Research by Author & Topic

Publications by Stephen Zuckerman on Health and Health Care

New data on health insurance coverage from the American Community Survey show extensive variation in rates of private and public coverage and uninsurance across congressional districts in the United States. Rates of private coverage are lowest in districts that have higher poverty rates which tend to be concentrated in the South and West and uninsurance remains most serious in districts with low rates of private coverage. This analysis identifies the districts in which residents would have the most to gain from health reforms that are designed to increase health insurance coverage toward a higher and more uniform national standard.

Pending health reform legislation would leave our largely private medical care system intact, give the federal government no new authority to intervene in private health care decisions, and increase health care options for millions of Americans, two senior researchers make clear.

This paper debunks claims that proposed health reforms represent a government takeover of health care. We show, among other findings, that pending legislation would: (1) retain the nation's largely private medical care system, in which more than 90 percent of doctors are in private practice and 84 percent of all hospital admissions are to private facilities; (2) avoid government interference in the practice of medicine, instead simply extending existing public responsibilities to fund coverage for low-income Americans and regulate insurance; and (3) cover only 12 million people through a public option, based on Congressional Budget Office projections.

Many have suggested that reducing or eliminating the tax exclusion of employer-sponsored health insurance (ESI) could generate significant additional tax revenue to fund expansions in health insurance coverage. In this paper, we focus on two specific policy design elements: (1) a cap, or dollar limit, on the amount of employer-sponsored health insurance premiums excluded from taxable income; and (2) an index that determines how this cap might grow over time. Our analysis shows that limiting the tax exclusion would provide substantial funding for health reform and mitigate the huge inequities built into the current treatment of employer premiums.

This article examines experiences under Medicaid and the State Children's Health Insurance Program (SCHIP), drawing on surveys of over 3,000 enrollees in California and North Carolina in 2002. In both States, Medicaid enrollees were less likely than SCHIP enrollees to have parents who were covered by employer-sponsored insurance (ESI). With the exception of dental care and provider perceptions, access experiences were fairly comparable across the two programs, despite differences in the characteristics of the children served by the two programs. Relative to being uninsured, Medicaid enrollment was found to improve access to care along a number of different dimensions, controlling for other factors. Furthermore, this study emphasizes the need for continued evaluation of access to care for both programs.

This paper demonstrates that while fees for physician evaluation and management increased over the first ten years of the Medicare Fee Schedule, the quantity of imaging services and non-major procedures increased even more, making the share of program spending on evaluation and management services in 2002 the same as it was in 1992. Two factors explained the differential spending growth across types of services: the introduction of new services and the process for reviewing and revising fees. The authors argue that differences in expenditure growth across service types affect Medicare's costs and should be considered in the program's spending control policies.

Using state survey data, researchers examined Medicaid supplemental payments, including disproportionate share hospital and upper payment limit payments in 2005 and changes in these payments between 2001 and 2005. The researchers found that states increased their use of general funds in financing Medicaid DSH payments while expanding the size and scope of other supplemental payments considerably. Although the federal government has made some headway in reforming state Medicaid financing in recent years, the paper concludes that problems persist and more work remains.

Congress mandated in the Balanced Budget Refinement Act of 1999 (BBRA) that the Secretary of the U.S. Department of Health and Human Services conduct an independent comprehensive study of the State Children's Health Insurance Program (SCHIP). This report presents the findings from the mandated surveys of SCHIP enrollees and disenrollees in 10 states (conducted during 2002). SCHIP programs were found to provide health coverage to the population SCHIP was intended to serve, primarily children who would otherwise have been uninsured. The programs availed enrollees of needed primary and other health care services, and were found to have a positive impact on enrollees' access to health care services, leaving enrollees with fewer unmet needs than they would have had in the absence of SCHIP. Families were satisfied with the ease of enrolling children, many of whom remained enrolled for 12 months, depending on the state.

The ongoing debate in California over two competing 2007 proposals for universal health coverage highlights both the strengths and weaknesses of the current insurance system in the District of Columbia as a platform for coverage expansion. The District's advantages include its relatively small uninsured population and existing mechanisms for administering a public coverage program tied to income. But its fiscal base is relatively small compared with California's, its largely unregulated insurance market could lead to severe adverse selection problems for new programs, and it is at much greater risk for border-crossing by both individuals and businesses in response to reform.

One of the more prominent concerns in the SCHIP reauthorization debate is that many children enrolling in the program could have been insured through their parents' employers. However, concern about parents dropping employer coverage to enroll their children in SCHIP typically ignores the affordability of that coverage. We show that families' spending burden is, on average, lower under public insurance than under employer-sponsored insurance (ESI), especially for the lowest-income families. For families in which children are covered by Medicaid or SCHIP, out-of-pocket spending is, on average, 4 to 5 percent of their income. However, for families in which children have ESI for a full year, the out-of-pocket spending burden is higher, ranging from 12.9 percent of income for families below 150 percent of the federal poverty level (FPL) to 6.1 percent for families between 250-400 percent of FPL.