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SUMMARIES OF
Commonwealth REPORTS
July - Oct, 2003
GOVERNMENT REGULATIONS CONTRIBUTE TO MEDICAL DEBT OF UNINSURED AND UNDERINSURED
Some patients face unmanageable medical bills that can result in long-term debt because of unclear federal laws and regulations. These rules may encourage health care providers to bill the uninsured more than those with insurance for the same service. Federal fraud and abuse laws and Medicare rules designed to prevent overbilling may have the unintended effect of discouraging health care providers from offering reduced-cost or free care to patients. In part because of these rules, many hospitals have not established procedures for identifying and offering discounts to patients who lack the means to pay large medical bills.
"Medical debt can undermine the financial stability of low- and middle-income individuals unlucky enough to get sick, forcing them and their families to change their way of life," said Karen Davis, president of The Commonwealth Fund. "Saddling people with large medical bills they can't afford to pay doesn't benefit providers or patients."
Hospitals often do not have procedures in place for negotiating discounts for uninsured patients who are not eligible for free care but lack the resources to pay full charges. Furthermore, a number of financial factors--tight operating margins, the need to maintain high bond ratings to fund capital expenses, and the need to establish a basis for negotiating discounts with insurers--may lead hospitals to charge high fees and aggressively pursue uninsured patients with unpaid bills.
CLICK HERE for Press Release
Health care spending represented 14.1 percent of the U.S. gross domestic product (GDP) in 2001, a major increase from the 13.3 of GDP spent in 2000. Although there is preliminary evidence that the weakening economy is slowing health care spending, costs are projected to rise 7 percent annually for the rest of the decade.
The federal government pays $455 billion for health care but devotes only $300 million to the budget of the Agency for Healthcare Research and Quality for learning effective ways to improve the performance of the U.S. health system. 'Rising costs put a premium on findings ways to improve the efficiency as well as the effectiveness of health care,' she said.
Davis outlined a number of steps that need to be taken to achieve a high-performing, accessible health system, including: public reporting of health care cost and quality data, establishment of quality standards, broad-scale demonstrations of new approaches to insurance coverage, investment in modern information technology and improved care processes, provider performance incentives, and elimination of waste and ineffective care.
CLICK HERE for Press Release
INTERNATIONAL HEALTH CARE SURVEY: WIDESPREAD ERROR, UNCOORDINATED CARE, AND MISSED COMMUNICATION
A new health care survey conducted in the United States and four other
industrialized countries--Australia, Canada, New Zealand, and the United
Kingdom--has found that people who have health problems must also contend with a host of other difficulties in their interactions with the health system, including high rates of medical error, lack of coordination in their care, poor communication with doctors, and barriers in accessing care.
CLICK HERE for Press Release
"NEW" COVERAGE PROPOSAL RELIES ON AUTOMATIC ENROLLMENT
Commonwealths "ambitious plan" to provide affordable, automatically
available health insurance to NEARLY all Americans. The proposed coverage framework, developed by the Fund's Karen Davis and Cathy Schoen would build on existing sources of public and private health coverage by combining tax credits for private insurance, public program expansions, and a new mechanism to make enrollment automatic. An estimated 39 million of the 42 million Americans who are uninsured would gain coverage.
CLICK HERE for Press Release
UNINSURED CANCER PATIENTS NOT GETTING THE CARE THEY NEEd
The amount that uninsured cancer patients spent on their care over a typical six-month period was just over one-half (57%) that spent by cancer patients with private insurance. Lower spending among uninsured cancer patients is partly, if not completely, due to their lower receipt of health services--including hospital admissions, physician visits, and emergency room visits. The results provide compelling evidence that expanding insurance coverage will likely improve cancer treatment for many Americans.
a substantial proportion of Americans with cancer have no health coverage, and that Hispanic patients are considerably more likely to be uninsured than either whites or blacks.
Just because uninsured cancer patients have lower overall spending does not mean they also have lower out-of-pocket medical expenses. In fact, in both absolute and percentage terms, uninsured patients paid much more out-of-pocket--$1,343 in the six-month period for those under age 65, compared with $576 for the entire under-65 sample and $165 for nonelderly patients with Medicaid.
CLICK HERE for Press Release
EMPLOYERS LESS APT TO OFFER INSURANCE TO THEIR LOW-WAGE WORKERS
Low-wage workers are at a serious disadvantage when it comes to health insurance coverage and access to care--even if they work for large firms.
While employer-sponsored health insurance is the primary system of health coverage in the United States, there are still 31 million workers who are not offered health benefits or are not eligible for their firm's health plan. Of these workers, more than half earn less than $10 an hour. One of five low-wage workers is uninsured.
CLICK HERE for Press Release
Nearly two of five college graduates and half of high school graduates who do not go on to college will undergo a time without health insurance in the first year after graduation, a new study finds. Young adults, who are often dropped from their parents' policies or public insurance programs at age 19, or when they graduate from college, are far more likely to be uninsured than older adults: four of 10 young adults between the ages of 19 and 29 can expect to be uninsured at some time during the year, twice the rate of adults ages 30 to 64. The problem has worsened over the last decade, with young adults from low-income households the hardest hit.
CLICK HERE for Press Release
DO HEALTH CARE PURCHASERS CONSIDER QUALITY?
Common sense would seem to have it that by wielding their purchasing power, public and private purchasers of health care would be able to hold providers and plans accountable for the quality of services they provide. Yet little evidence exists that attempts at "value-based purchasing"--collecting data on health care quality, for example, or contracting with only the best providers--are having any measurable impact.
CLICK HERE for Press Release
TRENDS IN PRIVATE MEDICARE+CHOICE PLANS PROVIDE WARNINGS FOR MEDICARE DEBATE
As Congress debates Medicare proposals that would shift more beneficiaries into private insurance plans, legislators may first want to examine the often tumultuous history of the six-year-old Medicare+Choice program, Medicare's managed care alternative to its traditional fee-for-service program. According to a new policy brief from The Commonwealth Fund, many Medicare+Choice enrollees have been faced with a limited choice of plans in their area and instability in provider participation compared with fee-for-service Medicare, as well as significantly increased out-of-pocket costs--especially for those with chronic and disabling illnesses--and a confusing, complicated benefit structure
"Seniors may suddenly find that their physician is no longer a member of their plan or, if they have health problems, that their out-of-pocket costs have increased substantially," said Karen Davis, president of The Commonwealth Fund. "These are the realities of the health care marketplace, and we should be cautious about inflicting them on the elderly and disabled."
CLICK HERE for Press Release
MEDICAL TECHNOLOGY NOT REACHING UNINSURED
Advances in medical technology are not reaching millions of Americans who lack health insurance - an access gap that is costing the nation an additional $1.1 billion a year, according to a new study. When it comes to treatment for heart attack, depression, or cataracts, uninsured patients ages 55-64 consistently have lower rates of technology use when compared to same-age patients with health coverage.
Technology use rates were compared for three common conditions that are treated in the hospital and in the outpatient setting. In every case, the uninsured group in the 55-64 age range had lower rates of outpatient and inpatient technology use than a comparable group with health insurance had. This lower rate amounts to an annual loss of about $350 in excess morbidity and mortality costs per uninsured person in this age group, the study says.
"Lack of insurance creates major barriers to medical technology and these barriers are costing society"
CLICK HERE for Press Release
CLICK HERE for Article Summary
ELIMINATION OF MEDICARE'S WAITING PERIOD FOR SERIOUSLY DISABLED ADULTS: IMPACT ON COVERAGE AND COSTS
More than 1.2 million seriously disabled Americans under age 65--including as many as 400,000 without health insurance--are currently in the two-year waiting period that Medicare requires before they are eligible for coverage, a new Commonwealth Fund study finds. Medicare rules stipulate that disabled adults first qualify for Social Security disability benefits by meeting work history requirements and proving they are too disabled to work; these individuals must then wait five months for disability benefits to begin and an additional two years for Medicare coverage.
According to the study, eliminating the wait would allow this vulnerable group of adults to gain immediate access to secure coverage. Authors Stacy Berg Dale and James M. Verdier of Mathematica Policy Research say that doing so would also provide significant fiscal relief to states: many of the disabled in the waiting period qualify for state Medicaid programs, and these individuals account for a substantial share of total Medicaid spending. Dale and Verdier find that dropping the two-year wait would save cash-strapped states an estimated $1.8 billion a year in Medicaid costs for disabled beneficiaries--savings that could help to avert benefit and eligibility cutbacks.
CLICK HERE for Press Release
CLICK HERE for Elimination of Medicare's Waiting Period for Seriously Disabled Adults
EMPLOYER-SPONSORED HEALTH INSURANCE AND PRESCRIPTION DRUG COVERAGE FOR NEW RETIREES: DRAMATIC DECLINES IN FIVE YEARS
A lengthy phase-in period could leave many seniors without supplemental medical or prescription drug benefits. Employer-sponsored health insurance for retirees ages 65-69 is on a sharp decline. The proportion of Medicare beneficiaries in the 65-to-69 age group receiving employer-sponsored drug benefits fell from 40 percent in 1996 to just over 35 percent in 2000. Erosion in retiree coverage, coupled with a lack of adequate alternatives, adds particular urgency to the Medicare drug debate.
CLICK HERE for the original Commonwealth document (ACROBAT).
CLICK HERE for the Commonwealth summary
CAUGHT IN BETWEEN: PRESCRIPTION DRUG COVERAGE OF MEDICARE BENEFICIARIES NEAR POVERTY
Many elderly and disabled Medicare beneficiaries with very modest incomes would see little benefit from prescription drug legislation pending in Congress. A couple living at only 160 percent of the poverty level in 2006 ($20,944) would still pay a substantial part of their income on prescription medications--11.6 percent, or $2,437--under the current House bill. Under the Senate bill, this couple would spend 15.3 percent of their income, or $3,208. While both bills would provide significant relief for beneficiaries at lower income levels, premium and cost-sharing subsidies would be phased out for those with only slightly higher incomes.
CLICK HERE for the original Commonwealth document (ACROBAT).
CLICK HERE for the Commonwealth Issue Brief
AVERAGE COSTS FOR MEDICARE+CHOICE ENROLLEES DOUBLED IN FOUR YEARS
Over the last four years, average plan premiums and other out-of-pocket costs have more than doubled for enrollees in Medicare+Choice, the Medicare program's managed care component. Average enrollee costs for 2003 are $1,964, an increase of 10 percent from 2002. Enrollees in poor health spend three times more out-of-pocket than those in good health. Meanwhile, out-of-pocket spending for Medicare beneficiaries in PPO demonstration plans was found to be higher, on average, than costs for those in either Medicare+Choice plans or traditional fee-for-service Medicare.
CLICK HERE for the original Commonwealth press release (ACROBAT).
CLICK HERE for the Commonwealth Issue Brief
MEDICARE COVERAGE BOOSTS USE OF CLINICAL SERVICES
Gaining access to Medicare coverage substantially improved previously uninsured older adults' use of preventive services such as cholesterol testing, mammography, and prostate exams. Prior to Medicare eligibility, only 41 percent of the uninsured adults ages 55 to 64 who were examined by the study received cholesterol testing, compared with 76 percent of insured adults. But once uninsured adults became eligible for Medicare coverage, the gap was dramatically reduced, from 35 percentage points to 18 percentage points. The difference in mammography testing, meanwhile dropped from 30 percentage points to 15 percentage points after Medicare coverage. Extending Medicare coverage to adults before age 65 has the potential to save many lives through prevention or earlier detection and treatment of major medical conditions, such as cancer or heart disease.
CLICK HERE for the original Commonwealth Press Release (ACROBAT).
CLICK HERE for the Commonwealth summary
STREAMLINING PUBLIC HEALTH INSURANCE RECERTIFICATION COULD KEEP MORE PEOPLE ENROLLED
New York State's laborious recertification process for public health insurance helps keep a large number of New Yorkers uninsured. Many people lose coverage from Medicaid, Family Health Plus, or Child Health Plus because they fail to complete required documentation--not because changes in their economic or family circumstances make them ineligible for continued coverage. The authors recommend that health insurance programs require a full eligibility review every other year, rather than every year, and rely on existing databases to confirm eligibility. This could save the state, health plans, and community-based organizations time and money, and provide a more stable source of coverage for hundreds of thousands of children and adults.
CLICK HERE for the original Commonwealth summary of the field report (ACROBAT).
CLICK HERE for the Commonwealth the full report
HEALTH INSURANCE SCAMS LEAVE THOUSANDS WITH LARGE MEDICAL DEBTS AND NO COVERAGE
An unprecedented increase in unauthorized and illegal health insurance plans, spurred by rising health care costs and increasing numbers of uninsured, has left nearly 100,000 people with millions of dollars in medical debts and no coverage. Companies selling phony insurance collect premiums from enrollees but fail to pay health care providers. The authors call for increased cooperation among state and federal fraud investigators, better training of insurance agents, and stronger criminal penalties against perpetrators, among other measures needed to stem the proliferation of phony health insurance.
CLICK HERE for the original Commonwealth press release (ACROBAT).
CLICK HERE for the Commonwealth Issue Brief
FUND REPORTS ON USE OF RACE/ETHNICITY DATA IN RESEARCH
California ballot Proposition 54, which goes before voters in the fall 2003, would restrict collection of data or classification of individuals by race or ethnicity. This would broadly affect many aspects of state and local government and potentially research as well. The Commonwealth Fund has supported research on the collection of race and ethnicity data that might be useful to those interested in the topic.
CLICK HERE for the original Commonwealth document (ACROBAT).
CLICK HERE for the Commonwealth Press Release
CLICK HERE for Eliminating Racial/Ethnic Disparities in Health Care: Can Health Plans Generate Reports? (Summary of Health Affairs article).
CLICK HERE for Developing a Health Plan Report Card on Quality of Care for Minority Populations (ACROBAT).
CLICK HERE for The California HealthCare Foundation resources on the topic, including the potential impact of the proposition on health-related research..
CLICK HERE for the original Commonwealth For the Summer 2003, Volume 9, Issue 2
"Substantial differences in use of clinical services between continuously uninsured and insured near-elderly adults . . . were reduced by half or more after they became eligible for Medicare coverage."
(From "Impact of Medicare Coverage on Basic Clinical Services for Previously Uninsured Adults," Journal of the American Medical Association, August 13, 2003)
JAMA Study: Medicare Coverage Boosts Use of Clinical Services
Gaining access to Medicare coverage dramatically improves previously uninsured older adults' use of a range of preventive services, including cholesterol testing, mammography, and prostate exams, according to a recent study in the Journal of the American Medical Association.
Uninsured Not Reaping Benefits of Medical Technology, Study Finds
A study of three common conditions treated in both hospital and outpatient settings has found that patients without health insurance are not getting the latest treatment as often as those with coverage. What's more, the access gap is costing society an estimated $1.1 billion yearly due to higher morbidity and mortality.
Medicare Waiting Period Puts Disabled Adults in Limbo
Nearly 1.3 million disabled Americans under age 65, including as many as 400,000 without any health insurance, are currently in the two-year wait for Medicare coverage. Analysts say that eliminating the requirement would not only would provide immediate coverage to those who cannot work because of their severe chronic condition, it would offer significant fiscal relief to cash-strapped states.
Dramatic Decline in Employer Drug Coverage for New Retirees
A recent Health Affairs Web Exclusive study has found a sharp decline in the proportion of retirees ages 65 to 69 with medical coverage, including prescription benefits, from an employer. Moreover, all indications point to further erosion as employers continue to cut back on coverage for new retirees.
Proposed Medicare Drug Bills Offer Limited Relief to 'Near-Poor'
Many elderly and disabled Medicare beneficiaries with very modest incomes would see limited benefit from prescription drug legislation pending in Congress, according to an analysis released by The Commonwealth Fund.
Medicare+Choice Costs for Enrollees Doubled in Four Years
Over the last four years, average plan premiums and other out-of-pocket costs have more than doubled for enrollees in Medicare+ Choice, the Medicare program's managed care component. The authors of a Commonwealth Fund Issue Brief that details cost trends in the program also report that enrollees in poor health spend three times more out-of-pocket than those in good health.
Medicare+Choice: A Cautionary Tale for Medicare Reformers
According to an analysis from The Commonwealth Fund, the nation's experience with Medicare+Choice highlights just how difficult it is for private plans not only to reduce their total health care costs from the level of fee-for-service Medicare, but to offer beneficiaries additional benefits and more coverage choices while still turning a profit.
CLICK HERE for the original Commonwealth For the Summer 2003, Volume 9, Issue 2
LESSONS FROM STATE PHARMACY ASSISTANCE PROGRAMS, HOW STATES DO IT
Examination of the pharmacy assistance programs created by some states provides timely lessons for designing drug benefits and targeting vulnerable populations. Programs with the simplest application procedures and fewest restrictions on enrollment, such as up-front fees or deductibles and in-person interviews, have the highest participation rates. In the six states without a fee, deductible, or in-person interview, more than half (56%) of eligible people were enrolled. In the states with any of these requirements, however, only 19.4 percent of eligible persons were enrolled.
CLICK HERE for the original Commonwealth summary of the report (ACROBAT).
CLICK HERE for the Commonwealth the full report
COMPARING THE PRESIDENTIAL CANDIDATES' HEALTH CARE PROPOSALS
Rising health care costs, an unstable economy, and the growing ranks of the uninsured have made health care reform a hot-button issue for the first time in a decade. So far, seven candidates for the 2004 presidential election, including President Bush, have offered their proposals to extend health insurance to millions of Americans. A new analysis reviews the candidates' strategies and compares the numbers of uninsured who would be covered under each plan as well as the estimated costs. Several of the plans aim to achieve 'near universal coverage' through incremental reforms, using varying combinations of Medicaid or Medicare expansions, tax credits for private insurance, new group coverage options, employer mandates, and automatic enrollment. Coverage estimates under each plan range from one of 10 of Americans who are currently uninsured to all 41 million, with estimated price tags over 10 years of $89 billion to $6 trillion. [EINO: Except Kucinich, Sharpton and possibly Mosley-Braun who would bring the USA into the camp of civilized nations all of which have real universal health care by fundamentally redesigning the system. These plans (single-payer and mixed financial plans) would cost us less than we know pay for our exclusionary crisis ridden system.]
CLICK HERE for the original Commonwealth Press Release (ACROBAT).
CLICK HERE for the Commonwealth summary
CLICK HERE for the Commonwealth full report
AMERICANS INCREASINGLY CONCERNED ABOUT LOSING EMPLOYER-SPONSORED HEALTH INSURANCE
Americans are increasingly worried about losing their employer-sponsored health coverage and rising health care costs, although a majority with employer coverage continue to say it is the best system, according to the 2003 Health Confidence Survey (HCS) released today by the Employee Benefit Research Institute (EBRI). One-fifth of Americans say health care is the most important issue facing the nation today, second only to the economy as the top priority.
"Shoring up our system of employer-sponsored health insurance should be a priority in reversing the trend of rising numbers of uninsured," said Karen Davis, president of The Commonwealth Fund. "Better alternatives for businesses to buy coverage for their employees, such as opening up the Federal Employees Health Insurance Benefits Plan to small businesses and uninsured workers, and financial assistance to low-wage workers to help them afford coverage, would go a long way to support the system that remains the mainstay of health care in this country."
Key findings from the Health Confidence Survey include:
Among those with employer-based health benefits 61% are confident their employer will continue to provide benefits, a decline from 68% in 2000.
More than half (55%) of those with employer-based coverage believe that the employment-based system of health care is the best.
Nearly one-half of Americans (44%) are unhappy about the cost of health insurance to them, up from 32 percent in 1998.
Over one-fourth (28%) of Americans rate the health care system as poor, up from 15% in 1998.
Twenty percent say that health care is the most critical issue facing the nation today, compared with 27% who rate the economy as the top priority.
CLICK HERE for the document
IMPORTANT CONSIDERATIONS FOR MEDICARE BENEFICIARIES IN PRESCRIPTION DRUG BILLS
While the House and Senate attempt to work out their differences in conference, noted health policy analyst Marilyn Moon considers how crucial issues in the two prescription drug bills would affect Medicare beneficiaries. the adequacy, complexity, and fairness of the proposed drug benefit, the legislation's emphasis on greater privatization, and whether provisions in the bills could penalize beneficiaries are all examined. "The success or failure of any Medicare drug benefit enacted by Congress will depend on how well it serves the needs of the program's beneficiaries," said Karen Davis, president of The Commonwealth Fund. "Contentious issues now being considered--such as the limits and complexity of coverage and the degree of shift towards privatization--should be weighed in terms of the effect on Medicare beneficiaries struggling to afford needed drugs."
CLICK HERE for the Commonwealth summary
LACK OF HEALTH INSURANCE A GROWING CONCERN FOR HISPANICS
Nearly two-thirds (65%) of low-income, working-age Hispanics were uninsured for all or part of the year in 2000, compared with less than half of low-income, working-age blacks (49%) and whites (48%). Nearly half (45%) of all Hispanics under age 65 were uninsured at some point during that year, compared with 35 percent of blacks and 22 percent of whites. Uninsured Hispanics have lower rates of certain kinds of preventive care compared with other groups. For example, among uninsured adults with diabetes (ages 18 to 64), just 39 percent of Hispanics had annual foot exams, compared with 62 percent of African Americans and 54 percent of whites. Sixteen percent of uninsured Hispanic men ages 40 to 64 received prostate exams, compared with 29 percent of uninsured blacks and 23 percent of uninsured whites in that age range.
The chartpack examines the links between lack of insurance, access to health care, and use of preventive services; and documents the extent to which limited English language proficiency undermines patients' communication with their health care provider.
CLICK HERE for the original Commonwealth chartpack.
NUMBER OF UNINSURED IN LARGE FIRMS UP SHARPLY
Thirty-two percent of workers lacking health coverage in 2001 were employed by large firms, up from 25% in 1987, a new Commonwealth Fund report finds. As of 2001, more than one of four of the nation's uninsured, or some 10 million Americans, worked for firms with 500 or more employees or were dependents of those workers. These findings are particularly troubling given that big companies have traditionally been the businesses most likely to offer health benefits to their employees.
Removing barriers to coverage, such as waiting periods or eligibility restrictions on part-time or low-wage workers, would help address the problem, the authors say, as would making employee premium shares more affordable to low-wage workers in large and small firms alike.
CLICK HERE for the original Commonwealth document (ACROBAT).
CLICK HERE for the Commonwealth summary
EFFORTS TO ELIMINATE RACIAL DISPARITIES IN HEALTH CARE GAIN TRACTION
Many studies have found that blacks, Hispanics, Native Americans, and Asians receive less adequate and less intensive health care than whites, and many find such disparities persist even after adjusting for health insurance status, age, sex, income, and education. To make this body of evidence widely available, Physicians for Human Rights (PHR) has created an annotated bibliography of key articles in the peer-reviewed literature on racial and ethnic disparities in health care. Users can search by 17 disease or clinical categories and by clinical trials, research methods, and other parameters.
CLICK HERE for the original PHR document
CLICK HERE for the panel on racial and ethnic disparities convened by PHR which issued policy and research recommendations, emphasizing the role of the federal government in identifying and monitoring such disparities.
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