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.
This issue paper presents information from nine states that have developed and implemented disease management programs for adult Medicaid enrollees with chronic conditions such as asthma, diabetes, and congestive heart failure, or who are trying to manage these populations through capitated managed care. It examines the motivations, goals, strategies and impact of these state efforts, in addition to describing the details of their initiatives.
Parents, Media and Public Policy: A Kaiser Family Foundation Survey
“Parents, Media and Public Policy,” a new national survey from the Kaiser Family Foundation, explores how parents feel about media content and ratings systems. The survey found that a majority of parents say they are “very” concerned about the amount of sex (60%) and violence (53%) their children are exposed to on TV. The survey of 1,001 parents of children ages 2-17 was conducted in July and August 2004.
A national Kaiser Family Foundation survey of parents found that a majority says they are “very” concerned about the amount of sex (60%) and violence (53%) their children are exposed to on TV.
The survey of 1,001 parents of children ages 2-17 was conducted in July and August 2004.
The survey – “Parents, Media, and Public Policy” – was released at a briefing on Thursday, September 23, 2004, that included Senator Sam Brownback, FCC Commissioner Kathleen Abernathy, former Chairman and CEO of the Motion Picture Association Jack Valenti, Senior Vice President at News Corporation Ellen Agress, and Director of the Children & the Media Program at Children Now, Patti Miller.
New reports show that between 2000 and 2003 the number of uninsured rose 5.1 million, with the number of uninsured children dropping due to Medicaid and SCHIP coverage and the number of uninsured adults rising due to a decline in employer coverage.
This paper, by John F. Hoadley, Ph.D., of the Health Policy Institute at Georgetown University, examines how formulary designs and other cost-management tools may affect Medicare beneficiaries’ access to medications through their Medicare Part D prescription drug plans. It is one in a series commissioned by the Kaiser Family Foundation that analyzes issues surrounding the implementation of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) and the proposed regulations.
Building an On-Ramp to Children’s Health Coverage: A Report on California’s Express Lane Eligibility Program
This report documents the results from California’s Express Lane Eligibility (ELE) initiative through the school lunch program (now one year into implementation), which has been piloted in 72 schools in 5 school districts in the state. ELE is an enrollment strategy that targets large numbers of uninsured children, who are eligible for the federal-state programs Medicaid and SCHIP, where they can be found: in other public programs like school lunch and food stamps.
Supports restoring full funding authorized to UNFPA 4
Health Coverage and Access to Care
Provides tax credits and health savings account contributions to low-income families and small employers to help people buy private insurance. Establishes insurance pools and authorizes association health plans. Expands community and rural health centers. Campaign estimates 11 to 17.5 million newly insured.
Expands public program coverage under Medicaid and S-CHIP, provides tax credits for businesses and individual to make insurance more affordable, and expands the safety net. All Americans could buy coverage through the “Congressional Health Plan,” (giving them the same range of plans currently available to members of Congress). Campaign estimates 27 million newly insured.
Work-Family Supports
Opposes allowing states to use unemployment funds to give employees paid-leave when caring for a new child, previously allowed by Dept. of Labor5
Extends Transitional Medicaid Assistance for 5 years for families receiving welfare cash assistance
Supports increasing TANF work requirements to 40 hours per week
Supports equal pay for equal work and requiring greater disclosure of employer pay practices
Supports raising minimum wage and indexing it to inflation
Supports dropping 5-year ban on Medicaid benefits for legal immigrant pregnant women and children
Supports expansion of family and medical leave
Long-Term Care and Caregiving
Proposes making long-term care insurance premiums tax deductible
Proposes new tax policy that would allow caregivers of ill family members an additional exemption
Proposes greater access to support services, such as training, respite, and counseling for caregivers
Supports Medicaid payment for community and home-based care without a waiver
Clinical Research on Women
No specific position outlined by campaign
Supports passage of Women’s Health Office Act, which would ensure that existing federal offices on women’s health receive permanent authorizations 6
Supports efforts to include more women in clinical trials
Proposes increased funding for research and treatment for breast and cervical cancer Supports increased funding for research on HIV prevention, including microbicides for women
1 Information drawn from candidate’s website, www.georgebush.com.2 Information drawn from candidate’s website, www.johnkerry.com.3 Planned Parenthood Federation of America, Interview with John Kerry, http://www.e-lection.org/videos/candidate_kerry_wm.html.4 Goodenough, P., “Decision Not to Fund UNFPA Highlights Bush-Kerry Divide,” www.CNSNews.com, July 19, 2004.5 Hoover, K., “Bush to Repeal Clinton’s Paid Family Leave ‘Experiment,’ Washington Business Journal, December 13, 2002.6 Society for Women’s Health Research, “Candidate Responses to Questionnaire,” www.votewomenshealth.org.
This report shows that number of uninsured Americans under age 65 increased by 5.1 million between 2000-2003 largely driven by continuing declines in employer sponsored insurance. For children, this decline was more than offset by increases in enrollment in Medicaid and the State Children’s Health Insurance Program (SCHIP), resulting in a decrease in the number of children without coverage. The same growth in public coverage did not occur for adults, and as a result all of the increase in the number of uninsured was among adults.
With nearly 45 million Americans under the age of 65 without health insurance – one in six Americans – addressing the uninsured population is a major issue in the upcoming election. Health insurance affects access to health care as well as the financial well-being of families. Thus, both the affordability of and access to insurance are of concern.
Nearly two-thirds of Americans under the age of 65 receive health insurance coverage as an employer benefit (156 million). While Medicare covers virtually all those who are 65 years or older, the nonelderly who do not have access to or cannot afford private insurance go with out health coverage unless they qualify for public programs. The number of uninsured has risen from about 31 million Americans in 1987 to 45 million in 2003 (12.9 percent in 1987 to 15 percent of the total population in 2003). Given the rising cost of health insurance, the number of uninsured is likely to grow in the absence of policy interventions.
Why is being uninsured a problem? Lack of health insurance compromises the health and financial well-being of individuals and families, but leaving so many uninsured also takes a toll on society. Health insurance makes a difference in whether and when people get necessary medical care, where they get their care, and ultimately, how healthy people are. Compared with the insured, the uninsured are less likely to have a regular doctor, less likely to obtain care when needed, and are less apt to get timely preventive and routine care, such as immunizations for children or annual check-ups and mammograms for adults. Further, there are often serious consequences of not obtaining appropriate care. The uninsured tend to be sicker when they are diagnosed, have higher rates of preventable and untreated illness, and are also more likely to be hospitalized for conditions like uncontrolled diabetes that could have been avoided. Having health insurance improves health overall and could reduce mortality rates for the uninsured by 10 to 15 percent. 2
Medical bills can mount quickly for an uninsured person. Insurance helps reduce the financial uncertainty associated with health care, as illness and health care needs are not always predictable and care can be very expensive. In 2000, about 50 percent of the one million Americans who filed for bankruptcy did so because of medical bills and other problems arising from serious illness or injury. Nearly half of the uninsured report that they are unable to pay their medical bills, and more than a third say that they had been contacted by a collection agency about unpaid medical bills. Fear of unpaid bills is a major reason why many of the uninsured do not get the care they need.3
Having a significant portion of the population without health insurance has societal costs as well. When an uninsured person receives care but cannot pay the medical bill, the cost must be borne by others and puts a particular burden on public health and medical resources.
Who are the uninsured? The uninsured are predominantly adults from low-income working families. Over 80 percent of the uninsured come from families with a full-time or part-time worker and nearly two-thirds come from low-income families (less than $30,000 for a family of three). In addition, those at the highest risk of being uninsured include the poor, young adults, those living in southern and western states, minorities, and noncitizens. While Medicaid and the State Children’s Health Insurance Program (SCHIP) have expanded in recent years to cover more children, public coverage for adults is limited. Among the nonelderly, the chances of experiencing a long spell without health insurance (12 months or longer) are highest for individuals with low incomes and young adults.
Why don’t all workers have coverage through their employer? Most Americans obtain coverage as a tax-free fringe benefit through an employer-sponsored health plan. However, employer-sponsored health insurance is voluntary— businesses are not legally required to offer a health benefit. Also, not all employees qualify for coverage, many employees cannot afford their share of the premium, and employees can choose not to participate. Coverage varies by industry, firm size, locale, and other factors. Certain types of industries, among them construction, retail, and personal services (e.g., child care) are less likely to provide insurance than manufacturing, transportation, or government service. Workers in small firms or who have part-time or seasonal jobs are less likely to have health insurance offered as a benefit by their employers. Low-wage workers are the least likely to be offered health insurance and, when offered, may not be able to afford their share of the premium.
What is the role of public health insurance programs? Medicaid and SCHIP provide health insurance coverage to certain low-income populations that meet eligibility requirements, but assistance is primarily targeted toward low-income children. Public coverage expansions for children helped to offset declines in employer-sponsored coverage in recent years. However, nine million children remain uninsured. The role of public programs for adults is far more limited, covering only some low-income parents and disabled individuals and leaving most childless adults ineligible, regardless of how poor they are. Public coverage is especially important during economic downturns as more people become eligible as they move into lower income categories and lose employer-based coverage, but, at the same time, during economic downturns state revenue constraints put financial pressure on public coverage.
Why is the uninsured population growing? Changes in the economy and rising health care costs have led to declines in employer-sponsored coverage in recent years and these declines are likely to continue, especially if health care costs continue to rise at their current double digit pace. In 2004, annual premiums averaged $9,950 for family coverage and $3,695 for single coverage. The employee share of premiums has been on the rise and now averages $47 per month for single coverage and $222 for family coverage.4 Since 2000, premiums for family coverage have risen nearly 60 percent.5
Changes in the economy are also contributing to growth in the uninsured as jobs shift from industries such as manufacturing that tend to provide health insurance benefits to those, such as the service industry, that are less likely to provide health benefits. Jobs are also shifting to small businesses, which are less likely to offer health insurance. Some uninsured are eligible for coverage through their jobs but turn it down, usually because they cannot afford or do not want to pay the required employee share of the premium. Those insured by Medicaid and SCHIP – primarily low-income children and some adults – may lose coverage if their incomes rise, or if state budget constraints lead to reductions in eligibility.
Options for Covering the Uninsured and the 2004 Debate
While most candidates reflect the public view that some type of government response is needed to reduce the number of uninsured Americans, there is little consensus on the solution. Proposals differ in terms of their scope and costs, and are often controversial because of their effects on different stakeholders. Proposed solutions range from adoption of a single payer government health insurance system to narrow proposals targeting certain categories of the uninsured. In recent years, most proposals emerging from Congress or the White House would expand health insurance coverage incrementally, helping particular groups of the uninsured – such as poor or near-poor children, workers in small firms, or the near-elderly. Some, however, aim for more expansive approaches that could potentially result in most Americans being insured. Major approaches include:
Expanding coverage through existing public health coverage programs: With Medicaid, SCHIP, and Medicare providing health insurance coverage to tens of millions of the population, some candidates propose further expansions of these programs to a broader group of children and adults. In the case of Medicaid and SCHIP, proposals to expand coverage to the parents of eligible children or including poor, childless adults have been put forward by some states and are now a part of the national debate. Some policymakers suggest that Medicare can serve as the vehicle for coverage expansions, especially for the near-elderly, many whom increasingly face losing employer-based health coverage and find it difficult or prohibitively expensive to buy health insurance in the private market.
The public program approach could reach many low-income people, but only with a sufficient, stable commitment of either state and/or federal government money to either adequately fund public coverage or subsidize the cost to individuals of buying into the programs. Additional challenges include educating the public about coverage opportunities and simplifying enrollment procedures for these expansions. There are currently millions of poor uninsured who could be covered through a concerted effort to sign up those now eligible, but not enrolled in Medicaid or SCHIP. However, enrolling children and some of their parents who are currently eligible for Medicaid and SCHIP will ultimately increase the cost of these programs, and require more dedicated government funds.
Expanding access to group coverage: Recognizing that the American health system relies heavily on an employer-based coverage approach and that nearly two-thirds of the nonelderly get coverage through employers, some proposals would make it easier for small employers and the self-employed to band into larger health insurance purchasing pools, potentially giving them large group negotiating power when purchasing insurance. A related proposal would let the uninsured purchase coverage through the Federal Employees Health Benefit Program (FEHBP) or through state public employee health programs. Establishing purchasing pools or allowing businesses and individuals to join existing pools of coverage could lower premiums and broaden the choice of policies available to the uninsured. However, many experts believe that these proposals would not reduce the number of uninsured significantly unless the government helps subsidize the premiums for the health coverage or, at least, provides some form of federal reinsurance for high cost enrollees.
Recognizing that expanding group purchasing may not be enough to reduce the uninsured population, some policymakers propose offering new tax incentives to employers to offer and partially subsidize the cost of health insurance for their employees. Employer tax credits can, however, be very costly to the government. Studies have shown that employers who currently do not offer insurance to their workers will not do so unless most of the cost of the insurance is covered by the tax credit.
Subsidizing the purchase of individual private health coverage: While job-based coverage is a dominant feature of the American health system, some experts and policymakers believe it is an outdated approach in the country’s new economy where workers change employers several times during their career and are unable to maintain their health coverage across jobs. Offering tax credits or deductions to help offset the cost of health insurance for the uninsured is an approach backed by some policymakers, although proposals vary by whom they would assist. Some would target tax provisions to the low-income; others would assist all uninsured, regardless of income.
Tax-based approaches could reduce the number of uninsured, but the cost to the government could be high, since those least able to afford insurance would require substantial financial assistance to pay their premiums. Moreover, such tax credits are likely to also be used by many people who are already insured, providing greater tax equity, but also increasing the cost for coverage.
Another set of proposals would change federal tax laws to make it easier for people to take advantage of tax-free health savings accounts (HSAs) and similar types of arrangements. An HSA is a tax-free way to set aside money in interest-bearing accounts to pay uncovered medical care expenses, coupled with high-deductible insurance. Proponents argue that these arrangements would help reduce the uninsured population and control costs by making individuals more cost-conscious. Opponents counter that HSAs tend to attract healthy people, driving up the cost of health insurance for others, and that HSAs are unlikely to reduce the number of uninsured because the premiums and deductibles are unaffordable for those most in need of insurance.
Assessing Candidate Positions
Various policy proposals have been offered to expand health coverage to the nation’s uninsured population. Although most proposals are incremental and build on our current system, they vary in whom they target, what strategies they use to expand insurance, and how much they cost. Given the size of our uninsured population and the large share who are low-income, ultimately, options to expand health insurance to most of the uninsured will require a substantial financial commitment from government.
Included below are a series of questions to help evaluate the different proposals set forth by policymakers and candidates in the 2004 election.
Who would gain coverage under the proposal? What segments of the population does the proposal target?
What share of the uninsured would be covered as a result of the proposal?
Would the proposal affect those who already have health insurance? If so, how?
How much would the proposal cost, and how would it be financed?
Would the proposal expand public programs like Medicaid, S-CHIP, or Medicare?
Does the proposal provide financial assistance to help people purchase private or public insurance through tax credits or some other mechanism?
Given the cost of health insurance policies, is the subsidy adequate for those for whom it is targeted?
Does the proposal provide a mechanism for reducing premium costs?
1 Unless otherwise noted, data are from the March 2004 Current Population Survey (CPS) as analyzed and reported in: U.S. Bureau of the Census, Income, Poverty, and Health Insurance Coverage in the United States: 2003. August 2004.
** Update: For information on health care and the 2008 election, visitwww.health08.org. **
Health care issues continue to be important for many Americans and a vital part of the policy debates in Washington and around the country. During an election season, candidates propose and debate their solutions for the pressing policy issues facing their constituents. The 2004 election season is no different and the Kaiser Family Foundation is issuing informational materials on some of the health policy issues that are of concern to the American public.
Over the next few weeks several background issue briefs and presidential candidate comparisons will be made available. For more detailed information, the Foundation has many other resources that are available via links on this page or on other parts of our website.
The Health Care Costs, Medicare, HIV/AIDS, Medical Liability, Uninsured and Long Term Care election issue briefs were prepared by Health Policy Alternatives, Inc. with support from Foundation staff. The Public Opinion Women’s Health Policy, Race, Ethnicity and Health Care, and Health Care for Americans with Disabilities briefs were prepared by Foundation staff.
