Lynn A. Blewett, Ph.D. Professor, University of Minnesota

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1 Lynn A. Blewett, Ph.D. Professor, University of Minnesota Westlake Forum III Healthcare Reform in China and the US: Similarities, Differences and Challenges Emory University, Atlanta, GA April 10-12, 2011 Funded by a grant from the Robert Wood Johnson Foundation

2 Overview of Presentation Definition of social insurance Examples of social insurance in the US Distribution of coverage by insurance type A few points on national health reform Projections of persistent rates of uninsurance Conclusions

3 Definition of Social Insurance A social insurance scheme is one in which the policyholder is obliged or encouraged to insure by the intervention of a third party Social Health Insurance (SHI): The costs of ill health are considered a public concern Society as a whole suffers from the resulting loss of wages, loss of productivity and loss of time Ill health is viewed as a social concern, not simply a personal problem; obtaining health insurance is mandatory, not a personal choice Source: OECD Glossary of Statistical Terms, 2011

4 Examples of Social Insurance in the United States Unemployment insurance Social Security Medicare Health Insurance Coverage

5 Health Insurance Coverage in the US, 2009 Employer- Sponsored Insurance 54% Uninsured 16% Medicaid/ Other Public 12% Medicare 14% Private Nongroup 4% Source: SHADAC-Enhanced CPS for Military Coverage considered ESI. Order of primary coverage assignment: Uninsured, Medicaid,Private Non-Group, ESI, Medicare.

6 Medicare: Program Design Title 18 Social Security Act Part A - Entitlement/Compulsory Part B - Supplementary/Voluntary With generous federal general fund subsidy Based on Principal of Social Insurance All employers/employees contribute Universal coverage for those eligible Administered by Federal government (CMS)

7 Eligibility Age 65+ Disabled (after a 24-month waiting period) HIV/AIDs Railroad Retirees End Stage Renal Disease (RSRD) Beneficiary or spouse paid into social security for 40 quarters or 10 years of work history

8 Key Facts: Medicare (2010) 2010 Expenditures: $509 Billion # Elderly and disabled: 49 million % of national health care spending: 23% % of federal budget: 12% Average cost per beneficiary: $8,344 For top 10% high cost beneficiaries: $48,211 (FFS)

9 Financing 2010 HI: Hospital Insurance Trust Fund 1.45% payroll tax on employers/employees Deductibles (e.g. $1,100 per hospital stay) Coinsurance (e.g. $275 per day from days 61 to 90 of a hospital stay; $550 per day for days , all costs over 150 days) SMI: Supplemental Medical Insurance Premiums: $ per month (now income tested ) Deductible ($155 year) Coinsurance (20%) General Fund Revenue ACA - increases the payroll tax for higher income taxpayers (more than $200,000/individual and $250,000/couple) from 1.45% to 2.35% in 2013

10 Projected Worker-to-Medicare Beneficiary Ratio

11 Employer-Sponsored Health Insurance (ESI) Primary source of coverage in US 60% Voluntary offer and voluntary take up Tax advantages for employer and employee contributions Trend of dropping health care as costs go up The challenge: where do people get coverage if not through their employer? Individual Market Today? Probably not. No pooling, underwriting, and individual risk-rating Makes up about 4% of under-65 coverage

12 70 60 Reduction in Employer-Sponsored Insurance (ESI) 65% 56% Source: SHADAC-Enhanced CPS for 2000 and Percentage is for any ESI and includes individuals with other sources of coverage.

13 Variation in ESI by State

14 National Reform: Affordable Care Act (ACA) Are there any elements of social insurance? Individual mandate Employer penalties Tax credits for small employers to offer coverage Subsidies to purchase private coverage No social contract or universal coverage commitment

15 Increasing Rates of Uninsurance Millions of Uninsured, all ages % of Population Source: U.S. Census Bureau, Current Population Surveys (March),

16 Universal Coverage for the Poor Medicaid Expansion 133% Premium Subsidy 400% Medicaid Subsidy $29,326 Family Of Four $88,000 Family of Four Federal Poverty Level 16

17 Exemptions to the Individual Mandate Financial hardship Religious objections American Indians and Alaska Natives Incarcerated individuals Those for whom the lowest cost plan option exceeds 8% of income Those whose income is below the tax filing threshold And the undocumented: 12 million people

18 Estimate of Uninsured After Health Insurance Reform 19 million uninsured under ACA Medicaid Eligible 37% Eligible: Penalty Affordable Unsubsidized Option 15% Eligible: Affordable Subsidized option 7% Undocumented Immigrants 25% With Affordability Exemption 16% Source: Urban Institute Who Will be Uninsured After Health Insurance Reform? March Estimates using 2011 Population with 2014 eligibility for programs.

19 Conclusion US has adopted social health insurance for the elderly/disabled - Medicare A welfare system for the poor Tension between private health insurance industry and social compact Increasing costs of care, budget pressures at both state and national level Reform may sever the link between ESI and uninsured by expanding Medicaid and providing tax credits in exchanges Making other affordable options available

20 Contact information Lynn Blewett State Health Access Data Assistance Center (SHADAC) Regents of the University of Minnesota. All rights reserved. The University of Minnesota is an Equal Opportunity Employer 20

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