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An alternative estimate: no pain, no gain.

The Health Security Act assures that all Americans will have access to comprehensive health insurance and clearly defines the roles of employers, governments, and individuals in financing this coverage. In the preceding essay Alice Rivlin, David Cutler, and Len Nichols provide an informative overview of these financial obligations and clearly explain how federal subsidies under the plan will be financed. Moreover, the authors should be congratulated for their part in developing models to estimate the cost of broad-scale health reform initiatives in such a short period of time. There are three important issues, however, that the authors do not touch upon in their paper. First, there is now mounting evidence that the Clinton administration has substantially underestimated premiums for the uniform benefit package, resulting in overly optimistic estimates of program impacts on employers, households, and the federal deficit. Second, the authors fail to explain that the administration’s financing plan shifts a large part of the cost of covering higher-cost, low-income populations (such as the Medicaid medically needy population) to employers through community rating. Third, the authors do not acknowledge the sensitivity of their estimates to assump tions on health care cost growth and individual and employer behavior. In this Perspective we compare the administration’s estimates with our own independent estimates of the financial impact of