THE COMMONWEALTH FUND 1 Shifting Health Care Financial Risk to Families Is Not a Sound Strategy: The...

THE

COMMONWEALTH FUND

1

Shifting Health Care Financial Riskto Families Is Not a Sound Strategy:

The Changes Needed to EnsureAmericans’ Health Security

Karen DavisPresident

The Commonwealth [email protected]

Invited TestimonyHouse Committee on Ways and Means

Subcommittee on HealthSeptember 23, 2008

THE COMMONWEALTH

FUND

2

THE COMMONWEALTH

FUND

A Broken System:The Growing Numbers of Uninsured

3

THE COMMONWEALTH

FUND

Health Insurance Coverage

Source: Authors’ estimates based on S. R. Collins, C. White, and J. L. Kriss, Whither Employer-Based Health Insurance? The Current and Future Role of U.S. Companies in the Provision and Financing of Health Insurance (New York: The Commonwealth Fund, Sept. 2007) and analysis of the Current Population Survey, March 2008, by Bisundev Mahato of Columbia University.

Uninsured(15%)

Employer (55%)

45.7 Million Uninsured, 2007

Medicaid(10%)

Medicare(13%)

Total population Under-65 population

Employer (62%)

Uninsured(17%)

Medicaid(11%)

Medicare(2%)

Military(1%) Military

(1%)

Individual(5%) Individual

(6%)

4

THE COMMONWEALTH

FUNDSource: P. Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2008 Current Population Survey” Issue Brief No. 321 (Washington, D.C.: Employee Benefit Research Institute, Sept. 2008).

17.1 17.618.9

13.1 13.6 13.6 13.912.5

11.6 11.3 11.2 11.0 10.5 10.911.7

11.0

17.2 17.3

19.8 20.3 19.7

17.717.7 17.217.9

19.5 19.5

12.7

0

5

10

15

20

25

19941995 19961997 19981999 20002001 20022003 20042005 20062007

Percentage of Uninsured Children Has DeclinedSince Implementation of SCHIP While UninsuredWorking-Age Adults Have Increased, 1994–2007

Percent of population group uninsured

Non-elderly Adults

(Ages 18–64)

Children(Ages 0–17)

5

THE COMMONWEALTH

FUNDSource: DeNavas-Walt C, Proctor B, and Smith J. “Income, Poverty, and Health Insurance Coverage in the United States: 2007.” Washington: Census Bureau, 2008.

11%–13.8%

17.25%–24.8%

13.8%–17.25%

7.9%–11%

Uninsured Rates, by State,Two-Year Average, 2006–07

TX 24.8%

MA7.9%

6

THE COMMONWEALTH

FUND

Inadequate Coverage:The Rise of the Underinsured

7

THE COMMONWEALTH

FUND

25 Million Adults Underinsured in 2007,Up from 16 Million in 2003

Uninsuredduring the year

49.5(28%)

Insured all year, not

underinsured102.3(58%)

Insuredall year,

underinsured25.2

(14%)

2007Adults ages 19–64

(177.0 million)

Uninsuredduring the year

45.5(26%)

Insured all year, not


Insuredall year,


2003Adults ages 19–64

(172.0 million)

*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 income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Source: C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Health Affairs Web Exclusive, June 10, 2008. Data: Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2007).

8

THE COMMONWEALTH

FUND

Almost Three-Fourths of Low-Income AdultsAges 19–64 Are Uninsured and Underinsured, 2007

28

48

16

24

11

14

0

20

40

60

80

Total Under 200% of poverty 200% of poverty or

more

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: 2007 Commonwealth Fund Biennial Health Insurance Survey (Schoen et al. 2008).

32

72

27

9

THE COMMONWEALTH

FUND

An Estimated 116 Million Adults Were Uninsured,Underinsured, Reported a Medical Bill Problem, and/or

Did Not Access Needed Health Care Because of Cost, 2007

Medical bill/debt problem17.7 million

10%

Cost-related access problem25.9 million

15%

Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).

Adequate coverage and no bill or access problem

61.4 million35%

Uninsured anytime during the year or underinsured

17.6 million10%

Medical bill/debt andcost-related access problem

54.4 million31%

177 million adults, ages 19–64

10

THE COMMONWEALTH

FUND

20

45

3125

31

9

1913 15

29

60

42

34

24

46

37

72

57

45

54

3945 47

60

71

0

25

50

75

Did not fill a

prescription

Did not see

specialist

when needed

Skipped

medical test,

treatment, or

follow-up

Had medical

problem, did

not see doctor

or clinic

Any of the four

access

problems

TotalInsured all year, not underinsuredInsured all year, underinsuredInsured now, time uninsured in past yearUninsured now

Uninsured and Underinsured Adults ReportHigh Rates of Cost-Related Access Problems

Percent of adults ages 19–64 who had cost-related access problemsin the past 12 months


11

THE COMMONWEALTH

FUND

26

19

813

8

43

23

31

47

61 61

3632

48

29

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

being paid off

over time

Any medical

bill problem or

outstanding

debt

Insured, not underinsured Underinsured Uninsured during year

Sixty Percent of Adults Who Were Underinsured or Uninsured Reported Medical Bill Problems or Debt

Percent of adults ages 19–64

* Includes only those individuals who had a bill sent to a collection agency when they were unable to pay it.Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).

12

THE COMMONWEALTH

FUND

Insured Adults with Less Comprehensive Coverage and Benefit Limits Are More Likely to Face Medical Bill and/or Debt Problems

43

56

65

59

53

44

33

29

30

22

24

27

0 25 50 75 100

Percent of continually insured adults ages 19–64 with bill and/or debt problems

Source: The Commonwealth Fund Biennial Health Insurance Survey, 2007.

MD did not charge more than insurance coveredMD charged more than insurance would pay; patient

paid difference

Health plan does not limit total dollar amountHealth plan limits total dollar amount

Annual premium is less than 10% of incomeAnnual premium is 10% or more of income

Deductible is less than 5% of incomeDeductible is more than 5% of income

Has both Rx and Dental CoverageHas neither Rx nor Dental Coverage

No expensive bills for services not coveredHad expensive medical bills for services not covered

by insurance

13

THE COMMONWEALTH

FUND

26 2834

51

22 2532

47

64

4238

44

0

25

50

75

Had expensive medical

bills for services not

covered by insurance

Doctor charged more

than insurance would

pay and you had to pay

difference

Had to contact

insurance company

because they did not

pay a bill promptly or

denied payment

Any problem with

health plan

All insured adults Insured all year, not underinsured Insured all year, underinsured

Underinsured Adults Report Higher Rates of Health Insurance Plan Problems than Adults with Adequate Insurance

Percent of adults ages 19–64 who were insured all yearand had problems with health insurance plan


THE

COMMONWEALTH FUND

14Prescription Drug Cost-Sharing, Average Copayments

Among Covered Workers, 2000–2007

$8

$15

$29

$11

$25

$43

$63

$0

$10

$20

$30

$40

$50

$60

$70

Generic Preferred Non-Preferred Fourth Tier

2000 2007

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

15

THE COMMONWEALTH

FUND

Annual Outpatient Visits Coverage Among Workers with Mental Health Coverage, 2006

All Plans

No Limit13%

20 or Less35%

21–3030%

31–5014%

>508%


16

THE COMMONWEALTH

FUND

Uninsured and Underinsured Adults with Chronic ConditionsAre More Likely to Visit the ER for Their Conditions

33

2633

1519

32

46 43

62 64

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

Total

Insured all year, not underinsured

Insured all year, underinsured

Insured now, time uninsured in past year

Uninsured now

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

* Hypertension, high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease.** Adults with at least one chronic condition who take prescription medications on a regular basis.Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).

17

THE COMMONWEALTH

FUND

Coverage Is Eroding in Small Firms

18

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 Erodefor Employees of Small Firms

Percent of firms offering health benefits

Source: S. R. Collins, C. White, and J. L. Kriss, Whither Employer-Based Health Insurance? The Current and Future Role of U.S. Companies in the Provision and Financing of Health Insurance (New York: The Commonwealth Fund, Sept. 2007). Data: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2007 Annual Surveys.

19

THE COMMONWEALTH

FUND

Three of Five Workers with Any Time Uninsured AreSelf-Employed or in Firms with Fewer than 100 Workers

Self-employed/1 employee12%

20–99 employees17%


Full-time or part-time working adults ages 19–64with any time uninsured, by employer size

(27.5 million)

500 or more employees19%

2–19 employees30%

100–499 employees15%

Don’t know/refused7%

20

THE COMMONWEALTH

FUND

$3,205 $3,134$3,146$3,354

$3,579$3,150

$3,383

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

$4,000

All small

(1-49)

All large

(50 or

more)

1-9

Employees

10-24

Employees

25-99

Employees

100-999

Employees

1000+

Employees

Single Premium by Size of Firm, Adjusted for Actuarial Value

Dollars

Source: J. Gabel, R. McDevitt, L. Gandolfo et al., “Generosity and Adjusted Premiums in Job-Based Insurance: Hawaii Is Up, Wyoming Is Down,” Health Affairs, May/June 2006 25(3):832–43.

THE

COMMONWEALTH FUND

21


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

for Family Coverage

72%

28% 24%

76%

Worker Contribution Firm Contribution

63%

37%

All Firms Large Firms(200+ workers)

Small Firms(3–199 workers)

22

THE COMMONWEALTH

FUND

Deductibles Have Risen 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)

THE

COMMONWEALTH FUND

23


Deductible for Single Coverageby Plan Type and Firm Size, 2007

$343

$667$751

$1,865

$408$382

$1,596

$0

$500

$1,000

$1,500

$2,000

HMO PPO POS HDHP

Large Firms Small Firms

24

THE COMMONWEALTH

FUND

People with ESI* Who Say That EmployersDo a Good Job Selecting Quality Insurance Plans

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

25

THE COMMONWEALTH

FUND

Individual Insurance Market WorksLess Well than Employer Coverage

26

THE COMMONWEALTH

FUND

Adults ages 19–64 with individual coverage or who thought about or tried to buy it in past three 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 Financial Well-Being of American Families, The Commonwealth Fund, September 2006.

27

THE COMMONWEALTH

FUND

Adults with Employer CoverageGive 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


53 54

34

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

28

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 Few—Sickest 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)

29

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


30

THE COMMONWEALTH

FUND

Public Programs Work

31

THE COMMONWEALTH

FUND

2%

2%

5–15%

15–25%

25–40%

0 10 20 30 40 50

Medicare

Medicaid

Large group

Small group

Non-group

Only Two Percent of Premiums in Medicare and Medicaid Are Spent on Non-Medical Expenditures

Percent of premiums spent on non-medical expenditures

Source: K. Davis, B. S. Cooper, and R. Capasso, The Federal Employees Health Benefit Program: A Model for Workers, Not Medicare, The Commonwealth Fund, November 2003; M. A. Hall, “The Geography of Health Insurance Regulation,” Health Affairs, March/April 2000 19(2):173–84.

32

THE COMMONWEALTH

FUND

809

413 400

279352

735

356

221 198 215

0

200

400

600

800

1000

Inpatient Office-based

doctor

Outpatient/ER Prescription Dental/other

Private Medicaid

Medicaid’s Spending on Health ServicesIs Lower Than That of Private Coverage

Expenditures ($) on health services for people without health limitations in private coverage and Medicaid

Source: J. Hadley and J. Holahan “Is Health Care Spending Higher Under Medicaid or Private Insurance?” Inquiry, Winter 2003 40(4):323–42.

33

THE COMMONWEALTH

FUND

Percent Annual Per Enrollee Growth inMedicare Spending and Private Health Insurance

and FEHBP Premiums for Common Benefits

9.0

5.9

10.1

8.89.6

10.7

0

2

4

6

8

10

12

1969–2003 1999–2003

Medicare Private Health Insurance FEHBP*Percent

* FEHBP estimates are for 1969–2002 and 1999–2002 from Levit et al., “Health Spending Rebound Continues in 2002,” Health Affairs 23 (January/February 2004):147–59.Source: Analysis by Office of the Actuary, Centers for Medicare and Medicaid Services, January 2005.

34

THE COMMONWEALTH

FUND

Medicare Extra Plan Would LowerAnnual Premiums for Individuals and Families

Source: C. Schoen, K. Davis, and S. R. Collins, “Building Blocks for Reform: Achieving Universal Coverage with Private and Public Group Health Insurance,” Health Affairs, May/June 2008 27(3):646–57; G. Claxton, “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):1407–16.

$12,106

$4,479

$3,108

$8,424

$0

$2,000

$4,000

$6,000

$8,000

$10,000

$12,000

$14,000

Single Coverage Family Coverage

Average Premium for Employer Coverage

Average Premium for Medicare Extra Plan

35

THE COMMONWEALTH

FUND

Medicare Beneficiaries Have Better Access toPhysician Services than Privately Insured People, 2005

7483

75

89

6775 75

86

0

20

40

60

80

100

Routine care Illness/injury Primary care Specialist

Medicare Privately InsuredPercent

Never had a delay to appointment No problem finding physician

Source: MedPAC Report to the Congress: Medicare Payment Policy, March 2006, p. 85.

36

THE COMMONWEALTH

FUND

Rising Premiums and Insurance Administrative Costs

37

THE COMMONWEALTH

FUND

Source: 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

20Health insurance premiums

Workers earnings

Overall inflation

National health expendituresper capita

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

Percent

38

THE COMMONWEALTH

FUND

Cumulative Changes in Annual National Health Expenditures and Other Indicators, 2000–2007

0

25

50

75

100

125

2000 2001 2002 2003 2004 2005 2006* 2007*

Net cost of private health insurance administration

Family private health insurance premiums

Personal health care

Workers earnings

Notes: Data on premium increases reflect the cost of health insurance premiums for a family of four/the average premium increase is weighted by covered workers. * 2006 and 2007 private insurance administration and personal health care spending growth rates are projections.

109%

65%

91%

24%

Percent change

Sources: A. Catlin, C. Cowan, S. Heffler et al., “National Health Spending in 2005: The Slowdown Continues,” Health Affairs, Jan./Feb. 2007 26(1):143–53; J. A. Poisal, C. Truffer, S. Smith et al., “Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs Web Exclusive (Feb. 21, 2007):w242–w253; Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, 2000–2007 (Washington, D.C.: KFF/HRET).

39

THE COMMONWEALTH

FUND

Percentage of National Health ExpendituresSpent on Insurance Administration, 2005

a 2004 b 2001

* Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2007, Version 10/2007.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

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

1.92.3

2.83.3

3.9 4.2 4.34.8

5.6

6.97.5

0

2

4

6

8

10

aa ab

40

THE COMMONWEALTH

FUND

Administrative Hassles Related toMedical Bills and Insurance Are Serious Problems

for More Than a Quarter of Adults

1018

8

18

22

18

0

10

20

30

40

50

Total Fair/Poor Health Excellent/Very

Good/Good Health

Serious problem

Very serious problem


28

40

26

Percent reporting serious problems spending time on paperwork or disputes related to medical bills and health insurance in past two years

41

THE COMMONWEALTH

FUND

Concentration of Managed Care Enrollment,1988–2000

Note: The largest national managed care firms include Blue Cross and Blue Shield plans, Aetna US Healthcare, Kaiser Permanente, United Health, and PacifiCare. HMO enrollment includes enrollees in both traditional HMOs and point-of-service plans.Source: Centers for Medicare and Medicaid Services, CMS Chart Series, Table 1.17.

Two-thirds of managed care enrollees are enrolled in the nation’s 10 largest managed care firms.

66.565.0

56.254.6

45.8

0%

20%

40%

60%

80%

1988 1991 1994 1997 2000

Percent enrolled in 10 largest firms

42

THE COMMONWEALTH

FUND

66%–80%

Less than 50%

50%–65%

81%–100%

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

MD

MEVTNH

MARI

CT

DE

DCCO

GAMS

OK

NJ

SD

Market Share of Three LargestHealth Plans, by State, 2002–2003

Note: No data are available for Alaska and Hawaii.Source: J. C. Robinson, “Consolidation and the Transformation of Competition in Health Insurance,” Health Affairs, November/December 2004 23(5):11–24.

43

THE COMMONWEALTH

FUND

Operating Earnings Margin in LargestU.S. Health Plans, 2000–2003

YearWellPoint (excluding Anthem)

AnthemUnitedHealth

GroupAetna CIGNA

2000 4.9 8.5 5.7 2.3 3.6

2001 6.6 5.1 6.7 -0.8 8.0

2002 7.1 6.6 8.7 3.2 5.9

2003 8.1 7.8 10.2 7.7 8.9

Note: Operating earnings = earnings before interest and taxes.Source: J. C. Robinson, “Consolidation and the Transformation of Competition in Health Insurance,” Health Affairs, November/December 2004 23(5):11–24.

44

THE COMMONWEALTH

FUND

Massachusetts Connector Has Improved Choicesand Lowered Premiums

Typical uninsured 37-year-old, pre- and post-reform

Pre-reform Post-reform

Monthly premium $335 $184

Rx coverage None $100 deductible

Deductible $5,000 $2,000

Source: Jon Kingsdale, Executive Director, Commonwealth Health Connector, “Design of Connector as an Element of NHI,” July 23, 2008.

THE

COMMONWEALTH FUND

45FEHBP Enrollment by Type of Plan

Employee Organizations(generally PPOs)

17%0.7 million

HMOs24%

1 million

Blue Cross/Blue Shield (PPOs)

58%2.3 million

Note: Excludes an estimated 4 million dependents.Source: Mark Merlis, Personal communication, September 16, 2008.

46

THE COMMONWEALTH

FUND

1. A standard benefit adequate is defined and available to all

2. Premiums to the enrollee for a standard plan are affordable regardless of income

3. Enrollees have and use comparable information

4. Marketing practices which mislead or discriminate against the sick are prohibited and strictly enforced

5. Market rules on guaranteed issue and renewal, community rating

6. Risk-adjustment of premiums

7. Insurers compete on the basis of value-added they bring in fostering quality and efficiency

8. Premiums are reasonable and have low administrative overhead

Rules to Improve Functioning of Insurance Markets

47

THE COMMONWEALTH

FUND

Conclusion

Action is needed to guarantee affordable coverage. This should include:

• Health insurance premium assistance to low-income and modest-income families who can not afford family premiums that now average over $12,000 even under employer plans.

• Strengthening not weakening employer coverage

• Setting national rules for the operation of individual health insurance markets

• Creating insurance connectors, such as the one in Massachusetts, that make affordable health insurance policies available to those without access to employer coverage

• Offering a public plan modeled on Medicare to small businesses and individuals would lower premiums by 30 percent and increase the stability of insurance coverage.

• Building on Medicare, Medicaid, and SCHIP to cover older adults, the disabled now in the Medicare two-year waiting period, and low-income adults as well as children. Private insurance markets do not serve these populations well.

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THE COMMONWEALTH FUND 1 Shifting Health Care Financial Risk to Families Is Not a Sound Strategy: The...

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