The Tattered Safety Net

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The Tattered Safety Net

• James G. Anderson, Ph.D.
• Purdue University

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Number of Uninsured in the U.S.
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Profile of the Uninsured

• 76.4 uninsured adults under 65 work full or part
  time during the year
• 34.9 earn more than 25,000 per year
• Uninsured by race and ethnicity
• 12.9 White
• 9.7 White non-Hispanic
• 18.5 Black
• 18.0 Asian and Pacific Islander
• 32 Hispanic

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Profile of the Uninsured

• Uninsured by education
• 26.6 No high school
• 16.4 High school
• 13.4 Some college
• 10.3 Associate degree
• 7.1 BS/BA degree

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Profile of the Uninsured

• Uninsured by income
• 22.7 Less than 25,000
• 17.0 25,000-49,999
• 11.0 50,000-74,999
• 6.9 75,000 or more

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Profile of the Uninsured

• Uninsured by age
• 11.8 Under 18 years
• 27.3 18 to 24 years
• 21.2 25 to 34 years
• 15.5 35 to 44 years
• 12.8 45 to 64 years
• 0.7 65 years and over

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Uninsured Children by Race and Ethnicity

• Uninsured by race and ethnicity
• 10.9 White
• 7.3 White non-Hispanic
• 13.6 Black
• 14.2 Asian and Pacific Islander
• 24.9 Hispanic

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Children Covered by Medicaid by Race and
Ethnicity

• Uninsured by race and ethnicity
• 17.0 White
• 13.2 White non-Hispanic
• 35.8 Black
• 18.6 Asian and Pacific Islander
• 32.8 Hispanic

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Reasons Given for Lack of Insurance

• 47 Insurance is too expensive
• 15 Job doesnt offer insurance benefits
• 15 Unemployed or between jobs

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Health Insurance Coverage for Children 1999
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Health Insurance Coverage 2000
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Health Insurance Coverage by Family Income
Level1999
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Medicaid Enrollments Selected years
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Medicaid Enrollment by Category 2003
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SCHIP Enrollment 1998 -2000
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Medicaid Managed Care EnrollmentDecember 31, 2001
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What is the Safety Net?

• Health providers who have a legal obligation to
  provide free or reduced-fee care to those who
  could not otherwise afford it.

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Why Do We Need a Safety Net?

• 75 million (est.) (29) of Americans without
  health insurance on any given day in 2002
• A cap on Medicaid enrollment would result in 67
  million (24) of population uninsured by 2002.

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Access to Care bythe Insured and Uninsured
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Who are the Safety-Net Providers?

• Medicaid (40.4 million low income adults,
  children, elderly and disabled in 2003).
• Safety Net Hospitals in 1997 (482 hospitals)
• Community and Migrant Health Centers (600
  centers).
• Family Planning Clinics (4,000 clinics).
• Ryan White AIDS Program (136 projects).
• Health care for the homeless (129 projects).
• Public Health Departments.
• Rural Health Clinics (2,500 clinics).

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Urban Public Hospitals (1980-1990)

• Accounted for 7 of all hospitals.
• Provided 19 of all emergency room visits.
• Provided 18 of all outpatient visits.
• Nearly 50 of these patients were uninsured.

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Who Pays for the Safety-Net?

• 129.9 billion federal funds for Medicaid in
  2001.
• 94.3 billion in state funds for Medicaid in
  1995.
• 17 billion federal funds for low-income
  hospitals in 1992.
• Medicaid costs consume 20 of state budgets.
• Local governments spent 17 of county budgets on
  health care in 1992.
• Hospitals provided 18.5 billion in
  uncompensated care in 1997.

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Medicaid The Insurance Safety-Net

• Provides coverage for 58 of those with incomes
  below the federal poverty line (2001 8,590
  individual 17,650 family of four).
• Pays for 1 of 3 births.
• Provides coverage for 1 of 4 children.
• Provides coverage for 40 AIDS patients.
• Pays for 66 of nursing home care.

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What Problems Do Safety net Providers Face?

• Marketplace pressures will make it difficult to
  make up losses.
• By 2002 hospitals will lose 20 billion in
  Medicaid 14.4 billion in Medicare 20 billion
  from private payers 25 billion due to
  uncompensated care.
• Teaching and inner-city hospitals will operate at
  a loss many will close.
• Providers will try to shift costs back to
  employers raising prices 1,000 per covered
  worker.

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Strategies for Expanding Health Insurance Coverage

• Tax Credits.
• Expanding Public Programs (e.g., Medicaid, SCHIP)
• Combination of the two approaches.

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Public Willingness to Pay

• 53 of the American public are willing to pay at
  least 30 per month to cover the uninsured
• 46 are only willing to pay 5 per month or
  nothing at all

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Public Support for Reform Options

• 21 Expand Medicaid and SCHIP
• 21 Require businesses to offer private health
  insurance to their employees
• 20 Provide tax deductions and credits to help
  people purchase private health insurance