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The Uninsured and the Health Care Safety Net. Grace-Marie Turner, Ph.D. President Galen Institute, Inc. Alexandria, VA . The U.S. health care system is in trouble. Rising insurance costs threaten coverage for many Millions are uninsured

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the uninsured and the health care safety net

The Uninsured and the Health Care Safety Net

Grace-Marie Turner, Ph.D.


Galen Institute, Inc.

Alexandria, VA

the u s health care system is in trouble
The U.S. health care system is in trouble
  • Rising insurance costs threaten coverage for many
  • Millions are uninsured
  • A plethora of rules, regulations, fines, penalties govern the system
2004 u s health expenditures estimated
2004 U.S. health expenditures (estimated)

Total $1.8 trillion15% of GDP

  • Private: $984 billion 55% of total
  • Public: $810 billion 45% of total


cost concerns drive debate
Cost concerns drive debate

“2004 Mercer U.S. National Employer-Sponsored Health Plans Survey,” Mercer Human Resources, November 22, 2004.

U.S. Department of Labor, Bureau of Labor Statistics. Consumer Price Index. January 19, 2005.

does the u s spend too much or too little on health care
Does the U.S. spend too much or too little on health care?

Robert Blendon and John Benson. “Americans’ Views on Health Policy” Health Affairs. March/April 2001.

consumers pay 15 of costs
Consumers pay 15% of costs

Office of the Actuary, Centers for Medicare and Medicaid Services

kaiser benefits study
Kaiser benefits study
  • Premiums now average $3,383 for single coverage and $9,068 for families
  • Worker contributions were stable for singles (at $508) and rising 13% for families (to $2,412)

Kaiser 2003 Employer Health Benefit Survey

cost drivers for health insurance
Cost drivers for health insurance

18% General health care inflation

22% New medical advances, drugs

18% Rising provider expenses

15% Government mandates and regulation

15% Increased consumer demand

7% Litigation and defensive medicine

5% Fraud and abuse, etc.

  • PriceWaterhouseCoopers 2002
research question
Research question

Can State health insurance regulations

reduce costs and increase access

to health insurance?

insurance regulations
Insurance regulations
  • Guaranteed issue
  • Guaranteed renewal
  • Community rating
  • Mandated benefits
  • Pre-existing condition exclusions
The GAO identified 16 States that passed these insurance regulations in the early- and mid-1990s.

What happened?

annual growth rate in number of uninsured
Annual growth rate in number of uninsured





% growth rate in number of uninsured







  • 34


# of States



“Uninsured Rates Rise Dramatically in States with Strictest Health Insurance Regulations,” Arnett GM, Schriver ML. The Heritage Foundation 1998.

expanding access to the uninsured
Expanding access to the uninsured

Why is it so hard for the States to solve this problem?

the tax treatment of health insurance
The tax treatment of health insurance
  • A huge Federal subsidy that discriminates against lower-income, working Americans who are most likely to be uninsured

Low income families hard to reach with job-based coverage


Persons with job-based health insurance, by income


U.S. Census Bureau, Current Population Survey, 2004 Annual Social and Economic Supplement. Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2003 (All Races)

Less than




the galen gap
The Galen Gap

Population under age 65 with

health coverage

42 Million





Conceptual depiction based upon the logo of the Galen Institute.

getting to the root of the problem
Getting to the root of the problem
  • Price controls in World War II
1943 health insurance to boost pay
1943:Health insurance to boost pay
  • Workers are scarce
  • Wage and price controls cap pay
  • Health insurance offered instead
  • Health insurance becomes job-based
sixty years and 1 trillion later
Sixty years and $1 trillion later...
  • A $189 billion annual tax subsidy that is:
    • Inefficient
    • Regressive
    • Discriminatory
  • Leads people to think health insurance is a gift from employers, not part of their pay, as it is
  • Consumers of health care drive up costs by demanding more expensive coverage without seeing the price
  • Higher costs drive more and more people out of the market for health insurance, especially low-income workers/families
a fresh idea create new fairer subsidies for health insurance
A fresh idea: Create new, fairer subsidies for health insurance
  • Tax credits for the uninsured to purchase health insurance
  • Credits are “refundable” and “advanceable”
  • Provide new help for those shut out of the system
  • A new fairness in subsidizing insurance

“Empowering Health Care Consumers through Tax Reform,” Grace-Marie Arnett, Ed. University of Michigan Press, Ann Arbor. September 1999.

Mark Pauly and Bradley Herring. “Expanding Coverage Via Tax Credits: Trade-Offs and Outcomes,” Health Affairs, January/February 2001.

the uninsured will need new places to purchase coverage
The uninsured will need new places to purchase coverage
  • Individuals with new subsidies will need new places to buy health insurance, outside the workplace, to get group rates
  • Labor unions, professional organizations, churches, and other affinity groups could offer insurance as a member benefit
  • This insurance would be portable from job to job and provide more continuity in coverage
bipartisan agreement
Bipartisan agreement
  • Tax credits for the uninsured
  • New purchasing pool arrangements
  • Enrolling those eligible for Medicaid and SCHIP
  • Gaining efficiencies through health information technologies

My assessment of general agreement based upon joint publications and position papers by political leaders, including President Bush, Senator Kerry, Senator Frist, Senator Clinton, etc.

public sector innovations
Public sector innovations
  • Secretary Leavitt will support greater use of 115 waivers for Medicaid to expand options
  • Governor Jeb Bush of Florida wants to bring competition and choice into Medicaid
  • South Carolina offers Medicaid Health Savings Account (HSA) option
  • New York State’s reinsurance program
  • Maine’s DirigoChoice for small businesses
a new conversation
A new conversation
  • Prevention
  • Disease management
  • Value in medical care
  • Greater access to information
  • More consumer input into care choices
care management programs have demonstrated success
Care management programs have demonstrated success
  • Florida’s Cash and Counseling programs give the disabled more choice and control
  • Pitney-Bowes’ positive experience in direct care management
  • The Asheville Project provides care for chronic conditions like diabetes, asthma, and heart disease
some options for the states
Some options for the States
  • About one-third of new purchasers of HSAs were previously uninsured
  • Encouraging HSAs can help some citizens to get coverage

“Health Savings Accounts: The First Year in Review,” eHealthInsurance, February 15, 2005.

Teresa Chovan and Hannah Yoo. “Health Savings Accounts Off to a Fast Start in the Individual Market,” America’s Health Insurance Plans, January 12, 2005.

hsa overview
HSA overview
  • HSAs allow individuals, employers, or employees to deposit tax-free money into a special account to pay for current and future medical expenses
  • Savings roll over from year to year
  • Individuals must have a “high-deductible health plan” to open a HSA
one example of an hsa
One example of an HSA

Catastrophic coverage + preventive care

High deductible insurance

$500 deductible

Employer, employee, or individual makes deposit to HSA. Unspent funds roll over to next year.

Funds routine health spending. Preventive care exempt.

$1,000 deposit

hsa options for the states
HSA options for the States
  • Enhancing the HSA option
    • Allow a State tax deduction for deposits to HSAs
    • Allow State tax deductibility for conforming health insurance
    • Allow cross-State purchase of health insurance
  • A new benefit option for State employees to save State funds on health costs
other state responses
Other State responses
  • Avoid new State mandates and regulations that drive up costs and reduce choice
  • Extend Medicaid and SCHIP $$:
    • Focus on better managing chronic care patients
    • Focus on value, not just cutting costs
    • Provide incentives for patients to stretch dollars
  • Develop private-public partnerships to strengthen the safety net
  • Expand community health centers
what is the new world about
What is the new world about?
  • Patient control: Consumers will have more choices in health insurance arrangements
  • Cost visibility: They will be more price conscious in shopping for insurance and some medical services
  • Savings incentives: Consumers have more incentive to get the best product, service, and value for their money
the next big thing
The next big thing…

Consumer choice in health care and coverage

the goal
The goal

Engaging consumers as partners rather than adversaries in managing health costs and getting the best value for health care dollars

for more information
For more information


Grace-Marie Turner

Galen Institute

(703) 299-8900