies trends in employer-sponsored insurance between 2000 and 2008 (Vistness et al, 2012). They find declining coverage rates in both small and large firms. Importantly, though, they show that while the drop in smaller firms was observed both because offer rates fell and because take-up by employees fell, in larger firms rates of offering insurance stayed relatively constant, but rates of take-up fell. Policy solutions that emphasize employer-based coverage may face varying issues in firms of different sizes and types, with particularly challenging issues in the case of small businesses in an environment of rising costs. Beyond policies aimed specifically at expanding coverage, achieving the overall aim of access to care also involves engaging with the complexities of the health care delivery system. Work in this issue by White (2012) emphasizes the point that expanding access to and use of care may require consideration of physician payments as well as coverage – expanding coverage in environments with other factors that limit access to care could easily fail to reach policy goals. The value to pursuing policies that could increase insurance coverage could be many. Work in this issue by Sabik () highlights one dimension of the broader effects that high rates of uninsurance can have, noting that increasing the rate of uninsurance in a community is associated with worse reported access to necessary care among the uninsured. By offering useful analysis and commentary, strong health services research can help keep attention on issues of importance – like the costs and benefits of expanding insurance coverage – and help policymakers identify useful solutions to the problems that recognize and cope with its complexity. It is far too easy to reduce complex problems to simple slogans, and even to attempt to entirely avoid discussion of inconveniently difficult issues. Witness recent debates that have spent an enormous amount of time and energy on the question of whether an individual mandate is appropriate, but at arms-length from the question of how the individual mandate would affect other aspects of health insurance and health care financing. This is far too easy to do, but will not help in the end. Health services researchers can play an important role in maintaining attention to and creating foundations for more useful solutions.