THE COMMONWEALTH FUND Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 2005. * Estimate is statistically different from the previous year.

THE

COMMONWEALTH FUND

Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 2005.* Estimate is statistically different from the previous year shown at p<0.05.^ Estimate is statistically different from the previous year shown at p<0.1.Note: Data on premium increases reflect the cost of health insurance premiums for a family of four. Historical estimates of workers’ earnings have been updated to reflect new industry classifications (NAICS).

12.0

18.0

0.8

13.9^

12.9*10.9*

8.2*

5.3*

11.2*

8.5 9.2*

0

5

10

15

20 Health insurance premiums

Workers earnings

Overall inflation

Figure 1. Increases in Health Insurance Premiums Compared with Other Indicators, 1988–2005

Percent

THE

COMMONWEALTH FUND

Figure 2. Deductibles Rise Sharply,Especially in Small Firms, Over 2000–2005*

* Out-of-network deductibles are for 2000 and 2004.Source: J. Gabel and J. Pickreign, Risky Business: When Mom and Pop Buy Health Insurance for Their Employees (Commonwealth Fund, Apr. 2004); KFF/HRET Employer Health Benefits 2005 Annual Survey.

210

383

157

319

469

676

254

510

$0

$150

$300

$450

$600

$750

$9002000 2005

In-network Out-of-networkOut-of-network In-network

Small firms(3–199 employees)

Large firms(200+ employees)

PPO in-network and out-of-network deductibles

THE

COMMONWEALTH FUND

606366666869

0

25

50

75

2000 2001 2002 2003 2004 2005

Figure 3. Percent of Firms Offering Health Benefits Declined Over 2000–2005

Source: KFF/HRET Employer Health Benefits 2005 Annual Survey.

Percent of firms offering health benefits

THE

COMMONWEALTH FUND

Figure 4. 47 Million Uninsured in 2005; Increasing Steadily Since 2000

Number of uninsured, in millions

31 33 33 35 3539 40 40 41 42 43 44

40 40 4144

56

474645

0

20

40

60

1987 1990 1993 1996 1999* 2002 2005 2008 2011

Projected

2013

*1999–2003 estimates reflect the results of follow-up verification questionsand implementation of Census 2000-based population controls.Note: Projected estimates for 2006–2013 are for nonelderly uninsured based onT. Gilmer and R. Kronick, “It’s the Premiums, Stupid: Projections of the UninsuredThrough 2013,” Health Affairs Web Exclusive, Apr. 5, 2005.Source: U.S. Census Bureau, March CPS Surveys 1988 to 2005.

THE

COMMONWEALTH FUND

0

1000

2000

3000

4000

5000

6000

0 100 200 300 400 500 600 700 800 900

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.

a 2002

Out-of-pocket health care spending per capita (US$)

National health expenditures per capita (US$)

United States

Australia

OECD Median

Canada

Japana

New Zealand

GermanyFranceNetherlands

Figure 5. Americans Spend More Out-of-Pocket on Health Care Expenses

THE COMMONWEALTH

FUND

Figure 6. Americans Are Spending More Out-of-Pocket for Health Care

0

100

200

300

400

500

600

700

800

900

Source: C. Smith et al., “National Health Spending in 2004: Recent Slowdown Led by Prescription Drug Spending,” Health Affairs 25, no. 1 (Jan./Feb. 2006); Centers for Medicare and Medicaid Services, National Health Expenditures Data; http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf

Dollars spent per capita (in 2004 dollars)

$577 $583

$774

$667

$788

THE

COMMONWEALTH FUND

Figure 7. Adults with Individual CoverageAre More Likely to Spend $5,000 or More Annually

on Personal Out-of-Pocket Expenses

4 3

8

332727

0

25

50

75

Total ESI Individual

Annual out-of-pocket costs $5,000 or more

Annual out-of-pocket costs $1,000–$4,999

ESI = employer-sponsored insurance.

Source: S.R. Collins, J.L. Kriss et al., Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families, The Commonwealth Fund, Sept. 2006.

31 30

41

Percent of adults ages 19–64 insured all year with private insurance

THE

COMMONWEALTH FUND

Figure 8. Adults with Higher DeductiblesAre More Likely to Spend $1,000 or More

on Personal Out-of-Pocket Expenses

27 2535 42

4 2

5

13

0

25

50

75

100

Total <$500 $500–$999 $1,000+

Annual out-of-pocket costs $5,000 or more

Annual out-of-pocket costs $1,000–$4,999

Annual deductible

31 27

40

55



THE

COMMONWEALTH FUND

Figure 9. One-Quarter of Adults Spent 10 Percentor More of Their Household Income Annually on Family

Out-of-Pocket Expenses and Premiums

40 38

65

25 24

43

0

25

50

75

100

Total ESI Individual

Spent 5% or more of income on out-of-pocket costs



ESI = employer-sponsored insurance.


THE

COMMONWEALTH FUND

Figure 10. Adults with Higher Deductibles Are More Likely to Spend a Greater Share of Household Income on Family

Out-of-Pocket Expenses and Premiums

4036

55

67

25 22

3643

0

25

50

75

100

Total <$500 $500–$999 $1,000+



Annual deductible



THE

COMMONWEALTH FUND

Figure 11. Low-Income Households at Most Riskfor Spending Greater Shares of Income on

Family Out-of-Pocket Expenses and Premiums

40

5761

3730

25

42 40

21 18

0

25

50

75

Total <$20,000 $20,000–

$39,999

$40,000–

$59,999

$60,000+



Annual income



THE

COMMONWEALTH FUND

Figure 12. Adults with High DeductiblesAre More Likely to Avoid Needed Health Care Because of

Cost

168 11 12

2522

1217 19

3127

1926 24

44

0

25

50

75

Did not fill a

prescription

Did not see

specialist when

needed

Skipped

recommended

test, treatment,

or follow-up

Had medical

problem, did not

see doctor or

clinic

Any of the four

access

problems

<$500 $500–$999 $1,000+



THE COMMONWEALTH

FUND

Figure 13. Cost-Sharing Reduces Use of Both Essential and Less Essential Drugs and Increases

Risk of Adverse Events

9

1514

22

0

5

10

15

20

25

Essential Less Essential

Elderly Low Income

Source: R. Tamblyn et al., “Adverse Events Associated with Prescription Drug Cost-SharingAmong Poor and Elderly Persons,” JAMA, Jan. 24/31, 2001 285(4):421–29.

Percent reduction in drugs per day

117

43

9778

0

20

40

60

80

100

120

140

Adverse Events ED V is its

E lderly Low Inc ome

Percent increase in incidence per 10,000

THE

COMMONWEALTH FUND

Figure 14. Adults with High DeductiblesHave Problems Paying Medical Bills

or Are Paying Off Medical Debt

148 6

172323

913

2735

20

5

17

31

41

0

25

50

75

Not able to pay

medical bills

Contacted by

collection

agency*

Had to change

way of life to

pay medical

bills

Medical bills/

debt being paid

off over time

Any medical bill

problem or

outstanding

debt

<$500 $500–$999 $1,000+


* Includes only those individuals who had a bill sentto a collection agency when they were unable to pay it.Source: S.R. Collins, J.L. Kriss et al., Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families, The Commonwealth Fund, Sept. 2006.

THE

COMMONWEALTH FUND

Figure 15. Increased Health Care Costs Have Reduced Savings

Has increased spending on health care expenses in the past year caused you to do any of the following? Among those with health insurance coverage who had increases in health care costs in the last year (n=731) (percentage saying yes)

45%

34%

29%

26%

24%

18%

Decrease your contributions to a retirement plan, such as a 401(k),

403(b) or 457 plan, or an IRA

Have difficulty paying for other bills

Decrease your contributions to other savings

Use up all or most of your savings

Borrow money

Have difficulty paying for basic necessities, like food, heat, and housing

Source: EBRI Health Confidence Survey, 2005.

THE COMMONWEALTH

FUND

Figure 16. Few Insured People Are Currently Covered by High-Deductible Health Plans (HDHP) or Consumer-

Directed Health Plans (CDHP) with a Savings Account

HDHP

9%

CDHP

1%

Comprehensive

89%

Note: Comprehensive = plan w/ no deductible or <$1000 (ind), <$2000 (fam);HDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), no account;CDHP = plan w/ deductible $1000+ (ind), $2000+ (fam), w/ account.

Source: P. Fronstin, S.R. Collins, Early Experience with High-Deductible and Consumer-DrivenHealth Plans: Findings From the EBRI/Commonwealth Fund Consumerism in Health Care Survey, EBRI Issue Brief, Dec. 2005.

THE COMMONWEALTH

FUND

Figure 17. FEHBP HDHP/HSA Plans Enroll7,500 Out of 9 Million Covered Lives

6.4

0.10

5

10

Percent of FEHBP plans that

are HDHP/HSAs

Percent of FEHBP enrollees

that are in HDHP/HSAs

Note: As of March 2005.Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC: GAO, Jan. 2006; OPM, http://www.opm.gov/insure/handbook/FEHBhandbook.pdf

Percent

THE COMMONWEALTH

FUND

Figure 18. Enrollees Who Chose HDHPs fromthe Federal Employees Health Benefits Program Are

More Likely to Earn Higher Incomes

43

23

0

25

50

75

HDHP All FEHBP plans

Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC: GAO, Jan. 2006.

Percent of FEHBP enrollees with incomes > $75,000

THE COMMONWEALTH

FUND

Figure 19. Age Distribution of HDHPand Other FEHBP Enrollees

0

5

10

15

20

25

30

35

<23 23–34 35–44 45–54 55–64 65–74 75–99 >99

HDHP enrollees All FEHBP enrollees

Source: Government Accountability Office, Federal Employees Health Benefits Program First-Year Experience with High-Deductible Health Plans and Health Savings Accounts, Washington, DC: GAO, Jan. 2006.

Percent FEHBP enrollees

THE COMMONWEALTH

FUND

Figure 20. Less than Half of ThoseEnrolled in Employer-Based High-Deductible Health

Plans Had a Choice

58

47 45

0

25

50

75

Traditional(n=1016)

CDHP HDHP

Percent of adults with employer-based coverage who were offered a choice of health plans

• CDHP and HDHP owners are less likely to have a choice of plans from their employer

• When they have a choice, the savings account is the leading reason for choosing CDHP, while premium cost is the most frequent reason for choosing HDHP. Traditional plans are chosen for low out-of-pocket costs.(n=134) (n=334)

Source: P. Fronstin, S.R. Collins, Early Experience with High-Deductible and Consumer-Driven Health Plans: Findings From the EBRI/Commonwealth Fund Consumerism in Health Care Survey, EBRI Issue Brief, Dec. 2005.

THE COMMONWEALTH

FUND

Figure 21. Enrollees of HDHP/CDHPsAre Less Satisfied with Their Coverage

8

28

63

29

3933 32

26

42

0

25

50

75

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied

Comprehensive HDHP CDHP

Percent

*

**

**

* Difference between HDHP/CDHP and Comprehensive is statistically significant at p < 0.05 or better.


THE COMMONWEALTH

FUND

Figure 22. Enrollees of HDHP/CDHPsAre Less Satisfied with Out-of-Pocket Costs

21

3642

31

12

57

1828

54

0

25

50

75

Extremely or very

satisfied

Somewhat

satisfied

Not satisfied




Percent

* *

**

*

THE COMMONWEALTH

FUND

Figure 23. Enrollees of HDHP/CDHPs Are Less Likely to Stay with Their Current Health Plan If They Had the

Opportunity to Change

11

28

61

33*37*

30*

21

33*

46*

0

25

50

75

Extremely or very

likely to stay

Somewhat likely to

stay

Not likely to stay




Percent of adults 21–64

THE COMMONWEALTH

FUND

Figure 24. Enrollees of HDHP/CDHPs Are Less Likely to Recommend Their Plan to a Friend or Coworker

2426

5143*

34*

22*31 35*34*

0

25

50

75

Extremely or very

likely

Somewhat likely Not likely





THE COMMONWEALTH

FUND

Figure 25. Employers’ Contributions Lower for Workers in HSA-Qualified HDHPs; Employees’ Premiums and

Deductibles Higher

431 610

2270

3413

1348323

553

0

1000

2000

3000

4000Deductible contributionPremium contribution

^ “All plans” refers to all conventional HMOs, PPOs, and POS plans in the survey,not just HDHP/HRA or HSA-qualified HDHPs.Source: Calculated based on G. Claxton et al., “What High Deductible Health Plans Look Like: Findings from a National Survey of Employers, 2005,” Health Affairs Web Exclusive, Sept., 14, 2005; J. Gabel et al., “Health Benefits in 2005: Premium Increases Slow Down, Coverage Continues to Erode,” Health Affairs, Sept./Oct. 2004.

All plans^

All plans^

$1,779

$933

$2,823

Dollars

$3,413

Worker contribution Employer contribution

HSA-qualified

HDHP

HSA-qualified

HDHP

THE COMMONWEALTH

FUND

Figure 26. Enrollees of HDHP/CDHPs Spend Higher Percent of Income on Out-of-Pocket Medical Expenses and

Premiums

9 132529

35

58

23 26

44

0

20

40

60

80

100

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

ComprehensiveHDHP

CDHP

10%+ of income 5–9% of income

Percent of adults 21–64 spending > 5% of income

Total Health problem<$50,000

Annual income

12

4231

17

3834

92

66

53

13* 9* 18* 12* 1033* 21

3 4

(n = 61)

(n = 90)



**

*

*

*

**

**

*

*

THE COMMONWEALTH

FUND

Figure 27. Enrollees of HDHP/CDHPs AreMore Likely to Delay or Avoid Getting Health Care When

Sick Due to Cost

2621

17

42

313135

48

40

0

25

50

75

Total Health Problem <$50,000 Annual

Income



(n = 61)

(n = 90)



*

*

*

**

*

THE COMMONWEALTH

FUND

Figure 28. Enrollees of HDHP/CDHPs Are More Likely To Skip Doses to Make Medications Last

32

20 212015

35

26 2829

0

20

40

60

Total Health Problem** <$50,000 Annual

Income


* Difference between HDHP/CDHP and Comprehensive is statistically significant at p < 0.05 or better.** Health problem defined as fair or poor health or one of eight chronic health conditions.Source: P. Fronstin, S.R. Collins, Early Experience with High-Deductible and Consumer-Driven Health Plans: Findings From the EBRI/Commonwealth Fund Consumerism in Health Care Survey, EBRI Issue Brief, Dec. 2005.

Percent of adults 21–64 with prescriptions in last 12 months

(n = 50)(n = 85)**

THE COMMONWEALTH

FUND

Figure 29. Enrollees of HDHP/CDHPs Are More Likely to Not Fill a Prescription Due to Cost

2027

2116

323326

2526

0

25

50

75

Total Health Problem <$50,000 Annual

Income



(n = 61)(n = 90)

**



THE COMMONWEALTH

FUND

Figure 30. Most Insured Do Not Have Quality and Cost Information to Make Informed Choices

Comprehensive HDHP/CDHPHealth plan provides information on quality of care provided by:

Doctors 14% 16%

Hospitals 14 15

Health plan provides information on cost of care provided by:

Doctors 16 12

Hospitals 15 12

Of those whose plans provide info on quality, how many tried to use it for:

Doctors 42 54

Hospitals 25 45

Of those whose plans provide info on cost, how many tried to use it for:

Doctors 15 36 (n = 76)

Hospitals 14 32 (n = 76)


THE COMMONWEALTH

FUND

Figure 31. Cost Conscious Decision-Making,by Insurance Source

27

43

49

19

32*

44*

55*

60*

14

23

0 25 50 75

Checked quality rating ofdoctor or hospital

Checked price of service

Asked doctor torecommend less costly

prescription drugs

Talked to doctor abouttreatment options & costs

Checked whether planwould cover care

Comprehensive

HDHP/CDHP



Percent of adults 21–64 who received health care in last 12 months

THE COMMONWEALTH

FUND

Figure 32. HSAs Won’t Solve the Cost Problem:Most Costs Are Concentrated in the Very Sick

0%

10%

20%30%

40%

50%

60%

70%80%

90%

100%

U.S. Population Health Expenditures

1%5%

10%

55%

69%

27%

Source: A.C. Monheit, “Persistence in Health Expenditures in the Short Run: Prevalence and Consequences,” Medical Care 41, supplement 7 (2003):III53–III64.

Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 1997

50%

97%

$27,914

$7,995

$4,115

$351

Expenditurethreshold (1997 dollars)

THE COMMONWEALTH

FUND

Figure 33. Uninsured Rates High Among Adults with Low and Moderate Incomes, 2001–2005

15 17 18

33 37 37

1724 28

9

9 9 9

1615 16

1111

13

9

6 7

97

3 320

25

50

75 Insured now, time uninsured in past year

Uninsured now

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, 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. Source: S.R. Collins et al., Gaps in Health Insurance Coverage: An All-American Problem—Findings from the Commonwealth Fund Biennial Health Insurance Survey, The Commonwealth Fund, Apr. 2006.

26

52

35

16

4

24

49

28

13

4

Total Lowincome

Moderate income

Middle income

Highincome

2001 2003 2005 2001 2003 20052001 2003 20052001 2003 20052001 2003 2005

28

53

41

18

7

THE COMMONWEALTH

FUND

Figure 34. Distribution of Uninsured Young Adults 19–29 by Poverty Status, 2004

Source: S.R. Collins, C. Schoen, J.L. Kriss et al., Rite of Passage? Why Young Adults Become Uninsured and How New Policies Can Help, The Commonwealth Fund, updated May 2006.

Less than 100% FPL

40%

100%–199% FPL

29%

200% FPL or more

31%

THE COMMONWEALTH

FUND

Figure 35. HSAs Won’t Solve the Uninsured Problem: Income Tax Distribution of Uninsured

55% (0% tax bracket)




1% (30%–39%

tax bracket)

Source: S.A. Glied, The Effect of Health Savings Accounts on Health Insurance Coverage,The Commonwealth Fund, Apr. 2005.

THE

COMMONWEALTH FUND

Adults ages 19–64 with individual coverage or who thought about or tried to buyit in past three years who: Total

Health problem

No health

problem<200% poverty

200%+ poverty

Found it very difficult or impossible to find coverage they needed

34% 48% 24% 43% 29%

Found it very difficult or impossible to find affordable coverage

58 71 48 72 50

Were turned down or charged a higher price because of a pre-existing condition

21 33 12 26 18

Never bought a plan 89 92 86 93 86

Figure 36. Individual Market Is Not anAffordable Option for Many People


THE

COMMONWEALTH FUND

Figure 37. Lacking Health Insurance for Any Period Undermines Quality and Efficiency

59

35

58

2718 16

0

25

50

75

Skipped doses or did not fill

prescription for chronic condition

because of cost

Visited ER, hospital, or both for

chronic condition

Uninsured now Insured now, time uninsured in past year Insured all year

Percent of adults ages 19–64 with at least one chronic condition*

* Hypertension, high blood pressure, or stroke; heart attack or heart disease;diabetes; asthma, emphysema, or lung disease. Source: S.R. Collins et al., Gaps in Health Insurance Coverage: An All-American Problem—Findings from the Commonwealth Fund Biennial Health Insurance Survey,The Commonwealth Fund, Apr. 2006.

THE

COMMONWEALTH FUND

15 1019

3026

41

1923

0

25

50

75

Test results or

records not

available at time of

appointment

Duplicate tests

ordered

Never received

lab/diagnostic test

results or delay in

receiving abnormal

results

Any lab test/

record problem

Insured all year Uninsured during the year

Figure 38. Adults Without Insurance Have More Problems With Lab Tests and Records

Source: S.R. Collins et al., Gaps in Health Insurance Coverage: An All-American Problem—Findings from the Commonwealth Fund Biennial Health Insurance Survey,The Commonwealth Fund, Apr. 2006.

Percent of adults ages 19–64 reporting the following problems in past two years:

THE COMMONWEALTH FUND Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 2005. * Estimate is statistically different from the previous year.

Documents

kffhret survey of employer

commonwealth fund source

sponsored health benefits

previous year

income totalhealth problem