Most of the newspaper coverage of the just-released Census Bureau data on health insurance coverage has focused changes in coverage between 2009 and 2010.  Since the advent of the Great Recession, the reduction in health insurance coverage has been dominated by the simple fact that as unemployment has risen, since most families with prime-age earners receive health insurance as a fringe benefit of employment, the number of uninsured has risen.  The increase was large from 2008 to 2009 when unemployment rose rapidly.  From 2009 to 2010, when unemployment stabilized at high levels, the increase was smaller, although still disturbingly large.

If one looks back a bit farther, however, some noteworthy differences by age group emerge, as shown in the table.  Health insurance coverage fell for all age groups but one from 2007 to 2010 and over the longer period starting with the boom year of 1999.  That coverage would have fallen in both periods is unsurprising because, as noted, health insurance for most people is linked to employment and unemployment rose over both of those periods.

The age group that stands as the major exception to this record of declining coverage is children through age 18.  That coverage for this group rose over both of those periods is striking.  Furthermore, although coverage of the elderly fell, the drop was minuscule.  What is going on?

The answer is that the safety net is working.  The proportion of young people insured privately declined as much as did that of older age groups, but total coverage of this age group not only was sustained but actually increased. The State Child Health Insurance program, enacted in 1997, has dramatically increased coverage for youngsters.  Medicaid expansions mostly enacted earlier have helped expand coverage among the young as their parents have lost coverage through work.

In combination, the number of children age 18 or younger with Medicaid coverage rose by 11.3 million since 1999 and by 5.1 million since 2007.  Without this expansion (and assuming no other offsets), the number of uninsured Americans would have been not 49.9 million, but more than 60 million.

These developments take on particular salience in light of the current debate about how best to control federal budget deficits.  If Congress, in the end, adheres to the principle, embodied in the August 2010 debt-ceiling legislation, that programs protecting the poor should be insulated from budget cuts, the gains in coverage among the young may be sustained, despite the erosion of employment-based coverage that has been going on for more than a decade.  If it abandons this principle, the increase in ‘health-insecurity’ would be large and deeply troubling.

The health coverage statistics also bear on the continuing debate about the future of the Affordable Care Act.  No one should exaggerate the influence of mere facts on a debate so driven by ideology as that over the Affordable Care Act, but the data on the erosion of employment-based coverage should not be ignored. Trends in employer-sponsored health insurance have long been a contest between two opposing forces: the belief among employers that group health insurance offered as a fringe benefit is a powerful incentive for attracting workers, especially when labor markets are tight, and the concern of employers that the need to boost premiums and cost sharing repeatedly drains management time and saps employee morale.

During the 1990s, the first of these forces was in the ascendant.  In the face of drum tight labor markets, increasing numbers of workers were offered health insurance as a fringe benefit and took up the offer.  Since 2000, two recessions have tipped the balance the other way. The 2010 survey data—and comparisons with past years shown in the table—suggest that, without the return of tight labor markets (and, perhaps even with them), employment-based health insurance is likely to continue to erode. Given the anemic character of the current economic recovery and the regrettable possibility of yet another downturn (particularly if Congress does not at least extend the current payroll tax holiday), overall health insurance coverage is likely to continue to narrow.

The only hope for extending health insurance currently on the horizon is implementation in 2014 of the requirement in the Affordable Care Act that individuals carry affordable insurance, the associated subsidies to make coverage affordable, and the expansion of Medicaid.  Without those measures, it is hard to avoid the conclusion that the absolute number of people and the proportion of the total population without health insurance is headed upward.

Without an economic recovery far more rapid than forecasters now anticipate, the Census Bureau reports on health insurance coverage are likely to be rather dismal over the next three years.  The 2011, 2012, and 2013 surveys—each reported in the succeeding year—are almost certain to show an increasing number of people and proportion of the total population without health insurance.  Nor is there any reason now on the horizon why the growth of health care spending is likely to slow.

For all its flaws, the Affordable Care Act is currently the only instrument around that holds any realistic prospect for dealing simultaneously with the twin problems of ‘cost’ and ‘access.’  It will take the 2012 elections to resolve the current dispute over whether the ACA is to remain law.  If the ACA remains law, one hopes that the 2012 election will also result in sufficient collaboration to fix its shortcomings and to implement it effectively.

Henry Aaron is a Bruce and Virginia MacLaury Senior Fellow in the Economic Studies program at the Brookings Institution. He focuses on health care finance reform and writes at Brookings where this post first appeared.

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15 Responses for “The Safety Net Is Working”

  1. nate ogden says:

    Couple corrections for the academic who doesn’t work in the industry and thus doesn’t know the facts on the ground as they say.

    “The only hope for extending health insurance currently on the horizon is implementation in 2014 of the requirement in the Affordable Care Act that individuals carry affordable insurance, the associated subsidies to make coverage affordable, and the expansion of Medicaid. ”

    This is incorrect, a far more immediate and sure way to extend health insurance would be the repeal of ACA. The cost increasing provisions of ACA alone has caused many people to lose insurance. The uncertainty of the cost of future aspects of ACA is also costing many people the chance to be insured.

    Absent from this academic analysis of the cause for increase uninsured is the number one reason people don’t have insurance, cost. One of the largest drivers of cost is government and government regulation specifically. The tightness of the labor market has far less to do with the number of uninsured compared to the cost of insurance for business. Lower the cost of insurance and millions more will be insured, no matter the labor market.

    • steve says:

      ” One of the largest drivers of cost is government and government regulation specifically.”

      Government insurance is cheaper. If we paid Medicare rates for all procedures, we would be paying about the same rates as in Europe. Let Medicare ration as much as the private insurers, and we see corresponding total decreases in costs.

      “This is incorrect, a far more immediate and sure way to extend health insurance would be the repeal of ACA.”

      We have gone many decades w/o the ACA. We did not see large scale increases in the number insured except when labor markets were tight.

      “The uncertainty of the cost of future aspects of ACA is also costing many people the chance to be insured.”

      Most people dont run a corporation. I do. Without the ACA I have faced yearly changes of anywhere between 5% and 42%. There has not been any certainty in health care costs for very many years.

      Steve

      • nate ogden says:

        “Government insurance is cheaper.”

        Can you provide any examples of this? Government reimbursements are cheaper but that is not insurance. Government waste is far worse which offsets any reductions in payments to providers.

        “Let Medicare ration as much as the private insurers,”

        Medicare already rations more then private insurance, they deny far more claims and don’t cover nearly as many benefits.

        “We have gone many decades w/o the ACA.”

        We haven’t gone any decades without major healthcare reform driving up cost and driving down the number of insured.

        Medicare, COBRA, HIPAA, Small group reform, Medicare secondary payor, etc etc

        Has your 42% ever equaled $2000 fine per employee? You also have always had the ability to cut benefits, charge employees more, or raise the deductible to anything you want. As a business you had control over what you spent. 2014 you can’t do any of that. If you pass on to much cost, raise the deductible to high, or make any other normal changes your not affordable or not credible and your subject to fees of $2000+ per employee.

        • steve says:

          “Can you provide any examples of this? Government reimbursements are cheaper but that is not insurance. Government waste is far worse which offsets any reductions in payments to providers.”

          They cover different populations. Cost per procedure is the purest comparison. If the Medicare age gets raised to 67, we can make a better comparison.

          “Medicare already rations more then private insurance, they deny far more claims and don’t cover nearly as many benefits.”

          Private insurers limit access to drugs. Medicare is not allowed to do that. I have overseen billing for my corporation for almost 20 years. I have never had Medicare deny payment. I have had private insurers deny payment many times. More commonly, they used to deny clean claims hoping we would neglect to resubmit.

          What does Medicare not pay for that is covered by private insurance? At what cost? MA costs much more than FFS for benefits recipients dont value very much.

          “Has your 42% ever equaled $2000 fine per employee?”

          42% of $15,000.

          “You also have always had the ability to cut benefits, charge employees more, or raise the deductible to anything you want. ”

          You have never run a business. I need to retain employees. The very large majority of insurance plans cost more than $2000. Besides, your cited issue is uncertainty. How do I plan when one year I face 5% and the next 42% increases? What do you think happens when I tell employees I will double their deductible? How do I plan for my best workers leaving?

          “If you pass on to much cost, raise the deductible to high, or make any other normal changes your not affordable or not credible and your subject to fees of $2000+ per employee.”

          The ACA allows for deductibles up to $12,000 per family. I am not sure it is practical to have them much higher.

          Steve

          • nate ogden says:

            “They cover different populations.”

            Actually no they don’t Steve, if they did then there wouldn’t be all the cordination of benefit issues. I cover many people over 65 and those with Medicare.

            “Cost per procedure is the purest comparison.”

            No its not Steve, its one of the most meaningless. Medicare has a history of lower reimbursement per service only to see volume increase and wipe out any savings.

            Paying less is meaningless if you pay for it multiple times or pay less for a service never delivered.

            “Private insurers limit access to drugs. Medicare is not allowed to do that.”

            Sorry Steve you just don’t know what your talking about. Search Medicare formulary and you see all sorts of limitations. In fact Medicare has an entire website for members to look up which plans cover their drugs.

            ” I have never had Medicare deny payment.”

            “Medicare was the most likely to deny any part of a claim, with a 6.9 percent rate. Aetna was a close second at 6.8 percent while the others ranged from 2.7 percent to 4.6 percent.”

            “MA costs much more than FFS for benefits recipients dont value very much.”

            MA delivers medicare benefits cheaper then Medicare does. The value argument is liberal BS, its a popularity pool and has no value or meaning. Notice liberals never ask the question of what people value medicare at. People never value something they get for free or next to it at its value.

            “You have never run a business.”

            I own one now. I have owned numberous businesses.

            “How do I plan when one year I face 5% and the next 42% increases? What do you think happens when I tell employees I will double their deductible? How do I plan for my best workers leaving?”

            I have 500 small business clients, I deal with these situtions dozens of times a month. When you have 5% increases you save money to cover the years you have 42% increases. Successful business owners plan for multiple years and years in advance. Health Insurance should be looked at in 5 year time frames.

            When you tell employees their contributions are doubling how do they respond? When you tell employees there will be no pay raises becuase insurance went up 42% how do they respond? Now you have options when ACA kicks in you don’t.

            The deductible for Family is not $12,000

            Set a maximum of $2,000 annual deductible for a plan covering a single individual or $4,000 annual deductible for any other plan (see 111HR3590ENR, section 1302).

            Further the problem with this is the limit the deductible that a company can buy not what they employee has, it was terribly written. Companies can no longer buy a high deductible and self funded under it to save money.

          • steve says:

            ““Medicare was the most likely to deny any part of a claim, with a 6.9 percent rate. Aetna was a close second at 6.8 percent while the others ranged from 2.7 percent to 4.6 percent.””

            When the California Nursing Association double checked the self reported rates by private insurers, they found much higher rates of claims denial, 22%. This fits with what I have seen in my practice. With over 250,000 cases over the last almost ten years, we run about 2% denial fro private insurance. My practice manager, I had her run the numbers, reminded me that we did have 2 Medicare denials that I had forgotten about. This is a frequent topic of discussion in the OFR at 3:00 AM. OR specialties, at least in PA, see much more denial among private carriers.

            “I have 500 small business clients, I deal with these situtions dozens of times a month. When you have 5% increases you save money to cover the years you have 42% increases. Successful business owners plan for multiple years and years in advance. Health Insurance should be looked at in 5 year time frames.”

            I plan accordingly, but the issue is uncertainty. I am not certain how big of an increase I am facing next year, or for any of the last 20 years. I have read the ACA. I see no more uncertainty than I have faced in the past.

            The limits on deductibles are also affected depending upon the type of plan a person chooses. They may specifically choose a plan with higher deductibles.

            “(A) BRONZE LEVEL- A plan in the bronze level shall provide a level of coverage that is designed to provide benefits that are actuarially equivalent to 60 percent of the full actuarial value of the benefits provided under the plan.”

            “Notice liberals never ask the question of what people value medicare at. ”

            They ask it all of the time, it is just difficult to answer. We do know that some MA plans are cheaper than FFS Medicare. When they have to bid against each other, costs can come down, but most MA programs avoid that, offering benefits with minimal value and maximum profit. (The MA HMOs are the cheaper ones.)

            http://www.healthbeatblog.com/2009/10/some-medicare-advantage-plans-do-provide-valuethe-hmos.html

            “The value argument is liberal BS”

            No, it is based upon pretty standard research techniques. This really should be based upon more than just feelings. The MA advocates should be able to demonstrate their value with similar studies if they think the existing ones faulty.

            ” I cover many people over 65 and those with Medicare.”

            The numbers I have seen put Medicare penetration at 96%-99% for the age 65 group. What percentage of the population are you insuring who have no Medicare? Does that population match well with the general population?

            “No its not Steve, its one of the most meaningless.”

            PxV. Both are important, but price is the easiest to verify. Let Medicare ration the same way private insurance does, and we get real total cost reduction.

            Steve

          • nate ogden says:

            ” Let Medicare ration the same way private insurance does, and we get real total cost reduction. ”

            Let me look as good as George Cloony I would have a hot girl friend. You can’t let someone do the impossible.

            Let me reimburse at Medicaid rates I can reduce insurance premium 50%. This ignores the fact there would be no providers left in business.

            “The numbers I have seen put Medicare penetration at 96%-99% for the age 65 group.”

            Pentration is an inaccurate measure, you need to find out what percent of those over 65 is Medicare prime.

            “it is based upon pretty standard research techniques.”

            What’s the perceived value of the DMV? Obviously we should get rid of it then right? Its a meaningless measure that doesn’t accurately reflect needed coverage.

            What’s the perceived value of invitro fertilization? 99% of the population would save nothing so why is it a mandated benefits. How about acupuncture, why is it mandated? Ask about the value of mental health, it won’t come out near the actual cost. Standard techniques don’t mean they are valid or scientific questions. Links to Maggie and her dishonest propaganda don’t make a point. Saying MA gets $114 for $35 WORTH of benefits is like saying a pear costing $0.50 is only worth $0.01 because I don’t like pears. It’s a misleading claim at best, dishonest to most.

            “I am not certain how big of an increase I am facing next year,”

            Why not? You should refuse to be in any insurance arrangement that doesn’t provide you data.

          • steve says:

            “Why not? You should refuse to be in any insurance arrangement that doesn’t provide you data.”

            Where does that exist? We have 47 employees (growing soon). How do I get an insurance company to guarantee rate increases? Are there insurance futures? I specifically asked our broker about such a possibility and he denies such a thing exists in PA.

            Steve

          • nate ogden says:

            Self Fund with stop loss

            Partially self fund under a fully insured high deductible

            Form an RRG with like minded small employers also not happy with the insurance market

            In your defence you are in PA so your sorta screwed, depending on which side of the state your on you have Highmark or UPMC to screw you, not much competition. If their fight picks up you should have some better options.

            I see programs with 18 month guarantees in Ohio. The NV Chamber does 2 year rates, the entire block renews 7/1 every 2 years.

            Employers, especially small ones, need to get feed up and tell the brokersd and carriers and hospitals the current system sucks and your done with it. Offer you better options or you will exit the system. The first two are not necessary to offer insurance and third you don’t need a contract with, in fact you can get better pricing by not having a contract.

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  4. BobbyG says:

    I see we have an infestation of site pimping trolls, Matt.

  5. DeterminedMD says:

    Safety Net? Really !? While I did a little research to the backround of Brookings and it seems to be somewhat a balanced organization, I can’t help but read a lean to the left her, but not a hard one at least. Getting everyone insured is not THE solution, it is just part of the big picture that is a possible solution. Costs are finite, interventions are infinite, yet a lot of you just don’t get that, as supplies and services are finite entities into the business model. Not paying attention to that fat square peg you just keep pounding away at the round hole, are ya?

    The issue that surrounds the largest dissent among doctors who do care and are attentive to maintaining the sanctity of the doctor-patient relationship is simple: the least amount of intrusions and misappropriation of funds that should stay in the system, note i did NOT say others’ pockets.

    You really think PPACA is going to improve health care outcomes?

    Yeah, only if you live by the Logan’s Run principles!!!

    By the way, to the site pimping troll who just squawks away about what do I offer as an alternative, how about asking first if boomers as a group will respect and work with limits into health care options for elderly and end of life care options. For every one response that would be reasonable and fair in expectation, they would be drowned out by the sheer mass of opposition that says, what is the mantra of this generation, “gimme that, it’s mine”, and “what’s in it for me?!” This generation, which I am unfortunately part of by age alone, has no F—-g clue how to accept limits and boundaries.

    Just check out the last 7 or so minutes of George Carlin’s 1996 show, Back in Town, he sums it up perfectly for me. They are cold, bloodless, and looking down the barrel of entrenched middle age and they don’t like it.

    And how ironic the playmaker behind PPACA is in their age group as well.

    Coincidences? Ask Occam!!!

  6. Martha Smith says:

    Very informative and impressive post. I will be back for more info.

  7. alex d says:

    Occupational health professionals must manage the complexities of medical surveillance. They have to record employee health data from workplace injuries and illnesses, clinic visits, immunizations, audiometric exams, flu clinics, wellness programs, and lab tests. And, it’s not enough to just collect the data: They must be able to report on it in multiple formats.

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