The chronic "working" poor generally are individuals employed by small companies with 11-50 employees. These employees lack funding and bargaining power to negotiate contracts with their employers, and are unable to afford individual, private plans. Chronic "working" poor account for 16% of the American population.2 The only real accesses these individuals have to medical providers are through urgent and emergency care, the lowest quality form of healthcare. .
It is important to consider what is at stake with reform in order to understand how the policymakers deal with the dilemmas in the healthcare debate. Private insurers offer plans with low co-pays and quality specialized care for those who can afford the high monthly premiums. Though, if the single-payer system were eliminated, private industry would reject the unhealthy poor and elderly from their networks. On the other hand, relying solely on a single-payer system to deliver universal coverage would lead to higher government expenditures and deterioration of the quality of care. .
Democratic reformers promote increasing single-payer coverage, lowering the cost of healthcare for poor and elderly, and increasing access to the working poor. Since neither level of government is interested in expanding their single-payer programs, a coordination problem arises. While the aggregate amount of single-payer expansion is clear to bureaucrats at all government levels, federal politicians try to assign more responsibility to state run Medicaid programs. In response, state representatives respond with delay tactics and litigation, often calling for the judiciary to review the constitutionality of federal orders and mandates. Disputes between state and federal governments are a major source of gridlock that delays democratic efforts to implement healthcare reform. .
` The main point of contention among reformers is the inability to present a comprehensive plan that delivers universal coverage in a cost effective manner.
