The 'graying' of group health insurance.

We examine differential declines in private insurance by income and age. We show that older, higher-income people in working families are more likely to retain private coverage as premiums rise, and we project these effects on future coverage rates. The analysis suggests that trends are leading to the "graying" of the employment-based health insurance system, where older, higher-income people get private health insurance, and others increasingly have public coverage or go without. These changes raise questions about the private health care system's ability to pool health risks. Population aging could interact with rising premiums and place additional pressure on an already strained employment-based health insurance system.

Biotechnology and Medicare's new technology policy: lessons from three case studies.

Biotechnology has figured prominently in recent Medicare coverage and payment policies. Biotech treatments push policy boundaries for several reasons: They attract strong patient demand; they often treat rare or life-threatening diseases; they may have uncertain evidence of health benefits; and they are often costly. This paper considers case studies of Medicare coverage for off-label uses of biotech cancer drugs and payments for anemia biopharmaceuticals. The cases suggest Medicare's ongoing challenge to balance access considerations, the role and strength of evidence, and cost consequences of new treatments.

Increasing health insurance costs and the decline in insurance coverage.

OBJECTIVE: To determine the impact of rising health insurance premiums on coverage rates. DATA SOURCES & STUDY SETTING: Our analysis is based on two cohorts of nonelderly Americans residing in 64 large metropolitan statistical areas (MSAs) surveyed in the Current Population Survey in 1989-1991 and 1998-2000. Measures of premiums are based on data from the Health Insurance Association of America and the Kaiser Family Foundation/Health Research and Educational Trust Survey of Employer-Sponsored Health Benefits. STUDY DESIGN: Probit regression and instrumental variable techniques are used to estimate the association between rising local health insurance costs and the falling propensity for individuals to have any health insurance coverage, controlling for a rich array of economic, demographic, and policy covariates. PRINCIPAL FINDINGS: More than half of the decline in coverage rates experienced over the 1990s is attributable to the increase in health insurance premiums (2.0 percentage points of the 3.1 percentage point decline). Medicaid expansions led to a 1 percentage point increase in coverage. Changes in economic and demographic factors had little net effect. The number of people uninsured could increase by 1.9-6.3 million in the decade ending 2010 if real, per capita medical costs increase at a rate of 1-3 percentage points, holding all else constant. CONCLUSIONS: Initiatives aimed at reducing the number of uninsured must confront the growing pressure on coverage rates generated by rising costs.

Medicare's national coverage decisions, 1999-2003: quality of evidence and review times.

In 1998 Medicare amended its procedures for making national coverage decisions for new technologies in an attempt to make the process more transparent and evidence based. We examined the quality of evidence for sixty-nine technologies reviewed by Medicare since then. Determinations by the Centers for Medicare and Medicaid Services (CMS) have generally been consistent with the strength of evidence. Good clinical evidence from rigorous studies is usually lacking for the technologies Medicare considers, although in most cases the CMS covers with conditions if there is at least fair evidence that benefits outweigh harms. Decisions referred to the external Medicare Coverage Advisory Committee (MCAC) have averaged eight months longer than non-MCAC decisions.

What's driving health care costs?

This Issue Brief was prepared for The Commonwealth Fund/John F. Kennedy School of Government Bipartisan Congressional Health Policy Conference, January 15-17, 2004.

Paying for performance.

This Issue Brief was prepared for The Commonwealth Fund/John F. Kennedy School of Government Bipartisan Congressional Health Policy Conference, January 15-17, 2004.