1. The National Medicaid Congress Strategies for Addressing the Uninsured
June 14, 2007
Scott Keefer
Director
Center for Policy and Research
America’s Health Insurance Plans

2. Recent Trends in Health Insurance Premiums
Federal Employees Health Benefits Plan
Mercer
National Health Expenditures
Kaiser Family Foundation

3. National Health Expenditures vs. GDP Growth
Nominal GDP

4. for Congress to address next year?
Providing access to affordable health care is the top domestic priority.
Question: Which of the following issues would you say should be the top domestic priority
for Congress to address next year?
Providing access to affordable health care
Improving the quality of our educational system
Combating illegal immigration
Fighting crime & drugs
Cutting taxes
Reducing the deficit
Protecting the environment

5. … with Americans agreeing regardless of their party affiliation.
Percent saying Congress and state legislatures should do more to extend health insurance coverage
Question: Recognizing the importance of many other problems as well as efforts to cut the federal budget deficit, over the next five years do you think Congress and the state legislatures should do more, do less, or do about the same on extending health insurance coverage to the uninsured?

6. Growth In Uninsured: Low-Middle and Moderate Incomes
2004
2005
Uninsured (millions)
Total Population
43.5
44.8
Children
7.7
8.1
Uninsured Rates
14.9%
15.3%
Low Income
24.1%
24.2%
Low-Moderate Income
19.2%
20.1%
Middle Income
12.3%
13.3%
Source: U.S. Census Bureau; revised estimates at .

7. Health Costs Outpace Median Income in Long Run
National Per Capita Health Expenditures as a Percentage of Median Household Income
Key Issue: Long-standing trend of household health premium costs exceeding income growth is at the heart of the uninsured problem and will lead to greater levels of uninsured in the future absent policy change.
Sources: Income, Poverty, and Health Insurance Coverage in the United States: 2004, Census Bureau, Table A-1, and CMS National Health Expenditure Data (

8. Employee Take Up Rates Are Falling
Percentage of Employees of Large Employers Accepting Offer of Health Insurance Coverage
87%
81%
Source: Agency for Healthcare Quality and Research.

9. Insurance Coverage Status by Firm Size
Probability of Public Insurance or Lack of Insurance Inversely Related to Firm Size
Public Insurance
Uninsured
Source: Notes, Employee Benefit Research Institute, Vol. 26, No. 10, October 2005, Figure 3.

10. U.S. Job and Health Insurance Turnover
Average Number of Jobs Held by U.S. Workers Between the Ages of 18 and 40
10.5
Number of Americans Switching Private Health Insurance Plans Annually
~35 Million (17%)
Sources: U.S. Bureau of Labor Statistics and “Health Insurance Switching: Choice or Circumstance?”, Peter J. Cunningham and Linda Kohn, Health Affairs, May/June 2000

11. Involuntary Insurance Switching Is Common
Reasons Cited for Health Insurance Switching
Two-thirds of switches are involuntary.
Source: “Health Insurance Switching: Choice or Circumstance?”, Peter J. Cunningham and Linda Kohn, Health Affairs, May/June 2000

12. Short Uninsurance Spells Are Common
Length of Uninsurance Spells,
Millions
84.8 Million Persons Were Uninsured at Some Point
10.1 Million Were Always Uninsured
Source: “Battery-Powered Health Insurance? Stability in Coverage of the Uninsured,” Pamela Farley Short and Deborah R. Graefe, Health Affairs, November/December 2003

13. AHIP Proposal to Expand Health Insurance to All Americans
SCHIP up to 200% FPL
Medicaid up to 100% FPL
Child Health Credit up to 300% FPL
Universal Health Account with subsidies up to 400% FPL
State Performance Grant

14. AHIP: Reauthorize and Expand SCHIP
Increase SCHIP funding to help states cover projected shortfalls (at minimum funding to cover all children to 200 percent of FPL)
Improve the environment for Premium Assistance
Provide incentive funding for improving quality

15. AHIP: New Health Tax Credit for Children
Encourage parents to maintain coverage for their children
Proposal: $200 per child / $500 per family

16. AHIP: Tax-Free Universal Health Account
Tax-free individual contributions
Federal subsidies up to 400% FPL
Employer contributions
Pays for any type of health insurance
Promotes portability
Promotes continuity of coverage
Serves as a “125”

17. AHIP: State Performance Grant Program
$50 billion seed money over 10 years to assist states in expanding access
States would submit plans to achieve coverage goals:
Ensure affordable coverage
Ensure availability of coverage
Establish Medicaid to FPL
Improve quality and reducing costs
Establish healthy living incentives

18. tell me if you support or oppose each idea.
For each proposal, majority support extends to Americans of each party.
Ranked by Percent “Support”
Rep
Ind
Dem
Giving a federal tax credit to low and moderate income parents
83%
65%
63%
75%
54%
66%
59%
83%
75%
67%
69%
64%
88%
89%
77%
68%
82%
65%
Increasing funding for health insurance program for children
Providing grants from the federal government
Having the federal government match contributions
Giving federal tax deduction for purchase of private insurance
Expanding the federal government’s Medicaid program
Establishing a tax-free Health Account for all Americans
Question: Now I am going to read some different ideas that some people have proposed
for providing health care coverage for people who are currently uninsured. Would you please
tell me if you support or oppose each idea.

19. State-Based Reform: Massachusetts
Massachusetts Uninsured by Income
(as a % of poverty)
Medicaid-eligible but not enrolled
Outreach
Mandatory enrollment
< 100% 106,000
Individual
Mandate to Carry Health Insurance
> 300%
204,000
Affordable Products
Sliding Scale Premium Subsidies
Insurance Connector
100%-300%
150,000
Affordable Products
Insurance Connector
Total Uninsured Population = 460,000 (7.2% of total)
Total Population = 6,400,000
Source: Presentation to the Medicaid Commission by Governor Mitt Romney, January 26, 2006

20. Schwarzenegger Proposal
Individual Mandate with Subsidies
Medi-Cal or SCHIP to 300% of Poverty for Kids
Subsidies under 250% of Poverty
Purchasing Pool
Employers With 10+ Workers: Coverage or “In Lieu” Fee of 4% of Payroll
Increased Medi-Cal Reimbursement
“Coverage Dividend:” 4% of Revenues for Hospitals; 2% for Physicians
Section 125 and HSA Contribution Improvements
Cost, Quality, Wellness Provisions

21. Environment for Reform is Less Predictable than Recent History
State-Based Reforms
SCHIP Reauthorization and Funding
Bush Standard Deduction Proposal
2008 Presidential Positioning
Hang Ups:
Coverage First vs. Reform as a Pre-Condition?
All-At-Once vs. Framework for Continuous Progress?
Altman’s Law? (2nd Favorite Alternative is Status Quo)
Public vs. Private or Public/Private Partnership?
Employer System vs. Individualized Private System?
Expansive Minimum Benefits vs. Affordability