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The Uninsured: Impact on the Nation, State and Region

The Uninsured: Impact on the Nation, State and Region. Kenneth J. Braithwaite, II Senior Vice President, The Hospital & Healthsystem Association of Pennsylvania Regional Executive Delaware Valley Healthcare Council of HAP February 15, 2008. How Many Are Uninsured?. (1).

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The Uninsured: Impact on the Nation, State and Region

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  1. The Uninsured:Impact on the Nation, State and Region Kenneth J. Braithwaite, II Senior Vice President, The Hospital & Healthsystem Association of Pennsylvania Regional Executive Delaware Valley Healthcare Council of HAP February 15, 2008

  2. How Many Are Uninsured? (1) Source: US Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States: 2005. Data released August 2006. Table 8. People With or Without Health Insurance Coverage by Selected Characteristics: 2004 and 2005. Link: http://pubdb3.census.gov/macro/032006/health/h01_001.htm. (1) 2004 and 2005 figures reflect revised estimates released by the Census Bureau on March 23, 2007.

  3. Pennsylvania’s UninsuredPercent of Total Population Without Health Insurance Coverage Source: U.S. Census Bureau, HHS Division

  4. Pennsylvania’s Working UninsuredPercent of Working-Age Adults (ages 18-65) Without Health Insurance Coverage Source: U.S. Census Bureau, HHS Division

  5. Pennsylvania’s Uninsured ChildrenPercent of Children (under age 18) Without Health Insurance Coverage Source: U.S. Census Bureau, HHS Division

  6. Low-Income* Uninsured PA Children(under age 18) Three-Year Average *At or Below 200% Poverty Level Source: U.S. Census Bureau, HHS Division

  7. The percentage of uninsured does not vary significantly across regions Source: Pennsylvania Insurance Department

  8. The largest concentration of uninsured reside in the Philadelphia and Pittsburgh regions Source: Pennsylvania Insurance Department

  9. <200% FPL 200-299% FPL 300% FPL+ Who are the Uninsured? Children Parents Children Other Adults Parents Children Parents Other Adults Other Adults Total = 46.5 million uninsured 1/3 (15 million) 200% to 300%+ FPL SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

  10. 2/3 Employed Uninsured Nonelderly Population by Work Status of Family Head, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  11. Income and Poverty Status Percentage Uninsured Among Nonelderly Population by Family Poverty Status, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  12. Educational Attainment Percentage Uninsured Among the Nonelderly Adults, by Education, 2006

  13. Race/Ethnicity Percentage Uninsured Among the Nonelderly Population by Race and Ethnic Origin, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  14. Uninsured Children Uninsured Children by Race and Ethnic Origin, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  15. Uninsured Rates are Increasing Most for Working Middle Class Adults Percent of working adults who are uninsured *In 1999, CPS added a follow-up verification question for health coverage. Source: Analysis of the March 1988–2004 Current Population Surveys by D. Ferry, Columbia University, for The Commonwealth Fund.

  16. Uninsured in PA • 71% are employed • 75% work for private companies • 62% are in service, 21 % in retail • 76% have incomes below 300% FPL • 49% are between 18-34 • 27% have been without health care for more than 5 years

  17. Uninsured in SE PA • One in every 14 adults is uninsured • Most are employed • 1/3 earn less than less than $20,500/year • Unlike national trends, 1/3 are African American … only 10% are Latino

  18. Why Are People Uninsured? • Erosion of employment-based health insurance • Employment shifting to jobs and industries without health benefits • The young and healthy • The undocumented • Escalating medical and health insurance costs

  19. Uninsured 47.0 (16%) Uninsured 46.5 (18%) Employer 164.0 (55%) Employer 162.7 (62%) Other 12.8 (4%) Other 12.5 (5%) Medicaid 32.7 (11%) Medicaid 32.6 (13%) Medicare 6.5 (2%) Medicare 40.3 (14%) Employers Provide Insurance for Almost 2/3 of Us 2006 Total population = 296.8 million Under 65 population = 260.8 million Source: The Commonwealth Fund; Data from the Current Population Survey, March 2007.

  20. But Employment-Based Health Coverage Is at Its Lowest Ever Sources: US Census Bureau, HHS Division

  21. Where Do the Unisured Work? Nonelderly Adult Uninsured Workers by Industry, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  22. In What Jobs? Nonelderly Adult Uninsured Workers by Occupation, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  23. 1/3 Work in Firms ≤ 9 2/3 Work in Firms ≤ 99 Nonelderly Adult Uninsured Workers by Firm Size, 2006 Source: Employee Benefit Research Institute estimates from the March Current Population Survey, 2007 Supplement. Last Updated: January 6, 2008

  24. Larger Firms More Likely to Offer Insurance Percent of firms offering health benefits Source: The Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits, 2000 and 2007 Annual Surveys.

  25. Percent Uninsured Workers by Firm Size and Hourly Wage Percent of working adults ages 19–64 who are uninsured Small employer (fewer than 50 employees) Medium to large employer (50 or more employees) ^Includes both part-time and full-time workers. Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated data from The Commonwealth Fund Biennial Health Insurance Survey (2005).

  26. Reasons for Lack of Insurance Coverage Worker doesn’t know if offered or eligible 4% Employer doesn’t offer coverage 48% Employer offers, worker ineligible 20% Employer offers, worker eligible, doesn’t participate 28% Source: S. R. Collins, C. Schoen, D. Colasanto et al., On the Edge: Low-Wage Workers and Their Health Insurance Coverage, The Commonwealth Fund, March 2003. Updated data from The Commonwealth Fund Biennial Health Insurance Survey (2005).

  27. Growth in “Uninsured” Employment(Firms, Sectors, Professions That Traditionally Do Not Offer Health Benefits) In PA since 2000: + 5.6 million in industries without health benefits – 2 million in industries that offer health benefits

  28. The Growing Cost of Health InsuranceHealth Insurance Premiums Growing Faster Than Inflation or Salaries Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. SOURCE: Employer Health Benefits, 2006 Annual Survey, Kaiser Family Foundation and Health Research & Educational Trust, September 2006.

  29. Growth in Health Costs Overall Average annual percent growth in health expenditures, 2000–2005 Source: A. Catlin et al., “National Health Spending in 2005: The Slowdown Continues,”Health Affairs, Jan./Feb. 2007 26(1):142–53.

  30. Net costs of health administration and health insurance as percent of national health expenditures c b a * Insurance Administration and Overhead Internationally a2002 b1999 c2001 *Includes claims administration, underwriting, marketing, profits, and other administrative costs; based on premiums minus claims expenses for private insurance. Source: The Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006. Data: OECD Health Data 2005.

  31. Americans Spend More Out-of-Pocket on Health Care Expenses Than Citizens in Other Industrialized Countries National health expenditures per capita (US$) United States Canada Germany Australia Netherlands France OECD Median Japana New Zealand a Out-of-pocket health care spending per capita (US$) a2002 Note: Adjusted for differences in the cost of living, 2003. Source: B. K. Frogner and G. F. Anderson, Multinational Comparisons of Health Systems Data, 2005, The Commonwealth Fund, April 2006.

  32. International Comparison of Health Spending Average spending on healthper capita ($US PPP) Total health expenditures as percent of GDP Source: OECD Health Data 2007.

  33. Average Annual Premium Costs for Covered Workers $12,106 $6,438 $4,479 $2,471 Family Coverage Single Coverage Note: Family coverage is defined as health coverage for a family of four. Data represents average for all types of plans. SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007.

  34. Deductibles Rise Sharply, Especially in Small Firms Mean deductible for single coverage (PPO, in-network) 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 2007 Annual Surveys.

  35. Low-Income Households at Most Riskfor Spending Greater Shares of Income onFamily Out-of-Pocket Expenses and Premiums Percent of adults ages 19–64 insured all year with private insurance Annual income Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

  36. Individual Market Is Not anAffordable Option for Many People Source: The Commonwealth Fund Biennial Health Insurance Survey (2005).

  37. The Young and Healthy30 Percent of Nonelderly Uninsured Adults Are Under 30 Ages 50–64 15% Age 18and under 20% Ages 36–49 23% Ages 19–23 14% Ages 24–29 16% Ages 30–35 12% Uninsured nonelderly adults = 44.4 million Source: The Commonwealth Fund. Analysis by S. Glied and B. Mahato of Columbia University of the March 2006 Current Population Survey .

  38. Rite of Passage:Losing Your Health Insurance Source: Analysis of the March 2006 Current Population Surveyby S. Glied and B. Mahato for The Commonwealth Fund.

  39. Uninsured Immigrants(Documented and Undocumented) • 1 of every 4 uninsured is an immigrant • Almost ½ have public insurance or no insurance • Growing issue: Immigrants arriving between 1994 and 98 = 60% of growth from 1995 to 2005

  40. Community Health CentersThe Primary Care Safety Net for the Uninsured • 16 million patients at 1,100 FQ and look-alike CHCs in 2006 • 40% of FQHC patients uninsured • 50% increase over 5 years in number of uninsured served at FQHC (4 million in 2001 to 6 million in 2006 • Growth in center locations and the services offered

  41. CHCs Responding to Challenges • Referrals to speciality care and the healthcare continuum a growing challenge • Forging relationships with local health care delivery system to provide access to the continuum of care, provide affordable access to needed services • Beginning to invest in IT infrastructure to connect to affiliated safety net hospitals

  42. Philadelphia’s City Health Clinics • 8 clinics, more than 260,000 patient visits annually • All patients below 300% FPL • More than half of patients have no insurance • One in five have no prescription medication coverage and no primary care doctor, or medical home • 12% of those with chronic conditions (asthma, hypertension, diabetes) do not seek care due to the high cost of medications

  43. Hospital EDs – the Defacto Safety Net Emergency Department Visits and Emergency Departments in Community Hospitals, 1991 – 2005 Source: Avalere Health analysis of American Hospital Association Annual Survey data, 2005, for community hospitals. (1) Defined as hospitals reporting ED visits in 2005 AHA Annual Survey.

  44. Gateway to Hospital Services • EMTALA, and hospital missions, ensure that all will receive care • Uninsured and Medicaid patients have have much higher ED use than privately insured patients, but reimbursement for services provided is much lower • Admission through the ED account for 30 to 40 percent of all hospital admissions

  45. ER Utilization in PA • 11% more ER usage than the average American • Usage growing 2X U.S. average • 5.3 million visits in 2007

  46. Low-Income Adults Use EDs, Not Doctors’ Offices, More Often

  47. The Impact:Overburdened and Overwhelmed • Those who can least afford it are obtaining healthcare at the highest cost, with access to the minimal means of reimbursing the healthcare delivery system … • Impacts on individuals, communities, hospitals and the nation are costly

  48. Uninsured Up, Access to Primary Care Down • Physician charity care declined in 1990s due to reduced pubic and private payments • High uninsured rates in a community further disincent scarce primary care doctors • Community health centers and clinics overwhelmed • Hospital EDs end up providing primary care … jeopardizing access to care for all regardless of insurance status

  49. Care without CoverageToo Little, Too Late • Americans without health insurance: • Too little care, received too late • Are sicker, die sooner • Receive poorer care • 17-year study: adults without health insurance at the onset had a 25% greater chance of dying • Uninsured women with breast cancer have a 30 to 50 percent higher risk of dying

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