Date post: | 01-Jan-2016 |
Category: |
Documents |
Upload: | quentin-briggs |
View: | 29 times |
Download: | 0 times |
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%
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.
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
Among Firms Offering Health Benefits,How Important Are Firms’ Health Benefits in
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)
Very important Somewhat important
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
Among Firms Offering Health Benefits,How Important Are Firms’ Health Benefits in
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)
Very important Somewhat important
Percent
97%
91%
95%
*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.
43
THE COMMONWEALTH
FUND
Among Firms Offering Health Benefits,How Important Are Firms’ Health Benefits in
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)
Very important Somewhat important
Percent
96%
89%
94%
*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.
44
THE COMMONWEALTH
FUND
Among Firms Offering Health Benefits,How Important Are Firms’ Health Benefits in
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)
Very important Somewhat important
Percent
82%
71%
78%
*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.
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%
*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.
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%
Don’t know/refused
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
Percent of adults ages 19–64 insured all year with private insurance
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%
Don’t know/refused
2%One year or more
26%
4 to 11 months
39%
Don’t know/refused
1%
3 months or less6%
3 months or less34%
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.
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
Percent of adults ages 19–64 insured all year with private insurance
*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
Total ESI* Individual
Annual deductible $1,000 or more
Annual deductible $500–$999
22 20
48
Percent of adults ages 19–64 insured all year with private insurance
*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
Total ESI* Individual
Spent 5% or more of income on out-of-pocket costs
Spent 10% or more of income on out-of-pocket costs
Percent of adults ages 19–64 insured all year with private insurance
*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
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.
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–$999
18 19
54
Percent of insured adults ages 50–70
*ESI= employer-sponsored insurance.Source: S. R. Collins, C. Schoen, M. M. Doty, A. L. Holmgren, and S. K. How, Paying More for Less: Older Adults in the Individual Insurance Market, The Commonwealth Fund, June 2005.
9
92
THE COMMONWEALTH
FUND
8. Rising Health Care Costs Relative to Income
93
THE COMMONWEALTH
FUND
Financial Burden for Low- and Middle-Income Families Is Increasing
7
16
2426
16
10
2324
33
19
0
25
50
Total <100% FPL 100–<200%
FPL
200–<400%
FPL
400%+ FPL
1996 2003
Note: Financial burden includes out-of-pocket expenditures on premiums for private insurance and other health care services.Source: J. S. Banthin and D. M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger Than 65 Years, 1996 to 2003,” JAMA 296(22):2712–19, Dec. 13, 2006.
Percent of nonelderly adults who spend >10% of disposable household income on out-of-pocket premiums and expenditures on health care services
94
THE COMMONWEALTH
FUND
16 Million Adults Under Age 65 Were Underinsured in 2005
Uninsuredduring the year
47.8(28%)
Insured, notunderinsured
108.6(63%)
Underinsured16.1(9%)
Adults 19–64
Note: Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Source: M. M. Doty, Analysis of the Commonwealth Fund Biennial Health Insurance Survey (2005).
95
THE COMMONWEALTH
FUND
0
1000
2000
3000
4000
5000
6000
0 100 200 300 400 500 600 700 800 900
a
a2002Note: Adjusted for differences in the cost of living, 2003.Source: B. K. Frogner and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2005, The Commonwealth Fund, April 2006.
Out-of-pocket health care spending per capita (US$)
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+
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, 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.
Percent of adults ages 19–64 insured all year with private insurance
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
Percent of privately insured adults 21–64
2923
19
3636*33*38* 4042*
0
25
50
75
Total Health problem** <$50,000 annual
income
Comprehensive HDHP CDHP
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.
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
Percent of privately insured adults 21–64
292722
3135*
29* 31* 3338*
0
25
50
75
Total Health problem** <$50,000 annual
income
Comprehensive HDHP CDHP
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.
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
Comprehensive HDHP CDHP
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)
17% (10% tax bracket)
24% (15% tax bracket)
5% (25% 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
116
117
118
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
Don’t know/refused
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%
*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.
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
Firm size*Offer status
Percent
63%
42%50%
56%51%
*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.
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
Firm size*Offer status
Percent
62%
41%49%
57%51%
*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.
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%
*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.
133
THE COMMONWEALTH
FUND
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%
*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.
134
THE COMMONWEALTH
FUND
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
*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.
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
FUND
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
FUND
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
FUND
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
THE COMMONWEALTH
FUND
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
THE COMMONWEALTH
FUND
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
FUND
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