1. THE COMMONWEALTH FUND 1 Figure 1. We Can’t Continue on Our Current Path: Growth in the Uninsured Data: Analysis of the U.S. Census Bureau, Current Population Survey Annual Social and Economic Supplement (CPS ASEC), 2001–2008; projections to 2020 based on estimates by The Lewin Group. Uninsured (15%) Employer (55%) Medicaid (10%) Medicare (13%) Total population Military (1%) Individual (5%) Projected estimates Uninsured Projected to Rise to 61 million by 2020 Millions uninsured 45.7 Million Uninsured, 2007

2. THE COMMONWEALTH FUND 2 Figure 2. 75 Million People Were Uninsured for All or Part of the Year Before the Start of the Recession Total Population = 299 million Insured All Year 224m 75% Uninsured Part Year 37m 12% Uninsured All Year 38m 13% Source: Analysis of the 2006 of the Medical Expenditure Panel Survey by B. Mahato of Columbia University for The Commonwealth Fund. Under-65 Population = 260 million Insured All Year 189m 73% Uninsured Part Year 34m 13% Uninsured All Year 37m 14%

3. THE COMMONWEALTH FUND 3 Figure 3. Uninsured Rates High Among Adults with Low and Moderate Incomes, 2001–2007 Percent of adults ages 19–64 Note: Income refers to annual income. In 2001 and 2003, low income is <$20,000, moderate income is $20,000–$34,999, middle income is $35,000–$59,999, and high income is $60,000 or more. In 2005 and 2007, low income is <$20,000, moderate income is $20,000–$39,999, middle income is $40,000–$59,999, and high income is $60,000 or more. Subgroups may not sum to totals because of rounding. Source: S. R. Collins, J. L. Kriss, M. M. Doty, and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families: Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007 (New York: The Commonwealth Fund, August 2008). 4 24 49 28 13 Total Low income Moderate income Middle income High income 28 50 41 18 8 2001 2007 20012007200120072001200720012007

4. THE COMMONWEALTH FUND 4 Figure 4. The Majority of U.S. Workers Get Their Health Insurance Through Employers, 2007 Own employer coverage (56%) Other employer coverage (16%) Public programs (5%) *Includes those with individual insurance and “other” responses. Source: M. M. Doty, S.R. Collins, S.D. Rustgi, and J.L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance and How Health Care Reform Can Help: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007, The Commonwealth Fund, September 9, 2009. Data: The Commonwealth Fund Biennial Health Insurance Survey (2007). Uninsured (14%) Other coverage* (9%) 122.2 Million Full- and Part-Time Workers Ages 19–64

5. THE COMMONWEALTH FUND 5 Figure 5. 2009 Changes in Coverage at Different Levels of Unemployment (Base of 4.6% in 2007) Source: J. Holahan and A.B. Garrett, Rising Unemployment, Medicaid, and the Uninsured, Publication No. 7850 (Washington: Kaiser Commission on Medicaid and the Uninsured, January 2009). Millions of People

6. THE COMMONWEALTH FUND 6 Percent of firms offering health benefits Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2008 Annual Surveys. Figure 6. Employer Coverage Continues to Be Major Source of Coverage for Employees of Larger Firms But Has Declined Among Small Firms

7. THE COMMONWEALTH FUND 7 Figure 7. Employer-Sponsored Insurance Coverage Declined Among Small Firm Employees, 2003–2007 *Includes both part-time and full-time workers. Note: Subgroups may not sum to totals due to rounding. Source: M. M. Doty, S.R. Collins, S.D. Rustgi, and J.L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance and How Health Care Reform Can Help: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007, The Commonwealth Fund, September 9, 2009. Data: The Commonwealth Fund Biennial Health Insurance Survey (2003 and 2007). Small Firms (fewer than 50 employees) Percent of working adults ages 19–64* Large Firms (50 or more employees) 85 49 57 84

8. THE COMMONWEALTH FUND 8 Figure 8. Low-Wage Employees in Small Firms Are Less Likely to Have Employer-Sponsored Insurance Coverage *Includes both part-time and full-time workers. Note: Subgroups may not sum to totals due to rounding. Source: M. M. Doty, S.R. Collins, S.D. Rustgi, and J.L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance and How Health Care Reform Can Help: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007, The Commonwealth Fund, September 9, 2009. Data: The Commonwealth Fund Biennial Health Insurance Survey (2007). Small Firms (fewer than 50 employees) Percent of working adults ages 19–64* 38 68 62 94 Large Firms (50 or more employees) 85 49

9. THE COMMONWEALTH FUND 9 Figure 9. Percent of Adults Ages 18–64 Uninsured by State Data: Two-year averages from the U.S. Census Bureau, CPS ASEC, 2000–2001 and 2007–2008; 1999–2000 estimates updated with 2007 CPS correction.

10. THE COMMONWEALTH FUND 10 Figure 10. 25 Million Adults Underinsured in 2007 60 Percent Increase Since 2003 Uninsured during the year 49.5 (28%) Insured all year, not underinsured 102.3 (58%) Insured all year, underinsured* 25.2 (14%) 2007 Adults ages 19–64 (177.0 million) Uninsured during the year 45.5 (26%) Insured all year, not underinsured 110.9 (65%) Insured all year, underinsured* 15.6 (9%) 2003 Adults ages 19–64 (172.0 million) *Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Data: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2007). Source: C. Schoen, S. R. Collins, J. L. Kriss, and M. M. Doty, “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Health Affairs Web Exclusive, June 10, 2008.

11. THE COMMONWEALTH FUND 11 Figure 11. Two of Five Adults Uninsured or Underinsured; Percent Underinsured Triples for Middle-Income Total200% of poverty or more Under 200% of poverty *Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income, or 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Data: The Commonwealth Fund Biennial Health Insurance Surveys (2003 and 2007). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008. Percent of adults (ages 19–64) who are uninsured or underinsured 42 35 17 27 68 72

12. THE COMMONWEALTH FUND 12 Figure 12. Over Half of Working Adults in Small Firms Were Uninsured or Underinsured During the Year, 2007 Firms with fewer than 50 employees 39.0 million Uninsured anytime 36% Underinsured 16% Adequately insured 48% Uninsured anytime 15% Underinsured 13% Adequately insured 73% Firms with 50 or more employees 76.9 million ^Includes both part-time and full-time workers. Underinsured is defined as having continuous health insurance coverage and spending 10 percent or more of income on out-of-pocket health care costs (or 5 percent or more if low income), or having deductibles of 5 percent or more of income. Source: M. M. Doty, S.R. Collins, S.D. Rustgi, and J.L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance and How Health Care Reform Can Help: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007, The Commonwealth Fund, September 9, 2009. Data: The Commonwealth Fund Biennial Health Insurance Survey (2007).

13. THE COMMONWEALTH FUND 13 Figure 13. Deductibles Rise Sharply, Especially in Small Firms, 2000–2008 PPO = preferred provider organization. PPOs covered 57 percent of workers enrolled in an employer-sponsored health insurance plan in 2007. Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2008 Annual Surveys. Mean deductible for single coverage (PPO, in-network)

14. THE COMMONWEALTH FUND 14 Figure 14. Insurance Benefits Are Not As Generous for Workers in Small Businesses Percent of working adults ages 19–64 with own employer-sponsored insurance* Fair or poor rating of insurance plan No prescription drug coverage *Includes both part-time and full-time workers. Source: M. M. Doty, S.R. Collins, S.D. Rustgi, and J.L. Nicholson, Out of Options: Why So Many Workers in Small Businesses Lack Affordable Health Insurance and How Health Care Reform Can Help: Findings from the Commonwealth Fund Biennial Health Insurance Survey, 2007, The Commonwealth Fund, September 9, 2009. Data: The Commonwealth Fund Biennial Health Insurance Survey (2007). Coverage limits total amount it will pay for medical care

15. THE COMMONWEALTH FUND 15 Figure 15. Underinsured and Uninsured Adults at High Risk of Going Without Needed Care and Financial Stress Percent of adults (ages 19–64) *Did not fill prescription; skipped recommended medical test, treatment, or follow-up, had a medical problem but did not visit doctor; or did not get needed specialist care because of costs. **Had problems paying medical bills; changed way of life to pay medical bills; or contacted by a collection agency for inability to pay medical bills. Source: C. Schoen, S. Collins, J. Kriss, M. Doty, How Many are Underinsured? Trends Among U.S. Adults, 2003 and 2007, Health Affairs Web Exclusive, June 10, 2008. Data: 2007 Commonwealth Fund Biennial Health Insurance Survey.

16. THE COMMONWEALTH FUND 16 Figure 16. Uninsured and Underinsured Adults with Chronic Conditions Are More Likely to Visit the ER for Their Conditions Percent of adults ages 19–64 with at least one chronic condition* *Hypertension, high blood pressure; heart disease; diabetes; asthma, emphysema, or lung disease. **Adults with at least one chronic condition who take prescription medications on a regular basis. Data: The Commonwealth Fund Biennial Health Insurance Survey (2007). Source: S. R. Collins, J. L. Kriss, M. M. Doty and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families, The Commonwealth Fund, August 2008.

17. THE COMMONWEALTH FUND 17 Figure 17. Lack of Insurance Undermines Preventive and Chronic Care Receipt of Recommended Screening and Preventive Care*, 2005 Percent of adults Chronic Disease Under Control: Diabetes and Hypertension, 1999–2004 *Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot within a specific time frame given age and sex. **Refers to diabetic adults whose HbA1c is <9.0 ***Refers to hypertensive adults whose blood pressure is <140/90 mmHg. Data: Preventive care–B. Mahato, Columbia University analysis of Medical Expenditure Panel Survey; Chronic disease–J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008.

18. THE COMMONWEALTH FUND 18 Figure 18. Uninsured Adults and Adults with Gaps in Coverage Have Lower Rates of Cancer Screening Tests, 2007 Percent of adults ages 19–64 Note: Pap test in past year for females ages 19–29, past three years age 30+; colon cancer screening in past five years for adults ages 50–64; and mammogram in past two years for females ages 50–64. Source: S. R. Collins, J. L. Kriss, M. M. Doty, and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families: Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007, The Commonwealth Fund, August 2008.

19. THE COMMONWEALTH FUND 19 Figure 19. Cost-Related Problems Getting Needed Care Have Increased Across All Income Groups, 2001–2007 *Did not fill a prescription; did not see a specialist when needed; skipped recommended medical test, treatment, or follow-up; had a medical problem but did not visit doctor or clinic. Note: In 2001, low income is <$20,000, moderate income is $20,000–$34,999, middle income is $35,000–$59,999, and high income is $60,000+. In 2007, low income is <$20,000, moderate income is $20,000–$39,999, middle income is $40,000–$59,999, and high income is $60,000+. Data: The Commonwealth Fund Biennial Health Insurance Surveys (2001, 2007). Source: S. R. Collins, J. L. Kriss, M. M. Doty and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families, The Commonwealth Fund, August 2008. Percent of adults ages 19–64 who had any of four access problems* in past year because of cost

20. THE COMMONWEALTH FUND 20 Figure 20. Problems with Medical Bills or Accrued Medical Debt Increased, 2005–2007 Note: Low income is <$20,000, moderate income is $20,000–$39,999, middle income is $40,000–$59,999, and high income is $60,000+. Data: The Commonwealth Fund Biennial Health Insurance Surveys (2005 and 2007). Source: S. R. Collins, J. L. Kriss, M. M. Doty and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families, The Commonwealth Fund, August 2008. Percent of adults ages 19–64 with medical bill problems or accrued medical debt

21. THE COMMONWEALTH FUND 21 Figure 21. Medical Bill Problems and Accrued Medical Debt, 2005–2007 20052007 In the past 12 months: Had problems paying or unable to pay medical bills 23% 39 million 27% 48 million Contacted by collection agency for unpaid medical bills 13% 22 million 16% 28 million Had to change way of life to pay bills 14% 24 million 18% 32 million Any of the above bill problems 28% 48 million 33% 59 million Medical bills being paid off over time 21% 37 million 28% 49 million Any bill problems or medical debt 34% 58 million 41% 72 million Source: S. R. Collins, J. L. Kriss, M. M. Doty and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families, The Commonwealth Fund, August 2008. Percent of adults ages 19–64

22. THE COMMONWEALTH FUND 22 Insured All Year Uninsured Anytime During Year Percent of adults reporting:Total No underinsured indicators Underinsured Insured now, time uninsured in past year Uninsured now Unable to pay for basic necessities (food, heat, or rent) because of medical bills 29%16%29%42%40% Used up all of savings392646 47 Took out a mortgage against your home or took out a loan 1091211 Took on credit card debt3028333426 Insured at time care was provided 6180824624 Figure 22. More Than One-Quarter of Adults Under Age 65 With Medical Bill Burdens and Debt Were Unable to Pay for Basic Necessities Source: M. M. Doty, S. R. Collins, S. D. Rustgi, and J. L. Kriss, Seeing Red: The Growing Burden of Medical Bills and Debt Faced by U.S. Families, The Commonwealth Fund, August 2008. Percent of adults ages 19–64 with medical bill problems or accrued medical debt

23. THE COMMONWEALTH FUND 23 Figure 23. An Estimated 116 Million Adults Were Uninsured, Underinsured, Reported a Medical Bill Problem, and/or Did Not Access Needed Health Care Because of Cost, 2007 Medical bill/ debt problem 17.7 million 10% Cost-related access problem 25.9 million 15% Source: S. R. Collins, J. L. Kriss, M. M. Doty, and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families: Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007, The Commonwealth Fund, August 2008. The Commonwealth Fund Biennial Health Insurance Survey (2007). Adequate coverage and no bill or access problem 61.4 million 35% Uninsured anytime during the year or underinsured 17.6 million 10% Medical bill/debt and cost- related access problem 54.4 million 31% 177 million adults, ages 19–64

24. THE COMMONWEALTH FUND 24 Data: Two-year averages 1999–2000, updated with 2007 Current Population Survey correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 CPS. Figure 24. CHIP Has Reduced Rates of Uninsured Children in Most States Percent of Children Ages 0–17 Uninsured by State Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 24

25. THE COMMONWEALTH FUND 25 Figure 25. Low-Income Workers Are Eligible for COBRA at Only Half the Rate of Higher-Income Workers Below 200% FPL COBRA-eligible 38% Ineligible, insured but not through employer 27% Ineligible, uninsured 33% 200%+ FPL Ineligible, small- firm worker 3% Source: M. Broaddus et al., Measures in House Recovery Package—But Not Senate Package—Would Help Unemployed Parents Receive Health Coverage (Washington, D.C.: Center on Budget and Policy Priorities, February 2009); M. M. Doty et al., Maintaining Health Insurance During a Recession: Likely COBRA Eligibility (New York: The Commonwealth Fund, January 2009). COBRA-eligible 76% Ineligible, insured but not through employer 11% Ineligible, uninsured 7% Ineligible, small- firm worker 6%

26. THE COMMONWEALTH FUND 26 Figure 26. Even With ARRA Subsidies, COBRA Still Unaffordable for Individuals and Families at 150 Percent of Poverty Source: M. Broaddus et al., Measures in House Recovery Package—But Not Senate Package—Would Help Unemployed Parents Receive Health Coverage (Washington: Center on Budget and Policy Priorities, February 2009).

27. THE COMMONWEALTH FUND 27 Figure 27. Average Family Premium as a Percentage of Median Family Income, 1999–2020 Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums, The Commonwealth Fund, August 2009. Projected

28. THE COMMONWEALTH FUND 28 Figure 28. Average Annual Savings per Family Under Health Reform That Controls Premium Growth, 2020 Family Income ($ thousands) Savings in health care spending compared with projected trends Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: The Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, February 2009).