Start with the children and work up from there. For corporate America and Washington policy experts, that seems to be the emerging consensus about how to begin tackling the problem of the 47 million people in this country without health insurance: Start with the more than 8 million uninsured children.
Then maybe add four million college students who do not have insurance but might not cost all that much to cover because they tend to be young and healthy.
Next might come the 1.4 million or so uninsured people in households with total income at least $75,000, who are perhaps in a position to purchase insurance if insurance became mandatory and if a market for affordable personal policies was created.
Those are among the ideas arising from corporate America as change in the nation’s health insurance system seems increasingly to become a political imperative.
Employers, much of the glue holding the nation’s piecemeal health care system together for half a century, have been reluctant to agree to a larger government role in medical coverage. But straining under runaway costs for providing health insurance partly because of the costs imposed on the medical system by people with no insurance at all many executives and their representatives see the time as ripe for starting to overhaul the system.
“There is more frustration and less acceptance of the current system among employers than we have ever seen in my 30 years in this field,” said Helen Darling, president of the National Business Group on Health, an organization made up of large companies.
As a starting point, many employers and health care industry executives are pushing for expansion of the federal-state Children’s Health Insurance Program, which covers children from families with incomes too high for Medicaid.
Increasing the funds and expanding eligibility, business leaders say, would be an important start not only in providing better care for the children, but in reducing the expensive visits to hospital emergency rooms that end up as higher costs for employers who pay for health care for the majority of American workers and their families.
The program, which depends on federal funds with matching grants from states, is up for renewal in Congress this year. The federal contribution is currently $5 billion a year. With the budget deficit a contentious matter, it will not be easy to enact that or any other new spending measure.
But the head of another representative of large corporations said that not taking action was no longer an option for American companies as they compete with foreign businesses whose governments shouldered medical and hospital costs.
“Health costs are the single largest cost pressure that employers face far exceeding energy, labor, material, even litigation,” said John J. Castellani, president of the Business Roundtable, an association of 165 of the largest companies.
The national grocery chain Safeway, for example, says the $1 billion it spent on employee health care last year exceeded its net income. By next year, that will be true for most large businesses, according to Safeway’s chairman and chief executive, Steven A. Burd, who cited a McKinsey & Company study.
The November election results sent a message that voters want the government to address personal concerns like access to good health care, Mr. Castellani of the Business Roundtable said.
President Bush proposed his own approach in the State of the Union address on Tuesday night, though some Congressional Democrats are deriding it, saying it has no chance of passage.
But Democrats are pushing for new powers for Medicare to have a role in drug pricing, for example. And California has joined the states that are experimenting with mandatory health insurance for individuals and employers as a way to address the problems of the uninsured.
Mr. Burd, whose company is based in California, has urged his counterparts to support Gov. Arnold Schwarzenegger’s proposal for requiring universal coverage of individuals who can afford it, while providing subsidies for low-income people to purchase policies.
Such requirements would mean creating a market for individual health policies that would resemble the market for car insurance, Mr. Burd said.
WellPoint, the largest health insurer, said it had been signing up about 380,000 previously uninsured people annually by devising new types of lower-price policies.
Jude Thompson, a senior vice president, said the company had made a target of the 18-to-34-year-old group sometimes called “young invincibles” attracting them with reduced premiums that are offset by higher annual deductibles of $1,500, and throwing in vision and dental benefits.
The insurance industry has both short- and long-term reasons for wanting market-based approaches to succeed, said Charles Boorady, a health care analyst at Citigroup. Short term, they get more customers. But in the longer run, “their biggest risk is nationalized health care.”
The government already accounts for 40 percent of total health spending $1.99 trillion in 2005, Mr. Boorady said. “The decision on should we nationalize all of it will be heavily influenced by the outcome of some of these state universal health plans,” he said.
Jack O. Bovender, chief executive of HCA, the hospital company, said that a patchwork of state plans would not work. For one thing, he said, state regulation of health care financing had often been overturned by lawsuits filed under the federal Employee Retirement Income Security Act, which the courts have said was intended to let big companies set up uniform health benefits across the country, rather than navigate state-by-state requirements.
“Ultimately there has to be a federal solution,” Mr. Bovender said. But he cautioned, “I think we need to move quickly but not grab at what appear to be quick easy fixes; things that sound good always have unintended consequences.”
Some business executives said they were reluctant to prescribe solutions. “We certainly don’t have it all figured out,” H. Lee Scott, chief executive of Wal-Mart Stores, said in a statement. The company is the nation’s largest employer.
“We have said all along that it is going to take businesses working with leaders in government, the health care industry and others to come up with health care solutions,” Mr. Scott added.
Charles N. Kahn III, a longtime strategist in the Washington health policy wars, said that the chances for government action were now unusually bright.
But even with a growing political will to tackle the problem, Mr. Kahn, who is president of the Federation of American Hospitals, is not expecting the complicated problems in the health care system to be solved quickly. He cautioned that federal budget deficits made it “hard to visualize major health reform before the 2008 elections.”