the future of employer-sponsored health insurance

THE COMMONWEALTH

FUND

The Future of Employer-Sponsored Health Insurance

The Commonwealth Fund andThe Century Foundation

Business and National Health Care ReformSeptember 14, 2007

Chartpack is available at www.commonwealthfund.org

2

THE COMMONWEALTH

FUND

The Future of Employer-Based Health InsuranceTable of Contents

• Employer-Based Coverage is the Backbone of the U.S. Health Insurance System

• Steady Growth in Health Care Costs is Placing Pressure on Employers’ Ability to Provide Comprehensive Benefits

• Many Americans Are Left Out of the Employer-Based System• Employer Views of Employment-Based Coverage• Employee Views of Employment-Based Coverage• Few Options Outside of Employer-Based Coverage: Growing

Numbers of Uninsured• The Individual Insurance Market is Not an Affordable Option for

Many People• Rising Health Care Costs Relative to Income• Consumer Driven Health Plans Not Attractive to Workers• Universal Health Insurance Is Essential to a High Performance

Health System• What is the Employer Role in Achieving Universal Coverage?

3

THE COMMONWEALTH

FUND

1. Employer-Based Coverage is the Backbone of the U.S. Health Insurance System

4

THE COMMONWEALTH

FUND

Figure 1. Employers Provide Health Benefits to More than 160 Million Working Americans and Family Members

Source: Current Population Survey, March 2007.

Uninsured47.0

(16%)Employer

164.0(55%)

2006

Medicaid32.7

(11%)

Medicare40.3

(14%)

Total population = 296.8 million

Under 65 population = 260.8 million

Employer 162.7(62%)

Uninsured46.5

(18%)

Medicaid32.6

(13%)

Medicare6.5

(2%)

Other12.8(4%)

Other12.5(5%)

5

THE COMMONWEALTH

FUND

92 Million U.S. Workers* Ages 19–64 Have Coverage Through Their Own or Another Employer

Own-employer coverage

71.3 million

Other employer coverage

21.0 million

Public programs4.6 million

*Includes full-time and part-time workers (including self-employed).^Includes those with individual insurance and don’t know responses.Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated with data from the The Commonwealth Fund Biennial Health Insurance Survey (2005).

Uninsured19.0 million

Other coverage^10.0 million

6

THE COMMONWEALTH

FUND

People With Employer Insurance Have More Stable Coverage Than Those with Individual Market Insurance

Source: K. Klein, S. A. Glied, and D. Ferry, Entrances and Exits: Health Insurance Churning, 1998–2000, The Commonwealth Fund, September 2005. Authors’ analysis of the 1998–2000 Medical Expenditure Panel Survey.

Employer insurance Individual insurance

Retained initial insurance status

One or more spells uninsured

Other transition

86%

12%

2%

53%

21%

26%

Retention of initial insurance over a two-year period, 1998–2000

7

THE COMMONWEALTH

FUND

Risk Pooling and Employer Premium Contributions Lower the Cost of Health Benefits for Adults with Employer Coverage Relative to Those

with Individual Market Coverage

13 1322

7 5

32

0

25

50

75

Total Employer Individual

Annual out-of-pocket premium $6,000 or more

Annual out-of-pocket premium $3,000–$5,999

20 18

54

Percent of adults ages 19–64 insured all year with private insurance

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, The Commonwealth Fund, September 2006.

8

THE COMMONWEALTH

FUND

2. Steady Growth in Health Care Costs is Placing Pressure on Employers’ Ability to Provide

Comprehensive Benefits

9

THE COMMONWEALTH

FUND

Percentage of National Health Expenditures Spent on Insurance Administration and Overhead, 2003

a2002 b1999 c2001*Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2005.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

Net costs of health administration and health insurance as percent of national health expenditures

1.9 2.1 2.12.6

3.34.0 4.1 4.2

4.85.6

7.3

0

2

4

6

8

France

Finlan

d

Japan

Canada

United K

ingdom

Netherla

nds

Austria

Australi

a

Switzerla

nd

German

y

United S

tatesa b c *

10

THE COMMONWEALTH

FUND

Source: G. Claxton, J. Gabel et al., "Health Benefits in 2007: Premium Increases Fall To An Eight-Year Low, While Offer Rates And Enrollment Remain Stable," Health Affairs, September/October 2007 26(5):1407–1416. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.*Estimate is statistically different from the previous year shown at p<0.05.^Estimate is statistically different from the previous year shown at p<0.1.Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).

12.0

18.0

0.8

6.1*7.7*

13.9^

12.9*10.9*

8.2*

5.3*

11.2*

8.5 9.2*

0

5

10

15

20

1988

1989

1990

1991

1992

1993

1994

1995

1996

1997

1998

1999

2000

2001

2002

2003

2004

2005

2006

2007

Health insurance premiums

Workers earnings

Overall inflation

National health expendituresper capita

Increases in Health Insurance Premiums Compared with Other Indicators, 1988–2006

Percent

11

THE COMMONWEALTH

FUND

999791

80

57

69

9994

8376

45

60

0

25

50

75

100

Total 3–9

workers

10–24

workers

25–49

workers

50–199

workers

200+

workers

2000 2007

Employer Coverage Continues to Be Major Source of Coverage for Employees of Larger Firms

Percent of firms offering health benefits

Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2007 Annual Surveys.

12

THE COMMONWEALTH

FUND

Deductibles Rise Sharply, Especially in Small Firms, Over 2000–2007

PPO = preferred provider organization. PPOs covered 57 percent of workers enrolled in an employer-sponsored health insurance plan in 2007.Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2007 Annual Surveys.

187 210157

461

667

382

$0

$150

$300

$450

$600

$750

$900

Total Small firms, 3–199

employees

Large firms, 200+

employees

2000 2007

Mean deductible for single coverage (PPO, in-network)

13

THE COMMONWEALTH

FUND

0

20

40

60

80

1996 1997 1998 1999 2000 2001 2002 2003 2004 2005

Enrolled in employer-sponsored health insurance Uninsured

Percent of Nonelderly Population Enrolled inEmployer-Sponsored Health Insurance or Uninsured, 1996–2005

Percent of nonelderly population

69

12 14

61

14

65

Note: Individuals were identified as enrolled in employer-sponsored health insurance if they were enrolled at any point during the year. Individuals were identified as uninsured if they were uninsured for the full year.Source: Analysis by S. Glied and B. Mahato of Columbia University of the Medical Expenditure Panel Survey, 1997–2006.

14

THE COMMONWEALTH

FUND

3. Many Americans Are Left Out of the Employer-Based System

15

THE COMMONWEALTH

FUND

Employer-Provided Health Insurance, By Household Income Quintile, 2000–2005

86%86%86%86%87%88%

82%82%83%84%84%85%

71%73%74%75%76%77%

53%53%55%57%59%61%

22%22%22%24%26%28%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

2000 2001 2002 2003 2004 2005

Highestquintile

Fourth

Third

Second

Lowestquintile

Source: E. Gould, Health Insurance Eroding for Working Families: Employer-Provided Coverage Declines for Fifth Consecutive Year, Economic Policy Institute, Sep. 28, 2006.

Percent of population under age 65 with health benefits from employer

16

THE COMMONWEALTH

FUND

Uninsured Rates are Increasing Most for Working Middle Class Adults

47%50%

48%

52%

48%

39%

35%

44%

33%

21%

15%18%

25%

8%6%9%

11%

2%5%

4%

5%

0%

25%

50%

1987 1989 1991 1993 1995 1997 1999* 2001 2003

Lowestquintile

Second

Third

Fourth

Highestquintile

*In 1999, CPS added a follow-up verification question for health coverage.Source: Analysis of the March 1988–2004 Current Population Surveys by D. Ferry, Columbia University, for The Commonwealth Fund.

Percent of working adults who are uninsured

17

THE COMMONWEALTH

FUND

Percent of Nonelderly Workers Enrolled inHealth Insurance Sponsored by Own Employer,

by Wage Quartile and Firm Size

61

4742

32

20

42

6067

76 788786

8177

55

66

82 8388 89

0

20

40

60

80

100

<50 employees,

1 location

<50 employees,

2+ locations

50 to 99

employees

100 to 499

employees

500 or more

employees

1st quartile wage 2nd quartile wage 3rd quartile wage 4th quartile wage

Percent of nonelderly workers

Source: Analysis by S. Glied and B. Mahato of Columbia University of the Medical Expenditure Panel Survey, 2001–05.

18

THE COMMONWEALTH

FUND

Population Under Age 65 With Employer Coverage, 2006

Source: Current Population Survey, March 2007 supplement.

Percent with employer coverage

687674

68

54

666863 60

49

60

69 7167

0

25

50

75

100

Total <65 <18 18–24 25–34 35–44 45–54 55–64

2000 2006

19

THE COMMONWEALTH

FUND

Percent of Children and Adults With Employer-Sponsored Coverage, by Poverty

79

42

19

76

41

19

0

20

40

60

80

100

Children

<100% FPL

Children

100–199%

FPL

Children

200%+ FPL

Adults*

<100% FPL

Adults*

100–199%

FPL

Adults*

200%+ FPL

Percent with coverage through their own or other employer

FPL = federal poverty level.*Adults age 19 and over; children are age 18 and under.Source: Analysis by S. Glied and B. Mahato of Columbia University of the 2006 Current Population Survey.

20

THE COMMONWEALTH

FUND

The Majority of Uninsured AdultsAre in Working Families

Family work statusAdult work status

At leastone

full-time worker67%

Onlypart-time worker(s)

11%

Full-time49%

Part-time15%

No worker in family

21%Not

currently employed

36%

Note: Percentages may not sum to 100% because of rounding.Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

Adults ages 19–64 with any time uninsured

21

THE COMMONWEALTH

FUND

More than Three of Five Working Adultswith Any Time Uninsured Are Employed in

Firms with Fewer than 100 Employees

Self-employed/1 employee10%

2–19 employees31%

20–99 employees22%

100–499 employees11%


Don’t know/refused4%

Percent of employed adults with any time uninsured, ages 19–64

500+ employees21%

22

THE COMMONWEALTH

FUND

Uninsured Workers By Firm Size 19872005

61 57 60

1412 11

25 2932

0

20

40

60

80

100

1987 2001 2005

Large (500+)

Medium (100–499)

Small (<100)Percent

Source: S. Glied, et al., The Growing Share of Uninsured Workers Employed by Large Firms, The Commonwealth Fund, October 2003, Authors’ analysis of March Current Population Survey, 1988–2002. 2005 data from analysis by S. Glied and B. Mahato of Columbia University of the Current Population Survey, 2006.

23

THE COMMONWEALTH

FUND

Workers Who Are Offered, Eligible for, and Participate in Their Employer’s Health Plan,

by Firm Size and Hourly Wage

98

89

51

4234

50

75

95

83

57

45

21

0

25

50

75

100

Less than $15/hr More than $20/hr Less than $15/hr More than $20/hr

Employer offers a planEligible for employer planCovered through own employer

^Includes both part-time and full-time workers.Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated data from The Commonwealth Fund Biennial Health Insurance Survey (2005).

Small employer(fewer than 50 employees)

Percent of working adults^ ages 19–64

Medium to large employer(50 or more employees)

24

THE COMMONWEALTH

FUND

Percent Uninsured Workers by Firm Size and Hourly Wage

1

1715

39

0

25

50

75

Less than $15/hr More than $20/hr Less than $15/hr More than $20/hr

^Includes both part-time and full-time workers.Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated data from The Commonwealth Fund Biennial Health Insurance Survey (2005).

Small employer(fewer than 50 employees)

Percent of working adults^ ages 19–64 who are uninsured

Medium to large employer(50 or more employees)

25

THE COMMONWEALTH

FUND

The Majority of Low-Income* Adults Are in Working Families, But Employment Is Unstable,

Employment Status of Head of Household Among Low-Income Adults, 1996–1999

24

24

16

62

63

63

56

14

12

1034

21

0% 25% 50% 75% 100%

Total 19–64

White

African American

Hispanic

Worked full time over 48 monthsWorked, less than full time over 48 monthsNo work over 48 months

*Low-income defined as less than 200% of the federal poverty level.Source: M. M. Doty and A. L. Holmgren, Unequal Access: Insurance Instability Among Low-Income Workers and Minorities, The Commonwealth Fund, April 2004.

26

THE COMMONWEALTH

FUND

73

5547

88

7675

57

2632

71

5449

0

25

50

75

100

White African

American

Hispanic White African

American

Hispanic

Any time uninsured Uninsured more than one year

Low-Income* Hispanics Are Less Likely to Have Insurance—Though More Likely to Be Steadily Employed

Percent uninsured by employment of head of household among low-income adults (19–64), 1996–1999

Worked, but less than full-time employment over 48 months

Full-time employment over 48 months

*Low-income defined as less than 200% of the federal poverty level.Source: M. M. Doty and A. L. Holmgren, Unequal Access: Insurance Instability Among Low-Income Workers and Minorities, The Commonwealth Fund, April 2004.

27

THE COMMONWEALTH

FUND

Percent of Children in Employer-Sponsored Insurance or Uninsured, by Employment Status of Adults in Family

232930

46

67

25

40

525959

1071075

0

20

40

60

80

1+ full-time

worker, large

firm

1+ full-time,

small firm

1+ part-time

worker,

multiple jobs

1+ part-time

worker, one

job

No workers

Enrolled in employer-sponsored health insuranceEnrolled in public insuranceUninsured

Percent of children (ages 0–18)

Source: Analysis by S. Glied and B. Mahato of Columbia University of the Medical Expenditure Panel Survey, 2005.Notes: Families are assigned to a unique employment status using the following hierarchy: one or more full-time adult workers employed by a large firm, one or more full-time adult workers employed by a small firm, one or more adult workers with multiple part-time jobs, one or more adult workers with one part-time job, no workers.

28

THE COMMONWEALTH

FUND

Uninsured Workers: Reasons for Lack of Insurance Coverage, Ages 19–64

Employer doesn’t offer coverage

48%

Employer offers, worker eligible,

doesn’t participate 28%

Employer offers, worker ineligible

20%

Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated data from The Commonwealth Fund Biennial Health Insurance Survey (2005).

Worker doesn’t know if offered or eligible

4%

29

THE COMMONWEALTH

FUND

Nonstandard Workers as a Shareof the Workforce

Source: E. Ditsler, P. Fisher, and C. Gordon, On the Fringe: The Substandard Benefits of Workers in Part-Time, Temporary, and Contract Jobs, The Commonwealth Fund, December 2005. Authors’ analysis of the 2001 Contingent Work Supplement to the Current Population Survey.

Standardworkers(regularfull-time)

71%

Temp. agency workers1%

On-call/day laborers2% Wage & salaried

independent contractor 1%

Self-employed independent contractor 6%

Contract company workers0.4%

Direct-hire temporaries2%

Regular part-time workers13%

Regular self-employed workers(neither standard nor nonstandard)

4%

30

THE COMMONWEALTH

FUND

Non-Standard Workers Are Less Likely to Have Access to Job-Based Health Insurance, 2001

74%

21%

13%

19%

13%

60%

0%

20%

40%

60%

80%

100%

Standard

workers

All nonstandard

workers

Not eligible/not offered

Eligible, but dec lined

Insured by own-employerplan

Notes: Self-employed independent contractors are excluded from this analysis. “Not eligible/Not offered” includes workers who are not eligible for the company plan as well as workers who are not offered coverage because their company does not sponsor a health insurance plan.Source: E. Ditsler, P. Fisher, and C. Gordon, On the Fringe: The Substandard Benefits of Workers in Part-Time, Temporary, and Contract Jobs, The Commonwealth Fund, December 2005. Authors’ analysis of the 2001 Contingent Work Supplement to the Current Population Survey.

Take-uprates: 85.1% 53.5%

31

THE COMMONWEALTH

FUND

Non-Standard Workers Are Less Likely to Have Health Insurance Coverage Through Their Own Job, 2001

74%

21%

11%

39%

3%

10%

12%

5%

1% 24%

0%

20%

40%

60%

80%

100%

Standard

workers

All nonstandard

workers

Uninsured

Medicare/Medicaid/ other government source

Other source of healthinsurance

Spouse/family member plan

Own employer's healthinsurance

Notes: Self-employed independent contractors are excluded from this analysis. “Other source of health insurance” includes insurance from the individual market, from another job, from a previous job, or from an association, school, or other unidentified source.Source: E. Ditsler, P. Fisher, and C. Gordon, On the Fringe: The Substandard Benefits of Workers in Part-Time, Temporary, and Contract Jobs, The Commonwealth Fund, December 2005. Authors’ analysis of the 2001 Contingent Work Supplement to the Current Population Survey.

32

THE COMMONWEALTH

FUND

People with Lower Incomes and Young Adults Have Less Stable Employer Coverage

*Low-income defined as less than 200% of the federal poverty level.Note: Numbers may not sum to 100% due to rounding.Source: K. Klein, S. A. Glied, and D. Ferry, Entrances and Exits: Health Insurance Churning, 1998–2000, The Commonwealth Fund, September 2005. Authors’ analysis of the 1998–2000 Medical Expenditure Panel Survey.

Young adults ages 17–22 with

employer insurance

Retained initial insurance status

One or more spells uninsured

Other transition

Low-income* with employer insurance

61%32%

6%

70%

3%

27%

Employer insurance

86%

12%

2%

33

THE COMMONWEALTH

FUND

Insurance Instability Among Older Adults in Working Families

*Difference across income is statistically significant at p < 0.05 or better.Note: Income groups based on 2003 household income.Source: S. R. Collins et al., Health Coverage for Aging Baby Boomers: Findings from the Commonwealth Fund Survey of Older Adults, The Commonwealth Fund, January 2006.

Percent of adults 50–64 not on Medicare who are employed or whose spouse is employed

8

29

114

5

12

87

7

13

14

7

0

25

50

75

Total <$25,000 $25,000–

$39,999

$40,000–

$59,999

$60,000+

Insured all last year, time uninsured since age 50

Insured now, time uninsured in past year

Uninsured now

20

54*

33

18

72

3

2

34

THE COMMONWEALTH

FUND

Nearly One Quarter of Medicare BeneficiariesWere Uninsured Just Before Enrolling

11

3841

1824

0

25

50

75

All on

Medicare

Ages 65–70 Ages 50–64,

disabled

Less than

200% poverty

200% poverty

or more

Percent of Medicare beneficiaries ages 50–70

Source: S. R. Collins et al., Will You Still Need Me? The Health and Financial Security of Older Americans, The Commonwealth Fund, June 2005. Data from the Commonwealth Fund Survey of Older Adults, 2004.

35

THE COMMONWEALTH

FUND

Workers With Employer-Sponsored Insurance Often Become Uninsured if They Leave or Switch Jobs

000

45

98

4351

1

3441

0

20

40

60

80

100

Same job Switched

jobs (n=1804)

Left job,

voluntary

(n=638)

Left job,

involuntary

(n=540)

Left job,

health

reasons

(n=122)

Kept employer-sponsored coverage Became uninsured

Percent of non-elderly workers

Source: Commonwealth Fund analysis of the 2001 through 2005 Medical Expenditure Panel Survey.Notes: Only includes workers age 19 to 64 who were initially enrolled in employer-sponsored insurance through their employer. Job changes were identified based on employment status reported in two survey rounds approximately four months apart.

36

THE COMMONWEALTH

FUND

Below 200% poverty 200% poverty or more

Other insurance 8%

Uninsured 32%

COBRA-eligible75%

ESI**Small firm

11%

ESI**Small firm

8%

Other insurance 20%

COBRA-eligible

40%

Uninsured 6%

Lower Income Workers Are Least Likely to Be Eligible for COBRA*

*The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) requires employers with 20 or more employees to offer continuation of health insurance coverage to former employees.**Employer-sponsored insurance coverage.Source: L. Duchon, C. Schoen, M. M. Doty et al., Security Matters: How Instability in Health Insurance Puts U.S. Workers at Risk, The Commonwealth Fund, December 2001.

37

THE COMMONWEALTH

FUNDSource: J.L. Lambrew, How the Slowing U.S. Economy Threatens Employer-Based Health Insurance (New York: The Commonwealth Fund) November 2001. Updated with data from the Commonwealth Fund Biennial Health Insurance Survey (2005).

More Than Half of Unemployed Adults are Uninsured

52

1518

0

20

40

60

80

100

All non-elderly adults Employed non-elderly

adults

Unemployed non-

elderly adults

Percent uninsured, 2005

38

THE COMMONWEALTH

FUNDSource: J.L. Lambrew, How the Slowing U.S. Economy Threatens Employer-Based Health Insurance (New York: The Commonwealth Fund) November 2001. Updated with data from the Commonwealth Fund Biennial Health Insurance Survey (2005).

Unemployed Uninsured People Have Lower Incomes

1531 3918

373238

27 2730

4 2

0

20

40

60

80

100

All nonelderly adults Unemployed

nonelderly adults

Unemployed &

uninsured nonelderly

adults

<100% 100–199% 200–399% 400%+

Distribution of adults 19–64 by income as percentage of poverty level

39

THE COMMONWEALTH

FUND

4. Employer Views of Employment-Based Coverage

40

THE COMMONWEALTH

FUND

Among Firms Offering Health Benefits,How Important Are Firms’ Health Benefits in

Attracting Highly Qualified Employees?*

34%

34%

34% 59%

55%

57%

0% 20% 40% 60% 80% 100%

All firms

Small firms

(3–199 workers)

Large firms

(200+ workers)

Very important Somewhat important

Percent

93%

89%

91%

*Tests found no statistically different estimates between subgroups.Note: Figure is shown with employee-based weights.Source: H. Whitmore, S. R. Collins, J. R. Gabel, J. D. Pickreign, “Employer Views on Incremental Measures to Expand Health Insurance,” Health Affairs, November/December 2006.

41

THE COMMONWEALTH

FUND


Retaining Highly Qualified Employees?*

37%

35%

39% 57%

54%

56%

0% 20% 40% 60% 80% 100%

All firms

Small firms

(3–199 workers)

Large firms

(200+ workers)


Percent

96%

89%

93%

*Difference between subgroups is statistically significant at p<.05.Note: Figure is shown with employee-based weights.Source: H. Whitmore, S. R. Collins, J. R. Gabel, J. D. Pickreign, “Employer Views on Incremental Measures to Expand Health Insurance,” Health Affairs, November/December 2006.

42

THE COMMONWEALTH

FUND


Improving Employee Morale and Satisfaction?*

28%

30%

26% 71%

61%

67%

0% 20% 40% 60% 80% 100%

All firms

Small firms

(3–199 workers)

Large firms

(200+ workers)


Percent

97%

91%

95%


43

THE COMMONWEALTH

FUND


Improving Employee Health?*

39%

44%

36% 60%

45%

55%

0% 20% 40% 60% 80% 100%

All firms

Small firms

(3–199 workers)

Large firms

(200+ workers)


Percent

96%

89%

94%


44

THE COMMONWEALTH

FUND


Improving Employee Performance or Productivity?*

43%

38%

46% 36%

33%

35%

0% 20% 40% 60% 80% 100%

All firms

Small firms

(3–199 workers)

Large firms

(200+ workers)


Percent

82%

71%

78%


45

THE COMMONWEALTH

FUND

Firms’ Agreement with Statement That All Employers Should Share in the Cost of Health Insurance for Employees by Either Providing Health

Insurance or Contributing to a Fund to Cover the Uninsured*

25%24%25%13%

24%

41%42%42%

41%

42%

0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat agree

Strongly agree

Firm sizeOffer status*

Percent

66%66%67%

54%

66%


46

THE COMMONWEALTH

FUND

Reasons Why New York Firms Did Not Offer Health Benefits, 2003

Percent of non-offering firms indicating reason was ‘very important’

Source: J. N. Edwards, S. How, H. Whitmore et al., Employer-Sponsored Health Insurance in New York: Findings from the 2003 Commonwealth Fund/HRET Survey, The Commonwealth Fund, May 2004.

5

5

15

20

22

28

54

85

0 25 50 75 100

Firm has seriously ill employee

Too newly established

Employee turnover too great

Administrative hassle too great

Can attract good employees w ithout

health insurance

Employees are covered elsewhere

Firm is too small

Premiums too high

47

THE COMMONWEALTH

FUND

5. Employee Views of Employment-Based Coverage

48

THE COMMONWEALTH

FUND

Percent of People with ESI* Who Say That Employers Do a Good Job Selecting Quality Insurance Plans to Offer Their Workers

7468

7569 70

75 76

0

25

50

75

100

Total <200% 200%+ <20 20–99 100–499 500+

Percent

*ESI = employer-sponsored insurance. FPL = federal poverty level.Note: Based on respondents age 19-64 who were covered all year by their own employer’s insurance.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, The Commonwealth Fund, September 2006.

% FPL Number of employees in firm

49

THE COMMONWEALTH

FUND

The High Cost of Coverage Makes Employee Health Benefits Very Valuable

Employers who provide health benefits now pay an average of $6,700 per employee each year for that coverage, which is not counted as taxable income to employees. Would you rather have…?*Among those employed full- or part-time (2006 n=572)

5%

20%

75%

5%

14%

80%

21%

76%

2%

25%

73%

3%

2001200420052006

$6,700 in employer-provided health

insurance coverage

An additional $6,700 in taxable income

Don’t know/refused

Note: The $6,700 amount was used in the 2006 survey. Smaller dollar amounts were used in earlier years, based on average premiums in those years.Source: R. Helman and P. Fronstin, 2006 Health Confidence Survey: Dissatisfaction With Health Care System Doubles Since 1998, EBRI Notes, Vol. 27, No. 11, November 2006, and earlier publications based on the EBRI Health Confidence Survey.

50

THE COMMONWEALTH

FUND

Many Workers Value Their Employer-Provided Health Benefits Far Above Their Actual Cost

How much would an employer have to give you each year in taxable income for you to willingly give up your employer-provided coverage?*Among those with employer-based coverage preferring employer-provided coverage to an additional $6,700 in taxable income (n=400)

$15,000+22%

No amount enough

13%


30%

$10,000– 14,999

25%

Under $10,000

11%

Note: Percentages may not sum to 100% due to rounding.Source: R. Helman and P. Fronstin, 2006 Health Confidence Survey: Dissatisfaction With Health Care System Doubles Since 1998, EBRI Notes, Vol. 27, No. 11, November 2006.

51

THE COMMONWEALTH

FUND

Source: J. Lambrew, "Choice" in Health Care: What Do People Really Want?, The Commonwealth Fund, September 2005.

Employer-chosen set of health

plans67%

Employer-funded account, find own

health plan24%

Unknown9%

Employed Adults or Those with Employer-Sponsored Insurance Prefer Having an Employer-Chosen Set of Health Plan

Options Over a Cash Account

52

THE COMMONWEALTH

FUND

Four of Five Adults with Employer-Sponsored Insurance Report Having “A Great Deal” or “A Fair Amount” of Choice in Where

To Go for Medical Care

35 3323

14

4637

41

33

0

25

50

75

100

Employer-

sponsored

insurance

Individual

insurance

Public/other

insurance

Uninsured

A fair amount of choice

Great deal of choice

Percent of adults 19–64

81

7064

47

Source: J. Lambrew, "Choice" in Health Care: What Do People Really Want?, The Commonwealth Fund, September 2005.

53

THE COMMONWEALTH

FUND

Employees in Large Firms Are Most Likely to Have Two or More Health Plan Choices

54

45

56

25

38

48

71

0

25

50

75

100

Total <200% 200%+ <20 20–99 100–499 500+

Percent of adults ages 19-64 insured all year with ESI*

% 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: 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, The Commonwealth Fund, September 2006.

54

THE COMMONWEALTH

FUND

Adults With Employer Coverage Give Their Health Plans Higher Ratings Than Those in the Individual Market

22 2214

31 32

20

0

25

50

75

Total ESI Individual

Very good

Excellent

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, The Commonwealth Fund, September 2006.

53 54

34


55

THE COMMONWEALTH

FUND

6. Few Options Outside of Employer-Based Coverage: Growing Numbers of Uninsured

56

THE COMMONWEALTH

FUND

47 Million Uninsured in 2006; Increase of 8.6 Million Since 2000

Number of uninsured, in millions

31 33 33 35 3539 40 40 41 41 42 43

39 38 4042

56

47454343

0

20

40

60

1987 1990 1993 1996 1999* 2002 2005 2008 2011

Projected2013

*1999–2006 estimates reflect the results of follow-up verification questions and implementation of Census 2000-based population controls.Note: Projected estimates for 2007–2013 are for nonelderly uninsured based on T. Gilmer and R. Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,” Health Affairs Web Exclusive, April 5, 2005.Source: U.S. Census Bureau, March Current Population Survey, 1988–2007.

57

THE COMMONWEALTH

FUND

Population Under Age 65 Without Health Insurance

17

12

16

20

12

18

0

10

20

30

All under 65 Children under 18 Adults 18–64

2000 2006

Percent uninsured

9 8 8 8 8 8 8 9

29 30 31 34 35 35 36 38

0

20

40

60

1999 2000 2001 2002 2003 2004 2005 2006

Adults 18–64

Children under 18

Millions uninsured

38 38 3942 43

4743

Source: The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006. Analysis of Current Population Survey, March 1995–2007 supplements. Updated data from March 2007 CPS.

44

58Uninsured Non-Elderly Adult RateIncreased from 17.8% to 20.0% in Last Five Years

*1999–2000 numbers are not yet updated with August 2007 Current Population Survey revised data.Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard on Health System Performance, The Commonwealth Fund Commission on a High Performance Health System, June 2007.Updated Data: Two-year averages 1999–2000 and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DE

DC

HI

CO

GAMS

OK

NJ

SD

19%–22.9%

Less than 14%

14%–18.9%

23% or more

1999–2000* 2005–2006

MA

RI

CT

VTNH

MD

NH

59

*1999–2000 numbers are not yet updated with August 2007 Current Population Survey revised data.Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard on Health System Performance, The Commonwealth Fund Commission on a High Performance Health System, June 2007.Updated Data: Two-year averages 1999–2000 and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

10%–15.9%

Less than 7%

7%–9.9%

16% or more

1999–2000*

DE

MARI

WA

ORID

MT ND

WY

NVUT

KS

NE

MN

MO

WI

TX

IA

ILIN

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DC

HI

CO

GAMS

NJ

SD

2005–2006

CT

VTNH

MD

AR

CA

AZ NMOK

U.S. Average: 11.3%U.S. Average: 12.7%

Percent of Uninsured Children Declined Since Implementation of SCHIP but Gaps Remain

60

THE COMMONWEALTH

FUND

One of Four People Under Age 65Was Uninsured During Part of 2005

Insured all year73.9%

Total population under age 65 = 256 million

Source: J. A. Rhoades and M. C. Chu, The Uninsured in America, 1996–2006: Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65, Agency for Healthcare Research and Quality, Statistical Brief #169, June 2007.

Uninsuredpart year

11.9%

Uninsuredall year14.2%

[66 million]

61

THE COMMONWEALTH

FUND

34

15

38

68

5

16

42

20

0

25

50

75

100

Total under age

65

Under 200% of

poverty

200%–399% of

poverty

400% or more of

poverty

Any time uninsured More than one year uninsured

Insurance Instability and Churning38 Percent of Nonelderly People – 85 Million –

Were Uninsured over the Four-Year Period 1996–1999

Source: P. F. Short, D. R. Graefe, and C. Schoen, Churn, Churn, Churn: How Instability of Health Insurance Shapes America’s Uninsured Problem, The Commonwealth Fund, November 2003.

Percent of population under age 65

62

THE COMMONWEALTH

FUND

Uninsured Rates High Among Adults with Low and Moderate Incomes, 2001–2005

15 17 18

33 37 37

1724 28

9

9 9 9

1615 16

1111

13

9

76 2 33

7 9

0

25

50

75 Insured now, time uninsured in past year

Uninsured now

Percent of adults ages 19–64

Note: Income refers to annual income. In 2001 and 2003, low income is <$20,000, moderate income is $20,000–$34,999, middle income is $35,000–$59,999, and high income is $60,000 or more. In 2005, low income is <$20,000, moderate income is $20,000–$39,999, middle income is $40,000–$59,999, and high income is $60,000 or more. Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

26

52

35

16

4

24

49

28

13

4

Total Low income Moderate income

Middle income

High income

2001 2003 2005 2001 2003 20052001 2003 20052001 2003 20052001 2003 2005

28

53

41

18

7

63

THE COMMONWEALTH

FUND

Distribution of Uninsured Adults Ages 18–64 by Poverty, 2006

0–99% of poverty

23%

100–149%of poverty

15%200–299%of poverty

20%

Source: Analysis by P. Fronstin of the Employee Benefit Research Institute of the Current Population Survey, March 2007.

300% of poverty or more28%

150–199%of poverty

14%

64

THE COMMONWEALTH

FUND

Uninsured Population, 2005Nearly Two-Thirds are Low Income*

Low-income children

13%

Low-income adults with children

16%

Low-income adults without children

36%

Other adults29%

Other children

7%

*Low-income defined as less than 200% of the federal poverty level.Source: Analysis by S. Glied and B. Mahato of Columbia University of the 2006 Current Population Survey.

44.8 million uninsured

65

THE COMMONWEALTH

FUND

Percent Under Age 65 Uninsured During Year by Poverty Level, 2004

Source: Analysis by S. Glied and B. Mahato of Columbia University of the Medical Expenditure Panel Survey, 2005.

14% 14%

12% 12%

24%25%

6%

18%18%

6%

0%

25%

50%

Total <100% FPL 100%–199%

FPL

200%–399%

FPL

>400% FPL

Uninsured all year Uninsured part year

26%

43% 43%

26%

12%

66

THE COMMONWEALTH

FUND

Length of Time Uninsured,Adults Ages 19–64

Uninsured at thetime of the survey

31.6 million

Insured now,time uninsured in past year

16.2 million

One year or more

82%

4 to 11 months

11%


2%One year or more

26%

4 to 11 months

39%


1%

3 months or less6%

3 months or less34%


67

THE COMMONWEALTH

FUND

Adults Ages 19–64 Who Are Uninsured and Underinsured, by Poverty Status, 2003

6583

32

4

19

2613

499

0%

20%

40%

60%

80%

100%

Total 200% of poverty or more Under 200% of poverty

Insured, not underinsured Underinsured* Uninsured during year

*Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 Commonwealth Fund Biennial Health Insurance Survey (Schoen et al., Insured But Not Protected: How Many Adults Are Underinsured?, Health Affairs Web Exclusive, June 14, 2005 W5-289–W5-302 ).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

68

THE COMMONWEALTH

FUND

Uninsured Rates Are HighAmong Hispanics and African Americans, 2005

18 1319

4898

13

14

0

25

50

75

Total White African American Hispanic

Insured now, time uninsured in past year

Uninsured now

Percent of adults ages 19–64

Note: Because of rounding, totals above stacked bars may not reflect the sum of each insurance category.Source: M. M. Doty and A. L. Holmgren, Health Care Disconnect: Gaps in Coverage and Care for Minority Adults, The Commonwealth Fund issue brief, August 2006.

28

62

33

20

69

THE COMMONWEALTH

FUND

There Are 13.3 MillionUninsured Young Adults Ages 19–29,

30 Percent of Nonelderly Uninsured Adults, 2005

Source: Analysis by S. Glied and B. Mahato of Columbia University of the March 2006 Current Population Survey .

Age 18and under

20%

Ages 30–3512%

Ages 50–6415%

Ages 36–4923%

Ages 24–2916%

Ages 19–2314%

Uninsured nonelderly adults = 44.4 million

70

THE COMMONWEALTH

FUND

Rates of Uninsurance Rise Dramatically After Age 19, Particularly Among Lower Income Young Adults, 2005

Percent Uninsured ChildrenAge 18 and Under

Young AdultsAges 19–29

Total 11% 30%

<100% FPL 20 51

100%–199% FPL 16 42

>200% FPL 7 16

FPL = federal poverty level.Source: S. R. Collins, C. Schoen, J. L. Kriss, M. M. Doty, and B. Mahato, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated August 8, 2007.

71

THE COMMONWEALTH

FUND

Nearly Two of Five College Graduates Had Time Uninsured in Year Following Graduation,

1996–2000*

21

38

62

0

40

80

Insured continuously Time uninsured Uninsured for six

months or more

*People who graduated from college during 1996–2000.Source: S. R. Collins, C. Schoen, J. L. Kriss, M. M. Doty, and B. Mahato, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated August 8, 2007; Analysis of the 1996 Panel of the Survey of Income and Program Participation by P. F. Short and D. Graefe for The Commonwealth Fund.

Percent of college graduates

72

THE COMMONWEALTH

FUND

Uninsured Rates Remain High Over the Life Span Among People With Lower Incomes, 2005

Percent Uninsured

18 and Under 19–29 30–35 36–49 50–64

Total 11% 30% 22% 17% 12%

<100% FPL 20 51 47 43 32

100%–199% FPL

16 42 39 34 24

>200% FPL 7 16 13 9 8

FPL = federal poverty level.Source: S. R. Collins, C. Schoen, J. L. Kriss, M. M. Doty, and B. Mahato, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated August 8, 2007.

73

THE COMMONWEALTH

FUND

28

15131018

60

443633

39

5949

393743

0

25

50

75

Did not fill a

prescription

Did not see

spec ialist when

needed

Skipped

medical test,

treatment, or

follow-up

Had medical

problem, did

not see doctor

or c linic

Any of the four

access

problems

Insured all year Insured now, time uninsured in past year Uninsured now

Lacking Health Insurance for Any PeriodThreatens Access to Care

Percent of adults ages 19–64 reporting the following problemsin past year because of cost:

Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

74

THE COMMONWEALTH

FUND

Receipt of Recommended Screening and Preventive Care for Adults, by Family Income and Insurance Status,

2004

29

46

52

38

46

57

48

0 50 100

Uninsured all year

Uninsured part year

Insured all year

<200% FPL

200%–399% FPL

400%+ FPL

National

Percent of adults (ages 18+) who received all recommended screening and preventive care within a specific time frame given their age and sex*

FPL = federal poverty level.*Recommended care includes seven key screening and preventive services: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. Updated data from B. Mahato, Columbia University analysis of 2004 Medical Expenditure Panel Survey.

75

THE COMMONWEALTH

FUND

Preventive and Primary Care Varies by Workers’ Job Compensation Levels

54

7464 66

8474

859189

0

20

40

60

80

100

Regular doctor (ages

19–64)

Blood pressure check in

past year (ages 19–64)

Cholesterol check in past

five years (ages 19–64)

Lowest compensated Mid-compensated Higher compensated

Note: Lowest compensated are all workers with wage rate <$10/hr; mid-compensated are workers with wage rate $10–$15/hour and those >$15/hour but no employer-sponsored insurance; higher compensated are workers with wage rate >$15/hour and employer-sponsored insurance.Source: S. R. Collins, K. Davis, M. M. Doty, and A. Ho, Wages, Health Benefits, and Workers' Health, The Commonwealth Fund, October 2004.

76

THE COMMONWEALTH

FUND

Percent of children (ages <18) who received BOTH a medical and dental preventive care visit in past year

Preventive Care Visits for Children, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003

35

63

70

58

62

48

73

59

49

48

0 50 100

Uninsured

Private insurance

<100% FPL

400%+ FPL

Hispanic

Black

White

Bottom 10% states

Top 10% states

U.S. average

FPL = federal poverty level.Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

77

THE COMMONWEALTH

FUND

Adults Without Insurance Are Less Likelyto Be Able to Manage Chronic Conditions

1618

27

58

35

59

0

25

50

75

Skipped doses or did not fill

prescription for chronic condition

because of cost

Visited ER, hospital, or both for chronic

condition

Insured all year Insured now, time uninsured in past year Uninsured now

Percent of adults ages 19–64 with at least one chronic condition*

*Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease. Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

78

THE COMMONWEALTH

FUND

Receipt of All Three Recommended Services for Diabetics, by Race/Ethnicity, Family Income, Insurance,

and Residence, 2002

4555

54

46

5061

55

53

54

47

24

38

0 50 100

Rural

Urban

Uninsured

Private

<100% of poverty

100%–199% of poverty

200%–399% of poverty

400%+ of poverty

Hispanic

Black

White

Total

Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year

*Insurance for people ages 18–64.**Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

*

**

79

THE COMMONWEALTH

FUND

Previously Uninsured Medicare Beneficiaries With History of Cardiovascular Disease or Diabetes Have Much Higher Self-Reported Hospital Admissions After Entering Medicare Than Previously Insured

Source: J. M. McWilliams, et al., “Use of Health Services by Previously Uninsured Medicare Beneficiaries,” NEJM 357;2, Jul 12 2007.

Number of hospital admissions per 2-year period

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

58 60 62 64 66 68 70 72

Uninsured before age 65 Continuously insured before age 65

80

THE COMMONWEALTH

FUND

129

82

104

92

0

25

50

75

100

Obtained any medic al

c are

Rec eived no

rec ommended follow -up

c are

Health s tatus muc h

w orse after onset of new

c hronic c ondition

U ninsured Insured

Among Adults with New Onset of Chronic Condition, Uninsured Receive Less Care, Health Status More Likely to Worsen*

Notes: Analysis only includes nonelderly individuals who experienced the onset of a new chronic condition.*Differences between uninsured and insured in receipt of care and changes in health status are statistically significant at p≤0.002.Source: J. Hadley, "Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition," Journal of the American Medical Association, March 2007 297(10):1073–1084.

Percent

81

THE COMMONWEALTH

FUND

14.110.5 9.47.5

0

25

50

All older adults Older adults in lowest quartile of

household income

Uninsured Insured

Among Older Adults, Uninsured Have Significantly Higher Mortality Rates*

Notes: Analysis included adults age 55 to 64. Results are adjusted for individual characteristics using a propensity score matching technique.*Differences in mortality rates between uninsured and insured are statistically significant at p≤0.01.Source: J. M. McWilliams, A. M. Zaslavsky, E. Meara et al., "Health Insurance Coverage And Mortality Among The Near-Elderly," Health Affairs, July/August 2004 23(4):223–233.

Percent of 55–64 year olds dying over eight-year period

82

THE COMMONWEALTH

FUND

More than Half of Uninsured Adults Reported Problems Paying Medical Bills or Are Paying Off Medical Debt

34

211413

23 26

18

98

16

53

292626

42

0

25

50

75

Not able to pay

medical bills

Contacted by

collection

agency*

Had to change

way of life to pay

medical bills

Medical bills/

debt being paid

off over time

Any medical bill

problem or

outstanding debt

Total Insured all year Uninsured during the year

Percent of adults ages 19–64 who had the following problemsin past year:

*Includes only those individuals who had a bill sent to a collection agency when they were unable to pay it. Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

83

THE COMMONWEALTH

FUND

Percent of adults reporting: TotalInsured all year

Insured now, time uninsured

during year

Uninsured now

Unable to pay for basic necessities (food, heat or rent) because of medical bills

26% 19% 28% 40%

Used up all of savings 39 33 42 49

Took out a mortgage against your home or took out a loan

11 10 12 11

Took on credit card debt 26 27 31 23

One-Quarter of Adults With Medical Bill Burdens and Debt Were Unable to Pay for Basic Necessities

Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

Percent of adults ages 19–64 with medical bill problems or accrued medical debt:

84

THE COMMONWEALTH

FUND

7. The Individual Insurance Market is Not an Affordable Option for Many People

85

THE COMMONWEALTH

FUND

Adults ages 19–64 with individual coverage or who thought about or tried to buy it in past 3 years who: Total

Health Problem

No Health

Problem<200% Poverty

200%+ Poverty

Found it very difficult or impossible to find coverage they needed

34% 48% 24% 43% 29%

Found it very difficult or impossible to find affordable coverage

58 71 48 72 50

Were turned down or charged a higher price because of a pre-existing condition

21 33 12 26 18

Never bought a plan 89 92 86 93 86

Individual Market Is Not an Affordable Option for Many People

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 Well-being of American Families, The Commonwealth Fund, Sept 2006.

86

THE COMMONWEALTH

FUND

Two of Five Adults withIndividual Coverage Spent 5 Percent or More

of Income on Premium Costs

43

1416

25

45

0

25

50

75

Total ESI* Individual

Spent 5% or more of income on out-of-pocket premium

Spent 10% or more of income on out-of-pocket premium


*ESI = employer-sponsored insurance.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, The Commonwealth Fund, Sept 2006.

87

THE COMMONWEALTH

FUND

More than One-Third of Adults with Individual Coverage Have Annual Deductibles of $1,000 or More

12 12 11

10 8

37

0

25

50

75


Annual deductible $1,000 or more

Annual deductible $500–$999

22 20

48


*ESI = employer-sponsored insurance.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, The Commonwealth Fund, Sept 2006.

88

THE COMMONWEALTH

FUND

More than 2 in 5 Adults with Individual Coverage Spent 10 Percent or More of Their Household Income Annually on Family

Out-of-Pocket Expenses and Premiums

40 38

65

25 24

43

0

25

50

75

100


Spent 5% or more of income on out-of-pocket costs

Spent 10% or more of income on out-of-pocket costs


*ESI= employer-sponsored insurance.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, The Commonwealth Fund, Sept 2006.

89

THE COMMONWEALTH

FUND

More than Half of Older Adults with Individual Coverage Spend $3,600

or More Annually on Premiums

104

11

286

2

6

26

0

20

40

60

Total Insured Medicare ESI* Individual

Annual out-of-pocket premium $6,000 or more

Annual out-of-pocket premium $3,600–$5,999

16 17

54

Percent of insured adults ages 50–70

*ESI= employer-sponsored insurance.Source: S. R. Collins, C. Schoen, M. M. Doty, A. L. Holmgren, and S. K. How, Paying More for Less: Older Adults in the Individual Insurance Market, The Commonwealth Fund, June 2005.

6

90

THE COMMONWEALTH

FUND

Percent of Older Adults Spending 5% or 10% of Income on Out-of-Pocket Premiums, by Insurance Coverage

23 22 21

57

10 10 8

33

0

20

40

60

All Insured Medicare ESI* Individual

5% or more of income

10% or more of income



91

THE COMMONWEALTH

FUND

More than Two of Five Older Adults with Individual Coverage Have Annual Deductibles of $1,000 or More

10 712 12

8

2

7

42

0

20

40

60

Total Insured Medicare ESI* Individual

Annual deductible $1,000 or more

Annual deductible $500–$999

18 19

54



9

92

THE COMMONWEALTH

FUND

8. Rising Health Care Costs Relative to Income

93

THE COMMONWEALTH

FUND

Financial Burden for Low- and Middle-Income Families Is Increasing

7

16

2426

16

10

2324

33

19

0

25

50

Total <100% FPL 100–<200%

FPL

200–<400%

FPL

400%+ FPL

1996 2003

Note: Financial burden includes out-of-pocket expenditures on premiums for private insurance and other health care services.Source: J. S. Banthin and D. M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger Than 65 Years, 1996 to 2003,” JAMA 296(22):2712–19, Dec. 13, 2006.

Percent of nonelderly adults who spend >10% of disposable household income on out-of-pocket premiums and expenditures on health care services

94

THE COMMONWEALTH

FUND

16 Million Adults Under Age 65 Were Underinsured in 2005

Uninsuredduring the year

47.8(28%)

Insured, notunderinsured

108.6(63%)

Underinsured16.1(9%)

Adults 19–64

Note: Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Source: M. M. Doty, Analysis of the Commonwealth Fund Biennial Health Insurance Survey (2005).

95

THE COMMONWEALTH

FUND

0

1000

2000

3000

4000

5000

6000

0 100 200 300 400 500 600 700 800 900

a

a2002Note: Adjusted for differences in the cost of living, 2003.Source: B. K. Frogner and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2005, The Commonwealth Fund, April 2006.

Out-of-pocket health care spending per capita (US$)

National health expenditures per capita (US$)

United States

Australia

OECD Median

Canada

Japana

New Zealand

GermanyFranceNetherlands

Americans Spend More Out-of-Pocket on Health Care Expenses Than Citizens in Other Industrialized Countries

96

THE COMMONWEALTH

FUND

Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2007 Annual Survey.

Small-Firm Workers More Likely than Large-Firm Workers to Contribute Large Share of Premium

6

3

13

47

58

25

31

34

25

15

5

37

All Firms

Large Firms

(200+ workers)

Small Firms

(3–199 workers)

0% 1%–25% 26%–50% 51%+

Percentage of premium contributed by covered workers for family coverage, by firm size, 2007

97

THE COMMONWEALTH

FUND

Low Income Adults are Less Likely to Have Rx Benefits, Those without Rx Benefits Less Likely to Fill Rx, And More Likely to

Report Problems Paying Medical Bill

76

56

88

0

25

50

75

100

Total Under

200% of

poverty

200% of

poverty

or more

Percent of adults 19–64 withRx benefits

16

28

0

25

50

75

100

Insured with

Rx benefits

Insured, No Rx

Benefits

Percent of adults 19–64 who did not fill Rx due to cost

2330

0

25

50

75

100

Insured with

Rx benefits

Insured, No Rx

Benefits

Percent of adults 19–64 unable to pay medical bill

Source: C. L. Schur, M. M. Doty and M. L. Berk, Lack of Prescription Coverage Among the Under 65: A Symptom of Underinsurance, The Commonwealth Fund, February 2004.

98

THE COMMONWEALTH

FUND

Adults with High DeductiblesAre More Likely to Avoid Needed Health Care Because of Cost

168 11 12

2522

1217 19

3127

1926 24

44

0

25

50

75

Did not fi ll a

prescription

Did not see

specialist when

needed

Skipped

recommended

test, treatment,

or follow-up

Had medical

problem, did not

see doctor or

clinic

Any of the four

access

problems

<$500 $500–$999 $1,000+


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, The Commonwealth Fund, Sept 2006.

99

THE COMMONWEALTH

FUND

People With Capped Drug Benefits Have Lower Drug Utilization, Worse Control of Chronic Conditions; Cost Savings From Cap Are Offset by

Increases in Hospitalization and Emergency Room Use

15

27

21

39

2017

45

1718

31

26

40

2120

49

19

0

25

50 Benefits not capped Benefits capped

*HBP=high blood pressure. **Rate per 100 person-years. Source: J. Hsu et al., “Unintended Consequences of Caps on Medicare Drug Benefits,” New England Journal of Medicine 354, 22 (June 1, 2006):2349–2386.

Percent of drug nonadherence

Percent of poor physiological outcomes

Rate** of medical services use

100

THE COMMONWEALTH

FUND

Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases Risk of Adverse Events

15

9

14

22

0

5

10

15

20

25

Essential Less essential

Elderly Low income

Source: R. Tamblyn et al., “Adverse Events Associated with Prescription Drug Cost-Sharing Among Poor and Elderly Persons,” JAMA, Jan. 24/31, 2001 285(4):421–29.

Percent reduction in drugs per day

43

117

97

78

0

20

40

60

80

100

120

140

Adverse events ED visits

Elderly Low income

Percent increase in incidence per 10,000

101

THE COMMONWEALTH

FUND

Adults with High Deductibles Have Problems Paying Medical Bills or Are Paying Off Medical Debt

2317

6814

23

913

2735

41

31

17

5

20

0

25

50

75

Not able to pay

medical bills

Contacted by

collection

agency*

Had to change

way of life to

pay medical

bills

Medical bills/

debt being paid

off over time

Any medical bill

problem or

outstanding

debt

<$500 $500–$999 $1,000+

*Includes only those individuals who had a bill sent to a collection agency when they were unable to pay it.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, The Commonwealth Fund, Sept 2006.


102

THE COMMONWEALTH

FUND

Increased Health Care Costs Associated with Reduced Savings

Has increased spending on health care expenses in the past year caused you to do any of the following? Among those with health insurance coverage who had increases in health care costs in the last year (percentage saying yes)

45%

34%

29%

26%

24%

18%

53%

37%

33%

36%

28%

21%

2005

2006Decrease your contributions to a retirement plan, such as a 401(k),

403(b) or 457 plan, or an IRA

Have difficulty paying for other bills

Decrease your contributions to other savings

Use up all or most of your savings

Borrow money

Have difficulty paying for basic necessities, like food, heat, and

housing

Source: R. Helman and P. Fronstin, 2006 Health Confidence Survey: Dissatisfaction With Health Care System Doubles Since 1998, EBRI Notes, Vol. 27, No. 11, November 2006.

103

THE COMMONWEALTH

FUND

9. Consumer Driven Health Plans Not Attractive to Workers

104

THE COMMONWEALTH

FUND

Comprehensive = health plan with no deductible or <$1,000 (individual), <$2,000 (family).HDHP = high-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.CDHP = consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.Note: Percentages may not sum to 100% due to rounding.Source: P. Fronstin and S. R. Collins, The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006: Early Experience With High-Deductible and Consumer-Driven Health Plans, EBRI and The Commonwealth Fund, December 2006.

2005 2006

HDHP9%

CDHP1%

Comprehensive89%

HDHP7%

CDHP1%

Comprehensive92%

Very Few Americans Are Enrolled in Consumer Driven Health Plans

105

THE COMMONWEALTH

FUND

Satisfaction with Out-of-Pocket Costs for Health Care, by Type of Health Plan, 2006

21

33

46

55*

27*

18* 20*

53*

28

0

25

50

75

Extremely or very

satisfied

Somewhat satisfied Not too or not at all

satisfied

Comprehensive HDHP CDHP

Percent of privately insured adults 21–64

Comprehensive = health plan with no deductible or <$1,000 (individual), <$2,000 (family).HDHP = high-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.CDHP = consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006; P. Fronstin and S. R. Collins, The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006: Early Experience With High-Deductible and Consumer-Driven Health Plans, EBRI and The Commonwealth Fund, December 2006.

106

THE COMMONWEALTH

FUND

More Enrollees in Consumer Driven and High Deductible Health Plans Spend Large Share of Income on Out-of-

Pocket Medical Expenses and Premiums

Percent of privately insured adults 21–64 spending ≥ 5% of income

9 1120

1317

23

40*43*29*31*

23*29*

22* 24*

21

21*23

26

0

25

50

75

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

10%+ of income 5–9% of income

Total Health problem** <$50,000 annual income

22

44*51*

28

55* 52*

43

64* 66*

Comprehensive = health plan with no deductible or <$1,000 (individual), <$2,000 (family).HDHP = high-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.CDHP = consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.**Health problem defined as fair or poor health or one of eight chronic health conditions.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006; P. Fronstin and S. R. Collins, The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006: Early Experience With High-Deductible and Consumer-Driven Health Plans, EBRI and The Commonwealth Fund, December 2006.

107

THE COMMONWEALTH

FUND

Enrollees in Consumer Driven and High Deductible Health Plans More Likely to Delay or Avoid

Health Care When Sick Due to Cost


2923

19

3636*33*38* 4042*

0

25

50

75

Total Health problem** <$50,000 annual

income



108

THE COMMONWEALTH

FUND

Enrollees in Consumer Driven and High Deductible Health Plans More Likely To Report Not Filling a Prescription Due to Cost or

Skipping Doses to Make a Medication Last Longer


292722

3135*

29* 31* 3338*

0

25

50

75

Total Health problem** <$50,000 annual

income



109

THE COMMONWEALTH

FUND

Consumer Driven Health Plans (CDHPs) Unlikely to Solve Uninsured Problem – Few in CDHPs Uninsured Prior to Enrolling

53

2124 21*1920

10* 9*10*

0

25

50

75

Total Employment-based Individual


Percent of privately insured adults 21–64 without health insurance prior to enrolling in their current plan

Comprehensive = health plan with no deductible or <$1,000 (individual), <$2,000 (family).HDHP = high-deductible health plan with deductible $1,000+ (individual), $2,000+ (family), no account.CDHP = consumer-driven health plan with deductible $1,000+ (individual), $2,000+ (family), with account.*Difference between HDHP/CDHP and Comprehensive is statistically significant at p ≤ 0.05 or better.Source: EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006; P. Fronstin and S. R. Collins, The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006: Early Experience With High-Deductible and Consumer-Driven Health Plans, EBRI and The Commonwealth Fund, December 2006.

110

THE COMMONWEALTH

FUND

The Tax Benefits Of Health Savings Accounts Will Not Benefit Most Uninsured Adults

53% (0% tax bracket)




1% (28–35% tax

bracket)

Source: Glied and Remler, The Effect of Health Savings Accounts on Health Insurance Coverage, The Commonwealth Fund, April 2005. Updated with analysis of the Current Population Survey, 2006, by S. Glied and B. Mahato of Columbia University

Income Tax Distribution of Uninsured

111

THE COMMONWEALTH

FUND

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

U.S. population Health expenditures

Health Care Costs Concentrated in Sick FewSickest 10% Account for 64% of Expenses

1%5%

10%

49%

64%

24%

Source: S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration of Health Care Expenditures,” Health Affairs, Jan/Feb 2007 26(1): 249–257.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2003

50%

97%

$36,280

$12,046

$6,992

$715

Expenditure Threshold

(2003 Dollars)

112

THE COMMONWEALTH

FUND

10. Universal Health Insurance Is Essential to a High Performance Health System

113

THE COMMONWEALTH

FUND

Mortality Amenable to Health Care

97 97 99106 107 109 109

115 115

129 130 132

7584 88 88 88

8192

0

50

100

150

Fran

ceJa

pan

Spain

Swed

en Italy

Aus

tral

iaC

anad

aN

orw

ay

Net

herla

nds

Gre

ece

Ger

man

yA

ustr

ia

New

Zea

land

Den

mar

k

Uni

ted

State

sFi

nland

Irela

nd

Uni

ted

Kin

gdom

Portu

gal

Deaths per 100,000 population*

110

8490

103

119

134

U.S.avg

10th 25th Med-ian

75th 90th

Percentiles

Internationalvariation, 1998

State variation,2002

*Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease.See Technical Appendix for list of conditions considered amenable to health care in the analysis.Data: International estimates—World Health Organization, WHO mortality database (Nolte and McKee 2003);State estimates—K. Hempstead, Rutgers University using Nolte and McKee methodology.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

Mortality from causes considered amenable to health care (deaths before age 75 that are potentially preventable with timely and appropriate medical care)

114

THE COMMONWEALTH

FUND

7.0

5.3

6.0

7.1

8.1

9.1

U.S.avg

10th 25th Med-ian

75th 90th

Infant Mortality Rate, 2002

*2001.Data: International estimates—OECD Health Data 2005;State estimates—National Vital Statistics System, Linked Birth and Infant Death Data (AHRQ 2005a).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

2.2

3.0 3.03.3 3.5

4.1 4.1 4.1 4.2 4.2 4.4 4.4 4.5 4.55.0 5.0 5.0 5.0 5.1 5.2 5.4 5.6

7.0

0

5

10

Icel

and

Japa

nFi

nlan

dSw

eden

Norw

aySpa

inFr

ance

Austri

a

Czech

Rep

ublic

Ger

man

yBel

gium

Denm

ark

Italy

Switz

erla

ndNet

herla

nds

Austra

liaPor

tuga

lIre

land

Gre

ece

Unite

d Kin

gdom

Canad

a

New Z

eala

nd*

Unite

d Sta

tes

Infant deaths per 1,000 live births

Percentiles

International variation State variation

115

THE COMMONWEALTH

FUND

*Did not get medical care because of cost of doctor’s visit, skipped medical test, treatment, or follow-up because of cost, or did not fill prescription or skipped doses because of cost.UK=United Kingdom; CAN=Canada; AUS=Australia; NZ=New Zealand; US=United States.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

9

17

2934

40

0

40

80

UK CAN AUS NZ US

Percent of adults who had any of three access problems* in past year because of costs

Access Problems Because of Costs in Five Countries, Total and by Income, 2004

12

26

35

44

57

612

2429

25

UK CAN AUS NZ US

Below average income Above average income

119

THE COMMONWEALTH

FUND

11. What is the Employer Role in Achieving Universal Coverage?

120

THE COMMONWEALTH

FUND

Majority of Americans Believe Paying forHealth Insurance Should Be a Shared Responsibility

Shared by individuals, employers, and

government61%

Mostly individuals6%

Mostly employers8%

Mostly government17%

Note: Percentages may not sum to 100% because of rounding.Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

Who do you think should pay for health insurance?

Don’t know/refused7%

Percent of adults ages 19 and older

121

THE COMMONWEALTH

FUND

Americans Across U.S. Believe Paying forHealth Insurance Should Be Shared Responsibility

61 59 58 64 62

21 151517

17

871098

68746

0

20

40

60

80

100

Total Northeast Midwest South West

Mostly individuals

Mostly employers

Mostly government

Shared byindividuals,employers, andgovernment

Percent

Note: Does not include “don’t know/refused.”Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

122

THE COMMONWEALTH

FUND

Three-Quarters of Americans Believe that Employers Should Provide Health Insurance or Contribute to a Fund

to Cover Uninsured Workers

777584

78

0

20

40

60

80

100

Total Democrat Republican Independent

Percent of adults ages 19 and older

Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

123

THE COMMONWEALTH

FUND

What Are the Most Important Health Care Issues for Presidential and Congressional Action?

Percent listing issue asfirst or second priority: Total Republican Democrat Independent

Ensure that all Americans haveadequate, reliable health insurance

52 38 64 51

Control the rising cost of medical care

37 36 36 38

Lower the cost of prescription drugs 31 29 31 31

Ensure that Medicare remainsfinancially sound in the long term

29 28 30 30

Improve the quality of nursing homes and long-term care

14 17 14 11

Reform the medical malpractice system

14 24 6 16

Reduce the complexity of insurance 12 13 10 13

Source: C. Schoen, S. K. H. How, I. Weinbaum, J. E. Craig, Jr., and K. Davis, Public Views on Shaping the Future of the U.S. Health System, The Commonwealth Fund, August 2006.

124

THE COMMONWEALTH

FUND

Health Care Opinion Leaders: Views on Health Insurance and Expansion

5%

16%

21%

22%

29%

32%

32%

35%

38%

41%

43%

51%

46%

Permit association health plans to provide coveragewithout state licensing

Promote tax-free health savings accounts

Reinsurance for small business insurance plans

Individual mandate with tax credits for uninsured tobuy individual market coverage

Provide incentives or requirements to expandemployer-based health insurance

Provide tax credits or other subsidies to low-wageworkers to buy coverage

Establish a single-payer insurance system

Provide federal matching funds for Medicaid/SCHIPcoverage of everyone below 150% poverty

Let near-elderly adults buy into Medicare

Require employers who don't provide coverage tocontribute to a fund that would pay for such coverage

Allow individuals and small businesses to buy intoFEHBP or similar federal group option

Source: The Commonwealth Fund Health Care Opinion Leaders Survey, March 2006.

"Which of the following should be top priorities for action?"

Open up Medicare to those not coverage by an employer plan

Eliminate 2-year waiting period for the disabled for Medicare

125

THE COMMONWEALTH

FUND

Achievable and Desirable Goals for Health Insurance Coverage in Next 10 Years According to Health Care Opinion Leaders

18% 15%

63%

8%16%

65%

0%

20%

40%

60%

80%

Proportion of under-65

population that has no

health insurance

Total cost of health care

as a percentage of GDP

Percent of under-65

population with employer-

provided insurance

Current Goal

Note: Goal percentages represent median responses.Source: The Commonwealth Fund Health Care Opinion Leaders Survey, February 2005.

“What you would see as both an achievable and a desirable target or goal for policy action for the next 10 years?”

126

THE COMMONWEALTH

FUND

Percent of adults in favor of: Total Democrat Republican Independent

Letting uninsured adults participate in state government insurance programs like Medicaid or SCHIP

77% 84% 67% 78%

Letting uninsured adults participate in Medicare 76 81 70 74

Offering tax credits/other assistance to help people buy health insurance on their own

75 77 77 79

Requiring all businesses to contribute to the cost of health insurance for their employees

79 87 70 76

Americans, Regardless of Political Affiliation, Support Providing Health Insurance Coverage

to Uninsured Adults

Source: S. R. Collins, M. M. Doty, K. Davis et al., The Affordability Crisis in U.S. Health Care: Findings from the Commonwealth Fund Biennial Health Insurance Survey, The Commonwealth Fund, March 2004. The Commonwealth Fund Biennial Health Insurance Survey (2003).

127

THE COMMONWEALTH

FUND

11%18%

70%

0%

20%

40%

60%

80%

Seven in Ten People Say They Would Prefer to Continue With Their Current Level of Health Benefits Even If Premium Is Taxed

The amount of money employers currently spend on your health insurance premium is not counted toward your taxable income. If Congress were to pass a law so that part of your premium was taxed, which would you prefer? *Among those with employer-provided coverage (n=582)

To continue receiving current level of health benefits and pay any

taxes

To reduce the level of health

benefits and pay no taxes


Source: R. Helman and P. Fronstin, 2006 Health Confidence Survey: Dissatisfaction With Health Care System Doubles Since 1998, EBRI Notes, Vol. 27, No. 11, November 2006.

128

THE COMMONWEALTH

FUND

How Willing Would Firms Be to AssistEmployee Enrollment in Government AdministeredHealth Programs by Making Payroll Deductions onTheir Behalf to the State for the Premium Amount?

51%24%34%

45%35%

35%

39%38%

31%37%

0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat willing

Very willing

Firm size*Offer status

*Difference between subgroups is statistically significant at p<.05.Note: All figures are shown with employee-based weights.Source: H. Whitmore, S. R. Collins, J. R. Gabel, J. D. Pickreign, “Employer Views on Incremental Measures to Expand Health Insurance,” Health Affairs, November/December 2006.

Percent

86%

63%72%76%72%

129

THE COMMONWEALTH

FUND

If A Tax Credit Were Available to Help Low-Income Workers Pay for Health Insurance, How Willing Would Firms Be to Collect

Credit and Apply to Employee Share of Premium?

27%14%18%24%19%

53%

50%51%58%

51%

0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat willingVery willing

Firm size*Offer status*

Percent

80%

64%69%

82%70%


130

THE COMMONWEALTH

FUND

How Interested Would Firms Be in Providing anOption to Employees That Would Allow Employees and Their

Dependents to Participate in Public Health Insurance Programs, with Firms Paying Part of the Monthly Premium Cost?

15%6%9%15%10%

48%

36%41%

41%41%

0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat interested

Very interested


Percent

63%

42%50%

56%51%


131

THE COMMONWEALTH

FUND

How Interested Would Firms Be in Covering Employees Through the Same Insurance Program That

Covers State Public Employees or the Federal Insurance Program That Covers the United States Congress,

with Firms Paying at Least Part of the Monthly Premiums?

6%11%17%12%

43%

35%38%

40%39%

19%0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat interestedVery interested


Percent

62%

41%49%

57%51%


132

THE COMMONWEALTH

FUND

What Are Firms’ Views of the Importanceof the Government Offering Reinsurance to ProtectEmployers Against Catastrophic Health Care Costs,

Even if Employers Had to Pay Part of the Cost?

22%18%19%22%19%

47%41%42%

57%44%

0%

20%

40%

60%

80%

100%

Small firms

(3–199

workers)

Large firms

(200+

workers)

Offer health

benefits

Don't offer

health

benefits

All firms

Somewhat importantVery important

Firm size*Offer status*

Percent

69%59%61%

79%

63%


133

THE COMMONWEALTH

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How Interested Are Firms in Offering aHigh Performance Provider Network to Employees,

Even if It Means They Might Have a Smaller Numberof Providers to Choose From?*

16%

8%

21%

47%

51%

45%

0% 20% 40% 60% 80% 100%

All firms

Small firms (3–199 workers)

Large firms (200+ workers)

Very interested Somewhat interested

Percent

66%

59%

63%


134

THE COMMONWEALTH

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To Best of Firms’ Knowledge, Which of the Following Five Measures Would Be the Most Beneficial in Reducing Administrative Costs for

Employers, Insurers, and Providers?*

21%

22%

20%

18%

16%

20%

22%

14%

25%

17%

18%

16%

15%

12%

7%

8%

7%

21%

0% 20% 40% 60% 80% 100%

All firms

Small firms (3–199

workers)

Large firms (200+

workers)

Standardization of health benefits

Standardization of payment methods

Universally accepted quality performance standards for providers

J oint purchasing of health insurance by employers

J oint purchasing of health insurance by employers and public insurance programs

Don't know

Percent


135

THE COMMONWEALTH

FUND

StateYear law passed or

implementedLimiting age of

dependency statusApplies to non-

students?

Colorado 2006 25 Yes

Delaware 2006 24 Yes

Idaho 2007 25 No

Indiana 2007 24 Yes

Maine 2007 25 Yes

Maryland 2007 25 Yes

Massachusetts 2006 25 Yes

Minnesota 2007 25 Yes

New Hampshire 2007 26 Yes

New Jersey 2006 30 Yes

New Mexico 2005 25 Yes

Rhode Island 2006 25 No

South Dakota 2005 24 No

Texas 2003 25 Yes

Utah 1994 26 Yes

Washington 2007 25 Yes

West Virginia 2007 25 Yes

17 States Have Passed Laws That Increase the Age Up to Which Young Adults Are Considered Dependents for Insurance Purposes

Source: S. R. Collins, C. Schoen, J. L. Kriss, M. M. Doty, and B. Mahato, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated August 8, 2007 .

136

THE COMMONWEALTH

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Some Reform Proposals Achieve Near-Universal Coverage While Reducing Total Health System Spending

(Change in Health Spending by Stakeholder Group, Billions of Dollars, 2007)

President Bush’s

Proposal

Healthy Americans Act2

(Wyden)

Federal/State Partnership15 States

AmeriCare(Stark)

Total Uninsured Covered, Millions

9.0 45.3 20.3 47.8

Federal Government $70.4 $24.3 $22.0 $154.5

State and Local Government

($0.3) ($10.2) $13.4 ($57.4)

Private Employers ($50.8) $60.2 $5.7 ($15.2)

Households ($31.0) ($78.8) ($18.4) ($142.6)

Net Health System Cost in 2007 (in billions)

($11.7) ($4.5) $22.7 ($60.7)

Total Uninsured Not Covered1, Millions

38.8 2.5 27.5 0

1Out of an estimated total uninsured in 2007 of 47.8 million.2Estimates reflect a mandatory cash-out of benefits on the part of employers that currently offer coverage.Source: S. R. Collins, K. Davis, and J. L. Kriss, An Analysis of Leading Congressional Health Care Bills, 2005-2007: Part 1, Insurance Coverage, The Commonwealth Fund, March 2007.

137

THE COMMONWEALTH

FUND

Employer and Individual Mandates are Critical Elements in Achieving Universal Coverage in Mixed Private-Public Reform Proposals Like the

New Massachusetts Law

-4.4

22.7

8.12.8 4.6

3.1

5.87.8

5.6

-3.0

11.0

19.0

-5

5

15

25

35

45

Less generous

subsidies, no

mandate

More generous

subsidies, no

mandate

More generous

subsidies,

employer

mandate

More generous

subsidies,

individual

mandate

New group pool

Medicaid

Employer coverage

5.6 million

38.1 million

31.3 million

8.0 million

Source: J. M. Lambrew and J. Gruber, “Money and Mandates: Relative Effects of Key Policy Levers in Expanding Health Insurance Coverage to All Americans,” Inquiry 43: 333–344 (Winter 2006/2007).

Net changes in sources of coverage (millions of nonelderly)

138

THE COMMONWEALTH

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Survey Data

Current Population Survey, March 1988–2007

Medical Expenditure Panel Survey, 1997–2005

Panel of the Survey of Income and Program Participation (SIPP), 1996

The Commonwealth Fund Biennial Health Insurance Survey, 2001, 2003, 2005

The Commonwealth Fund Health Care Opinion Leaders Survey, 2005, 2006

The Commonwealth Fund Survey of Older Adults, 2004

The Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2006

Employee Benefits Research Institute/Commonwealth Fund Consumerism in Health Care Survey, 2005, 2006

Employee Benefits Research Institute Health Confidence Survey, 2001–2006

Kaiser/HRET Employer Health Benefits, Annual Survey, 2000 -2007

139

THE COMMONWEALTH

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Sources

J. S. Banthin and D. M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger Than 65 Years, 1996 to 2003,” JAMA 296(22):2712–19, Dec. 13, 2006.

J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard on Health System Performance, The Commonwealth Fund Commission on a High Performance Health System, June 2007.

S. R. Collins, K. Davis, M. M. Doty, and A. Ho, Wages, Health Benefits, and Workers' Health, The Commonwealth Fund, October 2004.

S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, The Commonwealth Fund, April 2006.

S. R. Collins, K. Davis, and J. L. Kriss, An Analysis of Leading Congressional Health Care Bills, 2005–2007: Part 1, Insurance Coverage, The Commonwealth Fund, March 2007.

S. R. Collins, K. Davis, C. Schoen, M. M. Doty, and J. L. Kriss, Health Coverage for Aging Baby Boomers: Findings from the Commonwealth Fund Survey of Older Adults, The Commonwealth Fund, January 2006.

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, The Commonwealth Fund, June 2005.

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, The Commonwealth Fund, March 2004.

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, The Commonwealth Fund, September 2006.

S. R. Collins, C. Schoen, D. Colasanto, and D. A. Downey, On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003.

140

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Sources continued

S. R. Collins, C. Schoen, M. M. Doty, A. L. Holmgren, and S. K. How, Paying More for Less: Older Adults in the Individual Insurance Market, The Commonwealth Fund, June 2005.

S. R. Collins, C. Schoen, J. L. Kriss, M. M. Doty, and B. Mahato, Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, Updated August 8, 2007.

The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from a National Scorecard on U.S. Health System Performance, The Commonwealth Fund, September 2006.

G. Claxton, J. Gabel et al., "Health Benefits in 2007: Premium Increases Fall To An Eight-Year Low, While Offer Rates And Enrollment Remain Stable," Health Affairs, September/October 2007 26(5):1407–1416.

E. Ditsler, P. Fisher, and C. Gordon, On the Fringe: The Substandard Benefits of Workers in Part-Time, Temporary, and Contract Jobs, The Commonwealth Fund, December 2005.

M. M. Doty and A. L. Holmgren, Health Care Disconnect: Gaps in Coverage and Care for Minority Adults, The Commonwealth Fund, August 2006.

M. M. Doty and A. L. Holmgren, Unequal Access: Insurance Instability Among Low-Income Workers and Minorities, The Commonwealth Fund, April 2004.

L. Duchon, C. Schoen, M. M. Doty, K. Davis, E. Strumpf, and S. Bruegman, Security Matters: How Instability in Health Insurance Puts U.S. Workers at Risk, The Commonwealth Fund, December 2001.

J. N. Edwards, S. How, H. Whitmore, J. R. Gabel, S. Hawkins, and J. D. Pickreign, Employer-Sponsored Health Insurance in New York: Findings from the 2003 Commonwealth Fund/HRET Survey, The Commonwealth Fund, May 2004.

B. K. Frogner and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2005, The Commonwealth Fund, April 2006.

141

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Sources continued

P. Fronstin and S. R. Collins, The 2nd Annual EBRI/Commonwealth Fund Consumerism in Health Care Survey, 2006: Early Experience With High-Deductible and Consumer-Driven Health Plans, The Commonwealth Fund, December 2006.

T. Gilmer and R. Kronick, “It’s the Premiums, Stupid: Projections of the Uninsured Through 2013,” Health Affairs Web Exclusive, April 5, 2005.

E. Gould, Health Insurance Eroding for Working Families: Employer-Provided Coverage Declines for Fifth Consecutive Year, Economic Policy Institute, Sep. 28, 2006.

J. Hadley, "Insurance Coverage, Medical Care Use, and Short-term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition," Journal of the American Medical Association, March 2007 297(10):1073–1084.

R. Helman and P. Fronstin, 2006 Health Confidence Survey: Dissatisfaction With Health Care System Doubles Since 1998, EBRI Notes, Vol. 27, No. 11, November 2006.

J. Hsu, M. Price, J. Huang, R. Brand, V. Fung, R. Hui, B. Fireman, J. P. Newhouse, and J. V. Selby, “Unintended Consequences of Caps on Medicare Drug Benefits,” New England Journal of Medicine 354, 22 (June 1, 2006):2349–2386.

K. Klein, S. A. Glied, and D. Ferry, Entrances and Exits: Health Insurance Churning, 1998–2000, The Commonwealth Fund, September 2005.

J. Lambrew, "Choice" in Health Care: What Do People Really Want?, The Commonwealth Fund, September 2005.

J. M. Lambrew and J. Gruber, “Money and Mandates: Relative Effects of Key Policy Levers in Expanding Health Insurance Coverage to All Americans,” Inquiry 43: 333–344 (Winter 2006/2007).

J. M. McWilliams, E. Meara, A. M. Zaslavsky, and J. Z. Ayanian, “Use of Health Services by Previously Uninsured Medicare Beneficiaries,” NEJM 357;2, Jul 12 2007.

J. M. McWilliams, A. M. Zaslavsky, E. Meara, and J. Z. Ayanian, "Health Insurance Coverage And Mortality Among The Near-Elderly," Health Affairs, July/August 2004 23(4):223–233.

142

THE COMMONWEALTH

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J. A. Rhoades and M. C. Chu, The Uninsured in America, 1996–2006: Estimates for the U.S. Civilian Noninstitutionalized Population under Age 65, Agency for Healthcare Research and Quality, Statistical Brief #169, June 2007.

C. Schoen, M. M. Doty, S. R. Collins, and A. L. Holmgren, “Insured But Not Protected: How Many Adults Are Underinsured?,” Health Affairs Web Exclusive, June 14, 2005 W5-289–W5-302.

C. Schoen, S. K. H. How, I. Weinbaum, J. E. Craig, Jr., and K. Davis, Public Views on Shaping the Future of the U.S. Health System, The Commonwealth Fund, August 2006.

C. L. Schur, M. M. Doty and M. L. Berk, Lack of Prescription Coverage Among the Under 65: A Symptom of Underinsurance, The Commonwealth Fund, February 2004.

P. F. Short, D. R. Graefe, and C. Schoen, Churn, Churn, Churn: How Instability of Health Insurance Shapes America’s Uninsured Problem, The Commonwealth Fund, November 2003.

R. Tamblyn et al., “Adverse Events Associated with Prescription Drug Cost-Sharing Among Poor and Elderly Persons,” JAMA, Jan. 24/31, 2001 285(4):421–29.

H. Whitmore, S. R. Collins, J. R. Gabel, and J. D. Pickreign, “Employer Views on Incremental Measures to Expand Health Insurance,” Health Affairs, November/December 2006.

H. Whitmore, S. R. Collins, J. D. Pickreign, and J. R. Gabel, Expanding Health Insurance Coverage Through Incremental Reforms: Snapshots of Employer Views (chartpack), The Commonwealth Fund and the Center for Studying Health System Change, November 2006.

S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration of Health Care Expenditures,” Health Affairs, Jan/Feb 2007 26(1): 249–257.

Sources continued

the future of employer-sponsored health insurance

Documents

health insurance coverage

health insurance churning

employerbased coverage

employer coverage relative

millionother employer

cost of health benefits

future of employer

employer role