Millions await Obama's action on health insurance

Many are denied coverage because they have preexisting conditions or can't afford the high premiums they are quoted because of a preexisting condition.

Some have insurance but get so sick that they reach the lifetime cap on their plan - and promptly find themselves uninsured.

Some experts predict that next year's reform - whatever its final shape - could fill many of the cracks described in The Inquirer series.

Consider the case of Goroncy, the uninsured home health aide. Her employer could be mandated by law to give her health insurance or to make a contribution to new government-sponsored insurance plan that would cover her.

Goroncy herself might be required to purchase insurance - either through her employer, an individual plan, or a new government-sponsored insurance plan. And if she can't afford insurance, she might receive a government subsidy or a tax incentive.

Buying insurance might remain voluntary, not mandatory, supported by subsidies. The theory is that Goroncy would not be required to buy insurance, but a subsidy would make it affordable for her so naturally she'd purchase it.

In the campaign, Obama said he favored only making insurance mandatory for children, but voluntary for adults, sweetened by subsidies that would make it possible for the uninsured to afford it.

Hillary Clinton during the campaign favored mandatory participation.

Several experts say that the economic downturn, with so many people losing jobs and insurance, could give Obama and Congress the political cover they need to make participation mandatory. "I think the environment may have changed," said USP's Field. "We're in much more of a crisis setting."

The health-insurance industry last month came out in support of universal coverage and an end to a primary means of denying coverage to sick people - the preexisting-condition clause - but only if participation is mandatory.

"That's great political cover for Obama," said health economist Tom Getzen of Temple University's Fox School of Business. "It's what Hillary wanted to begin with. You need everybody in one system. If you're going to control costs, you can't have some people in the system and some people out of it."

The very simple theory of insurance is this: It only works with very broad participation. You can best afford to cover the sickest if the healthiest are also paying in.

Conservatives are leery of many of the proposals being discussed, in particular a new government-funded program intended to provide insurance to people who can't buy it anywhere else.

"The creation of a new public plan would result in millions of Americans losing their employment-based coverage coupled with a massive expansion of government coverage and financial control," writes Robert E. Moffit, director of the Center for Health Policy Studies at the Heritage Foundation.

Some experts say Obama must bring enough Republicans on board, and build a consensus, if he is to succeed. The new president will have his work cut out.

"I am concerned that some proposals will make your health insurance more expensive, not less, and do nothing to protect your current coverage," Jon Kyl, a Republican senator from Arizona, wrote to his constituents last week.

"A government-run plan and an employer mandate, I believe, would exacerbate, not fix, the problem of growing health care costs and would erode employer-sponsored health coverage," Kyl added. "I believe Congress must build upon, not completely dismantle, our current health care system."

Millions of Americans who can't afford the health care they desperately need are waiting to find out what that change will be.

Some who lacked coverage