figure es-1. how well do different strategies meet principles for health insurance reform?...
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Figure ES-1. How Well Do Different StrategiesMeet Principles for Health Insurance Reform?
Principles for Reform
Tax Incentives and Individual Insurance
Markets
Mixed Private–Public Group Insurance with Shared Responsibility
for Financing Public Insurance
Covers Everyone 0 + +Minimum Standard Benefit Floor – + +Premium/Deductible/Out-of-Pocket CostsAffordable Relative to Income
– + +
Easy, Seamless Enrollment 0 + ++Choice + + +Pool Health Care Risks Broadly – + ++Minimize Dislocation, Ability to Keep Current Coverage + ++ –
Administratively Simple – + ++Work to Improve Health Care Quality and Efficiency 0 + +
0 = Minimal or no change from current system; – = Worse than current system;+ = Better than current system; ++ = Much better than current system
Figure 1.
Figure 2. Employer-Provided Health Insurance,by Income Quintile, 2000–2006
88% 88% 87% 87% 87% 87% 86%
86% 85% 84% 84% 83% 82% 82%77% 77% 75% 74% 74% 72% 72%
62% 60%57% 55% 54% 54% 53%
22%29% 26% 25% 23% 23% 22%
0%
20%
40%
60%
80%
100%
2000 2001 2002 2003 2004 2005 2006
Highestquintile
Fourth
Third
Second
Lowestquintile
Source: Analysis of the March Current Population Survey, 2001–07, by Elise Gould, Economic Policy Institute.
Percent of population under age 65 with health benefits from employer
Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecardon Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.
Figure 3. Percentage of Uninsured Children Has DeclinedSince Implementation of SCHIP, but Gaps Remain
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: 12.0%
Figure 4. Uninsured Nonelderly Adult Rate Has Increasedfrom 17.3 Percent to 20.0 Percent in Last Five Years
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
Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecardon Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.
Figure 5. Prevalence of High Family Out-of-PocketCost Burdens by Poverty Status Among the
Nonelderly Population, 1996 and 2003
7.1
15.6
24.125.9
15.89.7
22.723.7
33.3
19.2
0
25
50
75
Total <100% FPL 100%–<200%
FPL
200%–<400%
FPL
400%+ FPL
1996 2003
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,” Journal of the American Medical Association, Dec. 13, 2006 296(22):2712–19.
Percent of nonelderly adults who spend >10% of disposable household income on out-of-pocket premiums and expenditures on health care services
* 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 Rx 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
Figure 6. 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
Figure 7. Receipt of All Three Recommended Servicesfor Diabetics, by Race/Ethnicity, Family Income,
Insurance, and Residence, 2002
45
55
54
46
50
61
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.
*
**
Figure 8. Adults Without Insurance Are Less Likelyto Be Able to Manage Chronic Conditions
161827
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, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).
Figure 9. Receipt of Recommended Screening and Preventive Care for Adults, by Family Income and Insurance Status, 2002
31
46
52
39
48
56
49
0 50 100
Uninsured all year
Uninsured part year
Insured all year
<200% of poverty
200%–399% of poverty
400%+ of poverty
National
Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*
* Recommended care includes seven key screening and preventive services: blood pressure,cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year
Figure 10. 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
48
49
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
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.
* Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enough time and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits.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.
23
53
58
39
53
36
60
46
30
31
0 50 100
Uninsured
Private insurance
<100% of poverty
400%+ of poverty
Hispanic
Black
White
Bottom 10% states
Top 10% states
U.S. average
Figure 11. Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003
Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated*
Figure 12.
Figure 13. People with Capped Drug Benefits HaveLower Drug Utilization, Worse Control of Chronic Conditions
14.6
26.5
21.2
38.5
19.617
45.2
16.618.1
31.4
26.2
39.5
21.319.7
49.2
18.7
0
25
50
Anti-HBP drugs
Lipid-lowerin
g drugs
Antidiabetic
drugs
High BP
High cholesterol
High blood glucose levels
ED visits
Nonelective hospita
lizations
Benefits Not Capped Benefits Capped
* Rate per 100 person-years.Source: J. Hsu, M. Price, J. Huang et al., “Unintended Consequences of Caps on Medicare Drug Benefits,”New England Journal of Medicine, June 1, 2006 354(22):2349–59.
Percent of Drug Nonadherence
Percent of Poor Physiological Outcomes
Rate* of Medical Services Use
Figure 14. Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases Risk of Adverse Events
9
1514
22
0
5
10
15
20
25
Essential Less Essential
Elderly Low Income
Source: R. Tamblyn, R. Laprise, J. A. Hanley et al., “Adverse Events Associated with Prescription Drug Cost-SharingAmong Poor and Elderly Persons,” Journal of the American Medical Association, Jan. 24/31, 2001 285(4):421–29.
Percent reduction in drugs per day
117
43
97
78
0
20
40
60
80
100
120
140
Adverse Events ED Visits
Elderly Low Income
Percent increase in incidence per 10,000
Figure 15. Many Americans Have ProblemsPaying Medical Bills or Are Paying Off Medical Debt
34
211413
23 2618
9816
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 problems in past year:
* Includes only those 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, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).
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 home or took out a loan
11 10 12 11
Took on credit card debt 26 27 31 23
Figure 16. One-Quarter of Adults with Medical Bill Burdensand 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, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).
Percent of adults ages 19–64 with medical bill problemsor accrued medical debt
Figure 17. Increased Health Care CostsAssociated 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: EBRI Health Confidence Survey, 2005 and 2006.
Figure 18. International Comparison of Spending on Health, 1980–2005
0
1000
2000
3000
4000
5000
6000
7000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
0
2
4
6
8
10
12
14
16
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.Updated data from OECD Health Data 2007.
Figure 19. Americans Spend More Out-of-Pocketon Health Care Expenses
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$0 $100 $200 $300 $400 $500 $600 $700 $800 $900
a2003b2003 Total Health Care Spending, 2002 OOP Spending
ba
United States
OECD Median
New Zealand
Netherlands
Japan
GermanyFrance CanadaAustralia
a
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
Total health care spending per capita
Out-of-pocket spending per capita
* 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).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, Sept./Oct. 2007 26(5):1407–16. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.
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
20Health insurance premiums
Workers’ earnings
Overall inflation
National health expendituresper capita
Figure 20. Increases in Health Insurance PremiumsCompared with Other Indicators, 1988–2007
Percent
Figure 21. Health Expenditure Growth 2000–2005for Selected Categories of Expenditures
12.0
8.6 8.0 7.96.1
10.7
0
5
10
15
20
Total Hospital care Physician &clinical services
Nursing home &home health
Prescriptiondrugs
Prog. admin. &net cost of
private healthinsurance
Average annual percent growth in health expenditures, 2000–2005
Source: A. Catlin, C. Cowan, S. Heffler et al., “National Health Spending in 2005: The Slowdown Continues,”Health Affairs, Jan./Feb. 2007 26(1):142–53.
Figure 22. Percentage of National Health ExpendituresSpent on Health Administration and Insurance, 2003
Net costs of health administration and health insuranceas percent of national health expenditures
1.9 2.1 2.12.6
3.34.0 4.1 4.2
4.8
5.6
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
tates
a b c *
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.
Figure 23. Employers Provide Health Benefits to More than160 Million Working Americans and Family Members
Source: Current Population Survey, March 2007.
Uninsured47.0
(16%) Employer 163.3(55%)
Medicaid27.9(9%)
Medicare39.1
(13%)
Total population = 296.7 Under-65 population = 260.7
Employer 160.8(62%)
Uninsured46.4
(18%)
Medicaid27.9
(11%)
Medicare6.4
(2%)
Military3.4
(1%) Military3.4
(1%)Individual16.0(5%) Individual
15.8(6%)
Numbers in millions, 2006
Figure 24. How Well Do Different StrategiesMeet Principles for Health Insurance Reform?
Principles for Reform
Tax Incentives and Individual Insurance
Markets
Mixed Private–Public Group Insurance with Shared Responsibility
for Financing Public Insurance
Covers Everyone 0 + +Minimum Standard Benefit Floor – + +Premium/Deductible/Out-of-Pocket CostsAffordable Relative to Income
– + +
Easy, Seamless Enrollment 0 + ++Choice + + +Pool Health Care Risks Broadly – + ++Minimize Dislocation, Ability to Keep Current Coverage + ++ –
Administratively Simple – + ++Work to Improve Health Care Quality and Efficiency 0 + +
0 = Minimal or no change from current system; – = Worse than current system;+ = Better than current system; ++ = Much better than current system