This brief describes the groups with the most to lose if comprehensive health care reform is not enacted—people who either lack coverage today or who are required to pay the most for health insurance and medical care. These include the self-employed, those working for small employers, those with health problems, older working-age adults and early retirees, the low-incomes, and others without access to employer-based insurance. Reform's combination of Medicaid expansions, subsidies for exchange-based coverage, broader-based sharing of risk, and administrative economies of scale would make meaningful coverage affordable for the vast majority of individuals disadvantaged by the current system.
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The fate of health care reform is now highly uncertain. The momentum for reconciling the two bills passed by the House of Representatives and the Senate stalled, leading the President to put a compromise proposal forward. Still, the original motivation and rationale for the reforms appears to have become obscured, as have an understanding of what the proposals would do and who would benefit from them. This brief describes the groups with the most to lose if comprehensive health care reform is not enacted—people who either lack coverage today or who are required to pay the most for health insurance and medical care. Based on 2008 data, these groups include:
- 13.1 million self-employed people;
- 47.8 million people employed in firms of fewer than 100 workers;
- 26.9 million non-elderly people working part-time and 20.8 million people working full-time but for only part of the year;
- 96.2 million non-elderly people in families with incomes below 200 percent of the federal poverty level; another 74.3 million living in families with incomes between 200 and 400 percent of the poverty level;
- Millions of people with significant health problems, including the highest spending 5 percent of the US population, who account for about 50 percent of total health expenditures. This concentration of health care costs limits access to affordable, meaningful coverage for them as well as many others with less expensive conditions, including many older working-age adults
and early retirees.
In addition, 14.8 million people were unemployed, as of January 2010, and this number is expected to remain high for several years.
Reform's combination of Medicaid expansions for the very low-income, subsidies for the purchase of exchange-based coverage for those up to 400 percent of the FPL, broader-based sharing of risk, and administrative economies of scale reaped from exchanges would make coverage affordable for the vast majority of individuals without access to employer-based coverage, irrespective of age, health-status, or employment status.
Some of the people in those groups overlap, not all are uninsured, and not all those with incomes that would make them eligible for financial assistance would avail themselves of the federal subsidies and expanded public programs at the same time. But all would have the reforms as at least a backstop, e.g., if they lost employer-based coverage, the reforms would limit their financial burdens and ensure them access to meaningful coverage that many would not have otherwise.
To walk away from the proposals developed, including the individual mandate, insurance exchanges, regulatory reforms of insurance markets, expanded public insurance eligibility, and premium and cost-sharing subsidies for the modest income, does even greater harm than leaving these populations in the difficult circumstances in which they find themselves today. That is because without legislative change, the cost of medical care will continue to grow faster than incomes, just as it has in recent memory. As a consequence, not only would the numbers of uninsured and the under-insured grow as premiums for meaningful coverage became increasingly expensive, but the cost of obtaining care with direct out-of-pocket payments would become even more of a financial burden over time. Finally, the increasing numbers of individuals seeking charity care and public coverage would put yet more financial pressures on state, local, and federal government, as well as on the health care system as a whole.
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