Figure ES-1. How Well Do Different StrategiesMeet Principles for Health Insurance Reform?

Principles for Reform

Tax Incentives and Individual Insurance

Markets

Mixed Private–Public Group Insurance with Shared Responsibility

for Financing Public Insurance

Covers Everyone 0 + +Minimum Standard Benefit Floor – + +Premium/Deductible/Out-of-Pocket CostsAffordable Relative to Income

– + +

Easy, Seamless Enrollment 0 + ++Choice + + +Pool Health Care Risks Broadly – + ++Minimize Dislocation, Ability to Keep Current Coverage + ++ –

Administratively Simple – + ++Work to Improve Health Care Quality and Efficiency 0 + +

0 = Minimal or no change from current system; – = Worse than current system;+ = Better than current system; ++ = Much better than current system

Figure 1.

Figure 2. Employer-Provided Health Insurance,by Income Quintile, 2000–2006

88% 88% 87% 87% 87% 87% 86%

86% 85% 84% 84% 83% 82% 82%77% 77% 75% 74% 74% 72% 72%

62% 60%57% 55% 54% 54% 53%

22%29% 26% 25% 23% 23% 22%

0%

20%

40%

60%

80%

100%

2000 2001 2002 2003 2004 2005 2006

Highestquintile

Fourth

Third

Second

Lowestquintile

Source: Analysis of the March Current Population Survey, 2001–07, by Elise Gould, Economic Policy Institute.

Percent of population under age 65 with health benefits from employer

Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecardon Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.

Figure 3. Percentage of Uninsured Children Has DeclinedSince Implementation of SCHIP, but Gaps Remain

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

10%–15.9%

Less than 7%

7%–9.9%

16% or more

1999–2000

DE

MARI

WA

ORID

MT ND

WY

NVUT

KS

NE

MN

MO

WI

TX

IA

ILIN

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DC

HI

CO

GAMS

NJ

SD

2005–2006

CT

VTNH

MD

AR

CA

AZ NMOK

U.S. Average: 11.3%U.S. Average: 12.0%

Figure 4. Uninsured Nonelderly Adult Rate Has Increasedfrom 17.3 Percent to 20.0 Percent in Last Five Years

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

MD

MEVTNH

MARI

CT

DE

DC

HI

CO

GAMS

OK

NJ

SD

WA

ORID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

ILIN

AR

LA

AL

SCTN

NCKY

FL

VA

OH

MI

WV

PA

NY

AK

ME

DE

DC

HI

CO

GAMS

OK

NJ

SD

19%–22.9%

Less than 14%

14%–18.9%

23% or more

1999–2000 2005–2006

MA

RI

CT

VTNH

MD

NH

Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecardon Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.

Figure 5. Prevalence of High Family Out-of-PocketCost Burdens by Poverty Status Among the

Nonelderly Population, 1996 and 2003

7.1

15.6

24.125.9

15.89.7

22.723.7

33.3

19.2

0

25

50

75

Total <100% FPL 100%–<200%

FPL

200%–<400%

FPL

400%+ FPL

1996 2003

Source: J. S. Banthin and D. M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for the Population Younger Than 65 Years, 1996 to 2003,” Journal of the American Medical Association, Dec. 13, 2006 296(22):2712–19.

Percent of nonelderly adults who spend >10% of disposable household income on out-of-pocket premiums and expenditures on health care services

* Did not get medical care because of cost of doctor’s visit, skipped medical test, treatment,or follow-up because of cost, or did not fill Rx or skipped doses because of cost.UK=United Kingdom; CAN=Canada; AUS=Australia; NZ=New Zealand; US=United States.Data: 2004 Commonwealth Fund International Health Policy Survey of Adults’ Experiences with Primary Care (Schoen et al. 2004; Huynh et al. 2006).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

9

17

2934

40

0

40

80

UK CAN AUS NZ US

Percent of adults who had any of three access problems* in past year because of costs

Figure 6. Access Problems Because of Costs in Five Countries, Total and by Income, 2004

12

26

35

44

57

612

2429

25

UK CAN AUS NZ US

Below average income Above average income

Figure 7. Receipt of All Three Recommended Servicesfor Diabetics, by Race/Ethnicity, Family Income,

Insurance, and Residence, 2002

45

55

54

46

50

61

55

53

54

47

24

38

0 50 100

Rural

Urban

Uninsured

Private

<100% of poverty

100%–199% of poverty

200%–399% of poverty

400%+ of poverty

Hispanic

Black

White

Total

Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year

* Insurance for people ages 18–64.** Urban refers to metropolitan area >1 million inhabitants; Rural refers to noncore area <10,000 inhabitants.Data: 2002 Medical Expenditure Panel Survey (AHRQ 2005a).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

*

**

Figure 8. Adults Without Insurance Are Less Likelyto Be Able to Manage Chronic Conditions

161827

58

35

59

0

25

50

75

Skipped doses or did not fill

prescription for chronic condition

because of cost

Visited ER, hospital, or both for chronic

condition

Insured all year Insured now, time uninsured in past year Uninsured now

Percent of adults ages 19–64 with at least one chronic condition*

* Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease. Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).

Figure 9. Receipt of Recommended Screening and Preventive Care for Adults, by Family Income and Insurance Status, 2002

31

46

52

39

48

56

49

0 50 100

Uninsured all year

Uninsured part year

Insured all year

<200% of poverty

200%–399% of poverty

400%+ of poverty

National

Percent of adults (ages 18+) who received all recommended screening andpreventive care within a specific time frame given their age and sex*

* Recommended care includes seven key screening and preventive services: blood pressure,cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot.Data: B. Mahato, Columbia University analysis of 2002 Medical Expenditure Panel Survey.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year

Figure 10. Preventive Care Visits for Children,by Top and Bottom States, Race/Ethnicity,

Family Income, and Insurance, 2003

35

63

70

58

62

48

73

59

48

49

0 50 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

U.S. average

Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

* Child had 1+ preventive visit in past year; access to specialty care; personal doctor/nurse who usually/always spent enough time and communicated clearly, provided telephone advice or urgent care and followed up after the child’s specialty care visits.Data: 2003 National Survey of Children’s Health (HRSA 2005; retrieved from Data Resource Center for Child and Adolescent Health database at http://www.nschdata.org).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

23

53

58

39

53

36

60

46

30

31

0 50 100

Uninsured

Private insurance

<100% of poverty

400%+ of poverty

Hispanic

Black

White

Bottom 10% states

Top 10% states

U.S. average

Figure 11. Children with a Medical Home, by Top and Bottom States, Race/Ethnicity, Family Income, and Insurance, 2003

Percent of children who have a personal doctor or nurse and receive care that is accessible, comprehensive, culturally sensitive, and coordinated*

Figure 12.

Figure 13. People with Capped Drug Benefits HaveLower Drug Utilization, Worse Control of Chronic Conditions

14.6

26.5

21.2

38.5

19.617

45.2

16.618.1

31.4

26.2

39.5

21.319.7

49.2

18.7

0

25

50

Anti-HBP drugs

Lipid-lowerin

g drugs

Antidiabetic

drugs

High BP

High cholesterol

High blood glucose levels

ED visits

Nonelective hospita

lizations

Benefits Not Capped Benefits Capped

* Rate per 100 person-years.Source: J. Hsu, M. Price, J. Huang et al., “Unintended Consequences of Caps on Medicare Drug Benefits,”New England Journal of Medicine, June 1, 2006 354(22):2349–59.

Percent of Drug Nonadherence

Percent of Poor Physiological Outcomes

Rate* of Medical Services Use

Figure 14. Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases Risk of Adverse Events

9

1514

22

0

5

10

15

20

25

Essential Less Essential

Elderly Low Income

Source: R. Tamblyn, R. Laprise, J. A. Hanley et al., “Adverse Events Associated with Prescription Drug Cost-SharingAmong Poor and Elderly Persons,” Journal of the American Medical Association, Jan. 24/31, 2001 285(4):421–29.

Percent reduction in drugs per day

117

43

97

78

0

20

40

60

80

100

120

140

Adverse Events ED Visits

Elderly Low Income

Percent increase in incidence per 10,000

Figure 15. Many Americans Have ProblemsPaying Medical Bills or Are Paying Off Medical Debt

34

211413

23 2618

9816

53

292626

42

0

25

50

75

Not able to pay

medical bills

Contacted by

collection

agency*

Had to change

way of life to pay

medical bills

Medical

bills/debt being

paid off over

time

Any medical bill

problem or

outstanding debt

Total Insured all year Uninsured during the year

Percent of adults ages 19–64 who had the following problems in past year:

* Includes only those who had a bill sent to a collection agency when they were unable to pay it.Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).

Percent of adults reporting: TotalInsured all year

Insured now, time uninsured

during year

Uninsured now

Unable to pay for basic necessities (food, heat, or rent) because of medical bills

26% 19% 28% 40%

Used up all of savings 39 33 42 49

Took out a mortgage against home or took out a loan

11 10 12 11

Took on credit card debt 26 27 31 23

Figure 16. One-Quarter of Adults with Medical Bill Burdensand Debt Were Unable to Pay for Basic Necessities

Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, and A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).

Percent of adults ages 19–64 with medical bill problemsor accrued medical debt

Figure 17. Increased Health Care CostsAssociated with Reduced Savings

Has increased spending on health care expenses in the past year caused you to do any of the following? Among those with health insurance coverage who had

increases in health care costs in the last year (percentage saying “yes”)

45%

34%

29%

26%

24%

18%

53%

37%

33%

36%

28%

21%

2005

2006Decrease your contributions to a retirement plan, such as a 401(k),

403(b), or 457 plan, or an IRA

Have difficulty paying for other bills

Decrease your contributions to other savings

Use up all or most of your savings

Borrow money

Have difficulty paying for basic necessities, like food, heat, and housing

Source: EBRI Health Confidence Survey, 2005 and 2006.

Figure 18. International Comparison of Spending on Health, 1980–2005

0

1000

2000

3000

4000

5000

6000

7000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

0

2

4

6

8

10

12

14

16

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

United StatesGermanyCanadaFranceAustraliaUnited Kingdom

Average spending on healthper capita ($US PPP)

Total expenditures on healthas percent of GDP

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.Updated data from OECD Health Data 2007.

Figure 19. Americans Spend More Out-of-Pocketon Health Care Expenses

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$0 $100 $200 $300 $400 $500 $600 $700 $800 $900

a2003b2003 Total Health Care Spending, 2002 OOP Spending

ba

United States

OECD Median

New Zealand

Netherlands

Japan

GermanyFrance CanadaAustralia

a

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Total health care spending per capita

Out-of-pocket spending per capita

* Estimate is statistically different from the previous year shown at p<0.05.^ Estimate is statistically different from the previous year shown at p<0.1.Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).Source: G. Claxton, J. Gabel et al., "Health Benefits in 2007: Premium Increases Fall to an Eight-Year Low, While Offer Rates and Enrollment Remain Stable," Health Affairs, Sept./Oct. 2007 26(5):1407–16. Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007, and Commonwealth Fund analysis of National Health Expenditures data.

12.0

18.0

0.8

6.1*7.7*

13.9^

12.9*10.9*

8.2*

5.3*

11.2*

8.5 9.2*

0

5

10

15

20Health insurance premiums

Workers’ earnings

Overall inflation

National health expendituresper capita

Figure 20. Increases in Health Insurance PremiumsCompared with Other Indicators, 1988–2007

Percent

Figure 21. Health Expenditure Growth 2000–2005for Selected Categories of Expenditures

12.0

8.6 8.0 7.96.1

10.7

0

5

10

15

20

Total Hospital care Physician &clinical services

Nursing home &home health

Prescriptiondrugs

Prog. admin. &net cost of

private healthinsurance

Average annual percent growth in health expenditures, 2000–2005

Source: A. Catlin, C. Cowan, S. Heffler et al., “National Health Spending in 2005: The Slowdown Continues,”Health Affairs, Jan./Feb. 2007 26(1):142–53.

Figure 22. Percentage of National Health ExpendituresSpent on Health Administration and Insurance, 2003

Net costs of health administration and health insuranceas percent of national health expenditures

1.9 2.1 2.12.6

3.34.0 4.1 4.2

4.8

5.6

7.3

0

2

4

6

8

France

Finlan

d

Japan

Canada

United K

ingdom

Netherla

nds

Austria

Australi

a

Switzerla

nd

German

y

United S

tates

a b c *

a2002 b1999 c2001*Includes claims administration, underwriting, marketing, profits, and other administrative costs;based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2005.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.

Figure 23. Employers Provide Health Benefits to More than160 Million Working Americans and Family Members

Source: Current Population Survey, March 2007.

Uninsured47.0

(16%) Employer 163.3(55%)

Medicaid27.9(9%)

Medicare39.1

(13%)

Total population = 296.7 Under-65 population = 260.7

Employer 160.8(62%)

Uninsured46.4

(18%)

Medicaid27.9

(11%)

Medicare6.4

(2%)

Military3.4

(1%) Military3.4

(1%)Individual16.0(5%) Individual

15.8(6%)

Numbers in millions, 2006

Figure 24. How Well Do Different StrategiesMeet Principles for Health Insurance Reform?

Principles for Reform

Tax Incentives and Individual Insurance

Markets

Mixed Private–Public Group Insurance with Shared Responsibility

for Financing Public Insurance

Covers Everyone 0 + +Minimum Standard Benefit Floor – + +Premium/Deductible/Out-of-Pocket CostsAffordable Relative to Income

– + +

Easy, Seamless Enrollment 0 + ++Choice + + +Pool Health Care Risks Broadly – + ++Minimize Dislocation, Ability to Keep Current Coverage + ++ –

Administratively Simple – + ++Work to Improve Health Care Quality and Efficiency 0 + +

0 = Minimal or no change from current system; – = Worse than current system;+ = Better than current system; ++ = Much better than current system