Many policy experts believe that sweeping general reform to our national health system is not likely to happen without success stories from state-level reforms. Yet many state reforms may be in conflict with the federal statute known as the Employee Retirement Income Security Act, or ERISA. This toolkit, supported by the Robert Wood Johnson Foundation, covers the basics and ERISA and presents expert opinion on both sides of the ERISA vs. state reform issue.
Over the past three years, enrollment in Medicare private fee-for-service (PFFS) plans has increased significantly. These plans offer a potentially greater choice of providers than beneficiaries will find in Medicare HMOs or PPOs. They often provide extra benefits not found in traditional Medicare. Beneficiaries attracted to the plans hope to lower their out-of-pocket costs compared to what they would pay in traditional Medicare. However, the plans have drawn the interest of federal budget cutters since they cost more per beneficiary than traditional Medicare. Moreover, beneficiaries have been reporting confusion about the plans and sometimes, enrollment fraud. Some private fee-for-service beneficiaries have been denied services by physicians who previously accepted their traditional Medicare coverage. This toolkit, supported by the Robert Wood Johnson Foundation, contains resources that describe the basics of PFFS plans, advantages and incentives included in the plans, and the challenges that PFFS enrollees have encountered along the way.
As presidential candidates of both major parties woo the American public, particularly in early caucus and primary states, they are gravitating toward a common public concern: the U.S. health care system. Potential voters are well aware of rising premiums and higher out of pocket costs to families, the impact of high health care costs on America’s economic competitiveness and on federal and state budgets, and the ever-growing number of uninsured – now nearly 45 million. A Kaiser Family Foundation poll released in March shows that health care ranks as the second most important issue that the public would like discussed by presidential candidates for the 2008 election.
Starting July 1, every adult in Massachusetts is required to have health coverage (except for 60,000 people exempted by the state). This toolkit, supported by the Robert Wood Johnson Foundation, is designed to help you understand the state's pace-setting near-universal coverage plan and its implications, with links to representative articles and documents from across the ideological spectrum. You will also find a list of selected experts and websites. We recommend these articles and experts to you, and welcome your suggestions for additions to our list. You may email those to firstname.lastname@example.org
Providing health insurance coverage to the 46 million Americans without it has been receiving more attention in recent months. Several polls have shown rising public interest in the topic. Coverage is fast becoming an issue in the 2008 presidential campaign, for both Democrats and Republicans. President Bush offered an uninsured proposal in his January State of the Union address. Bills dealing with the uninsured have been introduced by members of Congress from both parties. A number of states have also laid out ambitious coverage plans.
The Census Bureau’s recently released figure on the number of uninsured in 2005 is 46.6 million, an increase of 1.3 million people over 2004. Two new studies by John Holahan and Bowen Garrett of the Urban Institute offer in-depth analyses of the economic and demographic factors that underlie this troubling statistic.
Although it’s best known for introducing the Medicare prescription drug program, the Medicare Prescription Drug, Improvement, and Modernization Act (MMA) of 2003 also made a number of changes to the Medicare managed care program – Medicare Advantage. Among the aims: Keep managed care plans from leaving the program by offering higher payments, and give beneficiaries more reasons to consider joining.
On April 4, the Massachusetts legislature approved a plan that requires all adults to purchase health insurance by July 2007, or face a fine. The plan is projected to expand coverage to 95 percent of the state’s uninsured residents over the next three years.
Congress has actively considered whether and how to reorganize the health insurance market for small businesses. In Spring 2006, the Senate debated a legislative proposal, offered by Senators Michael Enzi and Benjamin Nelson, which centers on Small Business Health Plans (SBHPs). SBHPs are a new category of group health plans sponsored by bona-fide professional and other associations. The House has debated and approved related legislation on association health plans.
Health savings accounts (HSAs) offered in conjunction with high-deductible health plans are on an upswing nationally. Simply stated, HSAs require an individual to use his or her own money (or money set aside by an employer for the individual’s use) to pay for medical expenses up to a fairly substantial deductible, at which point traditional insurance coverage begins. Established by the Medicare Modernization Act, the minimum deductible this year for individuals is $1,050; for families, $2,100.
Congress made major changes in the Medicare managed care program, now named “Medicare Advantage,” affecting plans and beneficiaries in 2005 and 2006. The Department of Health and Human Services (HHS) has proposed regulations to implement this part of the new law, and comments on the draft regulations are due by October 4, 2004.
In August 2004, the U.S. Census released its most recent figures, showing that the number of Americans without health insurance increased to 45.0 million in 2003, up from 43.6 million people in 2002. Those covered by government health insurance programs increased between 2002 and 2003 — from 73.6 million to 76.8 million, largely as a result of greater coverage by Medicaid. At the same time, employer-based coverage shrank. The number of people covered by employment-based insurance fell from 175.3 million to 174.0 million from 2002 to 2003, and the share of the population covered declined from 61.3 percent to 60.4 percent.
More than 43 million U.S. residents lacked health coverage in 2002 and unless private or public coverage programs expand, the number of uninsured could continue to rise over the next decade. To address this growing problem, the Institute of Medicine (IOM), with support from The Robert Wood Johnson Foundation, has been conducting a three-year study of the uninsured to assess and consolidate evidence about the health, economic and social consequences of uninsurance for those without insurance, their families, health care systems and institutions, and communities as a whole.
After years of discussion and debate, Congress has passed legislation providing prescription drug coverage for Medicare beneficiaries. The President is expected to sign it shortly.
Having health insurance, more than any other factor, determines how soon a person will get needed health care and whether that care will be the best available. Unfortunately, minorities have much lower rates of insurance coverage compared with whites. African Americans, for example, are almost twice as likely as whites to be uninsured. Hispanics/Latinos are almost three times as likely to lack coverage.
But even when coverage is equal, disparities in care persist. Minorities tend to receive lower quality care than non-minorities, have less access to specialty care, and experience more difficulties when communicating with health care providers.
What can be done to narrow the disparity gap? What measures are being taken to improve minorities’ access to health services and their quality? How do we raise awareness in the provider community about these disparities? How do we improve communication between minority patients and non-minority providers? How do we increase the number of minority health providers?
To help address these and related questions, the Alliance for Health Reform sponsored an October 10, 2003 briefing with support from the Robert Wood Johnson Foundation. Panelists were: Risa Lavizzo-Mourey, president of the Robert Wood Johnson Foundation; Carolyn Clancy, director of the Agency for Healthcare Research and Quality; and Reed Tuckson, a senior vice president at UnitedHealth Group and an Alliance board member. Ed Howard of the Alliance moderated the discussion.
At the briefing, a new Alliance publication was released entitled Closing the Gap: Racial and Ethnic Disparities in Health Care. The brief was written by Brian Smedley, co-author of Unequal Treatment,a report by the Institute of Medicine on disparities in care with recommended solutions.
After years of discussion and debate, both Houses of Congress appeared ready in 2003 to begin floor consideration of bills on Medicare prescription drug coverage. These bills embody perhaps the biggest changes in Medicare since its enactment in 1965.
Finding ways to help the uninsured get coverage has never been easy, but Congress actually enacted one in 2002. Under the Trade Act of 2002, workers who receive payments from the Pension Benefit Guarantee Corporation or lose their jobs due to foreign competition are eligible for fully refundable federal tax credits to pay for health insurance premiums. The credit is equal to 65 percent of the premium, either to continue their previous coverage or to buy coverage in group programs set up by their state of residence. As of August 1, the tax credits can be paid in advance.
Incremental improvements in coverage have been the focus at both national and state levels for several years. But there are indications that lack of coverage is growing, and broader proposals, aimed at securing coverage for a large number of the uninsured, are beginning to get more attention—tax credits, employer or individual mandates, public program expansions, and various combinations. The plans differ widely in scope, cost and impact, but any of them would mean major change in the status quo.
The number of uninsured Americans is one important measure of how serious a problem the lack of health coverage is. But counting the uninsured is harder than it sounds. While Census Bureau estimates of the uninsured are the most widely quoted (41.3 million in 2001), Americans who lack health insurance are a constantly changing group. They may lose coverage when they are laid off, shift employers, no longer qualify for public insurance programs or go through divorce or the death of a covered spouse. Then many regain it.
Numerous comparisons have been made between the rates of spending growth in Medicare and private health insurance. Many believe that private sector innovations present opportunities for constraining Medicare costs. Nonetheless, recent research looking at the past 30 years concludes that Medicare spending growth has been similar to the private sector, and at times even slower. Figures from the Centers for Medicare and Medicaid Services show Medicare cost growth was lower than that of private insurance in 2000 and 2001. Some of the difference may be attributed to the fact that private insurance, unlike Medicare, usually covers outpatient prescription drugs, one of the fastest-growing segments of health care. Moreover, some analysts say that Medicare’s relative success in controlling costs has been at the expense of quality and access.
Employers enjoyed relatively low health care cost increases in the mid-1990s, but the situation since then has drastically changed. Employer-paid health care premiums in 2002 rose an average of 12.7 percent, the highest leap since 1990, according to a recent major survey. Benefits consultants project even higher increases for 2003. Meanwhile, small businesses have faced even steeper increases than larger firms. Many have responded by discontinuing health coverage for their workers. Sixty-one percent of small firms offered benefits in 2002, down from 67 percent in 2000.