Research by Author & Topic

Publications by Stan Dorn on Health and Health Care

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.

To combat the epidemic of obesity, lawmakers can adapt policy approaches that have substantially cut tobacco use. A 10 percent tax on fattening food, identified based on a model used by the British government to determine the foods that may not be advertised to children, would reduce consumption while raising more than $500 billion over 10 years. Adding simple, "traffic light" nutrition labels to the front of each food package would change consumers' buying habits, as would listing calories on menus at chain restaurants. Consumption of fattening food would be further reduced by banning its advertisement in the mass media.

This brief examines the potential effects of health care reform on the more than 25 million children who currently have coverage under Medicaid or the Children's Health Insurance Program (CHIP). Increased parental coverage will help these children since many have uninsured parents with unmet health needs. However, proposals to move these children into a new health insurance exchange could make them worse off through the potential loss of benefits and legal protections and possible exposure to higher cost-sharing; alternatively, if reimbursement rates are higher in the exchange than paid under Medicaid and CHIP, children's access to providers could improve.

Some policymakers propose capping the amount of employer-sponsored insurance that is exempt from federal income and payroll taxes. If such a cap is based on employer premiums, inequities will result. Workers could pay higher taxes if their employer is located in a high-cost area, if many co-workers are in their 50s and 60s, or if a few employees have a major illness or accident. To avoid such inequities, the cap could be based on benefit generosity, measured by actuarial value, which is the cost of expected claims if a nationally representative population received the covered benefits.

The American Recovery and Reinvestment Act of 2009 sought to help laid-off workers retain health insurance and to provide state Medicaid programs with fiscal relief. By paying 65 percent of premiums for COBRA coverage, the bill will help many unemployed purchase insurance, but a significant number will be unable to afford their 35 percent premium share. ARRA's $87 billion in fiscal relief will likewise prevent many Medicaid reductions, but because most of the money is not targeted to the states experiencing the greatest economic harm, those states may not get sufficient help to avoid major health care cutbacks.

Automated enrollment strategies have achieved remarkable results with many public and private benefit programs, dramatically increasing program participation while lowering administrative costs and reducing erroneous eligibility determinations. The recently passed Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) should make such steps much easier for states to take in covering eligible but uninsured children. Following CHIPRA's enactment, states have both new tools and new incentives to use automated strategies in fulfilling four key functions: identifying uninsured children; determining their eligibility for health coverage; enrolling eligible children into coverage; and retaining eligible children.

In 2004, 89.4 percent of uninsured children who qualified for Medicaid or the State Children's Health Insurance Program lived in families who filed federal income tax forms. This substantially exceeds the proportion of uninsured but eligible children who can be reached through many other outreach strategies. Federal lawmakers could cover uninsured children in these families by: (a) changing federal income tax forms so parents can identify their uninsured children and request coverage; (b) investing in information technology allowing data exchange between states and the Internal Revenue Service; and (c) letting states cover uninsured children if tax information shows they qualify.

Between increased Medicaid caseloads, rising indigent care costs, and Medicaid's share of state revenue losses, an economic downturn in the next two and a half years could impose between $74 billion and $118 billion in extra financial burdens on the 50 states, if unemployment averages between 8 and 10 percent. The amount Congress must spend to prevent state service cutbacks and tax increases depends on how fiscal relief is allocated. Basing each state's funding on objective, economic indicators makes federal dollars go farther towards solving state fiscal woes, since more of the money benefits the states that most need help.

This brief, part of the Urban Institute's "Recession and Recover" series, examines how the Medicaid and SCHIP programs respond during a recession and how that response may differ in the current recession from their responses in the past. It also assesses the extent to which health insurance coverage may decline as unemployment rises.