Health Affairs, 24, no. 6 (2005): 1446 doi: 10.1377/hlthaff.24.6.1446 © 2005 by Project HOPE	New Online   New Issue: China & India   Obesity In China   Pay Cuts For Medicare Docs   Access To Care Woes

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Dimensions Of Change

PROLOGUE

Dimensions Of Health System Change

First, John Cogan, Glenn Hubbard, and Daniel Kessler put forth a bold proposal to reinvigorate market forces to expand and amplify U.S. health insurance coverage. They advocate that all medical expenses—copays, premiums, and out-of-pocket expenses—should be deductible "above the line" from personal income taxes, if the person has insurance. The tax savings would allow many who are now uninsured to buy insurance, and various subsidies could work to provide insurance for those who still cannot buy on the open market.

Next, Richard Nathan takes a different tack. Nathan views the push-pull relationship between the states and the federal government as part of the overall history of federalism. The cyclical relationship between the states and the federal government has guaranteed the growth and development of Medicaid. Nathan champions states’ initiatives to preserve and expand coverage in the current period of federal retrenchment.

From Mexico, Felicia Knaul and Julio Frenk describe the wide-ranging reforms instituted by the federal government in Mexico to provide health insurance to the half of the population that lacked it. Reform in Mexico was multifaceted, made more challenging in the context of an economy moving toward greater development. For the authors, the goal is to promote social protection and fairness in Mexico and to serve as an example for other countries facing similar conditions.

Together the three papers demonstrate different routes toward system reform. Countries with a strong tradition of capital markets might find that letting them operate unhindered would create enough jobs and incentives for most citizens to obtain affordable insurance. Countries lacking a tradition of employer-sponsored insurance and dependent on a strong central government might find that the best engine for reform is that government. Countries with a tradition of several actors (markets and central and local governments) might find that the best avenues of reform emerge from the dynamic relationships among all players.

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