I start with the assumption that the vast majority of Americans—including those that are uninsured—want health care coverage. They know that being uninsured means living sicker, dying younger, and being one emergency away from financial ruin.

So the main issue isn’t how, it is how to remove the significant barriers to getting coverage and care. Is it available? Is it affordable? Is it administratively simple?

And health reform isn’t just providing aid to the uninsured, but helping those with coverage keep it. Too many Californians feel that their coverage won’t be there when they need it. Maybe they’ll have lost coverage when switching jobs or gone through a divorce. Maybe the insurance they have doesn’t cover the treatments they need.

Right now, most Californians get subsidized group coverage, through the two pillars of health coverage: employer-based coverage, and public insurance programs. Just over half of Californians (about 19 million) get on-the-job benefits, but many who work don’t qualify or can’t afford what is offered. In fact, over 80% of those who are uninsured are workers or the family members of workers.

Just about a third of Californians (about 10 million) get coverage through Medicare (mostly those over 65), Medi-Cal and Healthy Families (very low-income children, seniors, and people with disabilities), or other public programs. But there are many even under the poverty level who don’t qualify (for example, because they don’t have a child at home), and many administrative barriers for those who do.

Those who face the biggest barriers are those who are not eligible for either job-based or publicly-subsidized coverage, and have to attempt to buy as individuals. The individual insurance market is the most expensive, least efficient way to get coverage. There’s high overhead costs, with the marketing and broker’s fees, and other efforts to sell insurance one-on-one. More than that, individuals have little market power, and are at the mercy of the big insurers. In fact, the insurers can charge differently, or choose to simply deny you coverage based on your health history. There are many who can’t buy coverage at any price, based on their “pre-existing conditions.”
It is starting from this patchwork of a health system that many of the health reform proposals, including that of President Obama, would begin. He, along with many of his rivals for the Democratic nomination, started with the assurance that those consumers that want to keep the coverage they have can do so. The reforms would simply increase the security and stability of that coverage; provide new options, including a public health insurance option; and expand such coverage in all these form to include everyone, as part of a broader effort to bring down costs for all.

The focus, thankfully, is on group coverage. He would bolster employer-based coverage by requiring large employers to provide a minimum contribution to workers’ care, providing assistance to some smaller businesses, and providing new affordable options for them. He would expand the eligibility for some existing safety-net programs. Another bill in Congress takes this several steps farther, creating a single-payer system where everybody is in the same group policy.

For those who are left to get coverage as individuals, they still need significant help, and not just significant subsidies to make coverage affordable for the broad middle-class. There is a growing consensus—even within the industry—that we need to fundamentally change the way insurance companies do business. They should compete on quality and cost, and not—as they do now—on how aggressively they can collect premiums from healthy people and avoid sick people that actually need coverage. Consumers should also have the choice to buy into a public health insurance option, as another way to keep the private insurers honest. We are proud to be working with a national coalition, Health Care for America Now!, to work

So should people be required to buy coverage? It’s an impossible requirement in the current system. Governor Schwarzenegger started with that concept of “personal responsibility” a few years ago, but the concept forced him to recognize that it could not work without “shared responsibility,” from employers, the health sector, and government. After years of opposing such efforts, he eventually supported broad public program expansions, a minimum employer contribution to coverage, and significant oversight and regulation of insurers as part of a broader package.

That said, any health care system will require everyone to pay their fair share. To remove bureaucratic hassles, everyone should be automatically enrolled in coverage, but the requirement to keep coverage should be contingent on whether coverage is indeed available, affordable, and adequate. But then that will be a continuing public challenge for our political leaders, rather than a personal challenge for everyday people.

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