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1、THE COMMONWEALTH FUND1Shifting Health Care Financial Riskto Families Is Not a Sound Strategy:The Changes Needed to EnsureAmericans Health Security Karen DavisPresidentThe Commonwealth Fundkdcmwf.orgInvited TestimonyHouse Committee on Ways and MeansSubcommittee on HealthSeptember 23, 2008THE COMMONWE
2、ALTH FUND2THE COMMONWEALTH FUNDA Broken System:The Growing Numbers of Uninsured3THE COMMONWEALTH FUNDHealth Insurance CoverageSource: 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 Pro
3、vision 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, 2007Medicaid(10%)Medicare(13%)Total populationUnder-65 popul
4、ationEmployer (62%)Uninsured(17%)Medicaid(11%)Medicare(2%)Military(1%)Military(1%)Individual(5%)Individual(6%)4THE 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 (Washi
5、ngton, D.C.: Employee Benefit Research Institute, Sept. 2008).Percentage of Uninsured Children Has DeclinedSince Implementation of SCHIP While UninsuredWorking-Age Adults Have Increased, 19942007Percent of population group uninsuredNon-elderly Adults(Ages 1864)Children(Ages 017)5THE COMMONWEALTH FUN
6、DSource: 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, 200607 TX 24.8%MA7.9%6THE COMMONWEALTH FUNDInadequate Coverag
7、e:The Rise of the Underinsured7THE COMMONWEALTH FUND25 Million Adults Underinsured in 2007,Up from 16 Million in 2003Uninsuredduring the year49.5(28%)Insured all year, notunderinsured102.3(58%)Insuredall year, underinsured25.2(14%)2007Adults ages 1964(177.0 million)Uninsuredduring the year45.5(26%)I
8、nsured all year, notunderinsured110.9(65%)Insuredall year, underinsured15.6(9%)2003Adults ages 1964(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-incom
9、e (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
10、 (2003 and 2007).8THE COMMONWEALTH FUNDAlmost Three-Fourths of Low-Income AdultsAges 1964 Are Uninsured and Underinsured, 2007* 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
11、s if low-income (508%Source: Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2007 Annual Survey.16THE COMMONWEALTH FUNDUninsured and Underinsured Adults with Chronic ConditionsAre More Likely to Visit the ER for Their ConditionsPercent of adults ages 1964 wi
12、that 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).17T
13、HE COMMONWEALTH FUNDCoverage Is Eroding in Small Firms18THE COMMONWEALTH FUNDEmployer Coverage Continues to Erodefor Employees of Small FirmsPercent of firms offering health benefitsSource: S. R. Collins, C. White, and J. L. Kriss, Whither Employer-Based Health Insurance? The Current and Future Role
14、 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.19THE COMMONWEALTH FUNDThree of Five Workers with Any
15、Time Uninsured AreSelf-Employed or in Firms with Fewer than 100 WorkersSelf-employed/1 employee12%2099 employees17%Source: The Commonwealth Fund Biennial Health Insurance Survey (2007).Full-time or part-time working adults ages 1964with any time uninsured, by employer size (27.5 million)500 or more
16、employees19%219 employees30%100499 employees15%Dont know/refused7%20THE COMMONWEALTH FUNDSingle Premium by Size of Firm, Adjusted for Actuarial ValueDollarsSource: J. Gabel, R. McDevitt, L. Gandolfo et al., “Generosity and Adjusted Premiums in Job-Based Insurance: Hawaii Is Up, Wyoming Is Down,” Hea
17、lth Affairs, May/June 2006 25(3):83243.THE COMMONWEALTH FUND21Source: Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2007 Annual Survey.Small-Firm Workers More Likely than Large-FirmWorkers to Contribute Large Share of Premiumfor Family CoverageAll FirmsLar
18、ge Firms(200+ workers)Small Firms(3199 workers)22THE COMMONWEALTH FUNDDeductibles Have Risen Sharply,Especially in Small Firms, Over 20002007PPO = preferred provider organization. PPOs covered 57 percent of workers enrolled in an employer-sponsored health insurance plan in 2007.Source: The Kaiser Fa
19、mily Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2007 Annual Surveys.Mean deductible for single coverage (PPO, in-network)THE COMMONWEALTH FUND23Source: Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2007 Annual Surv
20、ey.Deductible for Single Coverageby Plan Type and Firm Size, 200724THE COMMONWEALTH FUNDPeople with ESI* Who Say That EmployersDo a Good Job Selecting Quality Insurance PlansPercent*ESI = employer-sponsored insurance. FPL = federal poverty level.Note: Based on respondents age 19-64 who were covered
21、all year by their own employers 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.% FPLNumber of employee
22、s in firm25THE COMMONWEALTH FUNDIndividual Insurance Market WorksLess Well than Employer Coverage26THE COMMONWEALTH FUNDAdults ages 1964 with individual coverage or who thought about or tried to buy it in past three years who:TotalHealth ProblemNo Health Problem200% Poverty200%+ PovertyFound it very
23、 difficult or impossible to find coverage they needed34%48%24%43%29%Found it very difficult or impossible to find affordable coverage5871487250Were turned down or charged a higher price because of a pre-existing condition2133122618Never bought a plan8992869386Individual Market Is Not an Affordable O
24、ption for Many PeopleSource: 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 2006.27THE COMMONWEALTH FUNDAdults with Employer
25、CoverageGive Their Health Plans Higher RatingsThan Those in the Individual MarketSource: 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,
26、 September 2006.535434Percent of adults ages 1964 insured all year with private insurance28THE COMMONWEALTH FUNDHealth Care Costs Concentrated in Sick FewSickest 10% Account for 64% of Expenses1%5%10%49%64%24%Source: S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration o
27、f Health Care Expenditures,” Health Affairs, Jan/Feb 2007 26(1): 249257.Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 200350%97%$36,280$12,046$6,992$715Expenditure Threshold (2003 Dollars)29THE COMMONWEALTH FUNDRisk Pooling and Employer Premium Contributio
28、ns Lower the Cost of Health Benefits for Adults with Employer Coverage Relative to Those with Individual Market Coverage201854Percent of adults ages 1964 insured all year with private insuranceSource: S. R. Collins, J. L. Kriss, K. Davis, M. M. Doty, and A. L. Holmgren, Squeezed: Why Rising Exposure
29、 to Health Care Costs Threatens the Health and Financial Well-Being of American Families, The Commonwealth Fund, September 2006.30THE COMMONWEALTH FUNDPublic Programs Work31THE COMMONWEALTH FUNDOnly Two Percent of Premiums in Medicare and Medicaid Are Spent on Non-Medical ExpendituresPercent of prem
30、iums spent on non-medical expendituresSource: K. Davis, B. S. Cooper, and R. Capasso, The Federal Employees Health Benefit Program: A Model for Workers, Not Medicare, The Commonwealth Fund, November 2003; M. A. Hall, “The Geography of Health Insurance Regulation,” Health Affairs, March/April 2000 19
31、(2):17384.32THE COMMONWEALTH FUNDMedicaids Spending on Health ServicesIs Lower Than That of Private CoverageExpenditures ($) on health services for people without health limitations in private coverage and MedicaidSource: J. Hadley and J. Holahan “Is Health Care Spending Higher Under Medicaid or Pri
32、vate Insurance?” Inquiry, Winter 2003 40(4):32342.33THE COMMONWEALTH FUNDPercent Annual Per Enrollee Growth inMedicare Spending and Private Health Insuranceand FEHBP Premiums for Common Benefits Percent* FEHBP estimates are for 19692002 and 19992002 from Levit et al., “Health Spending Rebound Contin
33、ues in 2002,” Health Affairs 23 (January/February 2004):14759.Source: Analysis by Office of the Actuary, Centers for Medicare and Medicaid Services, January 2005.34THE COMMONWEALTH FUNDMedicare Extra Plan Would LowerAnnual Premiums for Individuals and FamiliesSource: C. Schoen, K. Davis, and S. R. C
34、ollins, “Building Blocks for Reform: Achieving Universal Coverage with Private and Public Group Health Insurance,” Health Affairs, May/June 2008 27(3):64657; G. Claxton, “Health Benefits in 2007: Premium Increases Fall to an Eight-Year Low, While Offer Rates and Enrollment Remain Stable,” Health Aff
35、airs, September/October 2007 26(5):140716.35THE COMMONWEALTH FUNDMedicare Beneficiaries Have Better Access toPhysician Services than Privately Insured People, 2005PercentNever had a delay to appointmentNo problem finding physicianSource: MedPAC Report to the Congress: Medicare Payment Policy, March
36、2006, p. 85.36THE COMMONWEALTH FUNDRising Premiums and Insurance Administrative Costs37THE COMMONWEALTH FUNDSource: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007,and Commonwealth Fund analysis of National Health Expenditures data.* Estimate is statistically different from the previo
37、us year shown at p0.05. Estimate is statistically different from the previous year shown at p0.1.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 (NAIC
38、S).Increases in Health Insurance Premiums Compared with Other Indicators, 19882006Percent38THE COMMONWEALTH FUNDCumulative Changes in Annual National Health Expenditures and Other Indicators, 20002007Notes: Data on premium increases reflect the cost of health insurance premiums for a family of four/
39、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 changeSources: A. Catlin, C. Cowan, S. Heffler et al., “National Health Spending in 2005: The Slowdown Con
40、tinues,” Health Affairs, Jan./Feb. 2007 26(1):14353; J. A. Poisal, C. Truffer, S. Smith et al., “Health Spending Projections Through 2016: Modest Changes Obscure Part Ds Impact,” Health Affairs Web Exclusive (Feb. 21, 2007):w242w253; Henry J. Kaiser Family Foundation/Health Research and Educational
41、Trust, Employer Health Benefits Annual Surveys, 20002007 (Washington, D.C.: KFF/HRET).39THE COMMONWEALTH FUNDPercentage of National Health ExpendituresSpent on Insurance Administration, 2005a 2004 b 2001 * Includes claims administration, underwriting, marketing, profits, and other administrative cos
42、ts; 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, 2008Net costs of health insurance administration as percent of national health expendituresaaab40THE COMMONWE
43、ALTH FUNDAdministrative Hassles Related toMedical Bills and Insurance Are Serious Problemsfor More Than a Quarter of AdultsSource: 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
44、 American Families, The Commonwealth Fund, September 2006.284026Percent reporting serious problems spending time on paperwork or disputes related to medical bills and health insurance in past two years41THE COMMONWEALTH FUNDConcentration of Managed Care Enrollment,19882000Note: The largest national
45、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.T
46、wo-thirds of managed care enrollees are enrolled in the nations 10 largest managed care firms.Percent enrolled in 10 largest firms42THE COMMONWEALTH FUND66%80%Less than 50%50%65%81%100%WAORIDMTNDWYNVCAUTAZNMKSNEMNMOWITXIAILINARLAALSCTNNCKYFLVAOHMIWVPANYMDMEVTNHMARICTDEDCCOGAMSOKNJSDMarket Share of T
47、hree LargestHealth Plans, by State, 20022003 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):1124.43THE COMMONWEALTH FUNDOperating Earnings Margin in Larg
48、estU.S. Health Plans, 20002003YearWellPoint (excluding Anthem)AnthemUnitedHealth GroupAetnaCIGNA20004.98.55.72.33.620016.65.16.7-0.88.020027.16.68.73.25.920038.17.810.27.78.9Note: Operating earnings = earnings before interest and taxes.Source: J. C. Robinson, “Consolidation and the Transformation of
49、 Competition in Health Insurance,” Health Affairs, November/December 2004 23(5):1124.44THE COMMONWEALTH FUNDMassachusetts Connector Has Improved Choicesand Lowered PremiumsTypical uninsured 37-year-old, pre- and post-reformPre-reformPost-reformMonthly premium$335$184Rx coverageNone$100 deductibleDed
50、uctible$5,000$2,000Source: Jon Kingsdale, Executive Director, Commonwealth Health Connector, “Design of Connector as an Element of NHI,” July 23, 2008.THE COMMONWEALTH FUND45FEHBP Enrollment by Type of PlanEmployee Organizations(generally PPOs)17%0.7 millionHMOs24%1 millionBlue Cross/Blue Shield (PP
51、Os)58%2.3 millionNote: Excludes an estimated 4 million dependents.Source: Mark Merlis, Personal communication, September 16, 2008.46THE COMMONWEALTH FUND1.A standard benefit adequate is defined and available to all2.Premiums to the enrollee for a standard plan are affordable regardless of income3.En
52、rollees have and use comparable information4.Marketing practices which mislead or discriminate against the sick are prohibited and strictly enforced5.Market rules on guaranteed issue and renewal, community rating6.Risk-adjustment of premiums7.Insurers compete on the basis of value-added they bring i
53、n fostering quality and efficiency8.Premiums are reasonable and have low administrative overheadRules to Improve Functioning of Insurance Markets47THE COMMONWEALTH FUNDConclusionAction is needed to guarantee affordable coverage. This should include:Health insurance premium assistance to low-income a
54、nd modest-income families who can not afford family premiums that now average over $12,000 even under employer plans. Strengthening not weakening employer coverageSetting national rules for the operation of individual health insurance marketsCreating insurance connectors, such as the one in Massachu
55、setts, that make affordable health insurance policies available to those without access to employer coverageOffering 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.
