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U.S. Health Insurance: Who can get it, who can't. Basics

The very basics of health insurance – what you need to know about insurance itself in order to understand why it’s such a problem 

Especially basic basics:

Risk pool: “A distinct population group, such as employees of a company, insured against costs of their potential use of health care resources. Premium projections are based on variables such as the age of the covered population, health status, sex, occupation, group size, and location.”  

In a large and diverse risk pool such as you might find in a giant corporation, you’d have a big bunch of covered people with all levels of risk for health problems. Those that will require serious coverage will far outweigh in spending what the half of the population unlikely to need much coverage will use.  But the idea is that we pay our premiums to cover the whole pool so that we can cover ourselves should we fall into the high risk category.

Health care expenditures overall are highly skewed. One set of figures which is pretty typical shows that:: 

· 1% of the population uses  30% of health care expenditures

· 10% uses 72%

· 50% uses 97%

· 50% uses only 3%. 

Risk segmentation means breaking groups into smaller segments which usually exclude some or all high expense users or limit their coverage. Risk segmentation is the biggest single problem with our current health insurance system in combination with…. 

Voluntary participation in insurance markets: We are not compelled to have health insurance as we are to have auto insurance. This means we often shop for the best deal at the moment. This leads to long-term problems for individuals and for all of us as a group. 

General consequences of efforts to keep prices low: 

· Health insurers have extremely strong incentives to identify and insure below-average risk populations – competition for good risks. “The lower the health risk of an insured group, the lower the expenses to the insurer and the lower the premiums the insurer must charge in order to be profitable.”

· It is in the insurers interest, therefore, to keep out high risk people in order to make profits, keep premiums affordable.

· This means high risk people may not be able to buy affordable insurance.

· Even moderate and low risk people may find premiums for good care out of reach.

Current make-up of the health insurance system

• Public Sector
  • Medicare: 65 and over, some none-elderly disabled
  • Medicare and Medicaid combination
  • Medicaid: Some limited categories of  low-income. Combined state and federal.
  • SCHIPS: Some low income children. Combined state and federal.
  • CHAMPUS: covers authorized medical  necessities only from civilian sources on a cost-sharing basis for retired military, and dependents of active duty and retired and deceased military.
  • State sponsored high risk pools: for individuals who as a function of pre-existing illnesses or conditions have been denied private coverage or have difficulty finding      comprehensive coverage at a rate lower than the high-risk pool.

• Public/Private mix:
  • Medicare and Medigap: Medigap is private insurance that pays to one degree or another for deductibles and copays of Medicare.
  • Past year part public, past year part private: Medicaid and none.
• Private Sector
  • ERISA (see below) protected coverage: exempt from state regulations. Mainly provided by large firms.
  • Experience rated commercial insurance coverage. Large firms of at least 500 workers, actuarially sound risk pool, subject to state regulations
  • Experience rated commercial, small firms or individuals, persistence in risk rating
  • No insurance coverage

The four categories of private insurance are considered four tiers. Below are some of their characteristics:

• Groups that purchase through an Employee Retirement Security Act (ERISA) protected plan (see ERISA at end of article): can be held by firms, multi-employer welfare arrangements (MEWAs) or individuals choosing  to self ensure. ERISA coverage is      exempt from state insurance laws:
  • Don’t have to abide by state mandated benefit laws such as mandatory benefits (think mammograms)
  • Don’t have to pay premium taxes tosubsidize high-risk or uninsured population.
  • Large groups and groups with better-than-average risk profiles (i.e. the 50% of the population that uses 3% of the money) are attractive candidates for self-insurance.

· Important concept here: For self-insurance groups, the Stop Loss provision: Stop loss is critical to a risk contract and the mathematics of how it is computed can radically alter the expected result. Stop loss coverage may be a single threshold amount for all expenses (institutional, physician and pharmacy) or there may be a stop loss level for each risk pool. In some cases, there may be other forms of stop losses built into the overall limit, such as a separately computed stop loss for inpatient days or for NICU (neonatal intensive care) or Obstetrics, with the uncovered costs rolling up into the computation of the overall stop loss level. The level at which losses are stopped is important as well. Inpatient stop loss levels are typically in the vicinity of $50,000, with 90% of the costs over that level paid by the insurer.

• Groups that purchase commercial experience-rated insurance through “actuarially balanced risk pools”…that  is, I think, where actuarial study has determined the spread of the risk      and the group is large enough so the vast majority are not high cost and the random risk of a high-cost person is spread over the whole group.
• Third tier private coverage. Firms which purchase experience-rated insurance and individual policies have third tier coverage which is the most unstable sort. The groups making up this tier are called “persistence of risk rating” groups. They are not large enough to be      considered actuarially balanced risk pools. At any moment they are subject to a a      member developing a high-cost problem (otherwise known as a “high risk event”) leading to a jump in all the group members´ premiums. Once a high risk event occurs, the group      likely to continue to be considered high risk for years. They will be continually penalized      because “economic theory” suggests that the gains to an insurer of selecting groups with relatively healthy experience are much greater than the net gain resulting from analyzing a group with recent high cost experience in order to determine if the high-cost event is completed or unlikely to recur. Think what happens to your car insurance rates after an      accident.
• Fourth tier: complete absence of insuranceincluding those completely unable to buy insurance because of pre-existing conditions or because conditions have resulted in them being dumped from the market or those choosing not to purchase because of high premiums or whatever.

        ERISA:  A federal law that sets minimum standards for most voluntarily established pernsion and health plans in private industry to provide protection for people in them.  Requires that plans provide participants with info about features and funding, establish who is responsible for managing and controling assets, has a grievance and appeals process.  It was amended to provide COBRA coverage after they leave their jobs.  It exempts plans from state regulations. 
        In 1996, ERISA was amended by the Health Insurance Portability and Accountability Act, known as HIPAA.  This will be discussed in another article, probably the next one.
(Note: Plans often divide the risk budget into two or three components: Inpatient or institutional services, Physician services and pharmacy. The risk in each of these "funds" or pools may be shared differently between the physicians, the Plan, and perhaps hospitals.)

Some sources:

Blumberg, Linda J. and Nichols, Len M., Health Insurance Market Reforms: What They Can and Cannot Do (1995) http://www.urban.org/urlprint.cfm?ID=5870
Delaware Healthcare Association, www.deha.org/Glossary/GlossaryR.htm.
Dietrich, Mark O. Dietrich and Wilson 2000, www.cpa.net/articles/soyouwant.html 

 

 

 

 

 

Risk pools: how they contain costs for health insurers

Risk pools:  Basic for understanding  health care coverage problems.

In the world of health insurance, a risk pool is a group of people for whom statisticians have figured the odds that a certain number are likely to need a lot of health care, a certain number likely to need a moderate amount and a certain number are not likely to much at all.  This provides the basis for decisions about whom to cover, how much to charge for premiums and so forth.

A good example of a risk pool, though it's not generally described at way, is all adult women.  The odds are usually given that 1 in 8 women are likely to get breast cancer.  This means in the total pool of adult women, 1.25% are likely to get breast cancer.  This does NOT mean that if you collect women in a group and count them individually every eighth woman will get breast cancer. The figure of 1 in 8 or 1.25% doesn't tell you anything about the odds of any one woman in the group of adult women getting it since the only definition of the group was that it included adult women.  It didn't say anything about women with a family history, women of a certain age, etc.

For health coverage purposes, we can start with the population of the United States as a whole.  As a risk pool, the odds are that in any given year one per cent of the group will need very expensive health care, nine per cent will need expensive healthcare, 40 per cent will need moderately expensive health care and 50 percent will need pretty inexpensive healthcare.  This snapshot of the population doesn't tell you anything about which individuals will get very sick or not sick.  The only thing we know is that statistically, it is likely that this is how healthcare costs will break down.

What we can generally also say about this pool is

• the sickest 1%  will use  30% of the health care funds,
• the top 10% (which includes the top 1 percent) will use 72% of the available funds,
• the sickest 50% will use 97% of the funds
• the remaining, relatively healthy 50% of the population will use only 3% of the funds.

So, put numbers of people, this means that if you have a group of 100 people using a healthcare expenses fund of $10,000,

• The most expensive person will use $3000.00
• The top ten most expensive people will use $7200.00
• The top fifty most expensive people will use $9700.00
• The remaining fifty people will use only $300.00

You can see that half the population will be pretty inexpensive to cover and half will be very expensive to cover.  When we pay our health insurance premiums, the more or less  healthy among us essentially pay for the coverage of the sick among us.  We should do this because for so many reasons we need to care for the least among us.  But that aside, we should do it because the sickest among us are likely at some point to be us.  The sickest one percent may recover; we may become the sickest.  We need each other if not today then someday. 

Next post will deal with insurance companies and risk pools.

Overview: Private Health Insurance as a free market product

Using the market to solve problems of health care coverage in this country is like using a lawn mower to vacuum the living room rug.  It ain't gonna do it.  This doesn't mean there isn't room for market forces within the healthcare industry, but that they're the wrong tool for health care coverage.

I don't remember what justification Hillary Clinton offered in 1993 for having her secret meetings for coming up with some kind of national plan for health coverage, or even if she offered one.  I can guess what Dick Cheney's reasons for secret meetings with the energy industry for coming up with an energy plan in 2000 were.  I know I have my biases, but I'm pretty sure Hillary wanted to come up with a way to help citizens afford health care and I'm just as sure Dick wanted to help out his buddies. I suspect the secrecy of the meetings had to do with the fact that both Hillary and Dick wanted to give the private sector world room to talk outside of public view: a private enterprise version of the smoke-filled back room.  And sometimes people need that.

Both Hillary and Dick were operating not only on the assumption that politics demand they not mention or even consider any kind of non-free-market solution, but even more important, they were operating on the assumption that they could in fact come up with private solutions to the very public problems of health care and energy.

A bit of review:

The operating forces in the free market are supply and demand. In the most general sense, the consumer tries to get the cheapest something and the producer tries to sell it for the most she can get.  (Remember this is all pretty much theoretical)

This is supposed to be a free market: consumers are supposed to be making voluntary purchases.  They choose to buy.

This means the producer will want to make his product as cheaply as he can to maximize profits.  He might

• try techniques like producing in bulk -- economy of scale, presuming that it gets cheaper and cheaper to make more and more of something in a uniform process.
• try techniques like having a gimmick or an improvement in his product that will add to rather than eat up profits.
• try to ensure that a customer or group of customers won't cut into his profits.  For instance, she won't want people asking for extras or changes to the basic design at no additional cost..  She won't want to be bothered delivering her product to a place where transportation costs outweigh profit, or where there aren't enough potential customers to make a profit. Think of cutting out train stations in small towns.

The consumer, on the other hand,

• will look for the cheapest price for the same article.  For instance, until the price of consumption outweights the price at the pump, people will drive around looking for the cheapest gas.
• Will buy the item with the gimmick only if  the price is comparable and the gimmick worth it.  Won't want to buy something with gimmicks or add-ons he has no perceived use for.
• Will  buy what is convenient rather than driving a huge distance to another town, for instance, to find it but will look for the cheapest available item in his area.

When healthcare coverage is a product on the free market just like, for instance, a home entertainment system, the producer

• will  want to minimize expenditures and maximize profit and so...
• will look for the equivalent of the cheapest methods of production.
• will want gimmicks and add-ons if and only if they increase profit.
• will not want to service consumers who will eat into his profits, especially eat most of them away.

The health insurance consumer

• will want to buy it at the lowest price he can.
• won't want gimmicks and add-ons  that jack up the cost and don't provide anything he needs.
• As a consumer in the market, won't want to pay more for the product so someone else can buy a better product at the same price he is paying for his cheap one.  That would be paying $30,000 for a Ford Escort so someone else can get a Lexus SUV  for $30,000.  Since buying the insurance at all is voluntary people who are young and healthy and possibly struggling to make a living aren't going to be willing to pay large premiums so old crocks can have expensive heart surgery or spend their last year on an expensive ventilator.

Although health care coverage is a product, that doesn't mean that it is the kind of product that can be successfully sold in the free market.

Health care coverage is a product in the sense that it has been created "by someone [or more than one] or by some process."   It is also a product in the sense that it is the consequence of  the problems individuals face when trying to pay health care costs out-of-pocket.

Home entertainment systems are products in the sense that they are "commodities offered for sale."

Yes, yes, I know.  Health insurance is currently a commodity offered for sale.  My point is that we've made the assumption that because it is a product, it must be saleable.  But there's no logical reason to assume that all products should be saleable.

Above I looked at products in terms of supply and demand: as the exchange in the process of supply and demand when it is understood as a market process.  So you can understand that all products are not necessarily suitable entries into the market process, here's a look at some products that are definitely not saleable, or at least aren't grabbed up as commodities:

• depression, a product of chemical imbalance, perhaps, or circumstances, or both.
• cigarette ashes, a product of the combustion of cigarettes used in smoking.
• dust bunnies
• parents' love for their kids, which some marketers try to exploit, but, which, by definition,  itself is not for sale to the kids.
• the cookies a parent makes for his kids.

Let's look specifically at  health care coverage as a product. (I say coverage instead of insurance, because what we need is coverage.  Coverage does not necessarily have to take the form of private insurance.)

• health care coverage is the product (result) of the need to pay for healthcare expenses.
• various kinds of health care coverage are products that have been created to meet the need to pay for healthcare expenses.

HOme entertainment systems are good products in the free market because:

• People don't need home entertainment systems. 

• People don't mind buying a more basic product for less money, though many will search for the most bang they can get for the buck.

• People don't need to go bankrupt to buy a home entertainment system. They don't need to buy the product to begin with if they can't afford it.

• The price of a home entertainment system goes up when it has more bells and whistles or if you choose to buy it on credit or to buy it somewhere close by but more expensive.  But  you don't have to buy it at all.
• Prices rise as demand rises, but the demand is a voluntary demand.

• The inability to buy  a fancy home entertainment center doesn't lead to pain and suffering or death or loss of a job or bankruptcy and loss of your home and your abilities.

On the other hand, people need healthcare coverage:

• While at any given moment in time, maybe half the population can get away with the more basic product for less money, at another given time, most people will need healthcare coverage.
• The sicker they are, the more they need it, the more expensive the coverage becomes.  They can't say, we can't afford the high-end product.
• The inability to buy a high end product can lead to increased health problems, job losses, disabilities of all sorts, bankruptcy, loss of your home and even death.

In the free market game between seller and buyer, both should be playing from positions of some strength.  In the home entertainment system game, both can, even if one is playing at the low end of the cost side of the field.  In the healthcare coverage game,  when health care coverage is part of the free market game, as the buyer's need becames greater, both buyer and seller lose out.  The buyer can't afford to buy what he needs because the seller can't afford to sell it at a price the buyer can afford.

 

Private health insurance as a luxury product

A system with ever-rising costs and ever-less protection:

• Premiums rise for all, but especially those with greatest need and often least ability to pay.
• Lack of affordable comprehensive coverage.
• Inadequate coverage can lead to inadequate treatment.
• Inadequate coverage can lead to bankruptcy.
• Interrupted coverage as well as no coverage can lead to bankruptcy.
• Coverage can be interrupted by the medical need itself.
• Health-care coverage related financial disaster can affect rich and poor alike.  In fact, the middle class is far more likely than the poor to find itself bankrupted since the poor don't have enough to face bankruptcy.  Medical expenses can  be so high they overwhelm the rich as well.

Currently, rather than absorbing  many of these rising costs in their coverageinsurance companies and employers shift them onto the consumer and the government.  They are not contained.  This is called cost-shifting.  Consumers see this in

• Increased copays, deductibles.
• Corporation cancellation of retirement coverage leading to increased burden for individuals, Medicare.
• Excluding increasng numbers of conditions from coverage  meaning individuals or states (try to) pay for treatment of the most expensive problems.

Administrative chaos reins:

• Healthcare providers must deal with a myriad of diagnostic guidelines, insurance forms, coverages and payment structures.
• Administrative costs overall for the U.S. are equivalent to at least 31.0 per cent of health spending.  Canada's national health program has costs amounting to about 16.7 percent.
• Administrative personnel were 27.3 percent of all health care work force employees in 1999, excluding almost 1 million life and health insurance company employees and 724,000 insurance brokerage employees.

Insurance companies need to make profits.

• They try to eliminate consumers who are likely to cost them money.  In this country, the 1 percent of the population that needs the most healthcare accounts for 30% of all health care spending, the most expensive 50% (which includes the above 1%) accounts for 97 percent of all health care spending, and the generally well 50% of the population accounts for a mere 3 percent of the healthcare spending.  Since half the people in the country are okay, with only minor problems, they are the most desirable customers since less of their premium goes to pay for healthcare.  They also are unlikely to be aware of the difficulties of the sicker members of our society in buying insurance, since if insurance companies have anything to do with it, those sick guys pay a lot more.
• An important concept:  very few of us will die instantly while completely healthy.  We will end up drifting into the more expensive care categories as we age and/or acquire chronic health problems. Some of us will drift in and out of the high-cost categories.   If we can only think of ourselves as a bunch of individuals, each one for himself, we will condemn most of us to misery when we are older and sicker and can not afford the insurance rates.  By sticking to the idea that it's okay to pay for a bit more than we use right now, we are insuring that there will be enough to help us out when we need it.  It's not just compassionate, it's self-interested to do this.  Similar principle with Social Security. 
• Insurance companies would rather not have to deal with the unexpected or the great cost of the very sick.  They try as hard as they can to cover people who need as few of their services as possible.  This doesn't really make the insurance companies villains: it means that they operate within the context of a free market system rather than outside it.

Some resources I used:
Note:  Since I am not writing this blog on assignment for anybody, I take liberties and am lazy about alphabetizing, and formatting my source lists.  I do, however, try hard to be accurate and reliable, to report things as they are written by others, and to use credible resources.

Blumberg, Linda J. and Nichols, Len M., Health Insurance Market Reforms: What They Can and Cannot Do, Urban Institute, 1995, http:// www.urban.org/urlprint.cfm?ID=5870.

Butrica, Barbara, Goldwyn, Joshua, Johnson, Richard W., Understanding Expenditure Patterns in Retirement, Center for Retirement Research at Boston College, January 2005, http://www.bc.edu/centers/crr/paper/wp_2005.3pdf.

Geyman, John P., Myths and Memes about Single-Payer Health Insurance in the United States:  A Rebuttal to Conservative Claims, International Journal of Health Services, Volume 35, Number 1, Pages 63-90, 2005.

Hall, Douglas, Commercial Health Insurers: Intermediaries in Health Care Finance, New Hampshire Center for Public Policy Studies, 2004, http:www.nhpolicy.org

--- What is HIPAA [The Health Insurance Portability and Accountability Act of 1996], Office of Medicaid and Medicare, Department of Health and Human Services,  http://www.cms.hhs.gov/hipaa/hipaa1/content/more.asp

Many ideas, insights, facts and paths for exploration come from  the ever-useful and interesting items that apppear on Don McCanne's Quote of the Day Mailing List, Quote-of-the-day@ccanne.org , http://two.pairlist.net/mailman/listinfo/quote-of-the-day
This mailing list sends short clips from articles and proceedings from journals, magazines and presentations addressing issues pertinent to our healthcare coverage system.  They support the concept of a single-payer system, but McCanne includes a fair amount of dialogue on the subject. 

   

Why is health care so expensive? A diagram

A diagram of all the factors driving up the cost of health care in the U.S:

Download the_current_state_of_health_care_coverage_is_a_mess.doc

A first look at capitalism: the role of people in macroeconomics

Economists' view of the world

Remember, economists view the world, at least the economic world, as a mechanical system.  This view can be diagrammed in black and white.  Many economists believe that while they may not completely understand the system, it exists in a pure and predictable form.  That is, they 're not going to create it: they are going to continue to discover  how it works.  Their assumptions are based on the belief that there are principles upon which the world and the universe operate which are pretty much unchanging.  This belief  comes from the development of what are called "hard sciences" like physics and chemistry where scientists make observations and test them and then conclude that they have found phenomena that are  predictable, like gravity or the rotation of the earth on its axis.  Since we humans are also phenomena of the universe, the assumption is that we, too, follow predictable rules even if our spouses don't think we do.  Efforts to find timeless rules for human behavior using what the scientific method have led to the development of the "soft sciences" like economics, political science, sociology and social psychology.  I would agree with people who also think the study of humans acquired a scientific veneer because beginning in the nineteenth century, people tended to overuse and overvalue scientific approaches to learning at the expense of more subjective ones.  Thus, to gain respectability, people interested in human development found it necessary to frame their investigations in the language of science.

This is not really bad when scientific tools of observation and measurement are not the only tools valued, but it is when they are the only ones.  Today, in our country at least, this is what has happened so that we see art and literature  devalued into fringey subjects, not things kids should learn about or from in school, and we see the emphasis put on only what is "practical." In fact, art and literature and theater and education now are framed in economic terms and seem to have to hold their own as simply economic products.  When a city decides it really needs its symphony orchestra as San Antonio, Texas has, its argument for funding it is that it will "attract business."  The new head of the symphony was hired because he would incorporate "good business practices" with the hope that the symphony by itself would turn a profit, necessary to continue justifying its support. 

Another negative consequenceof our devotion to the soft sciences not just of economics but of sociology and others  is that we allow ourselves to be driven by what is not even  good soft science: poorly tested hypotheses become driving forces in our culture: for instance, how our culture uses the concept of self-esteem.

While there is great value in a "social science" or "soft science" approach to some human problems, it is an approach which, if universalized, deprives us of awareness of much that is inherent in our nature.

So what does all this have to do with economics?  Economics is a "soft science."  Like other soft scientists, some economists think they are working in a "hard science."  They push and pull at the systems they perceive but do not really question whether the system as they see it actually exists.  The pushing and pulling makes things happen within the system they have defined, but that system excludes many of the forces shaping people, cultures, the physical environment  of the world and also blinds them to the consequences of pushing and pulling within their system.  More seriously, we've generalized their system and turned it into dogma.  Thus, in U.S. we have running our government people who might be called economic ideologues.

So.  Let's look at how human beings are defined in economics.

Most basically, economists think that humans act rationally. This doesn't mean that we would all agree that each others' decisions are sensible or smart, but rather that within the context of each person's mind, she is making a rational choice.   And our lives are, in this context, always a series of choices.  We choose whether to get out of bed each day, for instance.  When we make our choices, we do so bydeciding which decision is better according to our values and  prioritizing.  So when the alarm goes off, we might decide we can snooze for another ten minutes.  If we do that, maybe we've asked ourselves (almost without thinking about it) whether we value some more dozing more than we value getting up and getting ready for work right away.  We would consider things like whether we would be late or not, whether the pleasure of the sleep outweights the pleasure of a cup of coffee right away, and so on.

Generally, economists and many other people assume that this rational decision making for choosing alternatives is  always establishing priorities for the use of time and money or even just money:  a human being as homo economicus  That is, that every person's decisions, whether made consciously in these terms or not, could be quantified in terms of money. 

Today economists are not so simple-minded as to say that every decision people make is exclusively in one's own self-interest.  There is room for altruistic decisions and for group decisions.  But they would say that it is still an individual's rational decision to accept a group's decision.

In the United States, official economic thought is dominated by free market economists, perhaps ironically considered liberals.  These economists and the politicians they influence and the businesses that benefit from free market ideology consider that humans are  homines economici and that freedom is the freedom to make rational economic choices: therefore, the government should not in any way interfere with the freedom of the market so as not to interfere with a person's freedom to make market choices, the true meaning of freedom.  This is an extreme view in the larger world.

Remember, underlying this homo economicus the idea of people's choices always being rational, even if they might not all have economic implications.  Thus, today even in the United States there are efforts to enlarge the definition of  the rational choices people make.   There is still not too much attention paid to the idea that some choices may be completely irrational and that completely irrational choices may have a larger effect than on the individuals making them.

Some articles I referred to for the information on homo economicus:

McCaffery, Edward J and Siemrod, Joel (2004): "Toward an Agenda for Behavioral Public Finance" in University of Southern California Law School:  University of Southern California Law and Economics Working Paper Series

Mertinez Coll, Juan Carlos (2001): "Las deciones individuales"  en La Economía de Mercado, virtudes e inconvientes

Zafirovski, Milan (2003): "Human Rational Behavior and Economic Rationality"  in Electronic Journal of Sociology (2003)

--- (December 2, 199): "The human factor: rational economic man" in The Economist (US)

If you read Spanish, a wonderful site for explanations of economics of all sorts is at the University of Malaga en Spain:  http://eumed.net/cursecon/.

 

Costs of increased costs of healthcare coverage for employees

The  California HealthCare Foundation reports that increasing the share employees pay for their health coverage, originally intended to "encourage workers to spend wisely" -- the assumption being that when too much was covered, employees just ran to doctors at the drop of a hat -- has the unintended consequence of causing at least some to forego needed care.

A survey conducted by Harris Interactive of California employers, residents and adults with chronic illnesses revealed that the increase in cost to employees has resulted in a number of  those with lower incomes, fair to poor health or chronic diseases to forego needed medical care.  Some 40% of employers also think this contributes to lowered productivity.  The survey reported that overall one in seven adults with increased cost-sharing of medical coverage did not sseek medical care due to costs.

Kaiser PErmanente commissioned a survey that indicated that even the very wealthy had concerns about health care, in particular that catastrophic illness could eat up all their wealth even with coverage.

The information with links to the surveys can be found at Quote-of-the-Day.  To join the mailing list, go to http://two.pair list.net/mailman/listinfo/quote-of-the-day.