In the current US economy, poor people are unable to pay for care out-of-pocket, so their access to comprehensive primary care is dependent on affordable coverage for health services, whether that coverage is provided by commercial health insurance or government entitlements such as Medicaid. Broad coverage to pay for health services is, therefore, more than a matter of convenience. There are two critical public policy questions that this raises: who will pay for care for the uninsured poor, and how will that care be delivered?

At the foundation of the need to provide health care to more individuals is the need to make such services more affordable. If overall costs of medical care were lower, premiums for services would be lower, and more people would be able to afford coverage. There are a host of controversial arguments as to how this could be done. Reducing overall benefits (either services covered or amount reimbursed to providers) for all who receive publicly financed health care benefits is one way to cut health care spending. Malpractice reform, so that doctors have less liability and less risk of spending resources battling non-meritorious cases, is another strategy for potentially saving health care dollars. Group purchasing for services and medications can also yield economies of scale and reduced overall costs. Less controversially, funding for delivery of services could be tied to identification and use of best practices, including measures to incorporate cost-saving technological advances in the delivery and administration of services. Streamlining services would ensure that treatment would not be duplicated among multiple providers, unnecessary care (or care that results in only marginal health improvements) would be eliminated, and chronic conditions would be more efficiently managed. ^[1]   Finally, the complexity of the American health care system makes it very expensive to administer. Simplifying these processes would result in significant cost savings. ^[2]  

In addition to reducing costs, ensuring that more people receive health care coverage can increase overall access to care. Expanding participation in existing public programs is one means to this end. Every state uses its Medicaid program as the primary instrument for offering health care coverage to poor adults. Because of restrictions on eligibility, however, most low-income, uninsured adults-particularly if they are not parents-do not qualify for Medicaid, despite a burden of illness such as chronic or communicable disease. (See chart, "Key Assistance Programs for Low-Income Families with Children" in Policy Statement 34, Children and Family Systems, for more on the Medicaid program.) Without access to care and coverage for medication, among those who are poor but do not qualify for coverage, particularly those with chronic conditions, physical health will deteriorate, causing progressive diminution of function, pain, and ultimately, premature death. ^[3]  

Medicaid does not preclude the states from extending their coverage for low-income, uninsured people. Indeed, states should consider providing coverage for this needy population through Medicaid to prevent the serious morbidity and morality associated with interruptions in continuity of care and medication, as well as to diminish the costs associated with the lack of such care. State premium assistance programs are another way of helping individuals who may exceed the Medicaid eligibility threshold or who are prohibited from enrolling because their employer provides commercial coverage which they cannot afford. New York's Affinity Health Plan, for instance, is a managed care program that provides services through a large network of primary care sites and a network of contract specialists and hospitals. It is administered through the state Medicaid program and is fully-funded by the state to offer care for low-income individuals and families whose incomes exceed Medicaid or Medicare eligibility levels.

Notably, increasing state-funded Medicaid coverage is not the only strategy for increasing health care coverage. New or expanded federal programs could also meet this need. Alternatively, employers could be compelled to expand coverage to reach more people. Even where health care is not fully funded by public entities, federal, state, or local governments could assist individuals with health care subsidies to cover prohibitively expensive premium costs.