A REPORTER'S TOOLKIT: THE UNINSURED
An Alliance for Health Reform Toolkit -
This toolkit offers links to resources that will help you understand who lacks health coverage in the U.S. and the consequences of being uninsured. We also offer links to proposals for change, including websites that track presidential candidates' plans, as well as to public opinion polls and updates on state-level reform. This resource also offers story ideas, selected experts with contact information, selected websites and a glossary.
This toolkit was compiled and written by Dinesh Kumar.
Selected ResourcesPlease email email@example.com if you find that any of the links mentioned in this toolkit no longer work.
Statistics on the Uninsured - Where Do People Get Health Coverage and Who is Uninsured?
Consequences of Being Uninsured
Stories of Real People
Public Opinion Polls
National Proposals for the Future
PRESIDENTIAL CANDIDATES' REFORM PROPOSALS
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
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."
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 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.
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 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.
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
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