Four Problems Facing Meaningful State Health Care Reform and Coverage in the United States

I. INTRODUCTION According to the United States Census Bureau, the percentage and number of uninsured Americans has increased since 2000 to over 15.8%, or forty-seven million people. (1) Health care premiums are spinning out of control, so fewer employers are offering insurance to their employees or are passing along costs to those employees that are insured. (2) These statistics confirm the escalating health insurance crisis in America and the need for a comprehensive and feasible solution to provide affordable insurance in the midst of rising health care costs. Specifically in the United States, most insured people are covered through private employers, while some receive public health care insurance via government health plans, or with Medicaid or Medicare. (3) When the government does provide health insurance and benefits not tied to employment, it is generally based on income level along with other factors, and may include public assistance payments as well as health coverage. (4) Although Medicaid, a health benefit for low income individuals, covers several million Americans who would otherwise be uninsured, several inherent issues arise through astronomical spending, and covered patients may face second-class treatment by essential providers refusing to treat Medicaid patients. Many uninsured individuals are not eligible for Medicaid, however, due to the income and other eligibility requirements, but cannot afford private pay insurance premiums if not offered by their employer. (5) Although Congress attempted to change health care in America, no meaningful reform has yet passed, thus leaving reform to the states to create programs that will help those employed, without health care coverage, and who are above the poverty line. (6) Looming in the background, however, is the Employee Retirement Income Security Act of 1974 (hereinafter ERISA), which broadly preempts any state program relat[ing] to any employee benefit plan. (7) Specifically, many state-level health care reforms include mandatory employer-provided insurance, or a pay-or-play scheme, which requires employers to contribute a specific amount of payroll towards employee health insurance or pay the difference to the state for publicly-provided health programs. (8) However, ERISA preempts almost every type of pay-or-play plan; if allowed, these plans would help bridge the gap for uninsured Americans. (9) Therefore, without an express mandate from Congress or an exception to allow states to regulate employee benefits only for health insurance, employers may either limit health care benefits offered to employees or choose to stop providing health benefits altogether, forcing uninsured workers to seek health insurance in another arena. Although states may provide indirect incentives for employers to provide health insurance to their employees, such as tax credits, these methods are less effective without an actual mandate for employers. (10) As a result, the current federal government's policy of administrative uniformity in providing employee benefits across the nation apparently supersedes the need for greater health care coverage for all. (11) Since the federal government has failed to cover forty-seven million Americans, states may still attempt health care reform, but several significant obstacles exist. Specifically, the four main problems presented by the current state models of health care in America are: ERISA preemption of state health care employer mandates; compliance with state individual mandates or tax incentives for employers to obtain health insurance; continuity of coverage regardless of life situation; and fraud and abuse issues in single payer systems such as Medicaid in New York State, including quality of care issues concerning the type and number of health care providers a particular insured patient can utilize. Based on these problems inherent in different models of state health care programs, a comprehensive plan must be adopted to provide meaningful health care coverage for all Americans and high quality care. …