The goals of reform are clear: provide universal care that is affordable. So far, however, Congress has avoided any proposals that would require a major organizational shake-up--tabling Senators Wyden (D-OR) and Bennett's (R-UT) "Healthy Americans Act" ("Wyden-Bennett"), because it would eliminate employer-based healthcare as we now know it.
Conceptually, the most obvious way to achieve universal care without eliminating existing employer policies is through a voucher--plus an exchange where the voucher can be traded in. Employers would be free to top up the voucher and provide a more generous plan if they wanted to.
Most of the proposals on the table can be described as providing some sort of voucher. Massachusetts in effect gives vouchers to the needy. Wyden-Bennett also provides subsidies that can be reframed as voucher. But most of the proposals lack the clarity of a straightforward voucher framework. Vouchers provide a simple analytical framework for expanding care, for defining public assistance, and for deciding how much we want to spend. Moreover, by defining the amount of care we can afford, vouchers provide incentives for providers to improve efficiency in order to provide care within those limits, and provide a clear framework for evaluating cost and funding of universal healthcare. Vouchers do not require a "public option." Vouchers need not be universal, although some sort of offset for employer plans would be required if we want employers to maintain the incentive to provide their own plans.