Judy Feder, PhD
Dean of Public Policy, Georgetown Public Policy
"The Challenge of Expanding Health Insurance Coverage: Policy and Politics"
On March 8, 2002, Judy Feder, PhD, Dean of Public Policy at Georgetown University, discussed the policy and political challenges in expanding health insurance coverage. Dr. Feder, who played a key role in developing the Clinton Health Security Act, spoke at the Leonard Davis Institute's monthly health policy seminar.
Dr. Feder began by presenting an overview of the uninsured, and explaining the nature of the health policy problem. About 80% of the uninsured are working, most of them full-time. Uninsured employees are disproportionately low wage earners, setting up an "us" vs. "them" situation. "Although [losing insurance coverage] can happen to any of us," Dr. Feder noted, "it is more likely to happen to them."
She noted that the evidence of the last decade shows that economic prosperity, in itself, will not take care of the problem. Despite many years of an economic boom, by the end of the decade, a smaller proportion of low-wage workers were covered by employer health insurance that were covered at the beginning. She also rebuffed notions that the private insurance market could solve the problem. "It is clear that the market works to screen out risks."
Dr. Feder also noted that public programs, as presently constituted, are not likely to solve the uninsured problem. "Medicaid coverage is tied to children, and to some extent, to their pregnant mothers," she said. By federal statute, adults without children are not eligible for Medicaid (without a state waiver), regardless of their income-unless they are disabled or otherwise unable to work.
The political problem, as Dr. Feder sees it, is "distributional." Basically, 85% of the population has health insurance, and the remaining 15% are disproportionately low and moderate income workers. The political dilemma, she maintained, is the need to redistribute money from "us" (who vote) to "them," who do not. The legacy of tax benefits for employer-sponsored health insurance, plus public insurance for the "deserving" poor (meaning children and the elderly) has left the remaining uninsured without political power.
The haves vs. have-nots political problem leads to the key policy analysis challenge, according to Dr. Feder: how to make changes to the coverage system that affect only the population left out. "In any solution, it's difficult to not disrupt what's already there-employer-based coverage." Support for change disappears, she said, when the 85% of people with health insurance become concerned that they will be worse off.
Dr. Feder discussed her experience as a key analyst for President Clinton's 1993-94 Health Security Act. She noted that the country was just coming out of a recession, and even insured people were afraid of losing their jobs, and therefore, their health insurance. The Clinton team tried to change the system as a whole, promising security to workers at risk of losing their jobs, and promising to cover the uninsured at no additional overall cost to the nation, and few additional taxes. "The task of covering everybody, and spending no extra money, was essentially not believable on its face," Dr. Feder admitted. The key to the plan, she said, was the belief that health care costs could be controlled by "managed competition," thereby freeing up the needed resources to expand coverage.
The details of the Clinton plan included an employer mandate to provide health insurance, with subsidies to small employers; a federal contribution for the non-employed; and individual contributions. Basically, people would get support for about 80% of the average premium in a community, for a comprehensive package of benefits. Individuals would have a choice of health plans, which would compete on the basis of costs and price, rather than on avoiding risks. The plan involved many new rules that affected employers and insurers, and included a "regulatory backstop" that would prevent premium costs from rising more than a small amount each year.
The reaction to the Clinton plan was negative, Dr. Feder said. People didn't like regulation or big government. The "us" had a fear that the aggressive cost containment strategy would lead to rationing of care. Policy analysts were not successful in assuring insured people that they would be no worse off than before. Thus, the plan either "scared the hell out of you, or you didn't believe us," she said.
The experience of the Clinton health care initiative, "set the debate back dramatically," according to Dr. Feder. Now, there is less understanding of insurance, greater polarization around the role of government, and greater contention about mechanisms to provide coverage. She voiced some pessimism about the prospects for expanding coverage in the present environment. She ended by stating her longstanding advice within the present health care system: "Stay healthy, employed, and insured."
Feder is one of the nation's leaders in health policy- most particularly, in efforts to understand and improve the nation's health insurance system. A widely published scholar, her three decades of policy research began at the Brookings Institution, continued at the Urban Institute, and, since 1984, has flourished at Georgetown University. Her expertise on the uninsured, Medicare, Medicaid, and long-term care is regularly drawn upon by members of Congress, Executive officials, and the national media.
Feder has also held leadership policy positions, both in the Congress and in the Executive Branch. As staff director of the congressional Pepper Commission (chaired by Senator John D. Rockefeller IV), Feder is widely credited with setting the stage for the health reform debate of the 1990s. She became a key actor in that debate, as a senior official in the Clinton Administration. In her three years as Principal Deputy Assistant Secretary at Health and Human Services, Feder helped shape the Administration's health care policy, working intensively with members of Congress and with the national media to promote the expansion of health care coverage.
Feder today pursues her policy leadership as senior advisor to the Kaiser Family Foundation's Commission on Medicaid and the Uninsured; co-director (with Sheila Burke) of Kaiser's Incremental Health Reform Project and of Robert Wood Johnson's Long-Term Care project; member of the board of the Academy of Health Services Research and Health Policy and the editorial boards of health policy journals, and member of the National Academy of Public Administration and the National Academy of Social Insurance.
Feder is a political scientist, with a B.A. from Brandeis University (1968) and a Master's (1970) and Ph.D. (1977) from Harvard University.
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