This toolkit was compiled and written by Dinesh Kumar.
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Place your cursor over underlined terms to see definitions. You can also click on underlined terms to see definitions in the glossary at the end.
- Being uninsured makes it more likely that a person will not receive adequate medical care. Lack of coverage and coverage stability is particularly burdensome on the seriously and chronically ill, whose care is often delayed or denied when they cannot pay. 1
- The number of uninsured persons in the U.S. continues to grow, from 44.8 million in 2005 to 47.0 million in 2006. The percentage of uninsured is also rising, from 15.3 percent of the total population in 2005 to 15.8 percent in 2006. 2, 3
- Overwhelmingly, the uninsured live in working families, but either are not offered health insurance or cannot afford offered plans. In 2005, over eight in 10 uninsured came from working families. 4
- A decline in job-based coverage fueled growth in the uninsured. Sixty percent of employers offer benefits in 2007, compared with 69 percent in 2000. This drop is especially due to the decline in small businesses offering coverage. 5
- One recent study estimated that 29 percent of people who have insurance are "underinsured," with coverage that is inadequate to secure them access to needed care or protect again catastrophic medical bills. 6
- Although the high cost of health insurance is a leading reason why people lack coverage, many inexpensive insurance policies are for sale. However, covered benefits under low-cost policies may be limited, out-of-pocket deductibles are often high, and the uninsured may not be eligible for low premiums if they are older or in poor health. 7
Expanding coverage for the uninsured is back on the public agenda, after many years as a third-tier issue. Health care ranked second after Iraq when respondents in a September 2007 poll were asked which one issue was most important in their choice for president in 2008. 8
In an August 2007 poll, health care also ranked as the second most important issue (after Iraq) that the public wanted the government to address and presidential candidates to talk about. Asked which one health issue they most wanted presidential candidates to discuss, respondents picked "reducing the costs of health care and health insurance" first, followed by "expanding health insurance coverage for the uninsured." 9
As suggested by the poll results above, concern about rising health care costs is driving much of the revived interest in the uninsured. Some with employer-sponsored coverage worry that they might lose that coverage if their employer decides it's too expensive. Employers complain that the cost of health benefits for current employees, and sometimes to retirees, makes them uncompetitive in comparison to foreign companies. Unions worry that their members will have to pay more for coverage. Health care providers are concerned that treating more uninsured patients will reduce revenue and hurt quality, or put them out of business altogether. 10
A lack of health coverage increases a person's risk for other problems, some of which are bad enough to catch policymakers' attention. The federally chartered Institute of Medicine estimates that 18,000 people a year die because they don't have health coverage. 11
Being uninsured also makes it more likely that a person will:
- Get less-than-adequate health care.
- Not have a regular source of care.
- Go bankrupt because of high medical bills.
- Uninsured women with breast cancer are less likely than insured women to receive breast-conserving surgery.
- Hospitalized patients without health insurance receive fewer needed services and lower-quality care, and have a greater risk of dying in the hospital or shortly after discharge than patients with insurance.
- The uninsured are less likely to receive care even when they have serious symptoms.
- Uninsured trauma victims are less likely to be admitted to the hospital or receive the full range of needed services. Uninsured victims with trauma due to an auto crash are 37 percent more likely to die of their injuries.
- Uninsured adults with HIV wait to receive new, highly effective drug therapies an average of four months longer than patients who have insurance. Among adults infected with HIV, having insurance reduces mortality by 71 percent to 85 percent over a six month period.
The Institute of Medicine concluded: "Health insurance is associated with better health outcomes for adults and with their receipt of appropriate care across a range of preventive, chronic and acute care services. Adults without health insurance coverage experience greater declines in health status and die sooner than do adults with continuous coverage." 12
Among the most discussed options for helping the uninsured:
- Employer mandate - Employers with a certain minimum number of employees would have to offer health coverage to their workers and pay for a portion of the premium. If they chose not to do so, they would have to pay a tax to support a state-run insurance program, which their employees could sign up for.
- Individual mandate - Individuals would be required to have health insurance, just as car owners are required to have car insurance. Low-income people would be exempted or would have their insurance expenses subsidized.
- Expand existing public coverage programs - For instance, let parents buy into the State Children's Health Insurance Program if their kids are eligible. Offer Medicaid to low-income childless adults. Let uninsured 50 - 64 year olds buy into Medicare.
- Tax incentives - Offer individuals a tax credit for a portion of their expenses for health insurance premiums. Offer businesses a tax break if they provide coverage to their employees.
In the absence of federal action for the uninsured, some states have developed plans of their own to expand coverage Maine, Vermont and Massachusetts have enacted laws that intend to eventually cover almost all residents of their states. Debate on the issue is vigorous in California, Pennsylvania, Illinois, New York and several other states.
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Statistics on the Uninsured - Where Do People Get Health Coverage and Who is Uninsured?
- U.S. Census Bureau
The Census Bureau's figures on health coverage and the uninsured are the ones most often cited by reporters, analysts and politicians. Detailed historical tables covering 1999 to 2006 can be found at www.census.gov/hhes/www/hlthins/historic/index.html. These tables show figures on the uninsured and how people get their health coverage by age, race, state, birth in the U.S. vs. other countries, and poverty status. New figures are released each year, usually in August.
- Cover the Uninsured
This site, sponsored by the Robert Wood Johnson Foundation, offers easy-to-understand charts and graphs on who is uninsured, how people get coverage, costs of health care and health insurance, and uninsured children. The web portal for media, which shows links to fact sheets, state profiles and legislation, is http://covertheuninsured.org/media
Kaiser Family Foundation
This site gives a state-by-state rundown of uninsured figures, as well as the means through which people obtain health insurance within each state.
- "Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help"
Sara Collins and others, Commonwealth Fund Issue Brief, May 2006
Describes the reasons why young adults (19-29) are one of the largest segments of the uninsured in America, with a focus on how young adults lose their coverage under their parents' policies, Medicaid, or the State Children's Health Insurance Program (SCHIP) following high school graduation. The authors pose three policy measures through which more young adults could be covered: 1) extending Medicaid and SCHIP eligibility, 2) extending eligibility as a dependent, and 3) requiring colleges and universities to offer/provide full-time coverage to students.
- "2007 HHS Poverty Guidelines"
U.S. Department of Health and Human Services
The poverty guidelines from the U.S. Dept. of Health and Human Services are used by the federal government to determine eligibility for various public programs, including Medicaid and the State Children's Health Insurance Program (SCHIP). For 2007, the federal poverty level (FPL) for a family of four in the 48 contiguous United States was an income of $20,650. The poverty guidelines are one way the federal government measures poverty; the other is the poverty threshold, updated annually by the U.S. Census Bureau and mainly used for statistical purposes.
Consequences of Being Uninsured
- "Health Coverage in America: Understanding the Issues and Proposed Solutions"
Alliance for Health Reform, March 2007
Pages 4 - 6 of this publication by the Alliance for Health Reform summarize the effects of being uninsured on a person's health and the health care they receive (or don't receive), as well as their family finances. Includes endnotes with web links.
- "Care Without Coverage: Too Little, Too Late"
Institute of Medicine, May 2002
Produced by the federally chartered Institute of Medicine (IOM), this report describes the effects of uninsurance and underinsurance on health outcomes and general quality of life. The IOM concludes that uninsured adults are in poorer health, that they would be in better health if they had insurance, and that increased rates of coverage would most help those in the poorest health and in the most disadvantaged situations in terms of access.
- "Hidden Costs, Value Lost: Uninsured in America"
Institute of Medicine, June 2003
Executive summary at http://books.nap.edu/execsumm_pdf/10719.pdf
Another in a series of reports from the IOM on the consequences of uninsurance, this one illustrates some of the economic and social losses to the country of having so many people without health insurance. The report explores the potential economic and societal benefits that could be realized if everyone had health insurance on a continuous basis, as people over age 65 currently do with Medicare.
- "Insurance Coverage, Medical Care Use, and Short-Term Health Changes Following an Unintentional Injury or the Onset of a Chronic Condition"
Jack Hadley, JAMA 297(10): 1073-1084 (March 14, 2007)
This study found that among those experiencing a health shock (injury or chronic condition), uninsured individuals were less likely than insured persons to get medical care. In addition, the uninsured get less prescription medications and have worse health status than the insured. For a free abstract, go to http://jama.ama-assn.org/cgi/content/abstract/297/10/1073?maxtoshow=&HITS=10&hits=10&
- "Illness and Injury As Contributors To Bankruptcy"
David Himmelstein and others, Health Affairs Web Exclusive, February 2, 2005
Abstract available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.63
The authors find that about half of surveyed Americans who filed for bankruptcy in 2001 cited medical illness as a primary reason. Among this population, 75.7 percent had insurance at the onset of the illness.
- "Medical Bankruptcy: Myth vs. Fact"
David Dranove and Michael L. Millenson, Health Affairs Web Exclusive, February 26, 2006
Abstract available at: http://content.healthaffairs.org/cgi/content/abstract/hlthaff.25.w74
Dranove and Millenson take issue with the methodology and findings of the article by Himmelstein and others presented above. They conclude that a reexamination of Himmelstein's data suggests that medical bills are a contributing factor in just 17 percent of personal bankruptcies, and that those affected tend to have incomes closer to poverty level than to middle class.
Stories of Real People
- Video & Story Gallery - Cover the Uninsured
Stories of real people who are uninsured and the problems they face are gathered at this website, which is part of the Cover the Uninsured campaign.
- Families USA Consumer Story Bank
Media contact: David Lemmon or others on communications staff, 202/628-3030
For many years, Families USA has maintained a database that catalogues hundreds of health care hardship stories. The organization gets permission from each consumer before releasing his or her story. The group is currently collecting stories, in particular, about uninsured children, racial/ethnic minorities, the Medicare prescription drug benefit (Part D), and Health Savings Accounts (HSAs). For more information, go to www.familiesusa.org/tell-us-your-story.html
- Find-an-Expert Service - Alliance for Health Reform
The Alliance features a database of experts in 36 health policy topics, including the uninsured. Many have contact information for contacting real people. Access is limited to credentialed journalists. Registration required.
Public Opinion Polls
- The Polling Report
PollingReport.com is a compilation of polls from organizations such as the Associated Press, CNN, USA Today and Gallup, among others. The website is updated whenever new polls are released. To see how health care ranks among other national priorities, click on "National Priorities" under the "State of the Union" button. For instance, health care ranks as the second most important issue in determining a vote for president, as determined by a September 2007 poll for ABC News and the Washington Post.
- Kaiser Health Poll Report
The Kaiser Health Poll report contains three sections which track public opinion on key broad questions over time: 1) Health Care Priorities tracks which health care issues Americans want the government to address. 2) Health Security Watch tracks Americans' concerns about the future of their own health care, focusing on cost, quality, and trust in their health plans. 3) Health News Index tracks which health news stories Americans are following and what they understand about those health issues covered in the news.
- Health Poll Search - Kaiser Family Foundation
Health Poll Search is a searchable archive of public opinion questions on health issues that allows users to know what Americans think about health issues, as well as what Americans have thought about health issues over time. Health Poll Search is the result of a partnership between the Kaiser Family Foundation and The Roper Center for Public Opinion Research at the University of Connecticut. The Roper Center houses an archive of more than 350,000 public opinion questions dating back to 1935. The Health Poll Search archive covers 29 topics and more than 300 subtopics.
- Polls on Health Care Issues
This section of Covering Health Issues, 2006 - 2007, by the Alliance for Health Reform, contains many links to poll sources.
- WSJ Online/Harris Interactive Health-Care Poll
A new poll is published every two weeks on topics such as health coverage, obesity, prescription drugs, HIV/AIDS and organ donation.
National Proposals for the Future
- Modern Healthcare: "Legislating Access"
Modern Healthcare is tracking national and state proposals to expand access to health benefits for the uninsured and underinsured. This section will be updated with each new proposal. Each entry provides a link to the proposal and a brief description of the plan.
- AFL-CIO: "In America No One Should Go Without Health Care" (Aug. 2007)
The 10 million-member AFL-CIO is engaged in an effort to gain secure, high-quality health care for all in the U.S. by 2009. Among the features sought: preventive care, preserving the right to "choose and use your own doctor," lower employer costs and asking employer to pay "their fair share," and building on "what's best about American health care while drawing from what works in other countries."
- Business Roundtable: "A Call to Action for Covering the Uninsured" (June 2007)
Available at: www.businessroundtable.org/pdf/Health_Retirement/
This group of CEOs of leading U.S. companies lays out a plan to address the problem of uninsurance and, in particular, the dwindling ability of businesses to provide coverage for their employees in the face of rising health care cost. Among the Roundtable's proposals are incentives provided by both public programs and the private sector to individuals engaging in healthy lifestyles; precise information about the cost and quality of health services provided to individuals; and access by all Americans to information comparing all aspects of the health system.
- Coalition to Advance Healthcare Reform: Proposal for expanding health coverage (May 2007)
Press release at: www.coalition4healthcare.org/modules/article/list/release.php?pi=jhi926nkt3k34d&id=jho3jw1li3rk195&set=article_jhi90r8dttg0w1&search=
This consortium of almost 40 business and health care leaders was formed in May 2007 with a shared proposal for reforming the coverage landscape. Features of the plan include: a market-based health care system, universal coverage with individual responsibility, equal tax treatment, financial assistance for low-income populations, and incentives for healthier behavior. The CAHR chairman is Steve Burd, CEO of Safeway, Inc.
- Partnership for Quality Care: Proposal for expanding health coverage (May 2007)
Press release at: www.seiu.org/media/pressreleases.cfm?pr_id=1396
The Partnership for Quality Care is a coalition of health care management leaders (led by George Halvorson of Kaiser Permanente) and over a million members of the Service Employees International Union (SEIU). They have not yet put forth a comprehensive plan but instead list several goals for coverage expansion, including: the establishment of a broad-based, predictable, equitable health care financing system, universal coverage for all Americans, and greater reliability and portability of coverage.
- Health Coverage Coalition for the Uninsured: Proposal for expanding health coverage (January 2007)
Overview at: www.familiesusa.org/issues/uninsured/hccu/hccu-agreement.pdf
The HCCU (a coalition of 16 national physician, hospital, and business organizations and a division of Families USA) proposes a two-phase plan for coverage expansion. The first phase focuses on short-term changes, which include covering all kids who are eligible for SCHIP but not enrolled, and the institution of a family tax credit for private insurance. The second phase focuses on long-term changes and includes both public and private-sector reforms.
- American Medical Association: VoiceForTheUninsured.org (February 2007)
Overview at: www.ama-assn.org/ama1/pub/upload/mm/450/uninsured-overview.pdf
Voice for the Uninsured is a project of the Health Policy Group of the AMA. Their proposal for has three pillars: 1) providing subsidies to those who can't afford insurance, through tax credits; 2) giving individuals and families greater choice in what health plan is best for them; and 3) market regulations that protect high-risk patients and include greater individual responsibility for obtaining insurance. More of the group's documents (including personal stories, statistics, and campaign materials) are available at http://www.voicefortheuninsured.org
- Federation of American Hospitals: "Health Coverage Passport" (February 2007)
Detailed information at: www.fah.org/passport/
This group, the trade association for investor-owned hospitals, proposes the introduction of "Health Coverage Passports" (HCPs), which would cover individuals below 400 percent of the federal poverty level who are not eligible for Medicaid or SCHIP. In addition, Medicaid and SCHIP would be expanded. Individuals who do not qualify for any public program, including HCPs, would be required to purchase a private plan.
- Catholic Health Association of the United States: "Our Vision for U.S. Health Care" (June 2007)
The Catholic Health Association's proposal is founded upon their belief that health care is a basic life necessity, and that the U.S. has a moral obligation to ensure that no one is without basic life necessities. Their plan includes a basic health benefit package for everyone that includes preventative, acute, long-term, and end-of-life care. A special emphasis is placed on the needs of poor, immigrant, and elderly populations.
- America's Health Insurance Plans: "We Believe in High-Value Health Care" (November 2006)
Detailed information at: www.ahipbelieves.com
The key part of this proposal by AHIP, the trade association of health insurance companies, is the introduction of a Universal Health Account (UHA), which would allow individuals to purchase any type of health coverage and pay for medical expenses with pre-tax dollars. The UHA would function in concert with a new Federal Performance Grant of $50 billion to assist states in expanding access to coverage, and a $500 tax credit for low-income families to obtain insurance for their children.
- Citizens' Health Care Working Group (September 2006)
Of the many groups offering health coverage proposals, this is the only one established by an act of Congress. After 15 months of community forums, collecting ideas via the Internet, listening to experts and through other means, the group presented five recommendations to President Bush and Congress: establish public policy that all Americans have affordable health care, guarantee financial protection against very high health care costs, foster innovative integrated community care networks, define core benefits and services for all Americans, promote efforts to improve quality of care and efficiency, and fundamentally restructure the way end-of-life services are financed and provided.
PRESIDENTIAL CANDIDATES' REFORM PROPOSALS
- "Election 2008: Where do the candidates stand on health care?"
- Association of Health Care Journalists
As the 2008 presidential campaign intensifies, the association will be tracking candidates' positions on health care issues. This site notes whether the candidate has released a health care proposal and offers a brief description of the candidates' views on health issues, if they are known. Click on a candidate's name for links to more information about the person's positions.
- www.Health08.org -- Kaiser Family Foundation
This content-rich site offers regularly updated news of the candidates' views on health issues, polling results on health care as a campaign issue, analysis of health care issues addressed by the candidates, and links to videos and podcasts on this subject.
- The Presidential Candidates on Health Care -- New York Times
Offers quotes from the candidates on their health care positions and links to more information, when available.
- Candidates' Forum - Modern Healthcare
Modern Healthcare magazine has asked all presidential candidates to write about their plans for reforming the U.S. healthcare system, with particular emphasis on covering the uninsured. The section will be updated as candidates submit their plans.
- States in Action Newsletter - The Commonwealth Fund
The Commonwealth Fund offers summaries of certain candidates' health plans within the Fund's "States in Action" newsletter. Once at the "States in Action" landing page, enter a candidate's name in the upper right corner.
- "Legislating Access: State" - Modern Healthcare
Modern Healthcare is keeping up chronologically with state proposals to expand access to health benefits for the uninsured and underinsured.
- "2007 State of the States Report" - State Coverage Initiatives
This is a comprehensive annual report (56 pages) by State Coverage Initiatives, a project of the Robert Wood Johnson Foundation and AcademyHealth, on current and pending insurance coverage efforts undertaken by every state government.
- "State Health System Performance and State Health Reform"
Kathy Davis and Cathy Shoen, Health Affairs Web Exclusive, September 18, 2007
State policy officials are focusing on improving health insurance coverage, but other important dimensions of performance, including quality and cost, are receiving less attention. This paper explores the implications of new data on state personal health spending, quality, and health system performance. The authors argue that states need to link improved insurance coverage with policy strategies to improve quality and efficiency.
- "How Federalism Could Spur Bipartisan Action on the Uninsured"
Henry J. Aaron and Stuart Butler, Health Affairs, March 31, 2004
The authors argue that the best way to improve the uninsurance problem as a whole is to allow states the freedom to experiment with their own systems. States should be allowed to try widely differing solutions with federal financial support under legislated guidelines, including specific protections and measurable goals. Congress would enact a "policy toolbox" of federal initiatives that states could include, and funding to states would be linked to success in reaching the goals.
- States in Action Newsletter - The Commonwealth Fund
Every other month, the Commonwealth Fund publishes a newsletter describing innovations in health policy at the state level. These include coverage expansions.
- "Massachusetts Health Reform: Employers, Lower-Wage Workers, and Universal Coverage"
Laurie Felland, Debra Draper, and Allison Liebhaber
Center for Studying Health Systems Change, July 2007
Through interviews with Massachusetts health care leaders, the Center for Studying Health System Change (HSC) examined how the 2006 universal coverage law is likely to affect employer decisions to offer health insurance to workers and employee decisions to purchase coverage. The authors found that despite reform of the individual and small group markets, including development of new insurance products, concerns remain about the affordability of coverage and the ability to stem rising health care costs.
- "Massachusetts Health Care Reform Plan: An Update"
Kaiser Commission on Medicaid and the Uninsured, June 2007
This fact sheet, put together by the Kaiser Commission, outlines the components of the Massachusetts plan. Sections include the individual and employer mandates, the Commonwealth Health Insurance Connector, the Commonwealth Care Health Insurance Program, Medicaid expansions, insurance market reforms and preserving the safety net. The publication also poses and answers key questions about the affordability and employer responsibilities under the plan. Implications for other reform efforts are described.
- "The Massachusetts Health Plan: The Good, the Bad, and the Ugly"
David Hyman, Cato Institute, June 28, 2007
Executive Summary: http://www.cato.org/pub_display.php?pub_id=8431
This study briefly describes the basic structure of the Massachusetts plan and identifies the good, the bad, and the ugly. If Massachusetts wants to make health insurance more affordable and avoid the "bad" and the "ugly" of its plan, Congress - or, barring that, individual states - should consider a "regulatory federalism" approach. Under such an approach, insurers and insurance purchasers would be required to subject themselves to the laws and regulations of a single state but allowed to select the state.
- "Countdown to Coverage"
Alice Dembner, Boston Globe, June 18, 2007
The Boston Globe's special section on the Massachusetts Health Plan includes an extensive list of questions frequently asked by readers about the new plan and the mandate to obtain insurance. Also included is a flow chart of coverage options and a link to articles on recent developments in the state. Free registration may be required to access some articles.
- "How 10 People Reshaped Massachusetts Health Care"
Laura Meckler, Wall Street Journal, May 30, 2007
This article describes the dynamics of the Health Insurance Connector board - 10 people from very disparate perspectives who were charged with working out the details of the universal coverage plan approved by the Massachusetts legislature. Health policy reporter Laura Meckler shows how the members of the board were able to find compromises on a variety of issues, driven by a desire to make the Massachusetts plan work.
- "2006 Legislative Action on Health Care"
The Vermont Legislature
This is the official summary and text of the Vermont Health Care Affordability Act, also known as Catamount Health. The plan, which went into effect in 2007, extends coverage of adults to 300 percent of the federal poverty level (to match the current eligibility ceiling for the State Children's Health Insurance Program) through subsidizing private coverage. The new law also seeks to make private coverage more affordable by limiting the ways in which insurance companies can overcharge premiums to those in poorer health.
- "Vermont Health Care Affordability Act"
Families USA, December 2006
Summary and Fact Sheet: http://familiesusa.org/assets/pdfs/vt-catamount-health.pdf
This is a shorter fact sheet by the advocacy group Families USA that outlines the main points of the Vermont Health Plan that is presented in a simple Frequently Asked Questions format. The plan is designed to cover all adults with incomes up to 300 percent of the federal poverty level, while improving both public and private coverage, particularly for people with chronic diseases. (The state earlier enacted laws providing Medicaid or SCHIP coverage for children with family incomes up to 300 percent of poverty, has covered parents with incomes up to 185 percent of poverty, and has covered childless adults with incomes up to 150 percent of poverty.)
- "Profiles in Coverage: Maine Dirigo"
State Coverage Initiatives, May 2005
This comprehensive health plan was put into place with the goal of fully covering all Maine residents in six years (by 2009). It provides provide an affordable health insurance option to small businesses, the self-employed, and eligible individuals without access to employer-sponsored insurance.
- "Governor's Health Care Proposal"
California Office of the Governor, 2007
This document lays out Gov. Arnold Schwarzenegger's most recent plan to cover all California residents, through a combination of an individual mandate to obtain coverage and an expansion of public programs for those who are eligible. The plan is currently at the center of much state- and national-level debate. California has the highest number of uninsured residents in the nation, so such a change would have a dramatic effect.
- "Health Care Reform: Then and Now"
California Office of the Governor, October 2007
The details of Gov. Schwarzenegger's October 2007 are compared with those from his previous plan from January 2007, which had been met with criticism from various stakeholders and legislative leaders. For a version of the January 2007 plan, see: http://gov.ca.gov/pdf/press/Governors_HC_Proposal.pdf
- "California's Ambitious Health Plan Stalls"
Kevin Sack, New York Times, September 9, 2007
Kevin Sack outlines the reasons why Governor Schwarzenegger's January plan had been met with opposition by various interest groups. In order to pay for the plan, Schwarzenegger called for doctors to give up 2 percent of their gross receipts, hospitals 4 percent of net revenue, and employers 4 percent of their payroll. Each of these groups have voiced opposition to these proposals to various degrees, with the state medical association the most vociferous (after calculating that most doctors would be net losers) and the hospital association less so (after figuring most hospitals would still profit after the 4 percent cutback). These points of contention influenced the governor's decision to propose a new plan in October 2007.
- "Time is Running Out for Deals on Healthcare, Water"
George Skelton, Los Angeles Times, November 1, 2007
George Skelton describes the ways in which the California legislature has stalled on several issues that are on the table, most prominently health care. Governor Schwarzenegger and the Democratic legislative leaders are trying to fashion a compromise on health care by Thanksgiving 2007.
- "Healthy Wisconsin. Your Choice. Your Plan."
State Senate's Healthy Wisconsin proposal, June 2007
The Democratic-controlled State Senate passed legislation to create a $15 billion payroll tax that would go towards financing a single-payer health care system. The plan would leave Medicare as the primary option for seniors, but would require employers and all other residents to participate in the new plan. Individuals would pay 4 percent of their wages, and businesses would pay 10.5 percent of employees' wages into the fund.
- "Healthy Wisconsin"
Governor Jim Doyle's Healthy Wisconsin proposal, January 2007
This is an overview of Gov. Jim Doyle's plan to expand coverage within the state. It discourages businesses from dropping employee coverage plans by offering them "reinsurance" - protection from the state against high costs and catastrophic claims. Reinsurance would be offered to insurance companies as well.
- "Senators push universal health care; Payroll-tax plan likely to falter in Assembly"
Stacy Forster and Patrick Marley, Milwaukee Journal-Sentinel, June 24, 2007
Foster and Marley report on the plan by Wisconsin's State Senate (controlled by Democrats) and the Republican-controlled State Assembly's opposition to it. It also notes that Gov. Doyle (a Democrat) supports the Senate efforts but has not "immediately embraced" the Senate plan because he believes his own plan is more feasible. For more coverage on Wisconsin's health reform by the Milwaukee Journal-Sentinel, see www.jsonline.com/index/index.aspx?id=115.
- "Healthy Minnesota: A Partnership for Reform" (March 2007)
Summary and Text of Bill: www.healthyminnesota.org
The Healthy Minnesota Bill introduced in the State Senate after a bipartisan steering committee composed of legislators, educators, healthcare executives, and physicians convened for over a year to discuss a plan to expand coverage. The new proposal contains an individual mandate for all citizens to obtain coverage, with guaranteed private coverage from all employers, who must issue coverage for the minimum benefit set to any applicant. The bill has not yet passed and is still being considered in the state legislature. For the current status of the bill, see www.revisor.leg.state.mn.us/revisor/pages/search_status/status_detail.php?b=Senate&f=SF1689&ssn=0&y=2007.
- "Prescription for Pennsylvania: Right State, Right Plan, Right Time"
PowerPoint presentation by Anne Torregrossa at briefing of The Commonwealth Fund and the Alliance for Health Reform, October 26, 2007
www.allhealth.org/briefingmaterials/AnnTorregrossa-957.ppt#268,1,Prescription for Pennsylvania
This presentation by Ann Torregrossa, deputy director and director of the Pennsylvania Governor's Office of Health Care Reform, describes the rationale for Gov. Edward Rendell's proposal to insure all Pennsylvanians, and explains the intended impact of the plan for health care affordability, access and quality.
- "Prescription for Pennsylvania Fact Sheets"
Pennsylvania Office of the Governor, 2007
This page contains brief facts sheets outlining the general goals of each of the governor's proposals: Prescription for Pennsylvania (the general plan), Rx for Affordability, Rx for Access, and Rx for Quality.
- "Governor Rendell Unveils 'Prescription for Pennsylvania' to Provide Access to Affordable, Quality Health Care for All Pennsylvanians"
Pennsylvania Office of the Governor, January 2007
This press release outlines Gov. Edward Rendell's proposal to insure all Pennsylvanians while also improving quality of care and bringing costs under control. Since the announcement of this proposal in January 2007, there have been several legislative developments in the state. The Governor's office has set up a site to track all news: http://www.rxforpa.com/news.html
- Maine, Massachusetts and Vermont now have a track record in implementing near-universal health coverage. How are things working out? What lessons learned in these states might apply to your state?
- What's different now in debates about helping the uninsured, compared to the last time the nation seriously visited this issue in 1993?
- What's the prevailing mood among business leaders about continuing to offer health coverage to their employees (among those who offer coverage now)? Are any seriously considering dropping coverage?
- Talk with employees of businesses that don't offer coverage. Do they get coverage through another source, such as a spouse or Medicaid? If not, how do these get their health care? Do they face discrimination from health care providers as a result of being uninsured?
- Are any area businesses thinking of offering health coverage to uninsured part-time employees?
- What do providers in your area say about their willingness to care for the uninsured? Is the growing number of uninsured people causing them problems? How has this growing number affected local community clinics and emergency rooms and their ability to provide services to all residents?
- How do chronically ill individuals navigate the health care system if they're uninsured? What do waiting periods, pre-existing condition exclusions, or other coverage lapses mean for people with diabetes, asthma, or hypertension? How does a lack of health insurance affect their ability to manage their health conditions and avoid more serious complications?
- Companies across the country have increasingly limited retiree medical benefits. Are retirees in your area able to get health coverage if they're younger than 65? Talk with employers who may try to help even if they don't offer coverage.
Drawn from the Alliance for Health Reform's Find-an-Expert Service for reporters. Descriptions in quotes are written by the experts themselves. Credentialed reporters can see full profiles for these and other experts, including after-hours contact numbers, by going to www.allhealth.org/reporter_enroll.asp
Analysts and Advocates
- HENRY J. AARON
Senior Fellow, Brookings Institution
Washington DC 20036
"Areas of knowledge include entitlements in general, including Social Security and Medicare; general budget and tax policy."
- JOSEPH ANTOS
Wilson H. Taylor Scholar in Health Care and Retirement Policy, American Enterprise Institute
Washington DC 20036
"Areas of expertise include Medicare (including Part D), Medicaid, and other federal health programs; private health insurance (including consumer-driven health care); price/spending trends; health policy and the budget. Former senior official at CBO, CMS, and OMB."
- STUART BUTLER
Vice President, Economic and Domestic Policy Studies, The Heritage Foundation
Washington DC 20002
"Senior health expert in America's foremost conservative research organization. Expert on the uninsured -- especially tax credit solutions -- and Medicare. Frequently testifies and speaks on health issues."
- MICHAEL CANNON
Director of Health Policy Studies, Cato Institute
Washington DC 20001
"Expanding patient and provider freedom. Using market mechanisms to improve quality, reduce cost, generate information for patients, and drive IT innovation. Encouraging regulatory competition among governments, incl. devolving power over health care to states."
- GARY CLAXTON
Vice President, Director, Health Care Marketplace Project, Henry J. Kaiser Family Foundation
Washington DC 20005
"Gary Claxton is a Vice President and the Director of the Health Care Marketplace Project at the Henry J. Kaiser Family Foundation. The Project provides information, research, and analysis about trends in the health care market and about policy proposals that relate to health insurance reform and our changing health care system. Prior to joining the Foundation, Mr. Claxton worked as a senior researcher at the Institute for Health Care Research and Policy at Georgetown University, where his research focused on health insurance and health care financing. From March 1997 until January 2001, Mr. Claxton as the Deputy Assistant Secretary for Health Policy at the U.S. Department of Health and Human Services, where he advised the Secretary on health policy issues including: improving access to health insurance, Medicare reform, administration of Medicaid, financing of prescription drugs, expanding patient rights, and health care privacy."
- DAVID COLBY
Vice President, Research and Evaluation, Robert Wood Johnson Foundation
Dr. Colby "leads a team dedicated to improving the nation's ability to understand key health and health care issues so that informed decisions can be made concerning the way Americans maintain health and obtain health care."
- MICHAEL DAVERN
Assistant Professor, University of Minnesota School of Public Health
Minneapolis, MN 55414
Research interests include health survey research methodology, Census Bureau surveys, health insurance coverage, quantitative policy analysis, and social networks. Teaches courses in using demographic data in policy analysis; and aging, policy, and demography. Reseach Director and Co-Principal Investigator for the State Health Access Data Assistance Center (SHADAC), a Robert Wood Johnson funded initiative to help states monitor rates of health insurance coverage and to understand factors associated with uninsurance.
- KAREN DAVIS
President, The Commonwealth Fund
New York NY 10021
"My primary interests are the uninsured, Medicare, Medicaid, health policy, quality and organization of health services, international health, minority health, and women's health. My training is in economics with experience in government health policy, academia, and currently private foundation sponsoring independent research on health and social issues."
- LYNN ETHEREDGE
Consultant, Health Insurance Reform Project, George Washington University.
Chevy Chase MD 20815
"Office of Management and Budget professional health staff 12 yrs (nhi, Medicare, Medicaid), consulting/think tanks. Current areas include tax credits, Medicaid, insurance coverage, consumer health information, quality, related issues."
- PAUL FRONSTIN
Director, Health Research Program, Employee Benefit Research Institute
Washington DC 20037
"I specialize in economic security issues related to employment-based health benefits, health insurance coverage, and the uninsured."
- PAUL GINSBURG
President, Center for Studying Health System Change
Washington DC 20024
"As a health economist, my primary interests include health care costs, the uninsured, managed care and insurance trends, physician issues, market changes and Medicare issues."
- ROBERT HELMS
Resident Scholar, Health Policy Studies, American Enterprise Institute
Washington DC 20036
"I am an economist who has worked in the health policy area in Washington for about 30 years, including 8 years at HHS/ASPE during the Reagan years. I have written on the tax treatment of health insurance, private health insurance, tax credits for expanding coverage, Medicare and Medicaid reform, and the economics of the pharmaceutical industry."
- JOHN HOLAHAN
Director, Health Policy Center, The Urban Institute
Washington DC 20037
"My principal areas of interest are Medicaid policy, the uninsured and the uninsured."
- EDWARD F. HOWARD
Exec V-P, Alliance for Health Reform
Washington DC 20005
"Has run the nonpartisan Alliance for Health Reform since its founding in 1991, where he has arranged hundreds of policy briefings for Congressional staff and media in Washington and around the country."
- ANDREW D. HYMAN
Senior Program Officer, The Robert Wood Johnson Foundation
Princeton NJ 08543-2316
Responsible for developing and executing strategies designed to achieve the Foundation's goal of securing for all Americans meaningful access to health care coverage. He and the Coverage Team work with policy-makers, researchers and advocates to help our nation's leaders craft and enact policies designed to expand coverage. Came to the Foundation in 2006 after serving as director of Government Relations and Legislative Counsel for the National Association of State Mental Health Program Directors, which represents the public mental health systems in every state.
- CHIP (CHARLES) KAHN
President, Federation of American Hospitals
Washington DC 20004
"13 years as a Congressional staffer in the Senate and House working on most major Medicare and health legislation. Outside government experience as head of two major health trade associations Health Insurance Association of America and the Federation of American Hospitals."
- LEIGHTON KU
Senior Fellow, Center on Budget and Policy Priorities
Washington DC 20010
"My main areas of interest are health insurance coverage and how we pay for it; this particularly includes Medicaid and SCHIP. My organization is engaged in timely research and advocacy at both federal and state levels."
- RISA LAVIZZO-MOUREY
President and CEO, The Robert Wood Johnson Foundation
Princeton NJ 08543-2316
Contact through Gina Ivey, 609-627-5937
"Became The Robert Wood Johnson Foundation president and CEO in January 2003. Has served on a number of federal advisory committees, including the White House Task Force on Health Care Reform (co-chaired its working group on quality of care), the Task Force on Aging Research, Office of Technology Assessment Panel on Preventive Services for Medicare Beneficiaries, and the National Committee for Vital and Health Statistics (chair of Subcommittee on Minority Populations). Served as co-vice chair of a congressionally-requested Institute of Medicine study on racial disparities in health care."
- JOHN R. LUMPKIN
Senior VP, Director Health Care Group, The Robert Wood Johnson Foundation
Princeton NJ 08543-2316
Contact through Gina Ivey, 609-627-5937
"Responsible for the overall planning, budgeting, staffing, management and evaluation of all activities of The Robert Wood Johnson Foundation's Health Care Group. Before joining the foundation in April 2003, served as director of the Illinois Department of Public Health for 12 years. Practiced emergency medicine and taught medical students and residents at the University of Chicago and Northwestern University. Chairman since 1996 of the National Committee on Vital and Health Statistics. Served on a number of other national advisory groups, including the Advisory Committee to the Director of the U.S. Centers for Disease Control and Prevention, the National Institute of Medicine's Committee on Assuring the Health of the Public in the 21st Century, and the Council on Maternal, Infant and Fetal Nutrition."
- ENRIQUE MARTINEZ-VIDAL
Director, State Coverage Initiatives, AcademyHealth
Washington DC 20006
"The State Coverage Initiatives program works with states to plan, execute and maintain health insurance expansions. Areas of Expertise: State Coverage Programs; Health Insurance Markets; Medicaid/SCHIP; Quality/Cost Containment Efforts at the State Level."
- LEN NICHOLS
Director of Health Policy Program, New America Foundation
Washington DC 20009
"I study, write, and speak about private health insurance markets (decisions by employers, workers, health plans, and regulators), coverage expansion policy options, sources of and reactions to health care cost growth, and Medicare reform. I was the Senior Advisor for Health Policy at OMB during the Clinton health reform process of 1993-94, taught at Wellesley College, and did research at both AHRQ and the Urban Institute before joining the Center."
- RON POLLACK
Executive Director, Families USA
Washington, D.C. DC 20005
"Families USA is the national organization for health care consumers. As executive director of Families USA, health care expertise includes health coverage for the uninsured, prescription drugs costs and affordability, Medicare and Medicaid, patients' rights legislation, and health care ombudsman issues."
- KAREN POLLITZ
Project Director, Georgetown University Health Policy Institute
Washington DC 20007
"My research focuses on the regulation of private health insurance markets and plans by the states and federal government. I also focus on how private health insurance and the rules governing it impact the availability, adequacy, and affordability of coverage for consumers."
- ROBERT REISCHAUER
President, The Urban Institute
Washington DC 20037
"I am the Vice Chair of MedPAC and was the director of CBO so I have expertise in Medicare, budget issues, health insurance and the economy, and prescription drugs."
- MICHAEL RODGERS
Senior Vice President for Advocacy and Public Policy,
Catholic Health Association of the United States
Mr. Rodgers oversees CHA's advocacy and public policy efforts and advances CHA's advocacy agenda before Congress, the White House, and a variety of health-related federal agencies. Prior to joining CHA in 2000, he served for 13 years as senior vice president of the American Association of Homes and Services for the Aging, overseeing operations and directing staff functions of the government relations department. He also served in several Washington, DC-based federal and state government positions.
- JOHN ROTHER
Director, Policy and Strategy, AARP
Washington DC 20049
"Broad issue and advocacy expertise in health and healthcare, particularly for boomers and seniors. Prescription drugs, health access and quality, long-term care, and consumer attitudes are particular interests."
- SARA ROSENBAUM
Chair, Department of Health Policy, George Washington University
Washington DC 20006
Sara Rosenbaum is Hirsh Professor and founding chair of the Department of
Health Policy at the George Washington University School of Public Health and Health
Services. She has devoted her career to issues of health law and policy
affecting low income, minority, and medically underserved populations, and the health
care safety net. Between 1993 and 1994, she worked for President Clinton, directing the
legislative drafting of the Health Security Act and developing the Vaccines for Children
program. She has written more than 250 articles and studies focusing on all phases of
health law, as well as health care for medically underserved populations, and is coauthor
of Law and the American Health Care System (Foundation Press, NY).
- DIANE ROWLAND
Executive Vice President, Kaiser Family Foundation
Washington DC 20005
"My primary interests are Medicare and Medicaid policy, health coverage and the uninsured, coverage and access to care for the low-income population, and health care reform. As executive director of the Kaiser Commission on Medicaid and the Uninsured, much of my work examines coverage for the low-income and uninsured populations."
- UWE REINHARDT
Professor of Economics and Public Affairs, Princeton University
Princeton NJ 08540
609-258-4781 (Secretary: 609/258-1456)
"My interests are health economics and health policy, with emphasis on the uninsured, hospital economics and the economics of the pharmaceutical industry."
- MATT SALO
Director of Health Legislation, National Governors Association
Washington DC 20001
"I have been the director of health legislation for the National Governors Association since January 1999. Prior to that I spent 5 years working for the National Association of State Medicaid Directors."
- GREG SCANDLEN
President & CEO, Consumers for Health Care Choices
Hagerstown MD 21740
"Greg Scandlen is the founder of Consumers for Health Care Choices, a new organization aimed at mobilizing health care consumers to regain control of the health care system."
- CATHY SCHOEN
Senior Vice President, Commonwealth Fund
New York NY 10021
"Cathy Schoen is senior vice president at The Commonwealth Fund, a member of the Fund's senior management team and research director of the Fund's Commission on a High Performance Health System. Her work focuses on health insurance, access and initiatives to track and improve health system quality, access and cost performance. She has authored numerous publications on health policy and insurance issues, and national/international health system performance, including the 2006 National Scorecard on U.S. Health System Performance, the 2007 State Scorecard, and international comparative surveys of care experiences. She co-authored the book "Health and the War on Poverty." She holds an undergraduate degree and graduate degree in economics."
- PAT SCHOENI
Director of Public Affairs, National Coalition on Health Care
Washington DC 20005
"Expertise in public and private health care, i.e., Medicare, Medicaid, and private insurance. Worked in Medicare and Medicaid federal agency and in insurance industry's trade association. Public policy, as well as public relations, experience in all aspects of health care delivery and financing."
- GAIL SHEARER
Director, Health Policy Analysis, Consumers Union
Washington DC 20009
"My main area of focus is affordability of health care, from a consumer perspective. Issues I work on include: the uninsured, the underinsured, Medicare prescription drugs, tax credits for health insurance, medical savings accounts."
- JOHN SHEILS
Vice President, The Lewin Group
Falls Church VA 22042
"Sheils specializes in financial analyses of programs to expand insurance coverage including the impact on providers, consumers employers and governments. He has analyzed a broad range of proposals including tax credits, single-payer, Medicaid/SCHIP expansions, individual mandates and employer pay-or-play proposals."
- JAMES R. TALLON
President, United Hospital Fund
New York NY 10118
"President of United Hospital Fund and recognized nationally for leadership in health care policy. The United Hospital Fund is a health services research and philanthropic organization which addresses critical issues affecting hospitals and health care in New York City."
- MICHAEL TANNER
Director, Health & Welfare Studies, Cato Institute
Washington DC 20001
"As director of Cato's health and welfare studies, Michael Tanner oversees Cato's research on new, market-based approaches to health care reform and social welfare programs. He is the author or coauthor of several books, including Healthy Competition: What's Holding Back Health Care and How to Free It. His writings have appeared in nearly every major American newspaper, including the New York Times, Washington Post, Los Angeles Times, Wall Street Journal, and USA Today. A prolific writer and frequent guest lecturer, Tanner appears regularly on network and cable news programs."
- HUMPHREY TAYLOR
Chairman - The Harris Poll, Harris Interactive
New York NY 10003
"I am a survey researcher who spends more than half my time working on health care issues, including health policy, epidemiology, clinical trials and marketing -- for drug companies, NIH, insurers, universities and hospitals."
- KEN THORPE
Professor and Chair, Dept Health Policy Mgt, Emory University
Atlanta GA 30322
"Medicare reform, uninsured, cost of health insurance. Chair, Department of Health Policy and Management, Emory University. Former Deputy Assistant Secretary for Health Policy under President Clinton."
- GRACE-MARIE TURNER
President, Galen Institute
Alexandria VA 22320
"Primary interests are the uninsured, Medicare reform, and prescription drugs, with a focus on free-market policy alternatives such as tax credits for the uninsured and premium support for Medicare."
- ALEXANDER VACHON
President, Hamilton PPB
Washington DC 20008
"Dr. Alec Vachon spent nearly 10 years on the Hilll, working first for Senate Majority Leader Bob Dole (R-KS) and later as Senate Finance health staff -- on BBA 95, BBA 97, etc. Vachon is President of Hamilton PPB, a Washington consulting firm providing intelligence and insight, strategic advice, and advocacy before Congress and the Executive Branch."
- ALAN WEIL
Executive Director, National Academy for State Health Policy
Washington DC 20036
"My research focuses on Medicaid, the uninsured and state/federal issues. I also have experience as a state Medicaid administrator."
- KAREN IGNAGNI
President & CEO, AHIP
Washington DC 20036
"As President and Chief Executive Officer of the American Association of Health Plans, Karen Ignagni is the nation's leading authority on the public policy, legislative, and public affairs issues challenging the managed care industry today."
- ALICIA MITCHELL
Vice President, Media Relations, American Hospital Association
Washington DC 20004
"The American Hospital Association is the umbrella group for the nation's hospitals. The AHA has experts working on issues, including access and coverage for the uninsured, Medicare and Medicaid, medical liability reform, quality and patient safety, regulatory reform and relief, health care costs, bioterrorism and disaster readiness, among others."
- REED TUCKSON
Senior Vice President of Consumer Health and Medical Care Advancement, UnitedHealth Group
Minnetonka MN 55343
"A graduate of Howard University and Georgetown University School of Medicine, Dr. Tuckson is currently Senior Vice President of Consumer Health and Medical Care Advancement at UnitedHealth Group. He has served as Senior Vice President, Professional Standards, for the American Medical Association (AMA). He is former President of the Charles R. Drew University of Medicine and Science in Los Angeles from 1991 to 1997; has served as Senior Vice President for Programs of the March of Dimes Birth Defects Foundation from 1990 to 1991; and from 1986 to 1990, Dr. Tuckson was the Commissioner of Public Health for the District of Columbia. He currently is a member of Institute of Medicine of the National Academy of Sciences and serves as a member of the Secretary of Health and Human Services' Advisory Committee on Genetics, Health and Society and has held a number of other federal appointments, including cabinet level advisory committees on health reform, infant mortality, children's health, violence, and radiation testing."
Glossary on the Uninsured
ADVANCEABLE TAX CREDIT - A subsidy to help pay for health insurance that is available when the insurance premium is due, without having to wait until a year-end tax return is filed. Also see "tax credit."
ASSOCIATION HEALTH PLAN (AHP) - Health insurance arrangement sponsored by business coalitions and trade and professional associations. AHPs operate under states' insurance laws and regulations. Recent legislative proposals would regulate AHPs primarily under federal law. Also see "Small Business Health Plan."
CAPITATION - Method of payment for health services in which a health care provider is paid a fixed amount for each person on the provider's patient roster, regardless of the actual number or nature of services provided to each person.
CATASTROPHIC HEALTH INSURANCE - Health insurance which provides protection against the high cost of treating severe or lengthy illnesses. Such policies cover all or most of medical expenses above a relatively high specified amount.
CHERRY PICKING - The practice of insurance companies taking only those businesses or individuals that are good health risks, and avoiding businesses or people that have higher health risks. Also called "skimming."
CHRONIC CONDITION (CHRONICALLY ILL) - A condition that is not expected to improve, that lasts a year or longer or recurs, and may result in long-term care needs. Chronic illnesses include Alzheimer's disease, arthritis, diabetes, epilepsy and some mental illnesses.
COINSURANCE - A portion of the bill for a medical service, that is not covered by the patient's health insurance policy and therefore must be paid out of pocket by the patient. Coinsurance refers to a percentage, e.g., 10 percent of the total charge up to a specified maximum. Contrast with "copayment," which is stated as a flat amount, e.g., $5 per office visit.
COMMUNITY RATING - A method for setting premiums at the same price for everyone, based on the average cost of providing health services to all. The premium is not adjusted for the individual beneficiary's medical history or likelihood of using medical services. Contrast with "experience rating."
COPAYMENT - A flat dollar amount that a patient must pay out of pocket for a medical service, e.g. $5 per office visit.
COST SHARING - Any out-of-pocket payment the patient makes for a portion of the costs of covered services. Deductibles, coinsurance, copayments and balance bills are types of cost sharing.
CROSS-SUBSIDY - The concept of certain purchasers paying more for medical services than they otherwise would so that others can pay less (or nothing at all), or another activity can be funded. In the U.S. health system, this mechanism has been used to pay for medical services for the poor and uninsured, medical education and research.
CROWD-OUT - A phenomenon whereby public programs or expansions of public programs designed to extend coverage to the uninsured encourage some employers to drop health coverage, urging their employees instead to take advantage of the expanded public subsidy.
DEDUCTIBLE - A fixed amount, usually expressed in dollars in the form of an annual fee, that the beneficiary of a health insurance plan must pay directly to the health care provider before a health insurance plan begins to pay for any costs associated with the insured medical service.
DEFINED BENEFIT - A health insurance model used by an employer or government program where specified health services covered under the plan are standardized and guaranteed. The cost of providing the standard benefits may fluctuate. One example of a defined benefit plan is Medicare. Contrast with "defined contribution."
DEFINED CONTRIBUTION - A health benefit model used by employers or government programs where health services covered may fluctuate based on choice of plan, but the employer or government contributes a set amount (percentage or dollar amount) towards the purchase of the selected health plan. A defined contribution plan limits the financial liability of employers or the government, because the contribution is defined, or fixed. An example of a defined contribution plan is the State Children's Health Insurance Program. Contrast with "defined benefit."
EMPLOYEE RETIREMENT INCOME SECURITY ACT (ERISA) - Enacted in 1974, ERISA was primarily designed to secure workers' pension rights. The law established federal reporting and disclosure requirements for most private employee health plans. Under ERISA, companies that pay for their workers' health benefits directly (e.g. by self-insuring and assuming all or most financial risk) are exempt from state insurance regulations and taxes. ERISA also limits workers' ability to sue their insurer. For more information, see www.dol.gov/dol/topic/health-plans/erisa.htm.
EMPLOYER CONTRIBUTION REQUIREMENT OR "EMPLOYER MANDATE" - A requirement that employers either provide health care benefits to their workers or pay a fee that contributes to the cost of covering their workers under a public (state) plan. Such proposals are also called "pay or play."
EXPERIENCE RATING - Process of determining insurance premiums for a group that is based wholly or partially on that particular group's past use of services and expenses incurred. Contrast with "community rating."
FEDERAL EMPLOYEES HEALTH BENEFITS PROGRAM (FEHBP) - Health care plans offered to federal civilian employees who can annually choose among a number of approved, community-rated private health insurance plans. The federal government pays a major portion of the cost of the coverage (on average 72 percent). For more information, see www.opm.gov/insure/health.
FEDERAL POVERTY GUIDELINES - Income amounts set each February by the U.S. Department of Health and Human Services used to determine an individual's or family's eligibility for various public programs, including Medicaid and the State Children's Health Insurance Program. Sometimes called Federal Poverty Level/Line (FPL). (The poverty guidelines are different from the U.S. Census Bureau's "poverty thresholds," which are used for Census statistical purposes.) For the 2007 poverty guidelines, see http://aspe.hhs.gov/poverty/07poverty.shtml
GUARANTEED ISSUE - A requirement that health plans cannot reject coverage for an applicant based on medical history. For example, under federal law, small employers that purchase health insurance cannot be denied coverage for sick workers. However, plans can adjust premiums based on medical history or other factors. Health plan policies that operate under a "guaranteed renewability" clause cannot cancel coverage due to a beneficiary's health status.
HEALTH INSURANCE PORTABILITY AND ACCOUNTABILITY ACT (HIPAA) - A 1996 federal law that provides some protection for employed persons and their families against discrimination in health coverage based on past or present health. Generally, the law guarantees the right to renew health coverage, but does not restrict the premiums that insurers may charge. HIPAA does not replace the states' role as primary regulators of insurance. HIPAA also requires the collection of certain health care information by providers and sets rules designed to protect the privacy of that information. For more information, see www.hhs.gov/ocr/hipaa/.
HEALTH REIMBURSEMENT ARRANGEMENT (HRA) - A type of health insurance plan also known as "health reimbursement account" or "personal care account," HRAs are tax-preferred accounts with funds established by employers to reimburse employees for qualified medical expenses; often HRAs are paired with a high-deductible health plan. An HRA may be used by an employee to pay for medical coverage until funds are exhausted. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year, but do not follow the employee once he or she changes jobs. Compare to "health savings account."
HEALTH SAVINGS ACCOUNT (HSA) - A type of health insurance plan similar to HRAs, but which is owned by workers. An HSA is a tax-preferred savings account and is paired with a high-deductible health plan. Any employer can offer an HSA (or a self-employed individual can set one up on his or her own), and both employers and employees can contribute to it. The worker must pay for all services until the amount of the deductible is reached (in 2007, a minimum of $1,100 for an individual and $2,200 for family coverage). The worker can withdraw money from the HSA to pay for medical services under the deductible. Once the deductible is reached, normal coverage begins. Any unused funds are rolled over at the end of the year. Unlike HRAs, HSAs follow an employee when he or she changes jobs. Also see "health reimbursement arrangement" and "medical savings account."
MANDATE - Used in two senses in health policy discussions. (1) Employer or individual mandate, in which the government imposes a requirement on some or all employers to help pay for insurance coverage for their workers (and perhaps their families), or on individuals to obtain coverage. (2) State mandate, a requirement imposed by states on insurance companies to include, as part of any health insurance policy they sell, coverage for a specific service, such as well baby care, or provider, such as psychologists or optometrists.
MEDICAID - Public health insurance program that provided coverage for an estimated 60 million low-income persons for acute and long-term care at some point during 2006. It is financed jointly by state and federal funds (the federal government pays at least 50 percent of the total cost in each state), and is administered by states within broad federal guidelines. Contrast with "Medicare."
MEDICAL SAVINGS ACCOUNT (MSA) - A health insurance option consisting of a high-deductible insurance policy coupled with a tax-preferred savings account. MSA policies, put into place by a 1996 law, have been largely replaced by "health savings accounts."
MEDICARE - Federal health insurance program for virtually all persons age 65 and older, and permanently disabled persons under age 65, who qualify by receiving Social Security Disability Insurance. Contrast with "Medicaid."
MULTIPLE EMPLOYER WELFARE ASSOCIATION (MEWA) - A group of employers who band together for purposes of purchasing group health insurance, often through a self-funded approach. MEWAs are sometimes exempt from state benefit mandates, taxes and other regulations.
NON-GROUP INSURANCE - Insurance purchased by an individual directly from an insurer, rather than through an employer, union or other third party. Even though this is sometimes called "individual insurance," it can be purchased for an individual or a family.
PRE-EXISTING CONDITION - A physical or mental condition of an individual which is known to the individual before an insurance policy is issued. Insurers may choose not to cover treatment for such a condition, at least for a period, may raise rates because of it, or may deny coverage altogether.
PREMIUM - The cost of health plan coverage, not including any required deductibles or copayments.
PREMIUM ASSISTANCE - The use of federal funds available through public health coverage programs - especially Medicaid and the State Children's Health Insurance Program - to purchase or help purchase private insurance.
PREMIUM SUPPORT - A health benefit model that is considered by its designers to be a hybrid of the "defined contribution" and "defined benefit" approaches. This model would require general categories of health services to be covered, but benefits could be added or deleted within limits. The employer or government would then contribute a set amount of the premium for the purchased plan. Plans could set premiums at whatever dollar level they choose, with beneficiaries liable for any costs above the employer or government contribution. A Medicare demonstration designed to test a model similar to premium support is scheduled to begin in 2010.
RATING - The process of evaluating, or underwriting, a group or individual to determine a health insurance premium rate relative to the financial risk of needing healthcare the person or group presents. Key components of the rating formula include age, sex, location and plan design.
RATING BANDS - Amounts by which insurance rates for a specific class of insured individuals may vary. All states have laws regulating insurer rating practices, and many states periodically update these laws with small group market reform proposals to restrict or loosen allowable variations.
REFUNDABLE TAX CREDIT - A way of providing a tax subsidy to an individual or business, even if no taxes are owed (see "tax credit"). If a person owes no tax, the government sends the person (or a third party) a check for the amount of the refundable tax credit.
REINSURANCE/RISK CONTROL INSURANCE - Insurance bought to protect against catastrophic losses by an insurer or self-insured entity.
RISK - The probability of financial loss, relative to the probability of having to provide services to a patient or patient population at a cost that exceeds the payments received. Under capitation payment systems, providers share the risk that is borne by insurers.
RISK ADJUSTMENT - Increases or reductions in payment made to a health plan on behalf of a group of enrollees to compensate for health care expenditures that are expected to be higher or lower than average.
RISK SELECTION - Enrollment choices made by health plans - or by enrollees - on the basis of perceived risk relative to the premium to be paid.
RISK SHARING - A method by which the financial risk of covering a group of enrollees is shared by plan sponsors and purchasers, typically managed care organizations and states. In contrast, indemnity plans assume all risk of providing care paid for through insurance premiums which belong solely to the insurance company.
SINGLE PAYER SYSTEM - As referred to in the U.S., a proposed reorganization of the health care system, either at the national or state level, which would designate one entity (usually the government) to function as the central purchaser of health care services. Canadian provinces operate health insurance coverage for residents under this system.
SMALL BUSINESS HEALTH PLAN (SBHP) - Purchasing pools for small employers that have frequently been the subject of congressional proposals, SBHPs would include trade, industry and professional associations as well as 'cooperative' corporations or chambers of commerce. Known in other proposals as association health plans, SBHPs have generated controversy because they would be exempt from some state laws regulating health insurance.
SMALL GROUP MARKET REFORM - Generally refers to laws, regulations and proposals that are designed to simplify rules for small employers (50 workers or fewer) purchasing health insurance. While most regulation of health insurance is done at the state level, the 1996 Health Insurance Portability and Accountability Act made some key reforms.
STATE CHILDREN'S HEALTH INSURANCE PROGRAM (SCHIP) - A program enacted by Congress in 1997 that provides federal matching funds for states to spend on health coverage for uninsured kids. The program is designed to reach uninsured children whose families earn too much money to qualify for Medicaid but not enough to afford private coverage.
STATE MANDATE - State coverage laws requiring private insurers to cover specific services (such as well-baby care) or reimbursement for specific providers (such as psychologists). The Employee Retirement Income Security Act (ERISA) generally exempts self-insured companies from these requirements.
TAX CREDIT - A flat amount that can be subtracted from taxes owed. Under some health care reform proposals, tax credits would be given to moderate-income individuals/families to subsidize health insurance premiums. A tax credit is more progressive in its impact than a tax deduction of the same amount, since the value of a deduction is greater for those whose tax rates (and usually incomes) are higher.
TAX DEDUCTION - An amount that can be subtracted from taxable income if spent on a specific purpose. Currently, businesses and the self-employed can deduct the cost of health insurance provided to employees, but health expenses (including insurance) are a deduction for families with group health insurance only after they reach 7.5 percent of income. Contrast with "tax credit."
TAX PREFERENCE (FOR HEALTH BENEFITS) - Employer-paid health benefits are treated under federal tax law as a deductible business expense for the employer, and excluded from taxable income for the worker. This creates incentives for some employers and workers to prefer extra compensation in the form of more health coverage rather than wages.
UNDERINSURED - People with public or private insurance policies that do not cover all necessary health services, resulting in out-of-pocket expenses that often exceed their ability to pay.
UNDERWRITING - The process by which health insurers decide whether or not to accept an individual's application for insurance, and, if the applicant is accepted, what conditions to apply. Underwriting is also applied to small employers. If the insurer decides that a particular individual or group poses greater than normal financial risks, it might charge higher premiums, offer more limited benefits, or refuse to pay for services relating to a particular "pre-existing" condition.
VOUCHER - In various health reform proposals, a certificate or fixed dollar amount that is provided to low- or moderate-income persons, which is used to pay all or part of the cost of health insurance or services.
1 Institute of Medicine, "Care Without Coverage: Too Little, Too Late," May 2002, http://www.iom.edu/Object.File/Master/4/160/Uninsured2FINAL.pdf
2 U.S. Census Bureau, "Health Insurance Coverage: 2006 - Highlights." August 27, 2007, http://www.census.gov/hhes/www/hlthins/hlthin06/hlth06asc.html
3 For completed, updated Census Bureau tables on health coverage in 2005 and 2006, see http://www.census.gov/hhes/www/hlthins/hlthin06.html (2006) and http://www.census.gov/hhes/www/hlthins/hlthin05.html (2005)
4 Kaiser Commission on Medicaid and the Uninsured, "The Uninsured - A Primer: Key Facts about Americans Without Health Insurance" October 2006, http://www.kff.org/uninsured/7451.cfm
5 Kaiser Commission on Medicaid and the Uninsured, "2007 Employer Health Benefits Survey - Summary of Findings," September 2007, p. 29, http://www.kff.org/insurance/7672/index.cfm
6 Consumer Reports, "Health Insurance: CR Investigates Health Care," September 2007, http://www.consumerreports.org/cro/health-fitness/health-care/health-insurance-9-07/overview/0709_health_ov.htm
7 See, for example, www.ehealthinsurance.com. Request a quote for a 22-year-old male, and compare with a quote for a 52-year-old male.
8 Results of ABC News/Washington Post poll, September 4-7, 2007, summarized by The Polling Report -- http://www.pollingreport.com/prioriti.htm
9 Kaiser Family Foundation, "Iraq top issue, followed by health care, for the government to address and for presidential candidates to discuss." August 2007. http://www.kff.org/kaiserpolls/upload/7691.pdf
10 Daniel Costello and Susannah Rosenblatt, "Financial woes jeopardize area hospitals." Los Angeles Times, September 27, 2007 http://www.latimes.com/news/local/la-fi-hospitals23sep23,1,4466945.story
11 Institute of Medicine, "Care Without Coverage: Too Little, Too Late," Appendix D, p. 163, May 2002, www.nap.edu/catalog.php?record_id=10367
12 Institute of Medicine, "Report Brief: Care Without Coverage: Too Little, Too Late," pp. 5-6, May 2002, http://www.iom.edu/Object.File/Master/4/160/Uninsured2FINAL.pdf