ISSUE BRIEF JULY 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden Karen Davis Amber Willink Cathy Schoen Professor Emerita, Department of Assistant Scientist, Department of Senior Scholar in Residence Health Policy and Management Health Policy and Management New York Academy of Medicine Johns Hopkins Bloomberg School Johns Hopkins Bloomberg School of Public Health of Public Health ABSTRACT TOPLINES ISSUE: More Medicare beneficiaries are facing the costs of health care and The proportion of Medicare supplemental coverage in retirement without assistance from their former beneficiaries with supplemental employers. As a result, more Medicare beneficiaries, especially those with employer-sponsored insurance dropped from 38% to less than low to middle incomes, face financially burdensome premiums. 28% between 2010 and 2016, GOAL: With employers shouldering less of the cost of health care in old a decline that was particularly age, public policies will need to be developed to ensure an adequate safety marked for those with low and net of health insurance coverage for Medicare beneficiaries. This issue middle incomes. brief examines trends in supplemental health insurance coverage and implications for beneficiaries at different income levels. Medicare Advantage and Medicaid have expanded as METHODS: Profile trends in supplemental insurance coverage and sources of coverage, but many premiums of Medicare beneficiaries by income groups using the 2010 and beneficiaries are still exposed to 2016 Medicare Current Beneficiary Survey. high cost-sharing. KEY FINDINGS: The proportion of Medicare beneficiaries with supplemental employer-sponsored insurance (ESI) dropped between 2010 and 2016. The erosion of ESI was particularly marked for those with low and middle incomes. Beneficiaries not eligible for Medicaid face average annual premiums of more than $500 for Medicare Advantage coverage and four times that for Medigap coverage, on top of standard Medicare Part B annual premiums. CONCLUSION: Improving Medicare’s benefits would reduce the need for supplemental coverage and protect aging beneficiaries against the unpredictable cost of health care. How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 2 INTRODUCTION In this issue brief, we profile coverage trends for Medicare Medicare provides essential health insurance coverage beneficiaries between 2010 and 2016, looking at rates of for elderly and disabled beneficiaries, but the program’s employer-sponsored insurance (ESI), Medigap health benefit design can leave beneficiaries exposed to high insurance, and Medicare Advantage. Beneficiaries out-of-pocket costs. For 2019, the Part A deductible is sometimes report multiple sources of coverage during $1,364 per hospital episode; Part B has a $185 deductible the year, either because they have more than one type of plan in addition to Medicare or because they change plans with 20 percent coinsurance on covered services. There is during the year. no ceiling on out-of-pocket costs. As a result, 90 percent of Medicare beneficiaries obtain supplemental coverage to help pay Medicare’s high cost-sharing. FINDINGS In the past, large employers often provided supplemental Erosion in Employer-Sponsored Insurance for coverage for their retirees. However, because of economic Medicare Beneficiaries pressure on employers, fewer are now offering such Between 2010 and 2016, the proportion of Medicare benefits. Particularly for adults with limited incomes, the beneficiaries with ESI declined from 38 percent to 28 erosion of employer-sponsored retiree health insurance percent (Exhibit 1). Some beneficiaries are still working means that more Medicare beneficiaries are on their own and receive this coverage from their current employers, to obtain supplemental coverage to protect against high while others receive it as retiree health benefits from a out-of-pocket costs. former employer. As this coverage has eroded, risk-averse Approximately 18 million Medicare beneficiaries live beneficiaries have sought to obtain other sources of on annual incomes below 150 percent of the federal coverage to protect against unpredictable out-of-pocket poverty level — less than $18,000 a year for a single person costs. Medicaid provided supplemental coverage for 20 (see Appendix 1). Of those with incomes below the percent of beneficiaries in 2016, up from 17 percent in poverty level (i.e., less than $12,000, if single), two-thirds 2010. Enrollment in Medicare Advantage plans increased receive assistance with premiums and cost-sharing from from 20 percent to 25 percent, while Medigap coverage Medicaid; one-third of those with incomes between grew from 16 percent to 17 percent. poverty and 149 percent of poverty receive assistance The type of supplemental coverage varies markedly paying Medicare premiums. Nearly 40 percent of the near by income level. In the highest-income group of poor with incomes between poverty and 199 percent beneficiaries — incomes four times the poverty level or of poverty spend 20 percent or more of their income on greater ($48,000 or higher for a single adult) — slightly less premiums and health care each year. Prior research has than half (47%) had ESI as well as Medicare in 2016. This shown broad evidence of unmet care needs as well as was down from 63 percent in 2010 — a 25-percent drop in financial hardship.1 just six years (Exhibit 2). Beneficiaries with high incomes (i.e., four times the ESI is much less common among modest-income poverty level or higher, or $48,000, if single) are the most beneficiaries, and erosion of these benefits in this group likely to have coverage through retiree health plans from between 2010 and 2016 was more rapid. For beneficiaries former employers, or, if they are still in the workforce, with incomes between 150 percent and 199 percent of through current employer plans. Modest-income poverty, the proportion with ESI dropped from 31 percent beneficiaries with incomes between 150 percent and 399 to 19 percent — a decline of 39 percent. A small proportion percent of poverty ($18,000 to just under $48,000, if single) of poor and near-poor beneficiaries have ESI, which are caught in between. They typically purchase Medicare declined between 2010 and 2016. For those beneficiaries Advantage or Medigap private supplemental health with incomes below poverty, the proportion with ESI fell insurance to fill in for Medicare’s cost-sharing. from 7 percent to 6 percent (Exhibit 2). commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 3 Exhibit 1 Distribution of Insurance Coverage Among Medicare Beneficiaries, 2010 and 2016 of Insurance Coverage Among Medicare Beneficiaries, 2010 and 2016 Exhibit 1. Distribution Percent 2010 2016 38 28 25 20 20 17 16 17 10 10 Medicare only Medicaid Employer-sponsored Medicare Advantage Medigap insurance Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. Exhibit 2. Trends in Supplemental Coverage by Income, 2010–2016 Source: Karen Davis, Amber Willink, and Cathy Schoen, How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden (Commonwealth Fund, July 2019). 2010 Medicare Employer-sponsored Medicare Total only Medicaid insurance Advantage Medigap Coverage percent of each row Total 100% 9.83% 16.85% 38.00% 19.66% 15.66% Poverty group <100% FPL 14.33% 11.21% 65.22% 7.10% 10.95% 5.49% 100%–149% FPL 16.69% 15.07% 34.08% 14.90% 21.81% 14.14% 150%–199% FPL 13.72% 14.23% 8.04% 30.96% 26.58% 20.19% 200%–399% FPL 34.38% 7.83% 1.71% 49.46% 23.21% 17.79% 400%+ FPL 20.88% 5.09% 0.58% 63.43% 13.55% 17.36% 2016 Coverage percent of each row Total 100% 10.28% 19.93% 27.71% 25.09% 17.00% Poverty group <100% FPL 16.29% 9.92% 64.99% 5.76% 13.01% 6.32% 100%–149% FPL 14.73% 11.51% 41.86% 10.61% 23.98% 12.04% 150%–199% FPL 12.11% 15.67% 14.46% 18.76% 34.10% 17.01% 200%–399% FPL 27.25% 10.00% 4.44% 32.71% 30.98% 21.87% 400%+ FPL 29.62% 7.91% 0.73% 47.35% 23.17% 20.85% Note: FPL = federal poverty level. Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 4 Medicare Advantage Enrollment Is Higher Among seen beneficiaries with modest incomes (i.e., between Modest-Income Beneficiaries 150% and 399% of poverty) increasingly enrolling in MA The second-most-common form of protection against plans as employer coverage has eroded. Medicare cost-sharing is enrolling in Medicare Advantage MA enrollment is even more marked when we include (MA) plans. These are private managed care plans that people with multiple sources of coverage. ESI may enroll use restrictive provider networks or techniques like retirees in MA plans or provide financial assistance with prior authorization to control health care costs. MA MA premiums. Unduplicated counts of beneficiaries in is particularly attractive to beneficiaries with limited Exhibits 1 and 2 show such beneficiaries as covered by incomes. Twenty-five percent of Medicare beneficiaries ESI. Those with both Medicaid and MA — including, for enroll directly in MA plans (Appendix 1). In low- and example, those who switch coverage from MA to Medicaid middle-income groups, MA is more common than or the reverse in a given year — are counted as Medicaid Medigap. One-third (34%) of those with incomes between beneficiaries. 150 percent and 199 percent of poverty ($18,000 to just under $24,000) are enrolled in MA, as are 31 percent of Medicare beneficiaries enrolled in MA increased between those with incomes between 200 percent and 399 percent 2010 and 2016, including those in MA only, plus those with of poverty. Those with the highest incomes ($48,000 or both MA and ESI (Exhibit 3). In addition, a few Medicare more) are now, compared with six years ago, more likely beneficiaries report both MA and Medigap coverage. This to enroll in Medicare Advantage (23%) than to supplement is presumably people who switch from one to the other Medicare with Medigap coverage (21%). Over time we have over the course of the year. Exhibit 3 Medicare Advantage and Multiple Sources of Coverage, 2010 and 2016 Exhibit 3. Medicare Advantage and Multiple Sources of Coverage, 2010 and 2016 Percent 2010 2016 36 33 22 17 7 8 5 6 3 4 Total MA Medicaid + MA Employer-sponsored MA only Medigap + MA insurance + MA Note: MA = Medicare Advantage. Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. Note: MA = Medicare Advantage. Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. commonwealthfund.org Issue Brief, July 2019 Source: Karen Davis, Amber Willink, and Cathy Schoen, How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden (Commonwealth Fund, July 2019). How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 5 MEDICAID SAFETY NET HAS EXPANDED allowance for burial. Four states have higher income TO HELP OFFSET THE LOSS OF EMPLOYER- limits and 11 have higher asset limits than the federal SPONSORED INSURANCE minimums.5 Similarly, Medicare Part D’s Extra Help In 2016, 58 million people were covered by Medicare program helps pay for prescription drugs and premiums (Appendix 1).2 One-third (18 million people) had incomes for people with incomes up to 150 percent of poverty. below 150 percent of the federal poverty with, at best, limited assets to last their lifetimes. 3 For many, the PREMIUMS FOR SUPPLEMENTAL COVERAGE Medicare Part B premium, Part A hospital deductible, or a ARE EXPENSIVE 20 percent share of physician bills are simply unaffordable. Not everyone can afford to protect themselves against These people often go without care or accumulate debt. high potential medical bills, particularly as ESI continues For those with incomes near the poverty level (less than to shrink. Private coverage typically has 20 percent or $12,000, if single), the sum of the standard Part B annual higher administrative loading built into the premium. premium ($1,626), hospital deductible ($1,364), and The average annual premium for MA plans was $508 in medical deductible ($185) is more than 25 percent of their 2016 (Exhibit 4). Private Medigap coverage was even more income. costly, with average annual premiums of $2,161 in 2016 — Low-income provisions called Medicare Savings four times those of MA plans. These premiums come on Programs (MSPs) and Extra Help that pay for Medicare top of standard Part B annual premiums of $1,626 in 2019. premiums, cost-sharing, or Part D prescription drugs are For modest-income beneficiaries, premiums alone could limited, fragmented, and complex. Beneficiaries with make it difficult to pay bills for housing, food, utilities, and incomes below poverty may qualify for full Medicaid transportation, as well as uncovered medical services. to supplement Medicare but only if they have meager savings. In 25 states, they must have incomes levels lower than 75 percent of poverty.4 Medicaid coverage of Medicare beneficiaries increased Exhibit 4. Annual Premiums for Supplemental from 17 percent to 20 percent between 2010 and 2016. Coverage by Beneficiary Income and Type However, these existing provisions leave substantial gaps of Coverage, Not Including Medicare Part B in protection for Medicare’s low-income beneficiaries. Premiums, 2010 and 2016 One-third of people with incomes below poverty and more than half of those with incomes between 100 2010 2016 percent and 149 percent of poverty did not have Medicaid Total average premiums $963 $955 in 2016. <100% FPL $294 $422 100%–149% FPL $636 $673 Beneficiaries with incomes below 135 percent of poverty 150%–199% FPL $973 $809 who are not eligible for full Medicaid may qualify for help 200%–399% FPL $1,156 $1,042 with Medicare premiums and cost-sharing through MSPs. 400%+ FPL $1,361 $1,367 All states are required to provide MSPs through Medicaid, Medicare only $13 $252 with the federal government setting minimum income Medicaid $144 $362 and asset standards. Beneficiaries with incomes up to Employer-sponsored insurance $1,268 $1,306 Medicare Advantage $651 $508 poverty receive help paying for Medicare premiums and Medigap $2,095 $2,161 cost-sharing. Those with incomes between 100 percent and 135 percent of poverty receive help with premiums Notes: Total premium minus Medicare Part B. Many Medicare only beneficiaries report additional premium costs because of enrollment in Part D. only. In 2016, the federal asset standard for MSPs was FPL = federal poverty level. $7,280 if single and $10,930 for a couple, not including Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 6 POLICY IMPLICATIONS impairment continue to function independently.9 Several policy options would help ensure financial Providing premium and cost-sharing assistance on a security for Medicare beneficiaries. A ceiling on out-of- sliding scale to all poor and near-poor beneficiaries pocket expenses, which are common to private insurance with incomes up to 150 percent of poverty would target plans including Medicare Advantage, would help ensure assistance on those most severely strained by premiums beneficiaries are not wiped out financially by a serious and medical bills.10 illness.6 Replacing the Part A deductible — $1,364 in Medicare has served its 59 million beneficiaries well for 2019 — with a modest copayment of $100 to $300 per hospital admission would remove the most burdensome more than 50 years, meeting its goal of ensuring access to of Medicare’s cost-sharing.7 Expanding benefits to cover care and essential financial protection.11 Now Medicare essential uncovered services such as dental, vision, and will serve a generation that has experienced little or no hearing services (including hearing aids), would both growth in real wages, a reduction of assets and savings improve access to such services, which are central to through economic crises, and loss of employer-provided quality of life and health outcomes, and ease financial pensions and retiree health benefits. It is an urgent priority burdens. Adding a home- and community-based benefit 8 that policymakers reexamine the program’s benefits and to Medicare would help those with physical or cognitive financing to meet the needs of older adults. HOW WE CONDUCTED THIS STUDY All estimates in this brief are based on analysis of the eligible for full Medicaid, Medicaid only for Medicare cost- 2010 and 2016 Medicare Current Beneficiary Survey sharing and premiums, or Medicaid for Medicare premiums. (MCBS). The 2010 MCBS includes 10,741 respondents The database has a sufficiently robust sample to permit with population weights representative of the entire analysis of subgroups by income and type of coverage. Medicare population, including the disabled under-65 In the analysis, we grouped beneficiaries by income population and those primarily living in long-term-care based on their reported annual income relative to the institutions. The 2016 MCBS similarly includes 14,778 federal poverty level. We also grouped beneficiaries respondents. The issue brief displays results for the into one of five mutually exclusive insurance categories: population-weighted data. Medicare only, Medicaid, ESI, Medicare Advantage, and In addition to beneficiary reports, the MCBS cost-and- Medigap. If beneficiaries had more than one source of use files include information about incurred liability for supplemental coverage, we used the following hierarchy Medicare benefits and spending on Medicare premiums to assign them to a group: Medicaid, ESI if any ESI (and based on administrative data. The MCBS also includes not Medicaid), Medicare Advantage (if not Medicaid or information on Medicaid status: whether the beneficiary is ESI), and Medigap. commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 7 NOTES 1. Cathy Schoen, Amber Willink, and Karen Davis, 7. Schoen et al., Medicare Benefit Redesign, 2018. Medicare Beneficiaries’ High Out-of-Pocket Costs: Cost 8. Amber Willink, Cathy Schoen, and Karen Davis, Burdens by Income and Health Status (Commonwealth “Consideration of Dental, Vision, and Hearing Services Fund, May 2017); and Amber Willink, Karen Davis, and to Be Covered Under Medicare,” Journal of the American Cathy Schoen, Risks for Nursing Home Placement and Medical Association 318, no. 7 (Aug. 15, 2017): 605–6; Medicaid Entry Among Older Medicare Beneficiaries with and Amber Willink et al., How Medicare Could Provide Physical or Cognitive Impairment (Commonwealth Fund, Dental, Vision, and Hearing Care for Beneficiaries Oct. 2016). (Commonwealth Fund, Jan. 2018). 2. Centers for Medicare and Medicaid Services, National 9. Karen Davis, Amber Willink, and Cathy Schoen, Health Expenditure Projects, Table 1 and 17, updated June “Medicare Help at Home,” Health Affairs Blog, Apr. 13, 2015. 2016; and Karen Davis, Amber Willink, and Cathy Schoen, 3. Analysis of the Federal Reserve Board’s ongoing survey “Integrated Care Organizations: Medicare Financing for (every three years) finds the bottom half of retirees less Care at Home,” American Journal of Managed Care 22, no. likely to have any pension income than earlier decades or 11 (Nov. 2016): 764–68. than high-income retirees, and as a group, the bottom half 10. Cathy Schoen et al., A Policy Option to Enhance Access of the income distribution have median private financial and Affordability for Medicare’s Low-Income Beneficiaries assets of under $7,000. Sebastian Devlin-Foltz, Alice M. (Commonwealth Fund, Sept. 2018). Henriques, and John E. Sabelhaus, “The Role of Social Security in Overall Retirement Resources: A Distributional 11. David Blumenthal, Karen Davis, and Stuart Guterman, Perspective,” FEDS Notes (blog), Board of Governors of “Medicare at 50 — Origins and Evolution,” New England the Federal Reserve System, July 29, 2016. Only 25 percent Journal of Medicine 372, no. 5 (Jan. 29, 2015): 479–86. of the bottom quintile income receive any income from assets. Half of this low-income group received less than $150. Ke Bin Wu, Sources of Income for Older Americans, 2012 (AARP Public Policy Institute, Dec. 2013). 4. Molly O’Malley Watts, Elizabeth Cornachione, and MaryBeth Musumeci, Medicaid Financial Eligibility for Seniors and People with Disabilities in 2015 (Henry J. Kaiser Family Foundation, Mar. 2016). 5. National Council on Aging, “Medicare Savings Programs: A Profile of State Options,” NCOA, May 2016, and updated table, Mar. 2018. 6. Cathy Schoen et al., Medicare Benefit Redesign: Enhancing Affordability for Beneficiaries While Promoting Choice and Competition (Commonwealth Fund, Oct. 2018). commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 8 Appendix 1. Medicare Beneficiaries by Income Level and Supplemental Coverage, 2010 and 2016 2010 Medicare Employer-sponsored Medicare Total only Medicaid insurance Advantage Medigap Total 48,420,576 4,759,743 8,158,867 18,399,819 9,519,485 7,582,662 Poverty group <100% FPL 6,938,669 777,825 4,525,400 492,645 759,784 380,933 100%–149% FPL 8,081,394 1,217,866 2,754,139 1,204,128 1,762,552 1,142,709 150%–199% FPL 6,643,303 945,342 534,122 2,056,767 1,765,790 1,341,283 200%–399% FPL 16,646,994 1,303,460 284,664 8,233,603 3,863,767 2,961,500 400%+ FPL 10,110,216 514,610 58,639 6,412,910 1,369,934 1,755,134 Coverage percent of each row Total 100% 9.83% 16.85% 38.00% 19.66% 15.66% Poverty group <100% FPL 14.33% 11.21% 65.22% 7.10% 10.95% 5.49% 100%–149% FPL 16.69% 15.07% 34.08% 14.90% 21.81% 14.14% 150%–199% FPL 13.72% 14.23% 8.04% 30.96% 26.58% 20.19% 200%–399% FPL 34.38% 7.83% 1.71% 49.46% 23.21% 17.79% 400%+ FPL 20.88% 5.09% 0.58% 63.43% 13.55% 17.36% 2016 Total 58,641,440 6,028,340 11,687,239 16,249,543 14,713,137 9,969,045 Poverty group <100% FPL 9,552,691 947,627 6,208,294 550,235 1,242,805 603,730 100%–149% FPL 8,637,884 994,220 3,615,818 916,480 2,071,365 1,040,001 150%–199% FPL 7,101,478 1,112,802 1,026,874 1,332,237 2,421,604 1,207,961 200%–399% FPL 15,979,792 1,597,979 709,503 5,226,990 4,950,540 3,494,781 400%+ FPL 17,369,595 1,373,935 126,798 8,224,503 4,024,535 3,621,560 Coverage percent of each row Total 100% 10.28% 19.93% 27.71% 25.09% 17.00% Poverty group <100% FPL 16.29% 9.92% 64.99% 5.76% 13.01% 6.32% 100%–149% FPL 14.73% 11.51% 41.86% 10.61% 23.98% 12.04% 150%–199% FPL 12.11% 15.67% 14.46% 18.76% 34.10% 17.01% 200%–399% FPL 27.25% 10.00% 4.44% 32.71% 30.98% 21.87% 400%+ FPL 29.62% 7.91% 0.73% 47.35% 23.17% 20.85% Note: FPL = federal poverty level. Data: Authors’ analysis of Medicare Current Beneficiary Survey, 2010 and 2016. commonwealthfund.org Issue Brief, July 2019 How the Erosion of Employer-Sponsored Insurance Is Contributing to Medicare Beneficiaries’ Financial Burden 9 ABOUT THE AUTHORS Karen Davis, Ph.D., is professor emerita in the Cathy Schoen, M.S., is a Senior Scholar in Residence at Department of Health Policy and Management at the Johns the New York Academy of Medicine. She is the former Hopkins Bloomberg School of Public Health. She most executive director of the Commonwealth Fund Council of recently served as director of the Roger C. Lipitz Center for Economic Advisors and former senior vice president for Integrated Health Care at the school. Dr. Davis has served Policy, Research, and Evaluation at the Commonwealth as president of the Commonwealth Fund, chairman of Fund, as well as the former research director of the Fund’s the Department of Health Policy and Management at the Commission on a High Performance Health System. Johns Hopkins Bloomberg School of Public Health, and Previously, Ms. Schoen was on the research faculty of the deputy assistant secretary for Health Policy in the U.S. University of Massachusetts School of Public Health and Department of Health and Human Services. She also serves directed special projects at the UMass Labor Relations on the board of directors of the Geisinger Health System and Research Center. During the 1980s, she directed the and Geisinger Health Plan. Dr. Davis received her Ph.D. in Service Employees International Union’s research and economics from Rice University. policy department. Earlier, she served as staff to President Carter’s national health insurance task force. Prior to Amber Willink, Ph.D., is an assistant scientist in the federal service, she was a research fellow at the Brookings Department of Health Policy and Management and Institution. Ms. Schoen holds an undergraduate degree in assistant director of the Roger C. Lipitz Center for Integrated economics from Smith College and a graduate degree in Health Care at the Johns Hopkins Bloomberg School of economics from Boston College. Public Health. Her research uses predictive modeling to examine trajectories and health outcomes of older adults and inform policy for health and long-term services and Editorial support was provided by Deborah Lorber. supports. She also focuses on issues of access to and cost burdens of noncovered Medicare services. Dr. Willink received her doctoral degree in health services research and policy from Johns Hopkins University. For more information about this brief, please contact: Karen Davis, Ph.D. Professor Emerita Department of Health Policy and Management Johns Hopkins Bloomberg School of Public Health karen.davisjhu.edu commonwealthfund.org Issue Brief, July 2019 About the Commonwealth Fund The mission of the Commonwealth Fund is to promote a high-performing health care system that achieves better access, improved quality, and greater efficiency, particularly for society’s most vulnerable, including low-income people, the uninsured, and people of color. Support for this research was provided by the Commonwealth Fund. The views presented here are those of the authors and not necessarily those of the Commonwealth Fund or its directors, officers, or staff.