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Nurses say providing access to health care is one of the most important responsibilities of a health care system. In this, many agree, the system has failed. They are not alone. Politicians, physicians, employers, insurance company executives, and the general public agree that the health insurance crisis needs to be addressed. The Institute of Medicine of the National Academies has called for universal health coverage by 2010.

But the question nurses and the rest of the country are asking is: What is the best way to provide universal access? Provide tax credits to help pay for premiums? Mandate health insurance the way some states do car insurance? Require employers to provide it? Establish a government-financed health care system, similar to the one in Canada? Should such a health care system be national or should it be up to each state to decide its own system?

Groups such as the Institute of Medicine and Cover the Uninsured have identified some approaches to expanding coverage for the uninsured, including:

Employer mandates | Employer mandates, also called “pay or play” laws, require businesses with a certain number of employees to either provide coverage to workers or pay a tax to enroll workers in a public plan.

Some critics of the proposal say it creates an unfair burden on employers and discourages them from hiring more workers. Others say it doesn’t go far enough and leaves some without coverage, or with coverage that stops if they are laid off or go to work for an employer who isn’t required to provide coverage.

Individual mandates | Individual mandates would require everyone to have some basic form of health insurance just as every driver must have car insurance.

Because many people without health insurance now are young and healthy, proponents of this idea predict premium costs would decrease because of increased competition for new buyers and the addition of healthier people to the risk-sharing pool. Opponents say this system would not be fair to people with preexisting conditions who would have to pay higher premiums because of “bad genes.” They also say there is no way to enforce the mandates, and most voters would not approve of a law requiring them to buy insurance.

Tax credits | Tax credits would let employers or individuals deduct the cost of health insurance premiums, either with a fixed amount of money or a percentage of the premium.

Supporters say tax credits allow some choice in health insurance policies, but would be affordable because they would only reimburse on premiums up to a certain point. Opponents say the tax credits would be too small and too complicated to induce people to buy insurance, especially those with preexisting conditions who had to pay higher premiums.

Expanding existing programs | Expanding existing public health insurance programs, such as Medicaid, Medicare, SCHIP, and community clinics, would provide coverage for more uninsured people.

Many say this is the easiest way to expand coverage without adding more bureaucracy or creating a new, expensive, and untried system. But opponents say current programs are confusing and inefficient and have been unable to enroll those who are eligible. Also, many states are cutting back or freezing spending on health care programs, and the quality of health care programs would vary from state to state, depending on their economic situations.

Single-payer system | A tax-financed health care system, similar to the one in Canada, would turn the government into the nation’s major health insurer, administering payment for private health care services.

Supporters of a single-payer system say it would guarantee health care coverage for everyone and be more efficient because the government would negotiate prices with health care providers and drug companies. Others point to inefficiencies and low reimbursements in current government-sponsored health programs and argue that such a system creates too great a role for government and gives it too much power in managing health care.

Cathryn Domrose