Chapter 1

Introduction

Demand for reform of the United States health care system has been intensifying at both the state and national levels. Each year, the United States spends an increasing share of its resources to provide health care, while it remains one of the few industrialized nations that does not guarantee its citizens universal access to health insurance coverage. Growing health care costs and inadequate access to health care for many have led to a variety of proposals. These range from narrowly focused plans that address the problems of a select group, such as children or the small-group market, to comprehensive reform that addresses the problems of the entire health care market and attempts to ensure health insurance coverage for everyone.

Several states have developed and implemented programs that attempt to expand access or to contain health care costs. More states are currently debating a variety of similar proposals. In light of this activity, Chairmen John Dingell and Ron Wyden requested that we examine some of these state initiatives to assess the lessons they offer for health care reform.

The resources devoted to providing health care in the United States have increased steadily over the past several years, yet at the same time, the number of people without adequate health insurance has increased. In 1991, the United States spent over $700 billion-or 13 percent of its gross national product—to provide health care services, while, by 1990, the number of uninsured people under the age of 65 had increased to over 33 million (see figs. 1.1 and 1.2).

These problems of high health care costs and lack of insurance affect some groups more than others. Children, people with low incomes, and people with high-cost medical conditions are among the groups likely to be uninsured. As health care costs increase, it appears that these groups will have even greater difficulty obtaining health insurance coverage.