Figure ES-1. How Well Do Different Strategies
Meet Principles for Health Insurance 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 Costs
Affordable 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
+
+
Principles for Reform
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
Percent of population under age 65 with health benefits from employer
100%
80%
60%
88%
88%
87%
86%
85%
84%
77%
77%
62%
60%
75%
57%
87%
84%
74%
87%
83%
74%
87%
82%
72%
86%
82%
Highest
quintile
Fourth
72%
Third
55%
54%
54%
53%
40%
29%
26%
25%
23%
23%
20%
22%
22%
Second
Lowest
quintile
0%
2000
2001
2002
2003
2004
2005
2006
Source: Analysis of the March Current Population Survey, 2001–07, by Elise Gould, Economic Policy Institute.
Figure 3. Percentage of Uninsured Children Has Declined
Since Implementation of SCHIP, but Gaps Remain
1999–2000
2005–2006
U.S. Average: 11.3%
U.S. Average: 12.0%
WA
VT
NH ME
NH
WA
ND
MT
VT
MT
MN
OR
ID
NY
WI
SD
MI
WY
PA
IA
NE
CA
OH
IN
NV
UT
IL
CO
MA
KS
MO
WV
VA
KY
NJ
RI
CT
MN
OR
ID
MI
PA
IA
NE
CA
IL
CO
KS
MO
AZ
NM
MS
TX
AL
CT
DE
MD
DC
NC
AZ
GA
NM
OK
SC
AR
MS
LA
TX
AL
GA
LA
FL
AK
VA
NJ
TN
SC
AR
WV
KY
TN
OK
OH
IN
NV
UT
MA
RI
NY
WI
SD
WY
DE
MD
DC
NC
ME
ND
FL
AK
HI
16% or more
10%–15.9%
HI
7%–9.9%
Less than 7%
Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard
on Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages
1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007
Current Population Surveys.
Figure 4. Uninsured Nonelderly Adult Rate Has Increased
from 17.3 Percent to 20.0 Percent in Last Five Years
1999–2000
2005–2006
NH
NH ME
VT
WA
NH
WA
ND
MT
VT
MT
MN
OR
ID
NY
WI
SD
MI
WY
PA
IA
NE
CA
OH
IN
NV
UT
IL
CO
MA
KS
MO
WV
VA
KY
NJ
RI
CT
MN
OR
ID
MI
PA
IA
NE
CA
IL
CO
KS
MO
AZ
NM
MS
TX
AL
DE
MD
DC
NC
AZ
GA
NM
OK
SC
AR
MS
LA
TX
AL
GA
LA
FL
AK
VA
NJ
RI
CT
TN
SC
AR
WV
KY
TN
OK
OH
IN
NV
UT
MA
NY
WI
SD
WY
DE
MD
DC
NC
ME
ND
FL
AK
HI
23% or more
19%–22.9%
HI
14%–18.9%
Less than 14%
Source: J. C. Cantor, C. Schoen, D. Belloff, S. K. H. How, and D. McCarthy, Aiming Higher: Results from a State Scorecard
on Health System Performance (New York: The Commonwealth Fund, June 2007). Updated Data: Two-year averages
1999–2000, 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-Pocket
Cost Burdens by Poverty Status Among the
Nonelderly Population, 1996 and 2003
Percent of nonelderly adults who spend >10% of disposable household
income on out-of-pocket premiums and expenditures on health care services
75
1996
2003
50
33.3
25
15.8
19.2
25.9
24.1 23.7
15.6
22.7
7.1
9.7
0
Total
<100% FPL
100%–<200% 200%–<400%
FPL
400%+ FPL
FPL
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.
Figure 6. Access Problems Because of Costs in Five Countries,
Total and by Income, 2004
Percent of adults who had any of three access problems* in past year because of costs
80
Below average income
Above average income
57
44
40
40
35
34
29
29
26
24
25
17
12
9
12
6
0
UK
CAN
AUS
NZ
US
UK
CAN
* 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.
AUS
NZ
US
Figure 7. Receipt of All Three Recommended Services
for Diabetics, by Race/Ethnicity, Family Income,
Insurance, and Residence, 2002
Percent of diabetics (ages 18+) who received HbA1c test, retinal exam, and foot exam in past year
Total
53
55
White
54
Black
38
Hispanic
61
400% + of poverty
200% –399% of poverty
50
100% –199% of poverty
47
46
<100% of poverty
Private*
54
24
Uninsured
Urban**
55
45
Rural
0
50
* 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.
100
Figure 8. Adults Without Insurance Are Less Likely
to Be Able to Manage Chronic Conditions
Percent of adults ages 19–64 with at least one chronic condition*
Insured all year
Insured now, time uninsured in past year
Uninsured now
75
58
59
50
27
25
18
35
16
0
Skipped doses or did not fill
Visited ER, hospital, or both for chronic
prescription for chronic condition
condition
because of cost
* 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
Percent of adults (ages 18+) who received all recommended screening and
preventive care within a specific time frame given their age and sex*
National
49
400%+ of poverty
56
200%–399% of poverty
48
<200% of poverty
39
Insured all year
52
Uninsured part year
46
Uninsured all year
31
0
50
* 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.
100
Figure 10. Preventive Care Visits for Children,
by Top and Bottom States, Race/Ethnicity,
Family Income, and Insurance, 2003
Percent of children (ages <18) received BOTH a medical and dental preventive care visit in past year
59
U.S. average
73
Top 10% states
48
Bottom 10% states
62
White
58
Black
49
Hispanic
70
400% + of poverty
48
<100% of poverty
63
Private insurance
35
Uninsured
0
50
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.
100
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*
46
U.S. average
60
Top 10% states
36
Bottom 10% states
53
White
39
Black
30
Hispanic
58
400% + of poverty
31
<100% of poverty
53
Private insurance
23
Uninsured
0
50
100
* 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.
Figure 12.
Figure 13. People with Capped Drug Benefits Have
Lower Drug Utilization, Worse Control of Chronic Conditions
50
Benefits Not Capped
49.2
Benefits Capped
38.5
45.2
39.5
31.4
26.5
26.2
25
21.2
19.6
18.1
21.3
17
14.6
19.7
16.6
18.7
0
t i-H
An
B
r ug
Pd
s
e
ow
l
id
Lip
g
dr u
g
rin
s
A
b
dia
i
t
n
eti
s
rug
d
c
Percent of Drug
Nonadherence
h
Hig
BP
h
Hig
ch
s
ole
ol
ter
hb
Hig
loo
lu
dg
s
co
ev
el
els
Percent of Poor
Physiological Outcomes
E
is
Dv
it s
le
ne
o
N
cti
v
o
eh
i
sp
n
tio
za
i
l
ta
s
Rate* of Medical
Services Use
* 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.
Figure 14. Cost-Sharing Reduces Use of Both Essential and
Less Essential Drugs and Increases Risk of Adverse Events
Percent reduction in drugs per day
25
Elderly
22
140
120
20
14
15
10
Low Income
Percent increase in incidence per 10,000
15
100
Elderly
Low Income
117
97
78
80
9
43
60
40
5
20
0
0
Essential
Less Essential
Adverse Events
ED Visits
Source: R. Tamblyn, R. Laprise, J. A. Hanley et al., “Adverse Events Associated with Prescription Drug Cost-Sharing
Among Poor and Elderly Persons,” Journal of the American Medical Association, Jan. 24/31, 2001 285(4):421–29.
Figure 15. Many Americans Have Problems
Paying Medical Bills or Are Paying Off Medical Debt
Percent of adults ages 19–64 who had the following problems in past year:
Total
Insured all year
Uninsured during the year
75
53
50
25
42
23
26
16
13
8
26
14
21 18
29
34
26
9
0
Not able to pay
Contacted by
medical bills
collection
agency*
Had to change
Medical
way of life to pay bills/debt being
medical bills
paid off over
Any medical bill
problem or
outstanding debt
time
* 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).
Figure 16. One-Quarter of Adults with Medical Bill Burdens
and Debt Were Unable to Pay for Basic Necessities
Percent of adults ages 19–64 with medical bill problems
or accrued medical debt
Percent of adults
reporting:
Total
Insured
all year
Insured now,
time uninsured
during year
Uninsured
now
19%
28%
40%
Unable to pay for basic
necessities (food, heat,
or rent) because of
medical bills
26%
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
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 17. Increased Health Care Costs
Associated 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%
Decrease your contributions to
other savings
53%
34%
Have difficulty paying for other bills
37%
29%
Use up all or most of your savings
33%
Decrease your contributions to a
retirement plan, such as a 401(k),
403(b), or 457 plan, or an IRA
26%
36%
24%
Have difficulty paying for basic
necessities, like food, heat, and housing
Borrow money
Source: EBRI Health Confidence Survey, 2005 and 2006.
28%
18%
21%
2005
2006
Figure 18. International Comparison of Spending on Health,
1980–2005
Average spending on health
per capita ($US PPP)
7000
6000
United States
Germany
Canada
France
Australia
United Kingdom
Total expenditures on health
as percent of GDP
16
14
5000
12
4000
10
8
3000
6
2000
4
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
0
2
0
19
80
19
82
19
84
19
86
19
88
19
90
19
92
19
94
19
96
19
98
20
00
20
02
20
04
1000
United States
Germany
Canada
France
Australia
United Kingdom
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-Pocket
on Health Care Expenses
Total health care spending per capita
$7,000
United States
$6,000
$5,000
$4,000
France
$3,000
Netherlands
$2,000
Canada
Germany a
OECD Median
New Zealand
Australiab
Japana
$1,000
$0
$0
$100
$200
$300
$400
$500
$600
Out-of-pocket spending per capita
a2003
b2003
Total Health Care Spending, 2002 OOP Spending
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
$700
$800
$900
Figure 20. Increases in Health Insurance Premiums
Compared with Other Indicators, 1988–2007
Percent
Health insurance premiums
20
Workers’ earnings
18.0
Overall inflation
15
^
National health expenditures
13.9
per capita
12.9*
12.0
10
10.9*
8.5
8.2*
5.3*
5
9.2*
7.7*
0.8
19
88
19
89
19
90
19
91
19
92
19
93
19
94
19
95
19
96
19
97
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
0
11.2*
* 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.
6.1*
Figure 21. Health Expenditure Growth 2000–2005
for Selected Categories of Expenditures
Average annual percent growth in health expenditures, 2000–2005
20
15
10.7
10
8.6
8.0
7.9
12.0
6.1
5
0
Total
Hospital care
Physician & Nursing home &
clinical services home health
Prescription
drugs
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.
Prog. admin. &
net cost of
private health
insurance
Figure 22. Percentage of National Health Expenditures
Spent on Health Administration and Insurance, 2003
Net costs of health administration and health insurance
as percent of national health expenditures
8
7.3
5.6
6
4.8
4.0
4
4.1
4.2
3.3
2.6
2.1
1.9
2.1
2
0
a
ce
n
a
Fr
a2002
b1999
d
an
l
n
Fi
an
p
Ja
b
da
a
n
Ca
om
d
ng
e
Ki
th
e
d
N
ite
n
U
c
ds
n
rl a
a
tri
s
Au
l ia
nd
a
a
r
l
st
er
u
z
t
i
A
Sw
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.
*
y
s
n
e
t
a
ta
m
r
S
e
d
G
te
i
Un
Figure 23. Employers Provide Health Benefits to More than
160 Million Working Americans and Family Members
Numbers in millions, 2006
Military
3.4
(1%)
Uninsured
47.0
(16%)
Employer
163.3
(55%)
Individual
16.0
(5%)
Uninsured
46.4
(18%)
Military
3.4
(1%)
Employer
160.8
(62%)
Individual
15.8
(6%)
Medicaid
27.9
(9%)
Medicaid
27.9
(11%)
Medicare
39.1
(13%)
Total population = 296.7
Source: Current Population Survey, March 2007.
Medicare
6.4
(2%)
Under-65 population = 260.7
Figure 24. How Well Do Different Strategies
Meet Principles for Health Insurance 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 Costs
Affordable 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
+
+
Principles for Reform
0 = Minimal or no change from current system; – = Worse than current system;
+ = Better than current system; ++ = Much better than current system