Jobs without benefits: the health insurance crisis faced by small businesses and their workers.

The share of U.S. workers in small firms who were offered, eligible for, and covered by health insurance through their jobs has declined over the past decade. Less than half of workers in companies with fewer than 50 employees were both offered and eligible for health insurance through their jobs in 2010, down from 58 percent in 2003. In contrast, about 90 percent of workers in companies with 100 or more employees were offered and eligible for their employer's health plans in both 2003 and 2010. Workers in the smallest firms--and those with the lowest wages--continue to be less likely to get coverage from their employers and more likely to be uninsured than workers in larger firms or with higher wages. The Affordable Care Act includes new subsidies that will lower the cost of health insurance for small businesses and workers who must purchase coverage on their own.

Medicare beneficiaries less likely to experience cost- and access-related problems than adults with private coverage.

The experiences of people covered by Medicare and those with private employer insurance can help inform policy debates over the federal budget deficit, Medicare's affordability, and the expansion of private health insurance under the Affordable Care Act. This article provides evidence that people with employer-sponsored coverage were more likely than Medicare beneficiaries to forgo needed care, experience access problems due to cost, encounter medical bill problems, and be less satisfied with their coverage. Within the subset of beneficiaries who are age sixty-five or older, those enrolled in the private Medicare Advantage program were less likely than those in traditional Medicare to have premiums and out-of-pocket costs exceed 10 percent of their income. But they were also more likely than those in traditional Medicare to rate their insurance poorly and to report cost-related access problems. These results suggest that policy options to shift Medicare beneficiaries into private insurance would need to be attentive to potentially negative insurance experiences, problems obtaining needed care, and difficulties paying medical bills.

How the Affordable Care Act will strengthen the nation's primary care foundation.

As the country turns toward implementation of the Patient Protection and Affordable Care Act, realizing the potential of reform will require significant transformation of the American system of health care delivery. To that end, the new law seeks to strengthen the nation's primary care foundation through enhanced reimbursement rates for providers and the use of innovative delivery models such as patient-centered medical homes. Evidence suggests that these strategies can return substantial benefits to both patients and providers by increasing access to primary care services, reducing administrative hassles and burdens, and facilitating coordination across the continuum of care. If successfully implemented, the Affordable Care Act has the potential to realign incentives within the health system and create opportunities for providers to be rewarded for delivering high value, patient-centered primary care. Such a transformation could lead to better outcomes for patients, increase job satisfaction among physicians and encourage more sustainable levels of health spending for the nation.

A call for change: the 2011 Commonwealth Fund Survey of Public Views of the U.S. Health System.

More than seven of 10 adults believe the U.S. health system needs fundamental change or complete rebuilding. Most adults surveyed reported difficulties accessing care, poor care coordination, and struggles with the costs and administrative hassles of health insurance. In addition, the survey finds substantial evidence of inefficient and wasteful delivery of health services. When looking toward the future, nearly three of four adults worry about getting high-quality care or paying medical bills. Respondents favor policies that encourage more patient-centered and integrated care, and nearly nine of 10 think it is important for private and public payers to work together to negotiate prices and improve quality. These experiences attest to the value of reforms aimed at stimulating and supporting the spread of more patient-centered, accountable care organizations. To the extent reforms succeed, patients and their families stand to gain from more accessible, safer, responsive, and less wasteful care.

State trends in premiums and deductibles, 2003-2009: how building on the Affordable Care Act will help stem the tide of rising costs and eroding benefits.

Rapidly rising health insurance costs have strained U.S. families and employers in recent years. This issue brief examines data for all states on changes in private employer premiums and deductibles for 2003 and 2009. The analysis finds that premiums for businesses and their employees increased 41 percent across states from 2003 to 2009, while per-person deductibles jumped 77 percent in large as well as small firms. If these trends continue at the rate prior to enactment of the Affordable Care Act, the average premium for family coverage will rise 79 percent by 2020, to more than $23,000. The authors describe how health reform offers the potential to reduce insurance cost growth while improving value and protection. If reforms succeed in slowing premium growth by 1 percentage point annually in all states, by 2020 employers and families together will save $2,323 annually for family coverage, compared with projected trends.

Small businesses and the Affordable Care Act of 2010.

The Patient Protection and Affordable Care Act (ACA) includes several short- and long-term provisions designed to help small businesses pay for and maintain health insurance for their workers, and to allow workers without employer coverage to gain access to affordable, comprehensive health insurance. Provisions include a small business tax credit to offset premium costs for firms that offer coverage starting this taxable year, establishment of state-based insurance exchanges that promise to lower administrative costs and pool risk more broadly, and creation of new market rules and an essential benefit standard to protect small firms and their workers. Analysis shows that up to 16.6 million workers are in firms that would be eligible for the tax credit in 2010 to 2013. Over the next 10 years, small businesses and organizations could receive an estimated $40 billion in federal support through the premium credit program.

Innovation in Medicare and Medicaid will be central to health reform's success.

The health reform legislation signed into law by President Barack Obama contains numerous payment reform provisions designed to fundamentally transform the nation's health care system. Perhaps the most noteworthy of these is the establishment of a Center for Medicare and Medicaid Innovation within the Centers for Medicare and Medicaid Services. This paper presents recommendations that would maximize the new center's effectiveness in promoting reforms that can improve the quality and value of care in Medicare, Medicaid, and the Children's Health Insurance Program, while helping achieve health reform's goals of more efficient, coordinated, and effective care.

The impact of health reform on health system spending.

The health reform legislation passed in March 2010 will introduce a range of payment and delivery system changes designed to achieve a significant slowing of health care cost growth. Most assessments of the new reform law have focused only on the federal budgetary impact. This updated analysis projects the effect of national reform on total national health expenditures and the insurance premiums that American families would likely pay. We estimate that, on net, the combination of provisions in the new law will reduce health care spending by $590 billion over 2010-2019 and lower premiums by nearly $2,000 per family. Moreover, the annual growth rate in national health expenditures could be slowed from 6.3 percent to 5.7 percent.

How health reform legislation will affect Medicare beneficiaries.

Despite criticism that health reform legislation will result in cuts to Medicare, the bills passed by the House of Representatives and the Senate, as well as President Obama's proposal, contain provisions that would strengthen the program by reducing costs for prescription drugs, expanding coverage for preventive care, providing more help for low-income beneficiaries, and supporting accessible, coordinated, and comprehensive care that effectively responds to patients' needs. The legislation also would help to extend the program's fiscal solvency--for nine years, under the Senate bill. This issue brief examines the provisions in the pending legislation and how each one would work to improve benefits, extend the fiscal solvency of the Medicare Hospital Insurance Trust Fund, reduce pressure on the federal budget, and contribute to moving the health care system toward better access to care, improved quality, and greater efficiency.

Meeting enrollees' needs: how do Medicare and employer coverage stack up?

One key issue in health reform concerns the relative roles of coverage offered through private insurance and public programs. This paper compares the experiences of aged Medicare beneficiaries with those of people under age sixty-five who have private employer coverage. Compared with the employer-coverage group, people in the Medicare group report fewer problems obtaining medical care, less financial hardship due to medical bills, and higher overall satisfaction with their coverage. Although access and bill payment problems increased across the board from 2001 to 2007, the gap between Medicare and private employer coverage widened.

Progressive or regressive? A second look at the tax exemption for employer-sponsored health insurance premiums.

The major argument for capping the exemption of health insurance benefits from income tax is that doing so will generate significant revenue that can be used to finance an expansion of health coverage. This analysis finds that given the state of insurance markets and current variations in premiums, limiting the current exemption could adversely affect individuals who are already at high risk of losing their health coverage. Evidence suggests that capping the exemption for employment-based health insurance could disproportionately affect workers in small firms, older workers, and wage-earners in industries with high expected claims costs. To avoid putting many families at increased health and financial risk, and to avoid undermining employer-sponsored group coverage, any consideration of a cap would have to be combined with coverage for all, changes in insurance market rules, and shared responsibility for financing.

Health information technology and physician perceptions of quality of care and satisfaction.

OBJECTIVE: To examine across seven countries the relationship between physician office information system capacity and the quality of care. DESIGN: Multivariate analysis of a cross-sectional 2006 random survey of primary care physicians in seven countries: Australia, Canada, Germany, the Netherlands, New Zealand, United Kingdom, and United States. MAIN OUTCOME MEASURES: coordination and safety of care, care for chronically ill patients, and satisfaction with practice of medicine. RESULTS: The study finds significant disparities in the quality of health care between practices with low information system capacity and those with high technical capacity after controlling for within country differences and practice size. There were significant physician satisfaction differences with the overall experience of practicing medicine by information system level. CONCLUSIONS: For policy leaders, the seven-nation survey suggests that health systems that promote information system infrastructure are better able to address coordination and safety issues, particularly for patients with multiple chronic conditions, as well as to maintain primary care physician workforce satisfaction.

Measuring and improving health system performance: what can healthcare management educators do?

Healthcare managers of the future will need to be prepared to accept greater accountability for the quality and efficiency of healthcare. National and state scorecards on health system performance indicate wide variation across the U.S. and across hospitals and health systems on key dimensions of performance including health outcomes, quality, access, equity, and efficiency. Benchmark data on achievable performance will be useful to healthcare managers in identifying best practices, setting priorities for improvement, and closing gaps in performance. Payment reforms are likely to reward healthcare organizations that serve as patient-centered medical homes, or assume accountability for total acute care, including hospital readmissions and post-hospital care. Health reforms to extend affordable health insurance to all, align financial incentives to enhance value and achieve savings, organize the healthcare system around the patient to ensure that care is accessible and coordinated, assist providers in meeting and raising benchmarks for high-quality, efficient care, and support greater public-private collaboration are needed to set the U.S. health system on a path to high performance.