Abstract

Critics of the gaps in our nation’s health insurance decry the absence of a health insurance “system” and the resulting “patchwork” of private and public insurance that leaves so many Americans unprotected. There is no question that these gaps are unconscionable; but they are also no accident. They are the result of policy and political choices with substantial consequences for those who remain uncovered. In my view, the fundamental political barrier to universal coverage is that our success in insuring most of the nation’s population has “crowded out” our political capacity to insure the rest. This paper will explain how we arrived at the mix of private and public insurance we now have, how that mix impedes efforts to achieve universal coverage, and how “crowd-out” affects strategy for improving coverage in the future.