View Research by Author - Stephen Zuckerman

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Citation URL: http://www.urban.org/StephenZuckerman

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.

Medicaid physician fees increased 15.1 percent, on average, between 2003 and 2008. This was below the general rate of inflation, resulting in a reduction in real fees. Only primary care fees grew at the rate of inflation--20 percent between 2003 and 2008. However, because of slow growth in Medicare fees, Medicaid fees closed a small portion of their ongoing gap relative to Medicare--growing from 69 percent to 72 percent of Medicare. The increase in Medicaid fees relative to Medicare fees resulted from relative increases for primary care and obstetrical services, but not for other services.

In 2005, Missouri adopted sweeping Medicaid cutbacks. More than 100,000 people lost coverage, and many more faced reduced benefits and higher cost-sharing. Using a range of data sources, we show that the cutbacks were followed by a major increase in the numbers of uninsured people, greater uncompensated care burden on hospitals, and revenue shortfalls that forced community health centers to obtain larger state grants and charge patients more. Competing demands on state budgets and the need to balance budgets even during recessions could result in policies that disadvantage those with great needs as well as the providers who serve them.

Researchers from the Urban Institute and the State of Massachusetts explored why existing surveys generate very different estimates of the uninsurance rate in Massachusetts. The surveys they examined are the Current Population Survey (CPS), the Behavioral Risk Factor Surveillance System (BRFSS), the Massachusetts Health Insurance Survey, and the Massachusetts Health Reform Survey (MHRS). This brief described how estimates may vary because of differences in the wording of the insurance questions asked in the surveys, differences in question placement and context within the survey, differences in survey design and fielding strategies, differences in accounting for missing data and other data preparation, and differences in survey fielding time frames. The analysis concludes that there has been no single survey in Massachusetts that is clearly superior across all of these important dimensions.

The "patient-centered medical home" has been promoted as an enhanced model of primary care. Based on a literature review and interviews with practicing physicians, we find that medical home advocates and physicians have somewhat different, although not necessarily inconsistent, expectations of what the medical home should accomplish—from greater responsiveness to the needs of all patients to increased focus on care management for patients with chronic conditions. As the medical home concept is further developed, it will be important to not overemphasize redesign of practices at the expense of patient-centered care, which is the hallmark of excellent primary care.

Since 2001, more than half the states have changed their Medicaid programs, through either Medicaid waivers or provisions included in the Deficit Reduction Act of 2005. These changes are in benefit flexibility, cost sharing, enrollment expansions and caps, privatization, and structure of program financing. With a few important exceptions, the changes have been fairly circumscribed. However, states may exercise this new flexibility if, for example, national health care reforms do not occur or an economic downturn creates state fiscal pressures. If that happens, new policies could lead to profound changes in Medicaid and could be carried out relatively easily.

This study examines the effects of New York’s Health Care Reform Act of 2000 on the insurance coverage of eligible adults using the National Health Interview Survey (NHIS) and the Current Population Survey (CPS). We find a significant reduction in uninsurance for parents but for childless adults, for whom the coverage expansion was narrow, we find no evidence of a significant decline in uninsurance. The paper also explored the feasibility of using the NHIS as a data source for studies of state coverage policy changes, concluding that the NHIS is indeed a sound data source for such studies. Health Services Research, Vol. 42, No. 6, 2007, pp. 2332-2353.

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