KFF designs, conducts and analyzes original public opinion and survey research on Americans’ attitudes, knowledge, and experiences with the health care system to help amplify the public’s voice in major national debates.
The 2003 Kaiser Family Foundation Health Insurance Survey examines the public’s level of satisfaction with their insurance coverage, their expectations of health insurance, the role of costs and other factors in health insurance decision-making, and attitudes toward employer-sponsored coverage. It also explores people’s opinions about several alternative health insurance plans that are currently under consideration and explores how they might respond to these new options.
The 2003 Kaiser Family Foundation Health Insurance Survey examines the public’s level of satisfaction with their insurance coverage, their expectations of health insurance, the role of costs and other factors in health insurance decision-making, and attitudes toward employer-sponsored coverage. It also explores people’s opinions about several alternative health insurance plans that are currently under consideration and explores how they might respond to these new options.
The 2003 Kaiser Family Foundation Health Insurance Survey examines the public’s level of satisfaction with their insurance coverage, their expectations of health insurance, the role of costs and other factors in health insurance decision-making, and attitudes toward employer-sponsored coverage. It also explores people’s opinions about several alternative health insurance plans that are currently under consideration and explores how they might respond to these new options.
In 2000, Congress passed a landmark law that gave states the option of extending Medicaid coverage to certain low-income women with breast or cervical cancer. In California, approximately 10,000 women have been assisted by this program. This policy brief, “Hearing Their Voices: Lessons from the Breast and Cervical Caner Prevention and Treatment Act (BCCPTA),” reports on the impact of this program on low-income women in California, using focus group analysis.
The report was prepared by researchers at the George Washington University School of Public Health and Health Services and the Kaiser Family Foundation and is one of the first to look at this program from the perspective of the women it serves.
Now I’m going to read you a list of some stories covered by news organizations in the last month or so.As I read each one, tell me if you happened to follow this news story very closely, fairly closely, not too closely, or not at all closely.(First,) how closely did you follow this story…?
Total Closely
Very Closely
Fairly Closely
Total NotClosely
Not too Closely
Not at all Closely
DK/ Ref.
Military action and peace keeping efforts in Iraq
88
63
26
11
6
5
*
Campaigns for the 2004 U.S. Presidential Election
78
48
29
22
13
9
*
The recent hurricanes that hit Florida and other states in the Southeast
92
65
27
8
6
2
*
An FDA study on the link between antidepressants and the risk of suicide in children
52
27
25
47
18
29
1
Reports of former President Bill Clinton’s heart bypass surgery
46
17
29
53
28
26
1
The start of a federal racketeering trial against large tobacco companies
28
12
17
71
25
46
1
A survey reporting an increase in the cost of employer-sponsored health insurance premiums
51
25
27
47
21
26
1
Stories about the 2004 U.S. presidential candidates’ proposals for making health care more available and more affordable
70
36
35
29
17
13
*
Reports on the debate over the importation of lower cost drugs from Canada and other countries
67
34
33
33
19
14
*
The withdrawal of the drug Vioxx from the market because of a study finding it increased the risk of heart attack and stroke
60
34
27
39
19
20
1
The nationwide shortage of flu vaccine
81
53
28
18
11
7
*
Survey by Henry J. Kaiser Family Foundation, Harvard School of Public Health. Methodology: Fieldwork conducted by Princeton Survey Research Associates, October 14-17, 2004 and based on telephone interviews with a national adult sample of 1,202.
During the past three years, has the amount of money you pay directly each month or have deducted from your paycheck for your health insurance premiums gone up a lot, gone up a little, stayed the same, or gone down?
Based on those who are insured (n=1,080)
31
Gone up a lot
39
Gone up a little
22
Stayed the same
2
Gone down
6
Don’t know/Refused
Was this a major problem, a minor problem, or not a problem for you and your family?
Based on those whose insurance premiums have gone up in past three years (n=781)
26
Major problem
42
Minor problem
32
Not a problem
*
Don’t know/Refused
Survey by Henry J. Kaiser Family Foundation, Harvard School of Public Health. Methodology: Fieldwork conducted by Princeton Survey Research Associates, October 14-17, 2004 and based on telephone interviews with a national adult sample of 1,202.
I’m going to read you a list of things that some people worry about and others do not.I’d like you to tell me how worried you are about each of the following things.(First,) how worried are you about…?
Are you very worried, somewhat worried, not too worried, or not at all worried?
Very worried
Somewhat worried
Not too worried
Not at all worried
DK/Ref.
a.Having to pay more for your health care or health insurance
47
31
9
12
1
b.Not being able to afford the health care services you think you need
38
26
16
21
*
c.The quality of health care services you receive getting worse
30
28
16
26
1
d.Not being able to afford the prescription drugs you need
35
25
16
23
1
e.Being the victim of a violent crime
19
27
27
27
1
f.Being the victim of a terrorist attack
23
33
22
21
1
g.Your income not keeping up with rising prices
46
25
11
17
*
h.Losing your savings in the stock market
22
18
12
46
1
i.Not being able to pay your rent or mortgage
27
16
17
39
1
Item J based on those who are employed (n=746)
j.Losing your job
18
15
21
46
*
Item K based on those who are employed and insured (n=674)
k.Having to stay in your current job instead of taking a new job for fear of losing health benefits
19
13
16
51
1
Items L-M based on those who are insured (n=1080)
l.Losing your health insurance coverage
29
20
18
33
*
m.Your HEALTH PLAN being more concerned about saving money for the plan than about what treatment is best for you
** Based on those who are employed with health insurance coverage only.
*** Based on employed only.
Survey by Henry J. Kaiser Family Foundation, Harvard School of Public Health. Methodology: Fieldwork conducted by Princeton Survey Research Associates, October 14-17, 2004 and based on telephone interviews with a national adult sample of 1,202.
Sharp increases in medical liability insurance premiums in recent years, and the withdrawal of some insurers from this market have focused the attention of health care providers, patients, and policymakers on reform of the medical liability system. Of additional concern is that the fear of liability causes physicians to practice medicine in ways that raise costs. The key issues being debated this election season are how to assure the availability of affordable liability coverage in the future while maintaining access to care, and the impact medical liability has on rising health care costs. There are varying opinions of how medical liability reform should be addressed, including whether it should remain a state issue or be addressed at the federal level, and, if so, how.
Background
According to a recent study on medical liability by the Congressional Budget Office (CBO), medical liability insurance premiums for all physicians nationwide increased an average of 15 percent between 2000 and 2002. Those for some specialties rose even faster, with premiums for obstetrician-gynecologists increasing an average of 22 percent and those for internists and general surgeons growing an average of 33 percent during the same period. The same study indicated that malpractice costs account for less than 2 percent of health spending and that significant reductions in these costs would only modestly affect overall health spending growth. Concern has also been raised over spending related to the practice of defensive medicine. However, based on existing research and its own analysis, the CBO found that savings from reducing this practice would be “very small.” 1
Premium hikes have also varied substantially from one area to another. In a 2003 survey of seven states, the General Accounting Office (GAO) found that “premium levels varied greatly not only from state to state, but…even among areas within states.” 2 For example, it found that the largest professional liability insurer in Florida raised annual premiums for general surgeons in Dade County by 75 percent between 1999 and 2002 (to $174,300), while the largest such insurer in Minnesota hiked premiums for the same specialty during the same period by 2 percent (to $10,140). Outside Dade County, the Florida insurer’s annual premium rate for general surgeons for 2002 was $89,000.
This surge in premiums is only the latest episode in an insurance cycle that produced similar increases in the second half of the 1970s and again in the mid-1980s. These upswings in premiums are thought by most experts to be caused by higher-than-expected financial outflows from insurers, lower-than-expected financial inflows to them, or a combination of the two.
A number of factors may increase liability insurers’ spending, including growth in the size of pay-outs to patients, an increase in the number of lawsuits, the rising cost of health care for injured parties, and increased premiums for reinsurance (insurance that they purchase from other companies to protect themselves against extremely costly cases).3 While evidence on the role played by most of these factors is mixed, the available data suggests that the costs of malpractice lawsuits have risen significantly over time. For example, CBO has determined that average pay-outs to patients and average legal defense costs per case have both risen at annual rate of 8 percent between 1986 and 2002.4
Aside from premiums, the main factor affecting the financial inflows or revenues of liability insurers is income from the investment of their reserves. While agreeing that other factors play a role in determining liability premiums, the GAO has found that lower-than-expected investment income for 15 large insurers between 2000 and 2002 probably played an important role in their rate-setting.5 Likewise, an analysis by the American Academy of Actuaries also found that liability insurers’ investment income decreased as a percentage of premiums between 1995 and 2001, and it suggested that each one percent decrease in interest rates would require insurers to increase premiums 3 to 4 percent to offset the reduced investment income.6
Another factor contributing to the current round of premium hikes is that a number of insurers have withdrawn from the market, thereby limiting competition on premiums as well as the number choices for coverage available to physicians. In 2001, the St. Paul Company, which provided about 10 percent of all medical malpractice insurance nationally, withdrew from the market altogether. Some physician-owned insurance companies have also exited the market or restricted where they offer coverage.7
In response to current and past surges in premiums, many states have refashioned their laws governing medical liability lawsuits, which have traditionally been a state issue. As of October 2002, 28 states had adopted limits on the amount of non-economic damages (pain and suffering) that can be awarded to an injured party.8 California led the way with the adoption of the Medical Injury Compensation Reform Act of 1975, (MICRA) which, among other things, capped such damages at $250,000. Similar legislation is pending in most of the states that have not yet acted. California also has approved a referendum rolling back premiums on many types of insurance (including medical liability insurance) and instituted state regulatory review of proposed premium increases.
Options for Assuring Access to Affordable Liability Coverage
Federal limits on liability lawsuits. Although there are a number of policy prescriptions for remedying the problem of rising medical liability insurance premiums, most of the attention in Congress has focused on legislation that would limit medical malpractice lawsuits and awards. Preferred by most Republicans, such legislation has been passed twice by the House of Representatives in the past two years. While Republicans in the Senate have tried to bring similar legislation up for consideration, most Democrats (joined by two Republicans) have blocked these attempts.
The House-passed legislation, which would not limit damages for any economic losses (such as medical costs and lost wages) sustained by a patient, would:
cap non-economic damages (pain and suffering) at $250,000;
limit punitive damages to cases involving malicious intent to injure or deliberate failure to avoid unnecessary injury;
More than 50 million individuals, or roughly one in five Americans, have a disability. Diverse in health-care needs, levels of functioning, goals, and life circumstances, many count on Medicaid and Medicare to provide coverage for a range of health and long-term services and supports. While people with disabilities are relatively heavy users of healthcare services, they often receive these services much less frequently than is recommended. Health issues that are important to people with disabilities span a wide range, but center on access to health insurance, coverage for essential services including prescription drugs and long-term services, and the financing of Medicaid and Medicare, given the critical role that they play in the lives of people with disabilities of all ages.
Background
People with disabilities have a wide range of conditions including physical impairments such as blindness and spinal cord injury; severe mental or emotional conditions; and other serious and disabling conditions including cancer, cerebral palsy, cystic fibrosis, Down syndrome, mental retardation, Parkinson’s disease, multiple sclerosis, autism, and HIV/AIDS. Relative to the general population, those with disabilities have lower incomes and are far less likely to be employed. People with disabilities are also much more likely to have fair or poor health, to be limited in their activities of daily living, and to reside in nursing homes or other institutions. Some people with disabilities can obtain private health insurance, either from an employer or by purchasing it on their own, but significant gaps exist. Many people with disabilities do not work at jobs that provide access to employer-sponsored coverage, while individual insurance policies for persons with less-than-perfect health are too expensive, or not offered at all. Policies may also severely limit or exclude core disability services, such as prescription drugs, mental health services, rehabilitation services and personal care services.
Public programs—Medicare and Medicaid—play a major role in assuring healthcare for people with severe, permanent disabilities. Medicare provides health coverage to over 6 million non-elderly adults with permanent disabilities, in addition to 35 million seniors. Adults are eligible for Medicare if they receive Social Security Disability Insurance (SSDI), but must wait over two years before they can enroll. Medicare covers basic physician and hospital services, but does not currently pay for prescription drugs or long-term services. Beginning in 2006, Medicare will begin to provide prescription drug coverage.
Medicaid is the nation’s primary program serving people who cannot obtain or afford private health coverage. The program provides coverage for over 50 million Americans, including 8 million people under age 65 with disabilities, 5 million seniors, and 38 million adults and children in low-income families. Medicaid covers a broad spectrum of services, ranging from physician care and prescription drugs to behavioral health and support services that are often critical to enabling individuals with disabilities to work or remain in the community. Medicaid is often the only source of public financial assistance for long-term services, including institutional care. Long-term services provide assistance with activities of every day life, such as bathing and dressing, using the toilet, preparing meals, or managing finances. Low-income Medicare beneficiaries rely on Medicaid to fill in many of Medicare’s gaps, including prescription drugs and long-term care.
Major Issues of Importance to People with Disabilities
Health Coverage
Medicaid and Medicare both play a pivotal role for people with disabilities, but millions fall outside their reach because coverage is often restricted to the poorest and most severely disabled. Recent policy efforts have focused on targeted improvements. For example, some states now guarantee continued access to Medicaid under “buy-in” programs that enable people with disabilities to become competitively employed without fear of losing health coverage. In addition, a few states have extended Medicaid coverage to people who have certain progressive conditions, such as HIV/AIDS or multiple sclerosis, for whom early treatment could slow the progression of disease. Other targeted proposals being discussed include permitting states to expand Medicaid coverage for children with disabilities in families with slightly higher incomes (up to about $40,000 a year) and eliminating the Medicare two-year waiting period for people with disabilities under age 65.
Broader efforts to expand health coverage to the nation’s uninsured could help improve coverage for people with disabilities. Some have proposed subsidizing the purchase of individual health insurance plans. This strategy is likely to be of limited help to people with disabilities unless policies are offered to people with chronic conditions, premiums are affordable, and benefits are sufficiently broad. Broader insurance market reforms may be needed if the individual market is to address the needs of people with disabilities. Others have proposed expanding Medicaid and SCHIP to cover more of the low-income uninsured and shoring up the employer-market by providing federal financing for high-cost cases. Building on Medicaid and SCHIP would capitalize on the prominent role that public programs currently play for people with disabilities, but would work only if sufficient funding were provided by the federal and/or state governments to assure adequate benefits.
Prescription Drugs Under Public Programs
Access to the right medicines enables people with disabilities to participate in the workforce and in their communities, and, in some circumstances, may make the difference between life and death. However, affording prescription drugs can be a daunting challenge. In the absence of drug coverage under Medicare, Medicaid has played an essential role in helping low-income people with disabilities have access to a broad range of medicines.
Beginning in 2006, Medicare will begin offering new prescription drug plans. For Medicare beneficiaries who have multiple health conditions and take numerous prescription medications, critical issues will include whether the drug benefit is adequate in providing all of their needed medications and whether it will do enough to lower their drug costs. Low-income beneficiaries (generally those with incomes less than about $14,000/year) will be able to sign up for help in paying premium and cost-sharing requirements for the new plans, but efforts will be needed to let people know about this assistance and to facilitate enrollment.
For those who currently rely on Medicaid, Medicare will take over drug coverage and Medicaid coverage of prescription drugs will end. A critical issue for these “dual eligibles” will be how this transition from Medicaid to Medicare is handled, whether there are gaps in coverage, how much out-of-pocket spending is required, and how readily individuals and physicians will be able to challenge or appeal denials of prescribed drugs.
Coverage of Long-Term Services and Supports
Finding ways to assure adequate access and financing for long-term care services is an important policy issue for people with disabilities, as well as the broader population. The aging of the population and growth in the number of people under 65 with disabilities will increase the demand for long-term care services. Most long-term care is provided informally through family and friends, often at a considerable emotional, physical, and financial toll. When ongoing needs surpass caregiver’s capacities, nursing home or community care costs can quickly exceed most people’s financial resources. Medicaid is the nation’s primary program that pays for long-term services, but is generally available only to those who are poor or have exhausted their resources paying for care. Medicare does not generally cover long-term services, and private insurance for long-term care is not typically available or affordable for people with disabilities.
In the current fiscal environment, there is little discussion of expanding Medicare to cover more long-term services or developing a new national long-term care program, although proponents view a social insurance program, like Medicare, as the best way to share the risk that we all face for needing long-term care. Others support private sector solutions by changing the tax laws to provide greater incentives for individuals to purchase long-term care insurance and employers to offer long-term care insurance as an employee benefit. Proponents believe these actions could lessen future pressure to publicly finance long-term care, but others doubt that private long-term care insurance will be affordable for low or middle income Americans. More modest proposals would provide a tax deduction or credit to caregivers.
Some support strengthening Medicaid’s ability to serve low and middle income people with disabilities by increasing the income and asset guidelines that states employ or developing partnerships that are more affordable to the government and to families because they link private coverage with a public safety net. These options build on state long-term care systems, but recognize that given Medicaid’s role as the sole program to help with long-term care bills, rules that require impoverishment may be too severe and, in some cases, undermine the ability of people to stay in the community. Despite their appeal, public-private partnerships are limited to a handful of states and enrollment is low.
Reversing Medicaid’s “institutional bias” by promoting more home- and community-based alternatives is also an important goal of the disability community. Recognizing that most Americans do not want to be in nursing homes or other institutions, states have increasingly taken steps in their Medicaid programs to provide more community-based services. The 1999 Supreme Court decided, in the case of Olmstead v L.C., that unjustified institutional isolation of people with disabilities is illegal under the Americans with Disabilities Act (ADA). Unfortunately, progress has been slow and waiting lists for community services are often long. While community-based options are often less expensive than institutional care, some policymakers are reluctant to propose new programs or expand existing programs, fearful that overall costs will increase if more people seek assistance. The Administration has supported several “New Freedom” demonstration programs that have focused on supporting community services and providing greater consumer direction over services and individual budgets in the community by approving “Independence Plus” waiver programs. The Administration also supports “Money Follows the Person” legislation to support the transition from the nursing home to the community. In addition, some have called for modification of the Medicare homebound rules to permit individuals to participate more fully in community life.
Financing Medicaid and Medicare
Looking forward, the financing of both Medicaid and Medicare will be an important and challenging issue for policymakers. Medicaid is financed by the federal and state governments, but state resources have been strained in the last several years as economic conditions deteriorated. The future financing of Medicaid is a central issue for people with disabilities as more people at younger ages survive with significant needs and disabilities and the population in the United States continues to age. The recent period of fiscal stress has rekindled interest among states and at the federal level in restructuring federal Medicaid law, particularly with respect to the way the program is financed and the relative role of states and the federal government. The outcome of discussions about restructuring the program will have significant implications for state budgets, Medicaid beneficiaries, and the ability of the Medicaid program to continue to serve as a critical safety-net program.
Medicare will also face significant financing challenges in the coming decades. The number of beneficiaries is projected to grow from 41 million today to 76 million by the year 2030. To assure that financing is adequate to pay for benefits, policymakers are examining alternative options. Proposals to make Medicare financially solvent include: restructuring the Medicare program along the lines of the Federal Employees Health Benefit program, cutting the growth in Medicare payments to doctors, hospitals, and health plans, increasing beneficiary premiums and cost-sharing, and raising the age of Medicare eligibility.
Assessing Candidate Positions
Health coverage provided by public programs is an issue of crucial significance to people with disabilities, often meaning the difference between life and death. Many individuals with disabilities say their ability to lead active and independent lives is inextricably linked to their access to needed services, medications, and social support. These issues will play out as the future of public programs is debated, as the new Medicare drug law is implemented, and as the need for long-term services continues to grow. The following questions could be useful in understanding how the candidates propose to address some of the major areas of health policy affecting people with disabilities.
How would your plan to expand health coverage affect people with disabilities? Would benefits be comprehensive and coverage affordable?
How would you ensure that individuals with a disability or those supporting a disabled dependent do not lose their coverage when returning to work?
What strategies should be implemented to eliminate Medicaid’s institutional bias and increase the availability of services in the community?
Should Medicaid and Medicare financing be restructured? If so, how?
