Front and Center Ensuring That Health Reform Puts People First June 2009 t h e c o m m o n w e a lt h f u n d The Commonwealth Fund, among the first private foundations including low-income people, the uninsured, minority Americans, started by a woman philanthropist—Anna M. Harkness—was estab- young children, and elderly adults. The Fund carries out this mandate by supporting independent lished in 1918 with the broad charge to enhance the common good. research on health care issues and making grants to improve health The mission of The Commonwealth Fund is to promote a high care practice and policy. An international program in health policy is performing health care system that achieves better access, improved designed to stimulate innovative policies and practices in the United quality, and greater efficiency, particularly for society’s most vulnerable, States and other industrialized countries. Cover photos: Paula Lerner (top), Roger Carr (bottom) Front and Center Ensuring That Health Reform Puts People First K aren D avis , K ristof S tremikis , C athy S choen , S ara R. C ollins , M ichelle M. D oty , S heila D. R ustgi , and J ennifer L. N icholson J une 2009 Abstract: A comprehensive health care reform strategy proposed by the Commonwealth Fund Commission on a High Performance Health System could improve health and health care experiences for many people in the United States. This report focuses on those who would benefit from such health reforms, including the estimated 116 million working-age adults—two-thirds of all adults—who report that they are uninsured or underinsured, have medical bill or debt problems, or experience difficulties obtaining needed care. A national health insurance exchange with competing private plans and a new public plan has the potential to provide greater choices, better benefits, and more affordable premiums. If coupled with broad system reforms, the average family could save $2,314 a year by 2020, as the annual increase in health costs slowed from 6.7 percent to 5.5 percent. Cumulative national savings over the period 2010 to 2020 would be $3 trillion, compared with projected trends. Support for this research was provided by The Commonwealth Fund. The views pre- sented here are those of the authors and not necessarily those of The Commonwealth Fund or its directors, officers, or staff. To learn more about new publications when they become available, visit the Fund’s Web site and register to receive e-mail alerts. Commonwealth Fund pub. no. 1280. Acknowledgments The authors thank The Commonwealth Fund’s Martha Hostetter, Christopher Hollander, and Paul Frame for editorial support and Suzanne Augustyn for the report’s design and layout. Contents List of Exhibits......................................................................................................................iv Executive Summary................................................................................................................v A Health System in Crisis................................................................................................v . The Benefits of Comprehensive Reform..........................................................................vi Introduction. ........................................................................................................................ 1 . A Health System in Crisis..................................................................................................... 2 . Forty-Six Million Are Uninsured, Millions More Have Coverage Gaps........................... 2 Twenty-Five Million Are Underinsured........................................................................... 4 Seventy-Two Million Struggle to Pay Medical Bills or Have Medical Debt...................... 6 One-Third Frequently Change Health Plans................................................................... 6 Nearly Half of Workers with Employer Coverage Have No Choice of Plan..................... 8 Nearly Half of Small Business Employees Are at Risk...................................................... 9 Many in Individual Insurance Market Face High Costs, Limited Benefits..................... 10 Forty-Two Million Medicaid Beneficiaries Lack Stable Coverage................................... 12 Thirteen Million Young Adults Lack Insurance Coverage.............................................. 12 Women Face Financial Burdens of Health Care Expenses.............................................. 13 Older Adults and Early Retirees Face High Costs.......................................................... 15 Two Million Disabled Individuals Wait Two Years for Medicare.................................... 16 Forty Million Medicare Beneficiaries Face High Premiums. .......................................... 16 . Improved Coverage and Affordability for All....................................................................... 18 Putting People First: Making Health Reform Work for Individuals and Families................. 20 Notes.................................................................................................................................. 23 Further Reading.................................................................................................................. 27 iii List of Exhibits Exhibit ES-1 A Health System That Works for People Exhibit 1 Affordable Coverage for All: Foundation for Reform Policies in Path Report Exhibit 2 Uninsured Projected to Rise to 61 Million by 2020, Not Counting Underinsured or Part-Year Uninsured Exhibit 3 Trend in the Number of Uninsured, 2009–2020, Under Current Law and with Insurance Reforms and Exchange Exhibit 4 Underinsured and Uninsured Adults at High Risk of Going Without Needed Care and Financial Stress Exhibit 5 Seventy-Two Million Americans Have Problems with Medical Bills or Accrued Medical Debt, 2007 Exhibit 6 Switching Health Plans Is a Common Experience Across Incomes, 2007 Exhibit 7 People with Employer Insurance Have More-Stable Coverage Than Those with Individual Market Insurance Exhibit 8 Employees in Large Firms Are Most Likely to Have Two or More Health Plan Choices Exhibit 9 Employer Coverage Continues to Be Major Source of Coverage for Employees of Larger Firms But Has Declined Among Small Firms Exhibit 10 Individual Market Is Unaffordable for Many Adults Exhibit 11 Uninsured Young Adults Ages 19–29 by Poverty Status and Race/Ethnicity, 2007 Exhibit 12 Percent of Income Spent on Family Out-of-Pocket Costs and Premiums Exhibit 13 Women Are More Likely to Have Access Problems and Medical Bill Problems in Past Year, 2007 Exhibit 14 More Than One-Third of Older Adults Report Medical Bill Problems Exhibit 15 Sick, Disabled, and Waiting for Medicare: Source of Insurance During the Long Wait Exhibit 16 Access and Bill Problems for Elderly Medicare Beneficiaries and Nonelderly Adults Covered by Employer-Based Insurance, 2001–2007 Exhibit 17 Estimated Premiums for New Public Plan Compared with Average Current Premiums, Individual/Small Employer Private Market, 2010 Exhibit 18 Average Annual Savings per Family Under Path Reforms, 2020 Exhibit 19 Total National Health Expenditures (NHE), 2009–2020 Current Projection and Alternative Scenarios Exhibit 20 Potential Impact on Patients if the United States Improved National Performance to Benchmark Levels Exhibit 21 A Health System That Works for People iv Executive Summary inadequate care for those who are sick and unable to The stakes are high for U.S. families as the nation pay for care, or the fear of knowing that none of us is considers health system reforms. The major benefi- truly secure. ciaries of reform would be people who do not fare The current economic crisis only intensifies the well in our current systems for financing and deliver- crisis in our health care system, as millions more lose ing health care services, including those at risk for their jobs and enter the ranks of the uninsured. The losing their health insurance or affordable access to two purposes of insurance are to ensure access to care when they get sick. essential health care and protect against financial In a nation replete with modern medical centers, hardship of medical bills, yet we have increasingly there are countless stories of Americans whose lives designed insurance that does neither. With the com- could have been saved or disabilities averted if they prehensiveness and adequacy of insurance eroding, had been able to afford medical care or had timely medical bills are often beyond families’ ability to pay. access to high-quality, safe care. In today’s health sys- Health insurance premiums now exceed a year’s pay tem both the insured and the uninsured are at risk. for minimum wage workers—making them unaf- Even families whose incomes place them solidly in fordable for employees and employers alike. the middle class worry that they will not be able to In this report, we focus on the people who would afford to get sick, that they will see their children lose benefit most from health care reform: the uninsured; the protection of family coverage, or that they will the underinsured; those with unstable coverage who exhaust a lifetime of savings paying off medical debt. lose and gain insurance; those who lose their cover- This report examines the multiple ways in which age when their life circumstances change; those the current health insurance and care delivery sys- entering the labor market who cannot find a job with tems fail people when they need it. And it describes coverage; those who must wait to qualify for coverage the people who would benefit from health reforms until they have worked long enough or been disabled aimed at providing secure, comprehensive coverage long enough; those who cannot afford their out-of- and enabling the delivery of accessible, safe, patient- pocket costs or health insurance premiums; those centered health care. who are discriminated against because they are sick, older, or female; those who spend hours with hassles A Health System in Crisis over medical bills; and those who cannot find a doc- Health reform in many nations has been triggered tor who provides easy access and helps coordinate by tragic incidents caused by dysfunctional health their care. care systems. In the United States, 18,000 people die Most people in the U.S. fall into one of these every year as a result of being uninsured—and these categories and have personally experienced the short- preventable deaths are only the tip of the iceberg of comings of our current system. Even before the missed opportunities to improve health. The U.S. severe recession, an estimated 116 million working- remains the only wealthy country where a serious age adults—two-thirds of all adults—reported they illness could bankrupt an otherwise well-off family. were uninsured or underinsured, had medical bill or We may have reached the point where Americans debt problems, or experienced difficulties obtaining can no longer tolerate the human toll of delayed or needed care. The beneficiaries of reforms that ensure v affordable health insurance and access to high-quality The Benefits of Comprehensive Reform care would include: This report examines how a comprehensive, inte- • 46 million who were uninsured at the start of the grated strategy for health care reform could improve recession, and 55 million who were uninsured at the health and health care experiences for these some point during the past year; diverse groups. It is based on a framework previously • 25 million working-age adults who are set forth in The Path to a High Performance U.S. underinsured; Health System: A 2020 Vision and the Policies to Pave • 72 million working-age adults who have difficulty the Way, a report of the Commonwealth Fund paying medical bills; Commission on a High Performance Health System that outlined ways to ensure health insurance cover- • 49 million small business employees who now age for all and eliminate the financial burdens that pay higher premiums than employees in larger now undermine personal economic security (referred businesses; to here as the “Path report” or “Path framework”). • 4 million adults under age 65 with individual Building on current job-based health insurance coverage whose premiums go toward high while expanding the coverage choices available, the overhead costs, leaving less room for benefits; reforms would ensure affordable coverage to every- • one-third of insured people who change plans one—covering the uninsured and improving cover- frequently, often not by choice; age for those who are underinsured. A national • 46 percent of workers with employer coverage health insurance exchange would offer an array of who do not have a choice of plans; competing private plans and a new public health • Medicaid beneficiaries, who would have expanded insurance plan, helping to improve coverage for 138 choices and better access to care if Medicaid million currently insured individuals through more provider payments were increased; choices, better benefits, and/or more affordable pre- miums, which would be 20 percent to 30 percent • women, who as a group carry greater financial lower than those now charged in the individual and burdens from health care expenses; small-business markets for comparable benefits and • 13 million young adults without coverage; enrollees. Savings would be realized by employers • older adults and early retirees, who have few and households at every income level. affordable insurance options; If coupled with broad health system reforms, the • 2 million disabled individuals in the waiting average family would save $2,314 a year by 2020, as period for Medicare coverage; the annual increase in health care costs slowed from • any Medicare beneficiary who now pays high 6.7 percent to 5.5 percent. Cumulative national sav- premiums for supplemental coverage; and ings to the health system over the period 2010 to 2020 would be $3 trillion, compared with projected • 37 million adults and 10 million children who trends. While the federal government would need to lack easy access to a regular source of care. make upfront investments, the benefits would accrue over time to all of those who finance the health system. vi The most important outcome of health system Payment and system reforms would make the reform that puts people first would be the health organization and delivery of health care services more benefits to the American people. If the achievable responsive to peoples’ needs and preferences. In a targets included in the Path framework are reached, 2008 survey, three-quarters of all adults reported dif- by the year 2020 an estimated 100,000 lives per year ficulty accessing care, half reported problems with would be saved, 68 million more adults would care coordination, and one-quarter reported serious receive recommended preventive care, and 37 million problems related to time spent on paperwork or dis- more adults and 10 million more children would putes about medical bills or health insurance in the receive care from physician practices that ensure easy previous two years. Reforms that promote accessible, access to care and are accountable for providing coordinated, patient-centered primary care would be patients all essential health services. Avoidable hospi- of particular benefit to individuals with chronic ill- talizations would decline each year as well: 640,000 nesses. To ensure that people get the right care, at the fewer Medicare beneficiaries would be hospitalized right time, and in the right way—and to avoid waste for ambulatory care–sensitive conditions, and and duplication—it will be necessary to invest in 180,000 fewer Medicare beneficiaries would be read- health information technologies. By 2020, 98 per- mitted within 30 days following their initial hospital cent of physicians should have electronic information discharge. In addition, there would be 70,000 fewer systems that meet national standards, up from only children hospitalized for asthma-related complica- about one-fourth of primary care physicians today. tions each year, and 250,000 fewer adults hospital- Payment systems that enable providers to spend time ized for diabetes-related complications. with their patients and reward excellent results would Exhibit ES-1. A Health System That Works for People � Extends affordable health insurance coverage to everyone � Prohibits exclusion and risk-rating based on health status or gender � Covers preventive care � Ensures that premiums are affordable and medical bills are manageable � Allows individuals to keep the coverage they have while providing more insurance plan choices for all � Eliminates the need to forgo coverage or switch plans as job or family circumstances change � Gives every patient the option to enroll in a medical home, ensuring that they receive all recommended preventive care, help controlling chronic conditions, and assistance navigating the health care system � Enables patients to get care when it is needed, including on nights and weekends, and to get questions answered promptly by doctors or nurses by phone or e-mail � Reduces the hassle of filing insurance claims and getting bills paid � Makes health information such as medical records and test results available to patients on a timely basis vii raise the standards of care. There also should be that care and insurance are affordable to all, and incentives for providers to innovate and improve. reduce the numbers of uninsured. As the political deliberations over health reform The political challenges to doing so are formida- increasingly center on how those who provide care or ble, but the expectations for our political leaders are insurance would be affected by various reform also high. Too often, the voices heard in the halls of options, it is important to focus on the core purpose Congress speak for those who have a strong financial of reform: ensuring affordable health coverage and stake in the $2.5 trillion now spent on the health health care for all. Putting people first is a shared care system. At a time of severe economic crisis, now goal of health professionals, and it is one that needs is the time to listen to the concerns of individuals to guide health reform deliberations. This strategy and families. Designing health reforms that put peo- enjoys widespread support among the public across ples’ interests first should go a long way to forging income groups, geographic regions, and political consensus and enacting legislation during this his- affiliation. Nine of 10 people believe that health toric window of opportunity. reform should improve the quality of care, ensure viii Introduction work”), the strategy calls for a transformation of the In the political fray over health reform, it is impor- health care system to ensure that it centers on peo- tant to keep sight of a key question: What is best for ples’ needs and that everyone has the opportunity to people? Putting people first is a shared goal of health attain the best possible health outcomes.1 Most care professionals, and one that needs to guide health important, these reforms would make the health care reform deliberations. Keeping this goal at the fore- system work better for individuals and families. front will make it easier to enact reform that achieves The Path framework outlines a set of insurance health insurance coverage for all and improves the reforms that together provide a foundation for broad quality, affordability, and value of care. health system reform (Exhibit 1). These include: The Commonwealth Fund Commission on a • Creating a new insurance exchange that would High Performance Health System has set forth a offer everyone a choice of private insurance plans framework and a path to reach this goal. The strategy and a new public insurance option. The exchange is a comprehensive, integrated one that ensures would make it easy for people to compare affordable health insurance for all while improving plans and to enroll and keep insurance as their the quality and efficiency of the health care delivery circumstances change. system and investing in measures, such as health pro- • Establishing a health insurance standard with motion and chronic disease control, that yield long- comprehensive benefits and financial protection term payoffs. Described in the recent report, The that all insurance plans would have to meet. Path to a High Performance U.S. Health System: A • Making sure insurance is affordable relative 2020 Vision and the Policies to Pave the Way (hereinaf- to income and, with this protection in place, ter referred to as the “Path report” or “Path frame- requiring everyone to have health coverage. Exhibit 1. Affordable Coverage for All: Foundation for Reform Policies in Path Report • Builds on employer coverage and public programs • New national insurance exchange – Offers private plans and new public health insurance option – Makes it easy to choose and stay covered – Public plan: comprehensive benefits and low administrative overhead • All required to have coverage, with provisions for affordability – Low-income programs expanded – Income-related premium assistance to make coverage affordable • Shared responsibility for financing: all employers share • Insurance market reforms – Minimum national benefit standard – Guaranteed issue, renewal, and community rating (no underwriting) – Public comparisons; standardized format • Insurers compete on basis of added value Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). 1 • Opening up Medicaid and the Children’s Health A Health System in Crisis Insurance Program (CHIP) to people with incomes below 150 percent of the federal poverty Forty-Six Million Are Uninsured, Millions More Have Coverage Gaps level (under $33,000 for a family of four), The major goal of health care reform in the United providing full premiums and low cost-sharing, States should be to guarantee the availability of and raising Medicaid provider payment rates to affordable health insurance for all. An estimated 46 Medicare levels. million Americans were uninsured in 2007, up from • Sharing responsibility for health care by requiring 38 million in 2000.3 Even before the economic all employers to offer coverage or contribute to a downturn, their numbers were projected to grow to national health insurance trust fund. 61 million in 2020 (Exhibit 2). Millions more lose • Requiring all health insurers to offer coverage to coverage for a period as a result of becoming ill, anyone wishing to enroll and to charge the same changing jobs, or other circumstances. In 2006, premium, regardless of health status. 75 million people were uninsured for all or part of the year, representing 25 percent of the total popula- This report focuses on the beneficiaries of such tion and 27 percent of those under 65.4 Notably, this health reforms: the uninsured; the underinsured; was before the severe economic downturn and subse- those with unstable coverage who move in and out of quent loss of some 5 million jobs. coverage; those who lose their coverage when their Uninsured rates are particularly high among life circumstances change; those entering the labor low-income individuals. Half of those with family market who have cannot find a job with coverage; income under $20,000 were uninsured at some point those who must wait to qualify for coverage until during 2007. But over the last decade, more and they have worked long enough or been disabled long more middle-class families have joined the ranks enough; those who cannot afford their out-of-pocket of the uninsured. Two-fifths (41%) of those with costs or health insurance premiums; those who are moderate incomes ($20,000 to $39,999) were unin- discriminated against because they are sick, older, or sured at some point during 2007, up from 28 percent female; those who spend hours dealing with medical in 2001.5 bills; and those who cannot find a doctor who pro- The projected rise in unemployment endangers vides easy access and helps coordinate their care. the health coverage of many more working Most Americans fall into one of these categories and Americans. Since employer-sponsored insurance is have personally experienced the shortcomings of our the major source of coverage for working families, current system. An estimated 116 million working- loss of a job often means loss of insurance. A recent age adults—two-thirds of all adults—report being study found that for every percentage-point increase uninsured or underinsured, medical bill or debt in the unemployment rate, the number of uninsured problems, or difficulties obtaining needed care.2 First increases by approximately 1 million. If unemploy- and foremost, health reform must be designed in a ment were to rise to 10 percent, 6 million more peo- way that works for these individuals. ple would be uninsured than in 2007.6 2 The economic and health consequences of being life-threatening conditions can die from delays in uninsured and lacking access to affordable care are early detection as well as a lack of adequate treat- stark. In a nation replete with modern medical cen- ment.11 In many nations, major health reform has ters, there are countless stories of Americans whose been triggered by tragedies like these that were the lives could have been saved or whose disabilities result of dysfunctional health care systems.12 could have been averted if they had timely access to Recently, Congress enacted some modest mea- affordable, high-quality care.7 The Institute of sures to assist the uninsured. Reauthorization of Medicine estimates that 18,000 people die each year CHIP will cover an estimated additional 4 million as a direct consequence of being uninsured, and anal- uninsured children.13 Provisions in the American ysis of the 2007 Commonwealth Fund Biennial Recovery and Reinvestment Act of 2009 will offset Health Insurance Survey shows that 68 percent of 65 percent of health insurance premiums for recently the uninsured went without needed care because of unemployed workers who are able to retain their cost.8,9 Those with chronic conditions, for example, employer-based coverage under COBRA.14 However, are less likely than the insured to report managing many unemployed individuals and families will still their conditions, more likely to report not filling pre- find coverage unaffordable even with this assistance.15 scriptions or skipping doses of drugs, and more likely Moreover, Commonwealth Fund analysis suggests to use emergency rooms and be hospitalized.10 that many low-income individuals and families are The uninsured are also less likely than the not eligible for COBRA because they either worked insured to receive preventive care, including immuni- in small firms or did not have health benefits in their zations, Pap tests, mammograms, and colon cancer former job.16 screening. People without health insurance who have Exhibit 2. Uninsured Projected to Rise to 61 Million by 2020, Not Counting Underinsured or Part-Year Uninsured Number of uninsured, in millions 75 61 56 49 50 44 38 25 0 2000 2005 2010 2015 2020 Projected Lewin estimates Data: U.S. Census Bureau, Current Population Survey, Annual Social and Economic Supplement, 2001 and 2006; Projections to 2020 based on estimates by The Lewin Group. 3 The Path framework would extend affordable Fund survey, 53 percent of adults who were underin- coverage to everyone, ensuring access to needed care sured reported one of four instances of going without and financial protection to individuals and families needed care because of costs: not filling a prescrip- while providing a foundation for long-term reforms tion; skipping a recommended medical test, treat- to improve the quality and efficiency of care. The ment, or follow-up; having a medical problem but number of uninsured—projected to rise to 61 mil- not visiting a doctor; or not getting needed specialist lion in 2020 absent significant reform—would care because of costs.18 Forty-five percent of the instead fall to an estimated 4 million, or about 1 per- underinsured reported one of three medical debt or cent of the U.S. population (Exhibit 3). Even hard- bill problems: having problems paying medical bills; to-reach individuals would qualify for free or low- changing their way of life to pay medical bills; or cost coverage if they became ill and sought care. being contacted by a collection agency for inability to pay medical bills. Rising health care costs have Twenty-Five Million Are Underinsured fueled erosion in insurance benefits and shifted Under the current health care system, even those financial risk onto individuals and families.19 with coverage often have inadequate financial protec- The design of health insurance benefits clearly tion and access to care. Individuals with insurance matters.20 Yet the nation lacks a standard for coverage coverage are increasingly at risk of being underin- that ensures health care access and adequate financial sured or spending a high percentage of their income protection, and prevents “surprises” resulting from on medical care, despite having continuous coverage. arbitrary limits or holes in benefits. The Path frame- A recent study defined insured adults as being under- work features a public health insurance plan within a insured if they spent 10 percent or more of their national health insurance exchange that would estab- income (5 percent for low-income individuals) on lish a minimum standard benefit package, based on out-of-pocket health care costs, or had deductibles the Blue Cross Blue Shield option available to mem- equivalent to 5 percent or more of income.17 As of bers of Congress and federal employees. All health 2007, there were an estimated 25 million underin- plans, including employer-sponsored plans, would sured adults in the U.S., up 60 percent from 2003. be required to meet a minimum coverage standard While low-income individuals and families are hit under the framework. Deductibles in the public the hardest, the problem has moved up the income insurance standard plan would be $250 per person ladder and taken hold in the middle class. Between or $500 per family, rather than the $2,000 to 2003 and 2007, the underinsured rate nearly tripled $10,000 deductibles found in some insurance among adults with incomes above 200 percent of the policies today. Even the average deductible for federal poverty level. single coverage offered by companies employing Even though they have coverage all year, the fewer than 200 workers approached $1,000 in underinsured experience problems accessing care and 2008.21 Preventive services and services required paying medical bills at rates similar to those seen for for treatment of chronic conditions would be the uninsured (Exhibit 4). In a Commonwealth covered in full. 4 Exhibit 3. Trend in the Number of Uninsured, 2009–2020, Under Current Law and with Insurance Reforms and Exchange Millions 80 Current law Path proposal 58.3 59.2 60.2 61.1 60 56.0 57.2 51.8 53.3 54.7 48.0 48.9 50.3 40 20 19.7 6.3 4.0 4.1 4.1 4.1 4.1 4.2 4.2 4.2 4.2 0 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Note: Assumes insurance exchange opens in 2010 and take-up by uninsured occurs over two years. Remaining uninsured are mainly those who do not file taxes. Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). Exhibit 4. Underinsured and Uninsured Adults at High Risk of Going Without Needed Care and Financial Stress Percent of adults (ages 19–64) Insured, not underinsured Underinsured Uninsured during year 75 68 53 51 50 45 31 25 21 0 Went without needed care due to costs* Have medical bill problem or outstanding debt** * Did not fill prescription; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor; or did not get needed specialist care because of costs. **Had problems paying medical bills; changed way of life to pay medical bills; or contacted by a collection agency for inability to pay medical bills. Source: C. Schoen, S. Collins, J. Kriss, M. Doty, “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Health Affairs Web Exclusive, June 10, 2008. Data: 2007 Commonwealth Fund Biennial Health Insurance Survey. 5 Seventy-Two Million Struggle to Pay Medical Bills 5 percent of their income for standard coverage, and, or Have Medical Debt above that level, no family would pay more than 10 Rapidly rising health care costs and erosion in the percent of their income. adequacy of health insurance coverage have serious economic consequences for a growing number of One-Third Frequently Change Health Plans individuals and families. Analysis of the 2007 Linking health insurance to employment, without a Commonwealth Fund Biennial Health Insurance mechanism that enables people to keep their cover- Survey shows that 72 million adults under age 65 age as their circumstances change, undermines the have problems paying medical bills or are paying off continuity of care and endangers health. A change in accumulated medical debt; about 60 percent of these job, marital, or dependent status typically triggers a adults were insured at the time the expenses were change—and often a gap—in coverage. One-third of incurred (Exhibit 5).22 Adults with medical bill prob- adults changed insurance plans during the past three lems face dire financial tradeoffs: 29 percent are years, including 14 percent who have changed more unable to pay for basic necessities—food, heat, than once (Exhibit 6). This pattern persists even for rent—because of their bills. Meanwhile, 39 percent adults with chronic illness.23 Studies indicate that use their savings to pay bills, and 30 percent take on changing plans is typically not a matter of choice but credit card debt. rather is necessitated by a change in life circum- Establishing a standard benefit floor and income- stances.24 Volatility in enrollment, including short- related premium assistance is essential to stemming term enrollment, erodes incentives for insurance the rise in ruinous medical bills and medical debt. plans to invest in population health and disease pre- Under the Path framework, no family with income vention, drives up overhead costs, and undermines below twice the poverty level would pay more than the stability of patient–provider relationships. Exhibit 5. Seventy-Two Million Americans Have Problems with Medical Bills or Accrued Medical Debt, 2007 Percent of adults ages 19–64 2005 2007 In the past 12 months: Had problems paying or unable to pay 23% 27% medical bills 39 million 48 million Contacted by collection agency for 13% 16% unpaid medical bills 22 million 28 million 14% 18% Had to change way of life to pay bills 24 million 32 million 28% 33% Any of the above bill problems 48 million 59 million 21% 28% Medical bills being paid off over time 37 million 49 million Any bill problems or medical debt 34% 41% 58 million 72 million Source: M. M. Doty, S. R. Collins, S. D. Rustgi, and J. L. Kriss, Seeing Red: The Growing Burden of Medical Bills and Debt Faced by U.S. Families (New York: The Commonwealth Fund, Aug. 2008). 6 Commonwealth Fund–sponsored analysis of erage, there was a fourfold increase in the probability Medical Expenditure Panel Survey data shows that of hospitalization for diabetes, asthma, urinary tract people with coverage obtained in the individual infections, ruptured appendicitis, and other condi- insurance market are more likely than those with tions for which timely, appropriate care make a dif- employer-based coverage to switch insurance plans or ference.26 More than 60 percent of enrollees experi- carriers or undergo periods without coverage (Exhibit enced such gaps in coverage. With low-income fami- 7).25 Twenty-one percent of people with nongroup lies forced to demonstrate eligibility as often as every coverage reported having one or more spells without three months, the way that public insurance program insurance over a two-year period, compared with 12 criteria are designed frequently leads to discontinu- percent of those with employer-sponsored coverage. ous coverage. Meanwhile, an additional 26 percent of those with The Path report calls for the creation of a individual market coverage underwent an insurance national health insurance exchange offering a variety transition; by contrast, only an additional 2 percent of private plans and a public health insurance plan. of those with employer-based insurance experienced This would give people greater choices among plans, churning, such as changing plans or carriers, or gain- as well as the option to keep continuous coverage ing and losing coverage. that would follow them during life’s transitions— For those with chronic conditions, churning in thus enhancing population health by ensuring unin- insurance program enrollment and gaps in coverage terrupted access to preventive and primary care ser- introduce a high risk of complications that result in vices. Reducing the frequency of coverage interrup- preventable admissions to hospitals or emergency tions could prevent hospitalizations and other events care. For example, a recent study of Medicaid benefi- that trigger negative health consequences for individ- ciaries found that among those with interrupted cov- uals and high costs for families.27 Exhibit 6. Switching Health Plans Is a Common Experience Across Incomes, 2007 Percent of adults reported changing health insurance or plan in past 3 years 60 Changed two or more times Changed once 40 36 32 30 29 15 14 12 20 15 18 18 21 14 0 Total Below-average Average income Above-average income income Data: 2007 Commonwealth Fund International Health Policy Survey of Adults. 7 Exhibit 7. People with Employer Insurance Have More-Stable Coverage Than Those with Individual Market Insurance Retention of initial insurance over a two-year period, 1998–2000 Retained initial One or more Other transition insurance status spells uninsured 2% 12% 26% 18 86% 15 53% 21% 21 14 Employer insurance Individual insurance Source: K. Klein, S. A. Glied, and D. Ferry, Entrances and Exits: Health Insurance Churning, 1998–2000 (New York: The Commonwealth Fund, Sept. 2005). Authors’ analysis of the 1998–2000 Medical Expenditure Panel Survey. Nearly Half of Workers with Employer Coverage 25%) (Exhibit 8). Even when workers have plan Have No Choice of Plan choice, the plans are often different products offered Insurance companies increasingly require that small by the same insurer. businesses offer their employees only one plan to The decline in coverage choices presented to guard against adverse selection and keep risk pools working families has coincided with a nationwide intact. This has meant that firms with employees trend toward increasing insurance market consolida- spread across multiple locations often do not offer tion and decreasing competition.29 Currently, the top high-quality, regional health plans. Except for some two private plans account for 50 percent or more of large employers, including the federal government, enrollment in all but three states and 70 percent or large businesses also have moved away from sponsor- more of enrollment in 21 states. Increasing domi- ing multiple coverage options. As of 2008, only 14 nance by national insurance companies is making it percent of small firms (those with fewer than 100 difficult for regional health plans—including high- workers) and 44 percent of large firms (those with quality, efficient plans partnered with integrated 200 or more workers) offered their employees a health systems—to gain access to group markets. choice among different types of health plans.28 Setting up a national health insurance exchange Analysis of the 2007 Commonwealth Fund Biennial that would operate at the state or regional levels Health Insurance Survey shows that 42 percent of would offset the trend toward market concentration, workers with employer coverage had only one choice; provide multiple health plan choices, including those in firms with more than 500 employees were regional plans, and ensure that at least one insurance much more likely than those in firms with fewer option would be available to everyone. While than 20 employees to have a choice of plans (71% vs. employers would be free to contract directly for 8 Exhibit 8. Employees in Large Firms Are Most Likely to Have Two or More Health Plan Choices Percent of adults ages 19–64 insured all year with ESI* and choice of plans 100 80 71 60 55 57 49 40 40 25 28 20 0 Total <200% 200%+ <20 20�99 100�499 500+ % FPL Number of employees in firm * ESI = employer-sponsored insurance. Based on adults 19�64 who were who were insured all year through their own employer. Source: 2007 Commonwealth Fund Biennial Health Insurance Survey. coverage, the exchange would be open to employer offer a pathway to more secure coverage within our groups as well as individuals. An estimated 70 per- uniquely American insurance system. cent of employers would elect to purchase coverage through the exchange. The exchange would stimulate Nearly Half of Small Business Employees a new competitive dynamic in insurance markets, Are at Risk making it easy to compare and assess insurance plans While all working families are at risk of losing health by the quality and cost of care provided, generosity insurance coverage, employees of small businesses are of benefits, and beneficiary experiences. Competition particularly vulnerable. Many are simply not offered among health plans based on performance—rather insurance. Only 49 percent of those working for than health risks—has the potential to improve effi- firms with fewer than 10 employees had the option ciency and return value to workers and employers. to purchase job-based coverage (Exhibit 9).30 This Under the Path framework, employment-based rate has declined eight percentage points over the insurance would remain the mainstay of coverage previous decade, from 57 percent in 2000. The White for many working families, with the number of House Office of Health Reform notes that small busi- Americans receiving employer payments toward ness workers who are not offered coverage often end premiums projected to increase from 164 million up uninsured.31 According to a recent Commonwealth to 196 million. By building on our mixed private– Fund study, three of five uninsured workers are self- public coverage system and creating a new insurance employed or working for a firm with fewer than exchange that enables workers and their families to 100 employees.32 keep their coverage as they move from job to job Employees of small firms receive fewer benefits, would make affordable coverage options available to pay higher premiums, and often face larger deductibles all, while ensuring continuity and stability. It would compared with those working for larger businesses. In 9 2002, a firm with more than 1,000 employees paid Many in Individual Insurance Market Face High an estimated premium of $3,134 for single-person Costs, Limited Benefits coverage, while employers with fewer than 10 The individual health insurance market does not employees paid $3,579 for the same benefit pack- work well in terms of providing high-value plans or age.33 Smaller businesses also pick up a smaller share affordable choices. Those covered by individual of premiums, further increasing costs to their work- health insurance plans are much less satisfied with ers. Finally, deductibles have risen sharply in smaller their coverage than those covered by job-based plans. firms (with three to 199 employees), with the mean In fact, they are likely to drop individual coverage if deductible for single coverage rising from $210 in an alternative source becomes available from employ- 2000 to $917 in 2008. For larger firms, deductibles ers or public programs.34 A majority of those seeking increased from $157 to $413 over this period. insurance on the individual market found it very dif- The Path framework would pool risk across small ficult or impossible to find affordable coverage: and large employers in order to provide equitable nearly nine of 10 who tried to purchase it within the and affordable insurance options to all employees. By past three years never bought a plan (Exhibit 10). bringing risk pools together and reducing churning Except in a few states that require insurers to and marketing costs, the health insurance exchange have open enrollment and community-rated premi- would dramatically improve the efficiency of cover- ums, insurers in the individual market typically age. Administrative costs as a percentage of medical screen applicants for health risks and either exclude claims are now estimated to run between 31 percent high-risk individuals from coverage or charge them and 41 percent for the self-employed and businesses higher premiums.35 By design, such underwriting with fewer than 10 employees. The economies practices discriminate against the sick and disabled. achieved in the exchange are projected to lower Nongroup premiums are 20 percent to 50 percent administrative costs to between 13 percent and higher than employer plan premiums, and an esti- 15 percent of claims for very small groups. mated 40 percent of the premiums go toward admin- In addition, under the Path framework, millions istration, marketing, sales commissions, underwriting, of small business employees will gain access to cover- and profits.36 The costs of individual plan premiums age. Historically, employers have invested in the typically climb steeply with age.37 Individual plan health and well-being of their employees by sharing benefits are often limited and cost-sharing is typically responsibility for financing their coverage. The much higher than that found in group markets. framework would build on this foundation by requir- Premium costs and risk selection practices in the ing all businesses to offer insurance or contribute to a individual market are difficult for states to regulate.38 national health insurance trust fund. Within the The establishment of a national health insurance context of ambitious payment and system reforms, exchange offering a variety of private plans and a this would extend affordable health insurance to all public health insurance plan would ensure that and return significant savings to employees and everyone has access to affordable coverage. Requiring employers alike. everyone to have health coverage would make it pos- sible to pool risks among millions of individuals and 10 Exhibit 9. Employer Coverage Continues to Be Major Source of Coverage for Employees of Larger Firms But Has Declined Among Small Firms Percent of firms offering health benefits 97 94 99 99 100 2000 2008 91 90 80 78 80 71 69 63 57 60 49 40 20 0 Total 3�9 10�24 25�49 50�199 200+ Workers Source: Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2008 Annual Surveys. Exhibit 10. Individual Market Is Unaffordable for Many Adults Adults ages 19–64 with individual coverage or who thought about/ tried to buy it in past Health No health <200% 200%+ three years who: Total problem problem poverty poverty Found it very difficult or impossible to find 34% 48% 24% 43% 29% coverage they needed Found it very difficult or impossible to find 58 71 48 72 50 affordable coverage Were turned down or charged a higher price because of a 21 33 12 26 18 preexisting condition Never bought a plan 89 92 86 93 86 Source: S. R. Collins, J. L. Kriss, K. Davis, M. M. Doty, and A. L. Holmgren, Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families (New York: The Commonwealth Fund, Sept. 2006). 11 achieve substantial economies. Eliminating medical than do private health insurance plans and Medicare, underwriting, establishing open enrollment, and causing fewer providers to accept Medicaid patients enabling consumers to compare plans online would and limiting access to care for low-income individuals.41 achieve a marked reduction in administrative costs. The Path framework calls for opening up Within the insurance exchange, individual coverage Medicaid and CHIP to people with incomes below is projected to incur administrative costs that are at 150 percent of the federal poverty level (under least 26 percentage points lower than in our current $33,000 for a family of four), providing full premium system, resulting in dramatically lower premium subsidies and low cost-sharing and raising Medicaid costs for enrollees. Ninety-two percent of those who payment rates to Medicare levels. Enhancing federal currently hold private, nonemployer coverage would matching funds to finance coverage expansions and enjoy better and more affordable insurance under the offset state costs will provide relief to states that face Path framework. significant budgetary pressures during economic downturns. Together with the ambitious payment Forty-Two Million Medicaid Beneficiaries and system reforms, the enhanced funding proposed Lack Stable Coverage under the Path framework is projected to save state Medicaid is the workhorse of the U.S. health insur- and local governments $1 trillion by 2020. More ance system, covering low-income people with HIV/ important, providing adequate and dedicated financ- AIDS, the homeless, those with serious mental ill- ing will bring continuous, stable coverage to the nesses, and children with developmental disabilities. 42 million vulnerable individuals who rely on the While millions of vulnerable people rely on the pro- Medicaid program for their health care needs. gram for access to care, eligibility varies widely from state to state, with 14 states covering parents only if Thirteen Million Young Adults Lack their incomes are below 50 percent of the poverty Insurance Coverage level.39 Thirty-five states set thresholds for parents Young adults are a large and rapidly rising proportion below the poverty level, while 34 states provide no of the nation’s uninsured population: more than 13 Medicaid coverage for nondisabled adults who do million adults between the ages of 19 and 29 lacked not have children. As a result, in the vast majority of insurance coverage in 2007.42 Commonwealth Fund states, an adult who works full time at the minimum analysis shows that young adults now comprise wage is ineligible for coverage. nearly 30 percent of the nonelderly uninsured, Administrative barriers to Medicaid enrollment including a substantial number of low-income and and reenrollment often interrupt coverage for some minority populations (Exhibit 11).43 Those in low- of the country’s most vulnerable individuals. These income households are more likely to go without interruptions are widespread and have serious conse- insurance for both short and long periods: approxi- quences: in a recent study, more than 60 percent of mately 80 percent of young adults with incomes less Medicaid enrollees experienced gaps in coverage, put- than 200 percent of the federal poverty level were ting them at risk for complications that result in pre- uninsured at some point during a four-year period, ventable admissions to hospitals or emergency care.40 while 52 percent did not have health insurance for Medicaid pays providers at substantially lower rates 13 months or more.44 12 Exhibit 11. Uninsured Young Adults Ages 19–29 by Poverty Status and Race/Ethnicity, 2007 Percent uninsured 40 30 29 30 200% FPL or more Less than 32% 100% FPL 10 39% 20 100%– 199% FPL 29% 0 Ages 19–23 Ages 24–29 Uninsured young adults = 13.2 million Data: Analysis of the March 2008 Current Population Survey by S. Glied and B. Mahato of Columbia University for The Commonwealth Fund. Source: J. L. Kriss, S. R. Collins, B. Mahato, E. Gould, and C. Schoen, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, 2009 Update (New York: The Commonwealth Fund, forthcoming). These problems arise in part because young the poverty level would be eligible for Medicaid or adults do not fare well in our predominantly employ- CHIP, and those with incomes up to 200 percent of ment-based insurance system, as they often hold the poverty level would be eligible for premium assis- temporary positions or low-wage jobs that do not tance that caps premiums at no more than 5 percent include benefits. Moreover, transitions in employ- of income. A portable public health insurance plan ment during the early working years can translate within a national health insurance exchange would into time spent without coverage or waiting periods provide a continuous source of coverage for young before receiving coverage. Commonwealth Fund adults who make frequent job changes. research shows that gaps in coverage have important health and economic consequences for young adults Women Face Financial Burdens of Health and their families. Compared with those who have Care Expenses coverage all year, those spending at least part of the Recent work by the Commonwealth Fund shows year without coverage are more likely to experience that women face particular problems in securing barriers to care and more likely to report problems affordable health coverage and care.46 Steep rises in related to medical bills and debt.45 the cost of private health insurance have led to The policy framework put forth in the Path declining rates of coverage for working-age women report would extend affordable health coverage to the (ages 25 to 64) over the past 25 years.47 Compared 13 million young adults who lack insurance coverage with men, women are less likely to have access to and the millions more who undergo transitions dur- their own employer-sponsored insurance and more ing their early working years. Young adults could likely to purchase coverage in the individual market, remain covered under their parents’ policies until age which is more expensive than the group market. 26. Young adults with income up to 150 percent of Women also are more likely than men to have high 13 Exhibit 12. Percent of Income Spent on Family Out-of-Pocket Costs and Premiums Percent of adults ages 19–64 who are privately insured* >5% of income spent on out-of-pocket expenses 80 >10% of income spent on out-of-pocket expenses 60 48 50 47 40 34 32 29 20 0 Total Men Women * Employer-sponsored or individual insurance. Source: S. D. Rustgi, M. M. Doty, and S. R. Collins, Women at Risk: Why Many Women Are Forgoing Needed Health Care (New York: The Commonwealth Fund, May 2009). out-of-pocket costs as a share of income, avoid gender, a practice by which insurers charge women needed care because of cost, and have medical bill more than men on the basis of larger expected claims and debt problems (Exhibits 12 and 13). costs. A recent study found that many differentials Women face many obstacles when attempting to were arbitrary and not “justified by actuarial statis- secure coverage on the individual market. Thirty- tics.”48 Meanwhile, underwriting by health status and eight states do not prohibit or limit underwriting by age disproportionately affects women, who are more Exhibit 13. Women Are More Likely to Have Access Problems and Medical Bill Problems in Past Year, 2007 Percent of adults ages 19–64 reporting the following problems in past year 80 Men Women 60 52 45 39 40 36 20 0 Any of the four access problems* Any medical bill problem or outstanding debt** * Includes those individuals who did not fill a prescription because of cost, did not see a specialist when needed, skipped a medical test, treatment, or follow-up, or had a medical problem but did not see a doctor or go to a clinic. ** Includes those individuals not able to pay medical bills, having a bill sent to a collection agency when they were unable to pay it, changing way to life to pay medical bills, and having medical bills or medical debt being paid off over time. Source: S. D. Rustgi, M. M. Doty, and S. R. Collins, Women at Risk: Why Many Women Are Forgoing Needed Health Care (New York: The Commonwealth Fund, May 2009). 14 likely than men to need health care services through- of uninsured older adults and nearly a third (32%) of out their lifetimes and have chronic conditions those with individual coverage reported at least one requiring ongoing treatment. Finally, older women of these problems. More than one-third (35%) had a are more likely than older men to turn to the individ- problem paying their medical bills in the last 12 ual market after their spouses qualify for Medicare. months or were paying off medical debt they had The Path framework would limit health insur- accrued over the last three years (Exhibit 14). Those ance rating by gender, age, and health status, helping who were uninsured or purchased coverage on the make individual and group coverage more affordable individual market reported such problems at the for working-age women. Given their lower incomes highest rates. relative to men, women would disproportionately Given the relatively large proportions of older benefit from provisions that provide premium assis- Americans who report problems in accessing care and tance based on income. Under the framework, those paying medical bills, it is not surprising that nearly with incomes up to 150 percent of the poverty level three-fourths (73%) said they would be very or would be eligible for Medicaid and those with somewhat interested in receiving Medicare before age incomes below 200 percent of the poverty level 65. Support for this is particularly high among the would be eligible for premium assistance that caps uninsured (94%) and those with individual coverage the proportion of premiums paid by individuals at (84%), as well as those with very low incomes 5 percent of income. (86%). Commonwealth Fund–supported work sug- gests that in addition to being popular, this would be Older Adults and Early Retirees Face High Costs sound public policy: increasing health coverage Older adults seeking health insurance coverage typi- among older adults may not only improve health cally face prohibitively high premiums, large deduct- outcomes but also reduce future health care use and ibles, and troubling exclusions. Such problems are Medicare expenditures by providing recommended particularly prevalent among those without access to preventive care and lowering hospital admissions.50 a large group plan. A 2005 Commonwealth Fund Under the Path framework, insurance plans survey of older adults showed that more than half of could no longer turn people away or charge exorbi- respondents who secured coverage on the individual tant premiums and deductibles because people have market spent $3,600 or more annually on their an existing medical condition or are considered to be health insurance premiums and a quarter spent at high risk for developing one. Nor would individu- $6,000 or more.49 Meanwhile, 42 percent of older als with health conditions be charged higher premi- adults with individual coverage had deductibles ums than healthy people. Providing a public health higher than $1,000. insurance plan option with community-rated premi- Twenty-four percent of the near-elderly (ages 50 ums using broad age bands would give older to 70) failed to get health care services because of Americans access to coverage and care that enables cost, including not filling a prescription, not seeing a them to lead longer, healthier lives. It also would doctor or specialist when needed, or skipping a med- lower costs to the Medicare program in the long run. ical test or follow-up treatment. Fifty-seven percent 15 Exhibit 14. More Than One-Third of Older Adults Report Medical Bill Problems Percent of adults ages 50–70 with any medical bill problems or outstanding medical debt* 80 60 54 39 40 35 33 35 30 20 0 Total, Total insured Medicare Employer Individual Uninsured ages 50�70 * Problems paying/not able to pay medical bills, contacted by a collection agency for medical bills, had to change way of life to pay bills, or has medical debt being paid off over time. Source: S. R. Collins, K. Davis, C. Schoen, M. M. Doty, S. K. H. How, and A. L. Holmgren, Will You Still Need Me? The Health and Financial Security of Older Americans (New York: The Commonwealth Fund, June 2005). Two Million Disabled Individuals Wait Two Years would benefit from the premium assistance available for Medicare to Medicare beneficiaries under the Path framework. Newly disabled adults face innumerable challenges, not the least of which is securing affordable health Forty Million Medicare Beneficiaries Face insurance coverage. After waiting five months to High Premiums begin receiving cash benefits from the Social Security The Medicare program is working for more than 40 Disability Insurance (SSDI) program, such adults million elderly and disabled adults across the coun- must wait an additional two years to begin receiving try. Compared with those under age 65 with either Medicare benefits. Even after qualifying for coverage, public or private health coverage, Medicare beneficia- the disabled Medicare population faces a daunting ries over age 65 report better access to health care combination of low income, poor health status, services and superior financial protection from burden- heavy prescription use, and high medication bills.51 some medical bills (Exhibit 16).54 Such beneficiaries are A recent Commonwealth Fund–supported study less likely to go without needed care because of costs found that inability to get needed care is a serious and less likely to report access problems related to cost. problem for those caught in the waiting period.52 Those under age 65 with individual and employer The Path framework would end the two-year waiting coverage are more likely than Medicare beneficiaries period for the disabled, benefiting over 1.8 million over age 65 to not visit a doctor when sick; not fill a people, including 20 percent (or approximately prescription; skip a medical test, treatment, or fol- 350,000) who are uninsured at a time that is particu- low-up visit recommended by a doctor; and not see a larly critical for treatment and rehabilitation (Exhibit specialist when a doctor thought it was needed. 15).53 Many disabled adults have low incomes and 16 Exhibit 15. Sick, Disabled, and Waiting for Medicare: Source of Insurance During the Long Wait 13–24 mo. 1–12 mo. 1–12 mo. 13–24 mo. 25–36 mo. before before after after after SSDI SSDI SSDI SSDI SSDI Uninsured (%) 21 23 23 17 4 Private – own employer (%) 41 37 26 21 16 Private – family member 37 33 30 35 31 employer (%) Medicaid (%) 7 8 17 21 29 Medicare (%) (respondent) 3 2 4 11 61 Source: G. Livermore, D. Stapleton, and H. Claypool, Health Insurance and Health Care Access Before and After SSDI Entry (New York: The Commonwealth Fund, May 2009). Medicare’s cost-sharing, however, can be a deter- 2025. Few older adults entering retirement have rent to care for lower-income beneficiaries or those substantial savings on which to draw to meet without supplemental coverage.55 Meanwhile, elderly these expenses.57 beneficiaries spend an average of 22 percent of their To strengthen the program for the future, the income on premiums and out-of-pocket health care Path framework would improve financial protection costs.56 This is projected to grow to 30 percent by for Medicare beneficiaries. Premium caps of 5 percent Exhibit 16. Access and Bill Problems for Elderly Medicare Beneficiaries and Nonelderly Adults Covered by Employer-Based Insurance, 2001–2007 60 Employer-based coverage, 19�64 45 Medicare beneficiary, 65+ 40 35 33 28 20 18* 12* 13* 14* 0 2001 2007 2001 2007 Any access problema Any bill problemb Note: * Differences from employer-based insurance statistically significant, p < .001, after adjusting for health status, poverty, and prescription drug coverage. a Any access problem includes: did not fill prescription, get needed specialist care, skipped recommended test or follow-up, had medical problems but did not visit doctor. b Any medical bill problem includes: not able to pay bills, contacted by a collection agency for any medical bill, or had to change way of life significantly because of medical bills. To make 2001 and 2007 data comparable, any bill problem in 2007 includes being contacted by a collection agency about a medical bill regardless if it was for a billing error or unpaid bill. Source: K. Davis, S. Guterman, M. M. Doty, and K. Stremikis, “Meeting Enrollees’ Needs: How Do Medicare and Employer Coverage Stack Up?” Health Affairs Web Exclusive, May 12, 2009:w521–w532. 17 of income for low-income beneficiaries and 10 percent The requirement for everyone to obtain health of income for higher-income beneficiaries would provide insurance and the standards on covered benefits financial protection to elderly and disabled individuals. would ensure that everyone has affordable, compre- hensive coverage. It would assist 116 million working- age adults who are underinsured or uninsured at Improved Coverage and Affordability for All some point during the year, face problems obtaining The Path framework offers a comprehensive, inte- needed care, or have problems paying medical bills or grated strategy to ensure health coverage for all and medical debt. The requirement to have health cover- eliminate the financial burdens that now undermine age would be coupled with shared financial responsi- economic security for U.S. families. The creation of a bility among individuals, employers, and govern- national health insurance exchange with an array of ment. Under the Path framework, employers would competing private plans and a public health insur- have to pay at least 75 percent of employee premi- ance plan meeting standards for eligibility and bene- ums or contribute to a health insurance trust fund fits would be key to its success. and the federal government would provide premium Many sources of waste in our current insurance assistance guaranteeing that no one with income system would be eliminated. For example, rules below twice the poverty level would pay more than requiring insurers to cover everyone regardless of 5 percent of their income for a standard benchmark health status would eliminate the cost of medical plan. Those with higher incomes would pay no more exams and underwriting to ascertain health risk. than 10 percent of their income for such a plan. Reduced churning would lower the administrative The savings from insurance, payment, and sys- costs associated with disenrollment and reenrollment. tem reforms would be shared with employers and Enrollment through the national health insurance households. Under the Path framework, employers exchange’s Web-based system would reduce the need would save $231 billion over the period 2010– for brokers and brokers’ fees. 2020.58 By 2020, the average household would save Requiring everyone to have health insurance $2,314 (Exhibit 18). Slowing the growth in health would broaden the risk pool, incorporating many care outlays from 6.7 percent annually to 5.5 percent relatively healthy uninsured individuals. Paying phy- annually—while seemingly a modest target—would sicians, hospitals, and health systems through innova- result in significant savings to all health care payers tive methods that reward better health outcomes and and a total cumulative savings over 2010–2020 of provide incentives to avoid complications requiring $3 trillion (Exhibit 19). While the federal govern- hospitalization or emergency room use would further ment would need to make upfront investments in an lower costs. The combination of savings from reduced improved coverage and care system, the benefits and health care utilization, prices, and administrative savings would accrue over time to all those who cur- costs would be shared with families and employers. rently help finance the health system. Premiums would be an estimated 20 percent to 30 percent lower than current premiums in the indi- vidual and small business markets (Exhibit 17). 18 Exhibit 17. Estimated Premiums for New Public Plan Compared with Average Current Premiums, Individual/Small Employer Private Market, 2010 Average annual premium for equivalent benefits at community rate* $15,000 Public plan Private plans outside exchange, small firms Public plan premiums at least $10,800 20% lower than traditional $10,000 $8,988 fee-for-service insurance $5,000 $4,164 $2,904 $0 Single Family * Benefits used for modeling include full scope of acute care medical benefits; $250 individual/$500 family deductible; 10% coinsurance for physician service; 25% coinsurance and no deductible for prescription drugs; reduced for high-value medications; full coverage checkups/preventive care. $5,000 individual/$7,000 family out-of-pocket limit. Note: Premiums include administrative load. Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). Exhibit 18. Average Annual Savings per Family Under Path Reforms, 2020 Savings in health care spending compared with projected trends $3,500 $2,961 $3,000 $2,559 $2,612 $2,624 $2,426 $2,500 $2,314 $2,103 $2,202 $2,000 $1,857 $1,547 $1,500 $1,000 $500 $0 All <10 10–20 20–30 30–40 40–50 50–75 75– 100– 150+ 100 150 Family income ($ thousands) Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). 19 Putting People First: Making Health Reform being able to afford care; it requires having a patient- Work for Individuals and Families centered medical home that ensures access to care Given the widespread problems documented here, it and information 24 hours a day, seven days a week. is not surprising that half of U.S. adults think the There are also problems in the coordination of health system needs fundamental change, while care. Nearly half (47%) of adults report having expe- another 32 percent believe it needs to be rebuilt rienced some type of care coordination problem, completely.59 It is a system that is not working for with patients requiring care from multiple physicians people. The problems go beyond coverage and more likely to experience such problems. One-fourth affordability to the organization and delivery of care. (25%) of adults report not getting test results or hav- Health reform not only must ensure affordable cover- ing to call repeatedly for results. One-fifth (19%) age for all but also improve the accessibility, coordi- report not having test results available at the time of nation, and quality of care. a scheduled appointment, and one-fifth (21%) report Nearly three-fourths (73%) of Americans say they that their doctors failed to provide important infor- experience difficulty accessing care. Thirty percent of mation or test results to other doctors and nurses adults experience problems getting an appointment involved in their care. Breakdowns in the flow of with their doctor on the same or next day. Forty-one information between primary care physicians and percent report problems getting advice by phone specialists are especially common. from their physician during office hours. Sixty per- The health system is not designed to be conve- cent experience problems getting care on nights, nient for patients. Americans spend considerable weekends, and holidays without having to go to the time navigating a complex insurance system and a emergency room. Access to care means more than fragmented care delivery system. Nearly one of three Exhibit 19. Total National Health Expenditures (NHE), 2009–2020 Current Projection and Alternative Scenarios NHE in trillions $6 Current projection (6.7% annual growth) Path proposals (5.5% annual growth) 5.2 Constant (2009) proportion of GDP (4.7% annual growth) $5 4.6 $4 4.2 $3 2.6 $2 Cumulative reduction in NHE through 2020: $3 trillion $1 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 Note: GDP = Gross Domestic Product. Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009). 20 Exhibit 20. Potential Impact on Patients if the United States Improved National Performance to Benchmark Levels Current 2020 Impact on national average target* number of people Percent of adults (ages 19–64) insured, not underinsured 58% 99% 73 million increase Percent of adults (age 18 and older) receiving 50% 80% 68 million increase all recommended preventive care Percent of adults (ages 19–64) with an accessible primary care provider 65% 85% 37 million increase Percent of children (ages 0–17) with a medical home 46% 60% 10 million increase Percent of adult hospital stays (age 18 and older) in which 58% 70% 5 million increase hospital staff always explained medicines and side effects Percent of Medicare beneficiaries (age 65 and older) 18% 14% 180,000 decrease readmitted to hospital within 30 days Admissions to hospital for diabetes complications, per 100,000 adults 240 126 250,000 decrease (age 18 and older) Pediatric admissions to hospital for asthma, per 100,000 children 156 49 70,000 decrease (ages 2–17) Medicare admissions to hospital for ambulatory care–sensitive 700 465 640,000 decrease conditions, per 100,000 beneficiaries (age 65 and older) Deaths before age 75 from conditions amenable to health care, 110 69 100,000 decrease per 100,000 population Percent of primary care doctors with electronic medical records 28% 98% 180,000 increase * Targets are benchmarks of top 10% performance within the U.S. or top countries. Source: Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008 (New York: The Commonwealth Fund, July 2008). (28%) patients reports serious problems in terms of There is a better way. A patient-centered health the time spent on paperwork or disputes related to system would ensure that people get the care they medical bills and health insurance in the past two need, when they need it. The Path framework years. For those in fair or poor health, two of five encourages all individuals to enroll in a patient- (40%) report such problems. centered medical home, or a physician practice that Exhibit 21. A Health System That Works for People � Extends affordable health insurance coverage to everyone � Prohibits exclusion and risk-rating based on health status or gender � Covers preventive care � Ensures that premiums are affordable and medical bills are manageable � Allows individuals to keep the coverage they have while providing more insurance plan choices for all � Eliminates the need to forgo coverage or switch plans as job or family circumstances change � Gives every patient the option to enroll in a medical home, ensuring that they receive all recommended preventive care, help controlling chronic conditions, and assistance navigating the health care system � Enables patients to get care when it is needed, including on nights and weekends, and to get questions answered promptly by doctors or nurses by phone or e-mail � Reduces the hassle of filing insurance claims and getting bills paid � Makes health information such as medical records and test results available to patients on a timely basis 21 is held accountable for ensuring that care is accessible complications. Keeping people healthy and out of when needed, reminding patients about preventive hospitals would be a major benefit to individuals and services, maintaining a registry of individuals with families, as well as a significant source of savings to chronic conditions, and working with patients to the health system. control their conditions and prevent avoidable hospi- To ensure that people get the right care, at the talizations. Patient-centered medical homes would right time, and in the right way—and to avoid waste use information systems that, with patients’ permis- and duplication—it will be necessary to invest in sion, make medical records easily accessible to all of health information technologies. By 2020, 98 percent the doctors and nurses involved in an individual’s of physicians should have electronic information care. They would take responsibility for coordinating systems that meet national standards, up from only care, helping patients get appointments with special- about one-fourth of primary care physicians today. ists and providing information and follow-up care Achieving a high performance health system that after specialist consultations or hospitalizations. Most provides benefits commensurate with our investment important, patient-centered medical homes would be in health care requires multipronged strategies. By rewarded for achieving excellent results—ensuring extending affordable health insurance to all, aligning that people are satisfied with their care, receive rec- financial incentives to enhance value and achieve ommended preventive services, have their chronic savings, organizing the health care system around the conditions controlled, and avoid use of emergency patient to ensure that care is accessible and coordi- rooms and hospitalizations when possible.60 nated, meeting and raising benchmarks for high- The most important outcome of health system quality, efficient care, and ensuring accountable reform that puts people first would be the health national leadership and public–private collaboration, benefits to the American people. If the achievable the United States could build on examples of excel- targets included in the Path framework are reached, lence from around the nation, and provide what by the year 2020 an estimated 100,000 lives per year everyone wants: the best health care in the world and would be saved, 68 million more adults would be the best health outcomes. up-to-date with preventive care, and 37 million more Such a strategy enjoys widespread support among adults and 10 million more children would receive the public across income groups, geographic regions, care from accessible physician practices accountable and political affiliation. About nine of 10 Americans for ensuring they receive all essential care (Exhibit believe that health reform should improve the quality 20). Avoidable hospitalizations would decline each of care, ensure that care and insurance are affordable year, including 640,000 fewer Medicare beneficiaries to all, and reduce the numbers of uninsured.61 The hospitalized for ambulatory care–sensitive conditions political challenges to doing so are formidable, but and 180,000 fewer Medicare beneficiaries readmitted the expectations for our political leaders are also within 30 days following their initial hospital dis- high. Designing health system reform that puts peo- charge. There would be 70,000 fewer children hospi- ple’s interests first should go a long way to forging talized with asthma complications each year, and consensus and enacting needed changes during this 250,000 fewer adults hospitalized with diabetes historic window of opportunity. 22 11 Notes C. J. Bradley et al., Differences in Breast Cancer Diagnosis and Treatment: Experiences of Insured and 1 The Commonwealth Fund Commission on a High Uninsured Patients in a Safety Net Setting, NBER Performance Health System, The Path to a High Working Paper No. 13875, March 2008; C. J. Bradley, Performance U.S. Health System: A 2020 Vision and the D. Neumark, L. M. Shickle et al., “Differences in Policies to Pave the Way (New York: The Breast Cancer Diagnosis and Treatment: Experiences of Commonwealth Fund, Feb. 2009). Insured and Uninsured Women in a Safety-Net 2 Setting,” Inquiry, Fall 2008 45(3):323–39. S. R. Collins, J. L. Kriss, M. M. Doty, and S. D. 12 Rustgi, Losing Ground: How the Loss of Adequate Health A. Gawande, “Getting There from Here: How Should Insurance Is Burdening Working Families—Findings from Obama Reform Health Care,” The New Yorker, Jan. the Commonwealth Fund Biennial Health Insurance 26, 2009. Accessed at: http://www.newyorker.com/ Surveys, 2001–2007 (New York: The Commonwealth reporting/2009/01/26/090126fa_fact_gawande. Fund, Aug. 2008). 13 Congressional Budget Office, CBO’s Preliminary 3 C. DeNavas-Walt et al., Income, Poverty, and Health Estimate of Changes in SCHIP and Medicaid Enrollment Insurance Coverage in the United States: 2007 in Fiscal Year 2013 of Children Under the Children’s (Washington, D.C.: U.S. Census Bureau, Aug. 2008); Health Insurance Program Reauthorization Act of 2009 U.S. Census Bureau, Current Population Survey, (Washington, D.C.: Congressional Budget Office, Annual Social and Economic Supplement, 2001 and Jan. 2009). 2006; Projections to 2020 based on estimates by The 14 Federal subsidies are offered for as long as nine months Lewin Group. for workers who were involuntarily terminated from 4 Analysis of the 2006 Medical Expenditure Panel 09/01/2008–12/31/2009 and whose incomes do not Survey by B. Mahato of Columbia University for exceed $125,000 for individuals and $250,000 for The Commonwealth Fund. families. Public Law 111-5, American Recovery and 5 Reinvestment Act of 2009, Feb. 17, 2009. Collins et al., Losing Ground, 2008. 15 6 M. Broaddus et al., Measures in House Recovery J. Holahan and A. B. Garrett, Rising Unemployment, Package—But Not Senate Package—Would Help Medicaid, and the Uninsured, Publication No. 7850 Unemployed Parents Receive Health Coverage (Washington, D.C.: Kaiser Commission on Medicaid (Washington, D.C.: Center on Budget and Policy and the Uninsured, Jan. 2009). Priorities, Feb. 2009). 7 Consumers Union, Consumer Reports Health Finishes 16 M. M. Doty, S. D. Rustgi, C. Schoen, and S. R. Cross-Country “Cover America Tour,” Sept. 23, 2008. Collins, Maintaining Health Insurance During a Accessed at: http://www.consumersunion.org/pub/ Recession: Likely COBRA Eligibility (New York: The core_health_care/006175.html. Commonwealth Fund, Jan. 2009). 8 Institute of Medicine, America’s Uninsured Crisis: 17 Schoen et al., “How Many Are Underinsured?” 2008. Consequences for Health and Health Care (Washington, 18 D.C.: National Academies Press, Feb. 2009). Ibid. 9 19 C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, K. Davis, Shifting Health Care Financial Risk to “How Many Are Underinsured? Trends Among U.S. Families Is Not a Sound Strategy: The Changes Needed to Adults, 2003 and 2007,” Health Affairs Web Exclusive, Ensure Americans’ Health Security, Invited Testimony, June 10, 2008:w298–w309. House Committee on Ways and Means, Subcommittee 10 on Health, Hearing on “Health of the Private Health Collins et al., Losing Ground, 2008. Insurance Market” (New York: The Commonwealth Fund, Sept. 2008). 23 20 29 C. Schoen, Insurance Design Matters: Underinsured American Medical Association, Competition in Health Trends, Health and Financial Risks, and Principles for Insurance: A Comprehensive Study of U.S. Markets, 2008 Reform, Invited Testimony, U.S. Senate Health, Update (Chicago: AMA, 2008); J. Robinson, Education, Labor and Pensions Committee, Hearing “Consolidation and the Transformation of Competition on “Addressing the Underinsured in National Health in Health Insurance,” Health Affairs, Nov./Dec. 2004 Reform” (New York: The Commonwealth Fund: 23(6):11–24,; D. McCarthy, R. Nuzum, S. Mika, Feb. 2009). J. Wrenn, and M. Wakefield, The North Dakota 21 Experience: Achieving High-Performance Health Care G. Claxton, J. Gabel, B. DiJulio et al., “Health Through Rural Innovation and Cooperation (New York: Benefits in 2008: Premiums Moderately Higher, While The Commonwealth Fund, May 2008). Enrollment in Consumer-Directed Plans Rises in Small 30 Firms,” Health Affairs Web Exclusive, Sept. 24, The Kaiser Family Foundation/Health Research and 2008:w492–w502. Educational Trust, Employer Health Benefits, 2000 and 22 2008 Annual Surveys. M. M. Doty, S. R. Collins, S. D. Rustgi, and J. L. 31 Kriss, Seeing Red: The Growing Burden of Medical Bills White House Office of Health Reform, Helping the and Debt Faced by U.S. Families (New York: The Bottom Line: Health Reform and Small Business Commonwealth Fund, Aug. 2008). (Washington, D.C.: Executive Office of the President, 23 April 2009). C. Schoen, R. Osborn, M. M. Doty, M. Bishop, 32 J. Peugh, and N. Murukutla, “Toward Higher- S. R. Collins, C. White, and J. L. Kriss, Whither Performance Health Systems: Adults’ Health Care Employer-Based Health Insurance? The Current and Experiences in Seven Countries, 2007,” Health Affairs Future Role of U.S. Companies in the Provision and Web Exclusive, Oct. 31, 2007:w717–w734. The 2008 Financing of Health Insurance (New York: The international survey of sicker adults found similarly Commonwealth Fund, Sept. 2007). high rates—31 percent changed plans in the past three 33 years and 11 percent changed plans more than once. J. Gabel. R. McDevitt, L. Gandolfo et al., “Generosity Churning on and off of coverage was high across and Adjusted Premiums in Job-Based Insurance: income groups. Hawaii Is Up, Wyoming Is Down,” Health Affairs, May/June 2006 25(3):832–43. 24 P. F. Short, D. R. Graefe, and C. Schoen, Churn, 34 Churn, Churn: How Instability of Health Insurance S. R. Collins, J. L. Kriss, K. Davis, M. M. Doty, and Shapes America’s Uninsured Problem (New York: The A. L. Holmgren, Squeezed: Why Rising Exposure to Commonwealth Fund, Nov. 2003). Health Care Costs Threatens the Health and Financial Well-Being of American Families (New York: The 25 K. Klein, S. A. Glied, and D. Ferry, Entrances and Commonwealth Fund, Sept. 2006). Exits: Health Insurance Churning, 1998–2000 (New 35 York: The Commonwealth Fund, Sept. 2005). N. C. Turnbull and N. M. Kane, Insuring the Healthy or Insuring the Sick? The Dilemma or Regulating the 26 A. B. Bindman, A. Chattopadhyay, and G. M. Individual Health Insurance Market (New York: The Auerback, “Interruptions in Medicaid Coverage and Commonwealth Fund, Feb. 2005). Risk for Hospitalization for Ambulatory Care– Sensitive Conditions,” Annals of Internal Medicine, Dec. 2008 149(12):854–60. 27 Ibid. 28 The Kaiser Family Foundation and the Health Research and Educational Trust, Survey of Employer- Sponsored Health Benefits (Washington, D.C.: Kaiser/ HRET, Sept. 2008). 24 36 44 D. Bernard and J. Banthin, Premiums in the Individual S. R. Collins, Rising Numbers of Uninsured Young Insurance Market for Policyholders Under Age 65: 2002 Adults: Causes, Consequences, and New Policies, Invited and 2005, Medical Expenditure Panel Survey Statistical Testimony, Subcommittee on Federal Workforce, Brief #202, Agency for Healthcare Research and Postal Service, and the District of Columbia Quality, April 2008; M. A. Hall, “The Geography of Committee on Oversight and Government Reform, Health Insurance Regulation,” Health Affairs, March/ United States House of Representatives Hearing on April 2000 19(2):173–84; M. V. Pauly and A. M. “Providing Health Insurance to Young Adults Enrolled Percy, “Cost and Performance: A Comparison of the as Dependents in FEHBP” (New York: The Individual and Group Health Insurance Markets,” Commonwealth Fund, April 2008). Journal of Health Policy, Politics and Law, Feb. 2000 45 25(1):9–26. Ibid. 46 37 Bernard and Banthin, Premiums in the Individual S. D. Rustgi, M. M. Doty, and S. R. Collins, Women Insurance Market, 2008. at Risk: Why Many Women Are Forgoing Needed Health Care (New York: The Commonwealth Fund, May 38 K. Swartz, Reinsuring Health: Why More Middle Class 2009); E. M. Patchias and J. Waxman, Women and People Are Uninsured and What Government Can Do Health Coverage: The Affordability Gap (New York: (New York: Russell Sage Foundation, 2006). The Commonwealth Fund, April 2007). 39 47 Kaiser Family Foundation, “Income Eligibility S. Glied et al., “Women’s Health Insurance Coverage Levels for Children’s Separate SCHIP Programs, 2006” 1980–2005,” Women’s Health Issues, 2008 18:7–16. and “Income Eligibility for Parents Applying for 48 Medicaid, 2006,” available online at National Women’s Law Center, Nowhere to Turn: How http://www.statehealthfactsonline.org. the Individual Health Insurance Market Fails Women (Washington, D.C.: National Women’s Law Center, 40 Bindman et al., “Interruptions in Medicaid Coverage,” Sept. 2008). 2008. 49 S. R. Collins, K. Davis, C. Schoen, M. M. Doty, S. K. 41 P. J. Cunningham and J. Hadley, “Effects of Changes H. How, and A. L. Holmgren, Will You Still Need Me? in Incomes and Practice Circumstances on Physicians’ The Health and Financial Security of Older Americans Decisions to Treat Charity and Medicaid Patients,” (New York: The Commonwealth Fund, June 2005). Milbank Quarterly, 2008 86(1):91–123; P. J. 50 Cunningham and L. M. Nichols, “The Effects of J. M. McWilliams, E. Meara, A. M. Zaslavsky et al., Medicaid Reimbursement on the Access to Care of “Use of Health Services by Previously Uninsured Medicaid Enrollees: A Community Perspective,” Medicare Beneficiaries,” New England Journal of Medical Care Research and Review, 2005 62(6):676–96. Medicine, July 12, 2007 357(2):143–53. 51 42 J. L. Kriss, S. R. Collins, B. Mahato, E. Gould, and B. Briesacher, B. Stuart, J. Doshi et al., Medicare’s C. Schoen, Rite of Passage? Why Young Adults Become Disabled Beneficiaries: The Forgotten Population in the Uninsured and How New Policies Can Help, 2009 Debate Over Drug Benefits (New York: The Update (New York: The Commonwealth Fund, forth- Commonwealth Fund, Sept. 2002). coming). 52 G. Livermore, D. Stapleton, and H. Claypool, Health 43 Ibid. Insurance and Health Care Access Before and After SSDI Entry (New York: The Commonwealth Fund, May 2009). 53 S. Guterman and H. Drake, The Long Wait: The Impact of Delaying Medicare Coverage for People with Disabilities (New York: The Commonwealth Fund, May 2009). 25 54 K. Davis, S. Guterman, M. M. Doty, and K. Stremikis, “Meeting Enrollees’ Needs: How Do Medicare and Employer Coverage Stack Up?” Health Affairs Web Exclusive, May 12, 2009:w521–w532. 55 T. Rice and K. Y. Matsuoka, “The Impact of Cost- Sharing on Appropriate Utilization and Health Status: A Review of the Literature on Seniors,” Medical Care Research and Review, Dec. 2004 61(4):415–52. 56 S. Maxwell, M. Storeygard, and M. Moon, Modernizing Medicare Cost-Sharing: Policy Options and Impacts on Beneficiary and Program Expenditures (New York: The Commonwealth Fund, Nov. 2002). 57 S. R. Collins, M. M. Doty, K. Davis, C. Schoen, A. L. Holmgren, and A. Ho, The Affordability Crisis in U.S. Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, March 2004). 58 Commonwealth Fund Commission, Path to a High Performance U.S. Health System, 2009. 59 S. K. H. How, A. Shih, J. Lau, and C. Schoen, Public Views on U.S. Health System Organization: A Call for New Directions (New York: The Commonwealth Fund, Aug. 2008). 60 S. Guterman, K. Davis, S. C. Schoenbaum, and A. Shih, “Using Medicare Payment Policy to Transform the Health System: A Framework for Improving Performance,” Health Affairs Web Exclusive, Jan. 27, 2009:w238–w250. 61 How et al., Public Views, 2008. 26 Further Reading Publications listed below can be found on The Commonwealth Fund’s Web site at www.commonwealthfund.org. The Long Wait: The Impact of Delaying Medicare Coverage for People with Disabilities (May 2009). Stuart Guterman and Heather Drake. Health Insurance and Health Care Access Before and After SSDI Entry (May 2009). Gina Livermore, David Stapleton, and Henry Claypool. “Meeting Enrollees’ Needs: How Do Medicare and Employer Coverage Stack Up?” Karen Davis, Stuart Guterman, and Kristof Stremikis. Health Affairs Web Exclusive, May 12, 2009:w521–w532. Women at Risk: Why Many Women Are Forgoing Needed Health Care (May 2009). Sheila D. Rustgi, Michelle M. Doty, and Sara R. Collins. The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (Feb. 2009). The Commonwealth Fund Commission on a High Performance Health System. Maintaining Health Insurance During a Recession: Likely COBRA Eligibility (Jan. 2009). Michelle M. Doty, Sheila D. Rustgi, Cathy Schoen, and Sara R. Collins. “Using Medicare Payment Policy to Transform the Health System: A Framework for Improving Performance.” Stuart Guterman, Karen Davis, Stephen C. Schoenbaum, and Anthony Shih Health Affairs Web Exclusive, Jan. 27, 2009: w238–w250. “Interruptions in Medicaid Coverage and Risk for Hospitalization for Ambulatory Care–Sensitive Conditions.” Andrew B. Bindman, Arpita Chattopadhyay, and Glenna M. Auerback. Annals of Internal Medicine, Dec. 2008 149(12):854–60. Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families—Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007 (Aug. 2008). Sara R. Collins, Jennifer L. Kriss, Michelle M. Doty, and Sheila D. Rustgi. Organizing the U.S. Health Care Delivery System for High Performance (Aug. 2008). Anthony Shih, Karen Davis, Stephen Schoenbaum, Anne Gauthier, Rachel Nuzum, and Douglas McCarthy. Public Views on U.S. Health System Organization: A Call for New Directions (Aug. 2008). Sabrina K. H. How, Anthony Shih, Jennifer Lau, and Cathy Schoen. Seeing Red: The Growing Burden of Medical Bills and Debt Faced by U.S. Families (Aug. 2008). Michelle M. Doty, Sara R. Collins, Sheila D. Rustgi, and Jennifer L. Kriss. Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2008 (July 2008). The Commonwealth Fund Commission on a High Performance Health System. “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007.” Cathy Schoen, Sara R. Collins, Jennifer L. Kriss, and Michelle M. Doty Health Affairs Web Exclusive, June 10, 2008:w298–w309. 27 The Building Blocks of Health Reform: Achieving Universal Coverage and Health System Savings (May 2008). Karen Davis, Cathy Schoen, and Sara R. Collins. The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation and Cooperation (May 2008). Douglas McCarthy, Rachel Nuzum, Stephanie Mika, Jennifer Wrenn, and Mary Wakefield. Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending (Dec. 2007). Cathy Schoen, Stuart Guterman, Anthony Shih, Jennifer Lau, Sophie Kasimow, Anne Gauthier, and Karen Davis. A High Performance Health System for the United States: An Ambitious Agenda for the Next President (Nov. 2007). The Commonwealth Fund Commission on a High Performance Health System. A Roadmap to Health Insurance for All: Principles for Reform (Oct. 2007). Sara R. Collins, Cathy Schoen, Karen Davis, Anne Gauthier, and Stephen C. Schoenbaum. “Toward Higher-Performance Health Systems: Adults’ Health Care Experiences in Seven Countries, 2007.” Cathy Schoen, Robin Osborn, Michelle M. Doty, Meghan Bishop, Jordon Peugh, and Nandita Murukutla. Health Affairs Web Exclusive, Oct. 31, 2007:w717–w734. Whither Employer-Based Health Insurance? The Current and Future Role of U.S. Companies in the Provision and Financing of Health Insurance (Sept. 2007). Sara R. Collins, Chapin White, and Jennifer L. Kriss. “Use of Health Services by Previously Uninsured Medicare Beneficiaries.” J. Michael McWilliams, Ellen Meara, Alan M. Zaslavsky et al. New England Journal of Medicine, July 12, 2007 357(2):143–53. Aiming Higher: Results from a State Scorecard on Health System Performance (June 2007). Joel C. Cantor, Cathy Schoen, Dina Belloff, Sabrina K. H. How, and Douglas McCarthy. Slowing the Growth of U.S. Health Care Expenditures: What Are the Options? (Jan. 2007). Karen Davis, Cathy Schoen, Stuart Guterman, Tony Shih, Stephen C. Schoenbaum, and Ilana Weinbaum. Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families (Sept. 2006). Sara R. Collins, Jennifer L. Kriss, Karen Davis, Michelle M. Doty, and Alyssa L. Holmgren. 28 One East 75 th Street New York, NY 10021-2692 Tel 212.606.3800 Fax 212.606.3500 www.commonwealthfund.org