Running Head: THE UNINSURED AND NDERINSURED IN...

Running Head: THE UNINSURED AND UNDERINSURED IN HEALTHCARE 1

Brenda Rivas

Workshop 5

The Uninsured and Underinsured in Healthcare

Critical Issues in Healthcare

Professor Chris Tokonitz

December 2, 1013


Uninsured and Underinsured

Working for a Healthcare organization we are constantly changing and evolving we have

gone through changes in structure, laws, the rise of the uninsured patients and we are starting to

see a rise of underinsured patients. Today in healthcare we are experiencing many changes and

challenges when it comes to the Affordable Care Act, the health exchange, and how we are going

to be reimbursed. With all the changes that are taking place we can no longer choose if we want

to move forward with the changes if we want to be successful and continue being a leader in

patient care. We have to look at ways that we can evolve with the changes and how it is going to

affect us a health care organization and our patients.

We have always dealt with uninsured patients but when the recession happened in 2007-

2008 we saw an increase to individuals that lost their jobs, lost their insurance, some of these

individuals did not qualify for Medicaid they were receiving unemployment benefits and did not

meet the income guidelines or Medicaid had cut their funds and only insured children or mothers

that are expecting qualified, government programs were being cut such as behavior health,

employers could no longer afford to offer health insurance because of the cost, or the cost of

employee’s premiums went up and employees are no longer able to afford it. These are some of

issues that we are dealing with the rise of the uninsured and it affects individuals because they no

longer have access to receive care when they become ill. These individuals end up in our

emergency room or end up being admitted because they took so long to seek treatment and their

condition worsened. This is affecting not only the patients trying to figure out how they will pay

for their medical bills but it also affects us as a health care facility that provides the care but most

likely will end up writing off the balance to charity or bad debt if the patient has inability to pay.

This is does not imply that all uninsured patients do not pay their medical bills we do have


patients that make arrangements on their balances by paying their remaining balances in full or

setting up payment arrangements.

36th

Annual report from the CDC (Center of Disease and Control) it states that 20% of

U.S. adults reported to be seen at the emergency room once in the past year it also states that in

2001-2011 children under the age of 18 and adults ages 18-64 were seen at the emergency room

that carried Medicaid coverage and also private insurance, this contradicts the reports that are

reviewed by health care organization we are seeing an increase of adjustments due to charity or

bad debt and the lack of revenue coming in the door. Even though Medicaid patients are walking

into our emergency rooms we are only getting paid pennies on the dollar and the individuals that

carry private insurance they can potentially end up with high deductibles, high out of pocket, or

high co pay. We eventually have to end up writing the balances off to charity or bad debt and for

our Medicaid patients we take a larger contractual adjustment since we are unable to bill patient

for the remaining balance based on our contracts as an organization we are still affected at the

end.

As a health care facility we are reporting a rise in the uninsured and underinsured we are

having to consistently look at how we are going to shift cost in the past to be able to continue

providing charity care and be able to continue to offer benefits to the communities we serve. In

the past based on our contractual agreement contracts we set with insurance companies we could

shift some of the cost to them but now they are also looking at ways to reduce their cost. They

can no longer afford to have higher cost and are asking health care facilities to reevaluate their

contracts for us to be able to continue to work with them or we can potentially lose them and an

Insurance carrier that considers us within in network and this affects our patients. Insurance

companies now are reimbursing services at a lower percentage and leaving patients with higher


out of pockets. They are also denying claims and we have to end up adjusting it because based

on the patient’s insurance coverage patient is not responsible for the remaining balance.

Below is a graph that shows you the rise in the uninsured from 2007-2012 and which the

graph shows that in 2011-2012 we saw slight decrease we still have many individuals with no

health insurance that are adults and children.

The reason why we are seeing a decrease in children being covered because of the expansion of

Medicaid and the expansion of the CHIP (Children Health Insurance Act) program to cover all

children up to the age of nineteen that did not qualify for Medicaid because they did not meet the

income guidelines but could apply for CHIP but would end up with minimal out of pocket

expense. We also are seeing a decrease in adults because the Affordable Care Act (ACA) now

has a rule in place that if parents choose they can cover their adult child to the age of twenty six

and they do not have to be enrolled in school to be able qualify based on the new guidelines.

Individuals that are uninsured it does not mean that they are currently not employed there

is also a rise in uninsured employees that work for small and large companies, studies show that


when the recession hit employers could no longer afford to insure their employees because it

affected their business they had declines in manufacturing jobs, changes in structure. In, 1987 to

2001 the proportion of uninsured workers who were employed by firms of 500 or more

employees grew from 25 to 32 percent. The growing share of uninsured workers employed by

larger firms, Sherry Glied, Jean Lambier, and Sarah Little, The Commonwealth Fund, October

2012. The workers that were affected the most are the low wage work force they do not make

enough to pay for insurance and are part of one income household.

As we see a slight decrease in the uninsured we are starting to see an increase in

individuals that are underinsured that carry insurance but they now have to pay higher premiums

and more out of pocket because the insurance that their employer offers is not the best insurance

they selected for their company because they also had to shift their cost. This leaves the

employees with having to make choice to carry insurance or opt out or only cover insurance for

themselves versus purchasing insurance for the entire family because they are not able to afford


it or are worried about high deductibles, possible high prescription cost and they do not make

enough money to pay for balance owing after insurance has paid.

The underinsured are also affect us as a Health Care facility depending on the plan the

employees opted for we are being reimbursed at a lower rate, insurance companies deny certain

procedures that are no longer covered and depending on the plan selected patients are no longer

in net work and are not able to see our physicians or have procedures at our health care facilities.

The patient now has to make a decision to continue seeing their physician that they have seen for

years and pay a higher out of pocket or choose to be seen by a physicians that is in network or

facilities that would only leave them with a co pay. If patients choose to stay with their physician

or healthcare facility but are not able to afford to pay for their remaining balance after their

insurance has been billed after making attempts to collect as a health care organization we end up

having to make decisions to write these accounts off to bad debt or patients submit an application

to see if they qualify for charity care adjustment. The patient already have a hard time trying to

understand their insurance coverage and they do not pay attention until they get a statement

showing a balance due. Not only do the patients lose in this situation as an organization we lose

because our patients can lose faith in us or we end up affecting patient’s credit because at one

point we have to make the decision to adjust it to bad debt. Here is a graph that helps you

understand how many individuals are underinsured in health care.


Exhibit ES-2. In 2012, Nearly Half of Adults Were Uninsured During

the Year or Were Underinsured

Note: Numbers may not sum to indicated total because of rounding.

* Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but

experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled

5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income.

Source: The Commonwealth Fund Biennial Health Insurance Survey (2012).

Insured all

year, not

underinsured^

54%

100 million

184 million adults ages 19–64

Insured

all year,

underinsured^

16%

30 million

Uninsured during

the year*

30%

55 million

We know what is happening in our health care facilities but now the question is what do

we do about it? What are our challenges? And how do we set ourselves up for success with the

changes in the Affordable Care Act, health exchange, moving from a fee for service to global

payments and also providing the best quality of care to our patients.

I decided to a SWOT analysis on the ACA to see where they, strengths, weaknesses,

opportunities, and threats are at, below is the chart I came up with on this it shows that they have

more strengths than other areas but there is a lot of work that needs to be done.


Strengths

Access to Healthcare

No Pre Existing Conditions

Parents with Children on Medicaid

Medicaid- Cover Oregon

Federal Grant SNAP/CHIP

Coverage Options

Tax Credit lower monthly payments

Weaknesses

Tax Penalty

Certain Coverage does not apply to

individuals

Reimbursement

Opportunities

Raise Tax Penalty

Functional Site

Threat

Bronze Coverage

Overestimated how many individuals

would sign up for coverage

Website not working

Brokers

As shown in the SWOT Analysis there are many strengths that are going to assist in the

reduction of the uninsured by having insurance available to millions of individuals, no longer

having pre existing conditions restrictions and must spend $.80 of every premium dollar on care.


For example insurance companies in the past could deny your care if you had were previously

diagnosed with the condition you were being treated for and this caused for patient to either

discontinue there treatment or have to figure out how they were going to pay for balance owing

especially if the diagnosis they were dealing with was life or death this is a big win for

individuals. It is going to assist individuals with a tax credit to help reduce their insurance

premiums they have to meet certain guidelines to qualify. According to the IRS.gov website here

are the guidelines to qualify for a tax credit.

Buy health insurance through market place

Are ineligible for coverage through employer or government plan

Are within certain income limits

Filed a joint return if married and

Cannot be claimed as an dependant

While it has is strengths it also has weaknesses such as the tax penalty individuals can opt

not to apply for insurance and they will pay a fee 1% of their yearly income or $95 per person

whichever is higher and if parents choose not to insure they children they have to pay $47.50 per

child capped at $285 these fees will continue to increase every year and in 2016 it will increase

to 2.5% of income or $695 per person or whichever is higher. As a health care organization we

will be affected if individuals decide that they would rather pay for a one time penalty versus

having to pay a monthly premium especially those individuals that are currently struggling to

make ends meet and they have to choose if they will have money to spend on food or have pay

for their monthly premiums. We will also have the individuals that feel they do not get sick often

and opt out to receive health care benefits and rather endure the penalty cost. These individuals

end up at our health care facilities and we will continue to offer them care but we end up with


large debt that is owed to us. The tax penalty is set to increase in 2016 to 2.5% of income or

$695 per person, whichever is higher but this does not guarantee that individuals will choose to

apply for insurance.

Another strength would be that starting January of 2014 when patients presents

themselves at our health care facilities we can potentially qualify them onsite for Medicaid

coverage with the new Medicaid Expansion Cover Oregon as long as they meet the Federal

poverty guidelines that was increased to 138% from 100% if they meet income guidelines they

will be pre approved and it will cover their initial visit and follow up care for up to 30 days

while patient submits additional information needed to process their application. Even though

Medicaid is only reimburses us cents on the dollar this will be a win for us because in the past we

would have to adjust all of it off to charity or bad debt.

Below is a graph of our current 2013 Federal Poverty Level


Event though we can get individuals pre approved when they present themselves in the

emergency room one our biggest threats is that we overestimated how many individuals would

sign up by 2014 as an organization we are looking at being able to offset the cost by depending

on healthy young adults to obtain insurance even if they only purchase the bronze package that

covers their services at 60% this will still offset any catastrophic cost. The reality is that we are

not seeing an increase on individuals signing up for health care insurance and some of the

challenges that we are running into first and foremost is that Cover Oregon is not up and running

and the only applications that are being processed currently are paper applications and the people

that qualify for Medicaid are the ones that are getting priority over other regular insurance

coverage. This is discouraging individuals from applying and blaming the President Obama and

the Democrats that this was put in place and it is not working effectively. This is not the first

time this has happened when Medicare Part D was passed after several years of trying to get it

was enacted in 2003 things did not run smoothly an at the time this was put in place President

George Bush was in office. Rep. Steve Israel said in an interview on MSNBC, “When things go

wrong, there are two things we can do as a country. We can spend all our time figuring out who

to blame or we can spend all our time figuring out how to fix it”. He also stated, after eight years

of having Medicare Part D in place the seniors are happy and they seem to use it. The health care

exchange implementation is not running as smooth as expected and it will have an effect to our

health care organization because we planned to have millions of individuals insured by January

of 2014 and we started to budget for that but now we have to go back and revisit our strategic

plan and figure out how we are still going to meet the community’s needs while operating we

continue to service the same amount of patients with or without insurance.

Another area that I was able to look at in my SWOT analysis is that many are under the

impression that ACA is going to solve all our problems when it comes to the uninsured patients


According to the Federation for American Immigration Reform (FAIR) there is an estimate of

11.2 million individuals that are living in the Unites States illegally the illegal immigrants will

not be able to qualify for benefits based of the ACA guidelines. This does not mean that all 11.2

individuals are not working there is an estimate that 8 million of them are currently working and

are hired by companies that know they can pay them less than the minimum wage or they can

obtained fake documentation . These individual could potentially purchase insurance from a 3rd

party broker but the premiums can be costly or they still would not qualify depending on the

state they reside in. An article from The California Report states “Undocumented immigrants are

barred from purchasing health insurance on the California marketplace even if they have the

money to pay for it” These individuals will continue to seek care in our health care facilities and

we will continue to treat them but will be a loss for us since we potentially will have to write the

balances off. Below is data showing how many individuals are currently illegal immigrants but

are working and by states that have reported 5,000 and above individuals.

State Jobs Taken

Alabama 89,550

Alaska 7,165

Arizona 279,395

Arkansas 39,400

California 1,887,695

Colorado 139,700

Connecticut 85,965

DC 25,075

Delaware 21,490

Florida 587,440

Georgia 322,375

Hawaii 21,490

Idaho 21,490

Illinois 394,015

Indiana 85,965

Iowa 46,565


Kansas 50,145

Kentucky 35,820

Louisiana 42,985

Maryland 211,335

Massachusetts 136,115

Michigan 82,385

Minnesota 71,640

Mississippi 21,490

Missouri 42,985

Nebraska 28,655

Nevada 143,280

New Hampshire

10,745

New Jersey 293,720

New Mexico 71,640

New York 537,295

North Carolina 293,720

Ohio 78,805

Oklahoma 60,895

Oregon 121,785

Pennsylvania 128,950

Rhode Island 25,075

South Carolina 50,145

Tennessee 85,965

Texas 1,296,670

Utah 71,640

Virginia 186,260

Washington 197,010

Wisconsin 68,055

Data taken from (http://www.fairus.org/issue/illegal-aliens-taking-u-s-jobs)

http://www.fairus.org/issue/illegal-aliens-taking-u-s-jobs


As we look as some of our challenges we have to also look at the things that are going

well and the State of Oregon was able to receive a waiver from the Federal Government for

individuals that are currently receiving SNAP benefits (Supplemental Nutrition Assistance

Program) or have children that currently enrolled in Medicaid over 260,000 individual received

letters that were mailed out on September 26 with an enrollment form and they do not have to

apply through the exchange they just need to return the form or contact Medicaid office. As of

today it is estimated that about 56,000 individuals have enrolled and will be effective as of

January 1, 2014. Also, the individuals that are currently have Medicaid coverage with will be

automatically signed up for Cover Oregon what does this mean for an individual that they will

start receiving more benefits such as preventative/wellness care, Mental and Behavioral health,

prescription drugs, laboratory services, and this is just some that they did not have with their

current Medicaid coverage. How does this help health care organization patients will have better

coverage that will provide them with the care that they need and those services will be covered

instead of health care organization having to eat the cost because most likely they were already

performing the services and will have less to adjust to contractual, charity, or bad debt.

Underinsured individuals that have insurance but their current insurance does not qualify

based on the guidelines of the Qualifying Health Plan they have 10 key things they need to be

able to offer individuals for them to be able to sell health insurance to individuals. These are the

10 key things they have to have:

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care


5. Mental health and substance use disorder services, including behavioral health treatment

6. Prescription drug

7. Rehabilitative and habilitative services and device

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

(http://obamacarefacts.com/obamacare-health-insurance-exchange.php)

If they do not have these employees can apply through the exchange and potentially will pay less

out of pocket but receive more benefits. One of the issues that employee are currently having to

face is that they are receiving cancellation notices from their current health insurance because

they do not meet the 10 key points that QHP requires. It has been left to individual states to

approve for people that have received cancellation notices for their insurance to be rein instated

and it will affect us because all those individuals had great coverage and we will end up with

higher out of pocket expensed and premium cost from the individuals that are sick and are going

through the exchange. The health exchange is broken down by different packages Bronze, Silver,

Gold, and Platinum packages. Graph below illustrates what percentage is covered based on the

packages that are purchased

http://obamacarefacts.com/obamacare-health-insurance-exchange.php


Graph taken from (http://obamacarefacts.com/obamacare-health-insurance-exchange.php)

The health exchange can be a great for individuals that are lacking coverage, seeking coverage

but as many benefits as it covers some individuals are not happy that they will have to pay for

services that are not needed for example; a single male does not need maternity and new born

care, or pediatric services but they new health care package includes this and some individuals

would like the option to pay less for services that they are not going to use. The exchange has it

cons but overall even if you are not using certain services it still provides a much larger coverage

for other benefits that possibly were not covered by your current insurance.

We have talked about some of the pros and cons that come with the ACA and the health

care exchange but what can we do as a company to get ahead of all these changes or evolve with

the changes. One of the areas that I wanted to touch on is “How will it affect our Charity dollars

and our community benefits” I had the pleasure to sit down and interview Lesa Ellis, Director of

Financial Assistance and Charity care at Providence Health and Services (L.Ellis, personal

communication, November 13, 2013) some of the subjects that we discussed is has she made an

changes in the way financial counselors see patients when they are admitted to the hospital and



we know they are uninsured? She stated that we are not waiting until patients are admitted to the

hospital to find out if they are uninsured or will have high out of pocket expense. She stated that

they are currently piloting a program where they have financial counselors working in

scheduling patients and when patient expresses they are uninsured they are immediately asking

the questions to see if they would qualify for Cover Oregon and if they do they get patient pre

qualified for services. If this pilot works then they will train all of the registration team to ask

these questions and get people prequalified. She stated that way when patients come in they are

walking in the door with insurance versus them having a procedure done and then worried about

how they are going to pay for their hospital services at the end. She stated that the pilot is fairly

new but they are hoping that they will see big wins. The reality is that if they can get one patient

that could potentially end up with thousands of dollars in medical bills pre-qualified that is a big

win already. She stated that she is also looking at utilizing our new EPIC system to see if we can

use it to drive some of these uninsured patients’ visits into work queues or putting a flag on

account for financial counselors to work on this a work in progress because EPIC does had

limitations of what it can do or we are running scarce with analyst that can assist us because we

are still going through go lives with other hospitals. I asked if she is aware of anything else that

we pro actively are doing to get patients pre-qualified she stated that now when a patient presents

themselves at the emergency room that we can see if they can pre qualify for Medicaid benefits

this is for any patient that presents themselves at the ED department. In my interview with Lesa

I asked her, “I know that she has monthly meeting with our CFO’s, and I asked what main

concerns are there when it comes to the changes?” She stated they are worried about the

reimbursement, getting individuals enrolled in healthcare and also potential Medicare penalties

for re admissions since we need to prevent re admissions by working with the patients by

providing them with coordinated care.


When it comes to healthcare everyone is worried about all the changes that are happening

but they are happening faster then what some of us where prepared for or some organizations

have had a strategic plan in place long before the changes knowing that we are moving into a

new pay schedule from fee for service to a global payments system. That we are going to be

evaluated in the care we provide the patient, how we do educate patients about preventative care,

educate patients that they can go see a primary care doctor versus them coming to the emergency

room for a diagnosis that could have been treated at their primary care facilities. We are

responsible in putting programs in place to educate patients about all the benefits in providing

preventative care and also education our doctors and ensuring that all medical staff is providing

the highest quality of care.

While interviewing Lesa she asked that I reached out to Matt Shuler a Project Manager

(M.Shuler, personal communication, November 15, 2013) working on the charity reduction

workgroup and I was able to touch base with him and he gave me a primary example why we are

moving into the right direction with preventative care and Coordinated Care model. He asked me

if I ever heard Governor Kitzhaber’s air conditioning example and I had not heard of it. Well he

went on to explain the example that the Governor gives to everyone to better understand why

moving to coordinate care makes sense. The example that he gives is that a 90 year old woman

comes into the emergency room and presents with congestive heart failure while sitting in her

apartment on a hot day that the heat alone can send her body to having congestive heart failure.

We then bill Medicare for ambulance, care provided in ICU medical debt at $48,000 versus us

purchasing a $200 air conditioner to prevent her from coming into the emergency room and

through it all it has no effects in her quality of life. Yes, of course we are not in the business of

purchasing air conditioner for patients but with the new coordinate care model it will give a

patient advocate the accessibility to evaluate patient’s needs and be able to bill for that


preventative care that would cause less than the patients being admitted to the hospitals. This

would not be possible if we continued to bill as a fee for service versus us having global

payment. With the CCO patients will have a team of health care workers that will assist them in

getting the care that is needed for preventative care for chronic issues such as diabetes, heart

disease, respiratory this team could potentially go an evaluate their home to see if there is

anything that needs to be done at home first. They could potentially come to their household to

teach them how to shop and make meals of course with any change they will have challenges

because certain individuals are not comfortable with change. Health care individuals are going to

have to be trained in all the different cultures they will serve in their communities to understand

the difference in cultures for them to be successful. Coordinated care is going to look at the

overall well being of the individuals the picture below shows the team of individuals that a

patient might have when it comes to their care they are the center of it.

With coordinated care it involves everyone because in order of us to continue to get reimbursed

we have to able to provide high quality of care and also prevent from having re admissions to the

hospital for us not to be penalized. Unfortunately we are depending on our patients for them to


do their part and while they cannot be forced we just have to do a better job at showing them that

we truly care about their well being and they are just not a number walking into our doors.

Overall we are moving in the right direction when it comes to healthcare we are going to

have many challenges but with healthcare this is nonstop because there is always a change that

takes place whether it be a change in process, a new law put in place, or how we being

reimbursed we always adapt to change. Unfortunately some facilities have to close down, lay off

people, and some have to merge with other health care facilities. Through it all it does not

change the main focus that we have is that is our patients and the care that we provide to them.

The changes can affect them but it is our job when they walk into the doors that the care is

seamless, we provide high quality of care, and that the patient leaves knowing that we did

everything under our control to get them back to healthy. At Providence we have a commitment

to our patients and that is “Know Me, Care for Me, Ease my Way” and for us to get to know the

patients we care for, giving the best quality of care, and have them go through our delivery

system and have a positive experience from beginning to end and that all starts from the minute

they register to them calling into the call center.


References:

Health Well Foundation (n.d.). When Insurance Isn’t Enough; Underinsured America, Retrieved

November 23, 2013 from

http://www.healthwellfoundation.org/sites/default/files/About.the_.Underinsured.Final__0.pdf

Oregon Health Plan (n.d). Fast Track Enrollment, Retrieved November 22, 2013 from

http://www.oregon.gov/oha/healthplan/Pages/fast-track.aspx

AAOS NOW (March, 2008). Issues facing America: Underinsured Patients

http://www.aaos.org/news/aaosnow/mar08/reimbursement1.asp

S. R. Collins, R. Robertson, T. Garber, and M. M. Doty, Insuring the Future: Current Trends in

Health Coverage and the Effects of Implementing the Affordable Care Act, The Commonwealth

Fund, April 2013, Retrieved From November 22, 2013

http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Apr/Insuring-the-

Future.aspx

Kaiser Family (Sept 2013). Key facts about The Uninsured Population, Retrieved November 23,

2013 from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/

Obama Care Facts (n.d) Dispelling the Myths, Retrieved from November 23, 2013


http://www.healthwellfoundation.org/sites/default/files/About.the_.Underinsured.Final__0.pdf

http://www.oregon.gov/oha/healthplan/Pages/fast-track.aspx

http://www.aaos.org/news/aaosnow/mar08/reimbursement1.asp

http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Apr/Insuring-the-Future.aspx

http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Apr/Insuring-the-Future.aspx

http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/



Sherry Glied, Jeanne M. Lambrew, and Sarah Little, The growing share of uninsured workers

employed by large firms, The Commonwealth Fund, October 10, 1013, Retrieved from

November 23, 2013. http://www.commonwealthfund.org/Publications/Fund-

Reports/2003/Oct/The-Growing-Share-of-Uninsured-Workers-Employed-by-Large-Firms.aspx

Cathy Schoen, M.S., Sara R. Collins, PH.D, Jennifer L. Kriss, How many are underinsured?

Trends among the U.S. adults, The Commonwealth Fund, June 10, 2008, Retrieved from

November 23, 2013 http://www.commonwealthfund.org/Publications/In-the-

Literature/2008/Jun/How-Many-Are-Underinsured--Trends-Among-U-S--Adults--2003-and-

2007.aspx

Steve Israel, Interview on MSNBC, November 6, 2013, Things went wrong with the Medicare

prescription D plan that George Bush rolled out, Retrieved from November 22, 2013

http://www.politifact.com/truth-o-meter/statements/2013/nov/13/steve-israel/medicare-part-d-

and-obamacare-health-care-gov/

Kari Chisholom, Blue Oregon, May 21, 2013, What comes after Obama care? John Kitzhaber’s

air conditioner, Retrieved from November 23, 2013 http://www.blueoregon.com/2013/05/what-

comes-after-obamacare-john-kitzhabers-air-conditioner/

http://www.commonwealthfund.org/Publications/Fund-Reports/2003/Oct/The-Growing-Share-of-Uninsured-Workers-Employed-by-Large-Firms.aspx

http://www.commonwealthfund.org/Publications/Fund-Reports/2003/Oct/The-Growing-Share-of-Uninsured-Workers-Employed-by-Large-Firms.aspx

http://www.commonwealthfund.org/Publications/In-the-Literature/2008/Jun/How-Many-Are-Underinsured--Trends-Among-U-S--Adults--2003-and-2007.aspx



http://www.politifact.com/truth-o-meter/statements/2013/nov/13/steve-israel/medicare-part-d-and-obamacare-health-care-gov/

http://www.politifact.com/truth-o-meter/statements/2013/nov/13/steve-israel/medicare-part-d-and-obamacare-health-care-gov/

http://www.blueoregon.com/2013/05/what-comes-after-obamacare-john-kitzhabers-air-conditioner/

http://www.blueoregon.com/2013/05/what-comes-after-obamacare-john-kitzhabers-air-conditioner/

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