Can U.S. Afford to Insure All?

Escalating costs, budget shortfalls, rising needs could overwhelm health-care system

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cqresearcherAlso from Congressional Quarterly Researcher – June 14, 2002:

Universal Health Insurance: Not a Cure-All

Recurring Quest for Health Reform: First Enthusiasm, Then Failure

Local Health Reform: How Tampa Does It?


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It did not seem like a big thing. On the swing set at his rural North Carolina preschool three years ago, 5-year-old Dalton Dawes and a classmate bumped into each other. Then began his parents’ worst nightmare.

Dalton is a hemophiliac, and he began to bleed internally. Dalton had been receiving twice-weekly injections of a blood-clotting agent almost since birth. Now he would need them more often.

The drug would do more than simply allow him to live a normal child’s life, playing soccer and roaming the nearby woods. It would keep him from bleeding to death. Yet the family’s health insurer would not provide coverage. Nor could his parents, despite their good jobs, afford the $2,000 weekly expense — for years to come.

So Leonard Poe, a lawyer, and Heather Dawes, a paralegal, impoverished themselves. They sold off land and built a home from logs. They dispensed with the dishwasher and TV. By reducing their earnings to less than $23,000 a year, they qualified for Medicaid, the government health-insurance program for the poor.

After Dalton’s seventh birthday, his parents had to cut their income even further — to $15,492 — in order to remain eligible for Medicaid. Instead, they tried to enroll him in the Children’s Health Insurance Initiative (CHIP).

Congress passed CHIP in 1997 to tackle a worrisome statistic: the roughly 10 million American children whose families lacked health insurance. The largest single expansion of public health coverage in three decades, CHIP took direct aim at families too well off for Medicaid but too poor to afford private insurance.

Expensive medication makes a normal life possible for Dalton Dawes, a hemophiliac in rural North Carolina, but thecost forced his parents to impoverish themselves to qualify for Medicaid coverage.

Unfortunately, North Carolina’s CHIP program had run out of money by March 2001. And there were more than 23,000 other children besides Dalton waiting to join the program.

To keep up Dalton’s medication, his parents relied on drug-company charity and considered moving to a state with a CHIP program that was taking new clients.

By last September, when the North Carolina legislature restarted the program, Dalton had only three weeks’ worth of the life-preserving injections left. [1]

“It’s incredibly depressing,” Heather Dawes says. “The worst thing is, I wasn’t just fighting my own battle. There are millions of people in this county who are cut off from good medical care. They don’t deserve this. It’s awful.”

The United States spends $1.3 trillion on health care each year, more than any other industrialized nation, but it is the only developed country that does not assure universal access to basic health care. Unlike the British or Canadians, for instance, all Americans are not entitled to affordable medicine or treatment — or to keeping their existing coverage if their financial circumstances change. Partly as a result, the United States ranks 37th in the World Health Organization’s ranking of the world’s healthiest countries. [2]

Nearly one in seven Americans — 38.7 million people — lacks insurance, more than the combined populations of Texas, Florida and Connecticut. [3]Eight in 10 of the uninsured are members of working families — too well off for Medicaid and other public programs but too poor to pay private health insurance premiums.

The lack of universal coverage, some critics say, stems from the government’s historically piecemeal approach to health insurance — a complicated patchwork of private and government-subsidized coverage more like a sieve than a shield. And while there has been some progress in recent years — establishing the CHIP program and allowing workers to change or lose a job without losing insurance — many people still fall through the cracks in coverage. [4]For example, only 6 percent of the children eligible for CHIP benefits are enrolled in the program. [5]

The absence of universal health coverage has been called “one of the great, unsolved problems facing the United States at the onset of the 21st century.” [6]

The problem affects Americans regardless of their age, education or place of residence. More than half the uninsured are full-time workers or their dependents. Nearly 20 million are white, 11 million are Hispanic and 7 million are black, according to the Census Bureau. [7] Only Americans over 65 are theoretically assured of health security, through Medicare. But Medicare doesn’t cover the cost of most drugs, and critics say rising drug prices mean seniors are not really protected if they can see doctors but can’t afford the drugs they prescribe.

And the ranks of the uninsured have been rising for most of the last 15 years — even during recent periods of record-breaking economic prosperity. [8]Seven of every 10 American workers depend on their employers for health insurance, but as health-care costs have skyrocketed in recent years, companies have begun asking employees to pay a greater share of the cost, or eliminating coverage entirely. [9]

In Florida, a Chamber of Commerce survey found that only 77 percent of businesses offered health insurance to employees in late 2001, down sharply from 91 percent in 1999. [10]Nationwide, another survey found that 44 percent of U.S. employers were “very” or “somewhat” likely to increase workers’ out-of-pocket premiums during 2002. [11]

Others have solved the problem by downsizing their staffs and outsourcing work to contractors, who by definition do not qualify for medical benefits. During last year’s recession and layoffs, 2.2 million Americans lost their insurance, and a third of them probably lost their health coverage at the same time. [12]

“We face a crisis, and we need to act,” said Yank D. Coble Jr., president of the American Medical Association (AMA). “The good health of our patients — and our security as a nation — depends on it.” [13]

Even before the recession, real income and purchasing power were lagging behind the double-digit rates of inflation for drugs, health services and insurance, which are expected to rise 13 to 16 percent this year. “If we have more years of double-digit increases, people will be priced out of the market,” said Paul B. Ginsburg, president of the Center for Studying Health System Change.

And the situation is likely to get worse. According to the Centers for Medicare and Medicaid Services, health spending will reach $2.8 trillion by 2011 — a staggering 17 percent of the gross domestic product. [14]

Cash-strapped state governments — which pay for the bulk of Medicaid — can’t keep up with spiraling health costs. “Our challenge is to find a way to not cut services when we have less money than we had the year before,” said Gov. Paul E. Patton, D-Ky., vice chairman of the National Governors’ Association (NGA). [15]

State governments, collectively billions of dollars in the red, have begun trimming Medicaid benefits, sparking protests from Hawaii to Arkansas. [16]Dozens of states are trying to force drug manufacturers to provide discounts for the poor. [17]In Mississippi, the Medicaid program ran out of money in March. At least 14 states are considering increasing the eligibility requirements for Medicaid and CHIP, thus reducing the number of people who qualify for those safety-net services.

The health implications of inadequate insurance are stark. The Institute of Medicine estimates that 18,000 Americans die prematurely each year as a result of not having health insurance — usually because they discover too late that they have a treatable disease. [18] Others never receive timely treatment for diabetes, mental illness and other conditions and eventually must be hospitalized, a far more costly solution than early care in a doctor’s office. [19]

“The hard truth is that Americans without health-care coverage live sicker and die younger,” Coble said. “It’s bad fiscal policy. It’s bad public policy. And it’s bad medicine.” [20]

“Charitable physicians and the safety net of community clinics and public hospitals do not substitute for real health coverage,” said Adam Searing, project director of the North Carolina Health Access Coalition. “Need a concrete example? Look no farther than Dalton Dawes.” [21]

The issue brought together two Washington lobbying groups usually on opposite sides of the health-policy debate: the U.S. Chamber of Commerce and the AFL-CIO. In February, they helped create the Covering the Uninsured coalition — along with business groups, consumer and family advocates and health-care providers — dedicated to solving the problem. [22]

Nearly a third of voters want the health-care system “radically changed,” according to Republican pollster Bill McInturff. [23]President Bush has proposed new tax credits to help the uninsured pay for health coverage, a change he said would “reform health care in America.” [24]And both political parties have suggested prescription-drug subsidies for the elderly. [25]

Across the country this year, people are peppering campaigners for Congress with questions about health care. A Colorado candidate for the U.S. Senate expected a coal company executive to quiz him on energy issues — only to have him complain about the company’s $10 million annual bill for retired workers’ prescription drugs. [26]

The problem is hardly new. In 1912, presidential candidate Theodore Roosevelt pledged to make employees, employers and “the people at large” pay for insurance against the “hazards of sickness, accident, invalidism, involuntary unemployment and old age.” His proposal — often repeated by other politicians over the years — was most recently squelched in 1994, when President Bill Clinton’s call for universal coverage foundered spectacularly.

The failure of Clinton’s health-care reform “still hangs like a dark cloud over contemporary health-care debates,” writes Harvard political scientist Jacob Hacker. [27]And this year Washington again shows every sign of deferring the issue. “We’re not going to deal with it in an election year, that’s for sure,” said a key health-policy player, Sen. John B. Breaux, D-La. [28]People of both parties are “scared of being labeled Clintonites,” explained Robert Reischauer, who ran the Congressional Budget Office in 1993. [29]

Thus, while employers, hospitals, doctors and governors clamor for help, health-care proposals now pending in Congress would offer only limited benefits. Lawmakers believe — despite the opinion surveys — that Americans prefer their health-care progress in small doses and do not think a large federal bureaucracy can solve the problem.

Yet, if the situation isn’t remedied, the coming convergence over the next decade of escalating costs, budget shortfalls and vastly increased needs could overwhelm the health-care system and increase the ranks of the uninsured to as many as 61 million. “We are heading for a social and health-care debacle of gigantic proportions,” warned Harold G. Koenig, a professor of medicine at Duke University. [30]

As Congress, the White House and local leaders grapple with the nation’s uninsured, these are some of the questions being debated:

Can America afford health insurance for all?

On the surface, the nation shows every sign of not being able to afford caring for the uninsured and disenfranchised. Community and public health centers, hospital clinics, inpatient facilities and emergency rooms all are showing stresses from government cutbacks. As spending spirals to new levels, states, Congress, employers and insurers all are in the mood to cut and constrain — not add to financial obligations.

The Balanced Budget Act of 1997, for instance, reduced payments to federally licensed community health centers, cut Medicare reimbursement rates to hospitals and prevented hospitals from challenging the adequacy of Medicaid payments. Since then, states have cut back on Medicaid payments, and some large health plans have pulled out of the Medicaid market altogether. Communities are seeking creative solutions, but few at any level of government or industry are saying they can afford more. [31]

But Don Young, president of the Health Insurance Association of America, believes they can. “It’s more of a willingness to pay — and that willingness will have to come from a number of places,” he says. The task could be accomplished with expansions in Medicaid, CHIP, tax credits and tax incentives. “If the American public wants to do it, it is certainly affordable.”

Ron Pollack, executive director of the national consumer organization Families USA, agrees. “Covering the uninsured has never truly been a question of cost,” he says. “We’re the richest nation in the history of the planet. The question is whether we have the political will for it.”

But Kenneth S. Abramowitz, a managing director of the influential Carlyle Group investment firm and a longtime health-industry analyst, says Americans already pay for universal coverage — through higher health-care costs for everyone else.

“When you or I buy insurance — or the company we work for does — we’re paying for the uninsured,” says Abramowitz. Most insurance premiums are inflated by about 12.5 percent, he says, to compensate for non-payment or underpayment by others — a system called “cost shifting.”

The uninsured are “freeloaders,” he says bluntly. “When someone shoplifts a sweater, the rest of us have to pay for the sweater because it costs us more. The [uninsured] are shoplifters.”

Young admits that hospital revenues run at about 114 percent of costs — so the excess can subsidize the uninsured. Also, Medicare and Medicaid compensate hospitals that serve predominantly poor populations at a higher rate than other hospitals. “Those hidden costs are there,” Young says. “The uninsured are being covered — they’re getting services, paid for by the government through tax dollars and subsidies from private insurers.”

Abramowitz estimates that half the cost of any hypothetical government program to cover the uninsured is already being spent on the uninsured. It would cost less, he says, to compel every citizen to buy health insurance, with the poor receiving government vouchers for part of the cost and the poorest receiving certificates covering the entire amount. Others would receive tax credits, and employers would receive tax deductions.

“It would be cheaper — and everybody would be covered,” he says, estimating a total cost of between $11 billion and $86 billion a year. [32]

Under the current system, the uninsured end up using emergency rooms for most of their care because they tend to wait until their condition is critical before seeking care at hospitals, which must treat them. Research for the National Health Policy Forum shows that about three-fourths of all emergency room (ER) visits in which patients are not admitted should have been treated elsewhere.

Because ER care is one of the costliest forms of treatment, the current system helps drive up health-care costs, critics say. The lack of universal coverage prevents the poor from getting treatment more cheaply — in a primary physician’s office when their ailments are in their infancy — thus fueling the increase in health-care costs.

When the uninsured cannot afford emergency care, hospitals, businesses, insurers and taxpayers pick up the tab. Hospitals alone absorb an estimated $19 billion per year in uncompensated care for the uninsured. [33]

Such uncovered care amounts to “an unlegislated tax,” says Peter Schonfeld, senior vice president for policy of the Michigan Health and Hospital Association. Because legislators don’t want to raise taxes, he says, “They shift the cost elsewhere, hiding it from the public.”

And the hidden “tax” is going up. The number of emergency room visits increased 15 percent nationally between 1990 and 1999, according to the American Hospital Association, largely due to a surge in uninsured visits. In California, 82 percent of the more than 9.2 million patients who are treated in emergency rooms each year cost the hospitals money — up to $48 in uncompensated care per visit. [34]

Because of the overuse of emergency rooms and state and federal cutbacks in hospital reimbursements for Medicaid and Medicare patients, hospitals nationwide have begun diverting patients to other facilities. A survey by the Democratic staff of the House Government Reform Committee found that overcrowded ERs are causing “substantial problems accessing emergency services” in 22 states — especially in cities with large numbers of uninsured residents. Some hospitals simply close their doors to those unable to pay and for whom the hospital could collect no compensation elsewhere. [35]

More than 90 percent of large hospitals with 300 beds or more report emergency rooms at — or “over” — capacity. Hospitals over capacity place patients in other areas, such as hallways. [36]

“Unless the problem is solved in the near future,” cautioned the Annals of Emergency Medicine, “the general public may no longer be able to rely on emergency departments for quality and timely emergency care, placing the people of this country at risk.” [37]

An unprecedented alliance of normally adversarial business and consumer groups known as the Covering the Uninsured coalition has launched a nationwide publicity campaign to raise awareness about the 39 million Americans who lack health insurance. Covering the Uninsured Coalition

Should Medicare cover prescription drugs for the poorest seniors?

If Congress does anything on health care this year, it most likely will involve a distinct population already receiving huge publicly financed benefits — seniors and disabled persons enrolled in Medicare. Currently, Medicare covers only a few drugs, such as certain cancer medications. Some seniors purchase supplemental coverage — such as Medigap or Medicare + Choice, and some states provide additional coverage for services or prescriptions.

President Bush, members of both parties in Congress and a wide range of interest groups want the government to subsidize the skyrocketing cost of pharmaceuticals for Medicare recipients. Their interest in the issue is not only a sign of the problem — but also of politics: The more than 10 million seniors and persons with disabilities who lack prescription-drug coverage could be critical to the outcome of midterm congressional elections this year, which could alter the balance of power in Washington.

Seniors and the disabled — among the nation’s most dependent users of medications — often must pay full price for drugs, while those with private group insurance plans often pay less because of their company’s purchasing power. For instance, a cholesterol-lowering medication can cost a senior more than $300 for three months, compared with only about $50 for someone with private insurance.

The big question for lawmakers is not whether to add prescription benefits to Medicare but how many seniors to give it to — in other words, how to pay for it. Facing a budget deficit, even the smallest new benefit would hit taxpayers hard.

The president wants to spend $190 billion over the next 10 years to provide free prescriptions to any Medicare recipient with an annual income under $11,610, or couples earning up to $17,415. The proposal is especially controversial because Medicare has never had salary caps before. Opponents say providing benefits only to the lowest-income seniors undermines Medicare’s original covenant with the elderly — to provide coverage to every person over 65, regardless of income. Otherwise, they argue, Medicare becomes a welfare program.

Nevertheless, House Republicans propose covering only the poorest seniors: The plan calls for the government covering part of the first $5,000 a year in drug expenses, and everything above $5,000. Seniors would pay $37 in monthly premiums. The plan would cost the government $350 billion and benefit only half the nation’s Medicare recipients. Couples with incomes over $18,000, or individuals earning above $13,000, would not be covered.

Republicans argue that in belt-tightening times — and when so much money is being diverted to fight terrorism — benefits should go to those who need them most. They point out that Medicare beneficiaries who can afford it already pay for supplemental coverage, some of which covers prescriptions. Providing free drugs for all seniors could “bankrupt the program,” hurting all Medicare beneficiaries, according to a GOP “Talking Points” memo prepared for House members. Instead, it suggested, any solution should focus on the 35 percent of Medicare recipients “who truly need a prescription-drug benefit.”

In the Senate, Democrats propose spending up to $500 billion, arguing that Bush’s plan only covers 3 million seniors — a third of those needing help. “The best way to help low-income seniors is to help all seniors,” says Rep. John D. Dingell, D-Mich. The president’s proposals are “temporary solutions” that “ignore the larger task at hand” — creating a universal Medicare drug benefit.

AARP, the influential seniors’ lobby, estimates it would cost around $750 million to cover prescription-drug benefits to every American over 65. Without it, the group says, millions of elderly Americans will continue the dangerous practices they now use to stretch their medicine budgets: skipping doses, splitting pills and sharing medications with friends.

Some seniors go without pills entirely. In a 1995 survey, Medicare beneficiaries lacking drug coverage were less likely than those with drug coverage to fill prescriptions for anti-hypertensive medications needed to lower the risk of heart attack, heart failure, stroke and kidney failure. [38]

The average Medicare beneficiary with drug coverage fills 22 prescriptions per year, while those without it fill just 14. The ramifications are clear: Those in poor health take far fewer medications than their healthy counterparts. [39]

Price discrimination is not unique to the drug industry. Business travelers, for example, pay much higher airline fares than leisure travelers. In the pharmaceutical world, health maintenance organizations (HMOs) and benefits plan administrators negotiate price breaks.

HMOs and other “third-party” buyers account for more than 90 percent of all pharmaceutical sales. By purchasing large volumes of drugs, they can negotiate steep discounts, sometimes shaving 25 percent or more off the price of a drug. In addition, state prescription-drug assistance plans, programs sponsored by pharmaceutical companies and organizations like AARP offer discounts and other benefits to distinct populations. But uninsured consumers enjoy no such clout.

Meanwhile, average prescription-drug prices have doubled in the past decade. [40]Drug companies have resisted lowering prices, arguing that research, development and testing represent a huge investment, not to mention a high risk.

Clinical trials are more complex and costs have increased, noted an August 2001 Ernst & Young analysis for the Pharmaceutical Research and Manufacturers of America. One successful pill can represent 10-15 years and $802 million of research and development, as the medicine moves from the laboratory bench to the pharmacy shelf, says the analysis. Only three of 10 marketed drugs produce revenues that match or exceed average development costs.

However, rising drug prices could drive up the cost of an eventual Medicare drug benefit, making it impossible to calculate the long-term price tag for a new Medicare benefit. And once in place, such a benefit — despite its high cost or federal budget shortfalls — would be difficult to withdraw. Programs with such a large and influential constituency are not easily eliminated.

Thus, some policymakers have suggested imposing price controls on prescription drugs. The pharmaceutical industry opposes price controls, arguing they would have a chilling effect on the quest for cures and would impede free-market forces.

Adding a prescription-drug benefit to Medicare is widely viewed as in keeping with Medicare’s original intent of lessening the burden of health care for all seniors. Nevertheless, both supporters and opponents of Medicare benefits for prescription drugs lament that the nation’s biggest health problem — uninsured Americans — remains unaddressed.

“It’s really a shame the focus is so much on drugs for seniors,” says Chip Kahn, president of the Federation of American Hospitals, “when most of the uninsured are low-income working families. They’re the ones who are totally exposed.”

Should small businesses be allowed to band together to buy health insurance for their employees?

Ninety-nine percent of the nation’s big companies (those with more than 200 employees) offer tax-subsidized health benefits, which cost the average worker about $2,426 a year. Because large employers enjoy greater economies of scale and can pool their risk, their employees pay considerably less than if they purchased health insurance individually.

But small-business owners like John Nicholson, who operates a flower shop in Arlington, Va., have no such purchasing clout. Nicholson could not afford coverage for his 10 employees, and most insurers offered no policies appropriate for a small work force. Eventually, he signed up with a local HMO, paying $3,300 per worker. [41]

Soaring health-care costs hit small businesses harder than larger companies, and their premium rates are rising faster. But it’s not just a problem for employers. Since a large percentage of all employees work for small businesses, the lack of affordable health insurance among small businesses dramatically impacts the nation’s overall health-care costs. [42]In fact, a third of uninsured Americans work for employers that do not offer any health coverage, and 82 percent of the uninsured are members of families in which at least one person works part or full time. [43]

And the situation is getting worse: Small businesses’ cost of insuring employees is expected to jump as much as 20 percent this year — on top of a 10-12 percent increase over the last three years. In some parts of the country, the situation is even more severe. Annual premium increases for small-business owners in Florida were expected to go up 20-30 percent this year, according to the National Federation of Independent Businesses of Florida. [44]

After at least four years of aggressive lobbying for a change, small businesses and their employees may finally be close to having an alternative. Proposed patients’-rights legislation allows small employers to band together across state lines to buy health insurance, giving them greater power to bargain for prices and coverage. The legislation passed the House last August and is awaiting Senate action.

The proposed law would permit trade and professional organizations like the National Restaurant Association or the U.S. Chamber of Commerce to sponsor and negotiate not-for-profit health-care plans known as association health plans. In theory, efficiencies and savings would be passed along to employers and employees through lower premiums.

The measure faces formidable opposition in the Senate, which agreed to a patients’-rights bill — giving patients more of a voice in their treatment by HMOs — but excluded any provision for association health plans. Similar bills passed the House four times in recent years, only to languish in the Senate, where they couldn’t garner sufficient support because of pressure from the insurance industry.

This year, with intensifying pressure to tackle health costs, the tide finally may turn in the Senate. Association health plans are attractive to many, including President Bush, because — at least in theory — they promise to add working Americans to the ranks of the privately insured without spending a dime of public money.

“Before adding millions in new federal spending and more mandates, shouldn’t we look for free-market solutions that empower individuals?” Dan Danner, senior vice president of the National Federation of Small Business, asked the House in a letter a year ago. [45]

The Blue Cross and Blue Shield Association, the dominant small-business health insurer in at least half the states, opposes the measure. Danner told the House the group opposes it because “they’re against anything that forces them to compete for business.”

But Mary Nell Lehnhard, a Blue Cross senior vice president, called the current proposal for association plans “a shell game rather than a serious proposal for the uninsured.”

Because the House stipulated that the new plans should not be regulated by the states, they would provide only temporary savings and trigger a collapse of the state-regulated market, Lehnhard said, leading to a return to higher premiums and undoing years of reforms.

Pollack of Families USA said that without being subject to state rules, association plans could exclude mental health services or home health care and might engage in discriminatory underwriting. For example, he said, benefit packages could be designed to attract healthy people, while discouraging sick people from joining. As a result, Pollack says that while he supports businesses banding together to buy insurance, “the measure approved by the House could make the problems existing today even worse.”

The NGA supports the idea, but not the bill. State oversight is necessary, the governors say, “to protect consumers and small businesses from fraud and abuse and underinsurance.” [46]

But Kahn of the hospital federation counters, “Nothing that expands health coverage to more people will be ideal,” he says. “We’re not talking about Cadillacs here; we’re talking about Chevys, at best. But at least we’re talking about Chevys for people who now have no car at all.”

Just how many people would be newly insured? The Congressional Budget Office (CBO) foresees the innovation worsening conditions for four in five workers. It says 20 million employees would face increases in premiums, while insurance would be less expensive for 4.6 million. Meanwhile, only 330,000 of the uninsured would gain coverage, the CBO said.

But a public-policy research firm, CONSAD, estimates that the measure would extend benefits to 4.5 million workers at affordable rates. According to former Rep. Jim Talent, R-Mo., small businesses could save 10-20 percent in health-care costs.

The key, Talent said, lies in breaking the grip of the Blue Cross monopolies — and conventional wisdom. “Nobody questions that big businesses can offer comprehensive plans,” Talent said. “But for some reason, they seem to distrust small businesses.”

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Also in this issue of Congressional Quarterly Researcher:

Universal Health Insurance: Not a Cure-All

Recurring Quest for Health Reform: First Enthusiasm, Then Failure

Local Health Reform: How Tampa Does It?

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[1] Dawes’ plight is described in Trish Wilson, “Kids’ Insurance Needs CPR,” News and Observer, March 9, 2001, and Karen Tumulty, “Health Care Has a Relapse,” Time, March 11, 2002, p. 42.

[2] World Health Organization, “World Health Report,” 2000.

[3] “Health Insurance Coverage 2000,” U.S. Census Bureau, Sept. 28, 2001.

[4] Terminated workers can continue the same health coverage for 18 months under COBRA, the Consolidated Omnibus Budget Reconciliation Act of 1995, which became law in 1996.

[5] See Elizabeth Simpson, “State Reaches Out to Uninsured,” Virginian-Pilot/Ledger Star, March 7, 2002.

[6] Karen Davis, “Universal Coverage in the United States: Lessons from Experience of the 20th Century,” Journal of Urban Health: Bulletin of the New York Academy of Medicine 78 (March 2001), p. 46-58.

[7] Census Bureau, op. cit.

[8] John Holahan and Johnny Kim, “Why Does the Number of Uninsured Americans Continue to Grow?” Health Affairs, July/August 2000, pp. 188-196.

[9] Census Bureau, op. cit.

[10] Florida Chamber of Commerce Federation, Jan. 24, 2002.

[11] “Employer Health Benefits: 2001 Annual Survey,” Kaiser Family Foundation and Health Research and Educational Trust, September 2001.

[12] Jeanne Lambrew, “How the Slowing Economy Threatens Employer-Based Health Insurance,” Commonwealth Fund, November 2001. Paul Fronstin, “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2000 Current Population Survey,” Issue Brief No. 228, Employee Benefit Research Institute, 2000.

[13] Press conference, Coalition to Cover the Uninsured, Washington, D.C., Feb. 12, 2002.

[14] Mary Agnes Carey, “Analysts See a Seismic Shift in Health Policy Debate,” CQ Weekly, March 23, 2002.

[15] Ibid.

[16] In their biennial reports, the National Governors’ Association and National Association of State Budget Officers blamed the recession, fallout from the Sept. 11 terrorist attacks and Medicaid cost increases for creating a record $40 billion to $50 billion budget shortfall in more than 40 states in fiscal 2002. Meanwhile, 28 states had combined deficits of $7.1 billion in their Medicaid budgets.

[17] A federal judge in March 2002 allowed Maine to force pharmaceutical makers to provide discounts of up to 25 percent for those with incomes 300 percent of the poverty level. Under Maine’s law, the state would leverage its buying clout — $210 million in Medicaid drug purchases — to negotiate discounted prices for the 325,000 residents who lack health insurance and are not covered by Medicaid. If the drug makers refuse, the state could impose price caps in 2003. The industry is appealing the decision in Pharmaceutical Research and Manufacturers of America v. Commissioner, Maine Department of Human Services. The 1st U.S. Circuit Court of Appeals in Boston is considering the earlier ruling by U.S. District Judge D. Brock Hornby.

[18] “Care Without Coverage: Too Little Too Late,” Institute of Medicine, National Academy of Sciences, May 2002.

[19] Paul W. Newacheck, “Health Insurance Access to Primary Care for Children,” The New England Journal of Medicine, May 15, 2000, pp. 513-519.

[20] Quoted in Vicki Kemper, “Unlikely Coalition Declares Health Care Crisis,” Los Angeles Times, Feb. 13, 2002, p. A30.

[21] North Carolina Health Access Coalition newsletter, op. cit.

[22] The coalition also includes the American Medical Association, Service Employees International Union, Business Roundtable, American Nurses Association, Health Insurance Association of America, Families USA, American Hospital Association, Federation of American Hospitals, Catholic Health Association, AARP and the Robert Wood Johnson Foundation.

[23] From a September 2001 survey for the Institute for Legal Reform and the U.S. Chamber of Commerce.

[24] Speech at the Medical College of Wisconsin in Milwaukee, Feb. 25, 2002.

[25] For background, see Adriel Bettelheim, “Drugmakers Under Siege,” The CQ Researcher, Sept. 3, 1999, pp. 753-776, and Julie Rovner, “Prescription Drug Prices,” The CQ Researcher, July 17, 1992, pp. 597-620.

[26] Tumulty, op. cit.

[27] Jacob Hacker, “Health Care Reform: A Century of Defeat,” Harvard Health Policy Review, fall 2000.

[28] Carey, op. cit.

[29] Quoted in David Wessel, “After a Few Years of Relaxation, Health-Care Costs Rise Again,” The Wall Street Journal, May 9, 2002.

[30] Quoted in Bob Condor, “Look Beyond Politics Before Writing Off the Faith-Based Initiative,” Chicago Tribune, March 18, 2001, p. C3.

[31] For background, see Adriel Bettelheim, “Hospitals’ Financial Woes,” The CQ Researcher, Aug. 13, 1999, pp. 689-704.

[32] The amount depends largely on the breadth of benefits that would be offered, he says.

[33] Cited in testimony by Mary R. Grealy, president, Healthcare Leadership Council, House Energy and Commerce Subcommittee on Health, Feb. 28, 2002. HLC members include CEOs of pharmaceutical companies and major hospitals and clinics.

[34] California Medical Association figures, as of November 2001, cited by Norman Label, president, Emergency Physicians Medical Group, writing in the Sacramento, Calif., Business Journal, Feb. 1, 2002.

[35] “Emergency Crews Worry as Hospitals Say ‘No Vacancy,’ ” The New York Times, Dec. 17, 2000. See also “Trouble in the ER,” National Journal, May 19, 2001.

[36] “Emergency Department Overload: A Growing Crisis,” The Lewin Group for the American Hospital Association, April 2002.

[37] Robert W. Derlet and John R. Richards, “Overcrowding in the nation’s emergency departments: Complex causes and disturbing effects,” Annals of Emergency Medicine, January 2000, pp. 63-68.

[38] Jan Blustein, “Drug Coverage and Drug Purchases by Medicare Beneficiaries with Hypertension,” Health Affairs, March/April 2000, pp. 219-230.

[39] J.A. Poisal and L. Murray, “Growing Differences Between Medicare Beneficiaries With and Without Drug Coverage,” Health Affairs, March/April 2001, pp. 74-85.

[40] AARP Bulletin, March 2002.

[41] See J. Gabel et al, “Class and Benefits at the Workplace,” Health Affairs, May/June 1999, pp. 144-150.

[42] Small Business Administration, advo/stats/sbfaq.txt

[43] Catherine Hoffman and Mary Pohl, Health Insurance Coverage in America: 1999 Data Update, Kaiser Commission on Medicaid and the Uninsured, 2000.

[44] National Federation of Independent Business (nationwide data); for Florida, “Florida’s Small Businesses Struggle with Rapidly Rising Health Insurance Costs,” Florida Times-Union, April 8, 2002.

[45] Letter to House of Representatives, March 2001.

[46] National Governors’ Association, position paper.

The CQ Researcher • June 14, 2002 • VOLUME 12, No. 23
© 2002 Congressional Quarterly, Inc. All rights reserved.