Abstract
Abstract
Primary care coverage for the uninsured is the first necessary step to reform and can be more cost effective and tolerable than a major system reform. By providing foundational care to the uninsured, more care resources are targeted to those that most need the services, while providing benefits such as increased productivity and reduced inappropriate emergency department utilization. The authors aimed to design a primary care coverage system in the United States for the uninsured using established reimbursement, budgeting, and compliance methods. Providing four primary care visits for acute care, four associated ancillary and four fulfilled pharmaceutical–treatment prescriptions, and one preventive primary care visit per year for nearly 48,000,000 uninsured would cost $36 per month for every working American and legal alien resident. Theoretical and empirical literature was reviewed and the authors applied practical knowledge based on their experience in healthcare systems to develop the Access America Program.
Over the last decade the healthcare system has continued with relatively the same level of access to care for most Americans. Even though upwards of 84% of Americans have some form of health insurance, the rising cost of care, the large group of uninsured and underinsured (with a significant number consciously choosing not to have insurance), and the lack of focus on primary care have been contributors to the present economic situation. Looking back over the last decade, how prophetic is this statement? “Health Costs Rob Big 3 Bottom Line” (Webster 2002, p. 1A) was the headline of The Detroit News and Free Press on December 1, 2002, referring to the dilemma faced by the American producers of automobiles in providing health insurance benefits to their employees and the employees’ dependents.
In 2002, with health insurance accounting for $1,300 (Webster 2002) of the price tag for each American-made automobile, the United States automobile industry found itself losing ground to foreign competition in the global car market. Actual per capita spending in 2000 on healthcare in the United States was $4,631, whereas auto producing competitor nations spent far less during the same year. For example, Germany spent $2,748 per person and Japan's per capita medical bill was $2,012 (Webster 2002). U.S. per capita was $8,160 in 2009 with projections by the Center for Medicare and Medicaid Services (CMS) at over $13,000 by 2018 (Kaiser Family Foundation 2009). Germany and Japan's gross domestic product (GDP) attributed to healthcare has been stable, whereas the U.S. GDP attributed to healthcare continues to grow, making international competition even more difficult. At the same time, it is more than ironic that the average life expectancy is greater in Germany and Japan than it is in the United States. Debates continue to occur regarding healthcare costs in the United States, and solutions seem to be in short supply. However, in Germany for example, primary and preventive care hold far higher status for the nation's citizens as compared to the United States.
The cost of healthcare is a major problem in the United States, and it is a major factor in another very serious social conundrum: the number of Americans without any form of health insurance coverage. Trade and commerce organizations fear that even for otherwise robust business enterprises, “Healthcare costs would eventually cross a threshold of affordability for many Americans (or the businesses that subsidize their coverage)” (Cudney and Klepper 2002a, p 353). In 2002, over 41 million Americans had already fallen beneath this threshold, and are now in the ranks of the uninsured. In 2009, the number of uninsured ranged from 45 million to 48.1 million (Cover the Uninsured 2009; U.S. Census Bureau 2007). The problem continues to increase.
“The burden associated with the growth of the uninsured would fall directly on the nation's safety-net infrastructures, and without additional allocations many of those structures would begin to collapse.” (Cudney and Klepper 2002a, p. 353) Why is health insurance so important? Rhoades (2005) offered this explanation:
First health insurance was viewed as necessary to ensure that people had access to medical care and protection against the risk of costly and unforeseen medical events. Second, timely and reliable estimates of the populations’ health insurance status were vital to evaluate the costs and expected impact of public policy interventions to expand coverage or to change the way that private and public insurance was funded. (p. 1)
We suggest that although providing full medical coverage to all uninsured Americans may be cost-prohibitive, a very realistic incremental step would be to provide basic, primary health benefits (American Academy of Family Physicians 2010; Collins et al. 2007; Cudney and Klepper 2002; Freeman 2010) to all Americans.
Using the past decade as a barometer, the value of the healthcare dollar in the United States. has not been as high as in our automobile-producing allies. These trends continue today except that the U.S. GDP expenditure on healthcare is higher and thus, produced even less value over the past decade. A closer examination of healthcare in the United States as compared to other automobile producing nations reveals some interesting information about public programs (Organization for Economic Development and Cooperation 2001, 2009). Even though the following data focus on national rates, the value question needs examination for the United States. The infant mortality rate in the United States, for example, is more than twice the rate of Germany or Japan. These data exclude commercial/private insurance programs (estimates in brackets include commercial and private market share information).
| • | Life expectancy at birth in 1998 and 2006, with mean value for 1999–2006 | ||||
| • | United States: 76.7, 78.1, 77.4 years | ||||
| • | Germany: 77.5, 79.8, 78.8 years | ||||
| • | Japan: 80.6, 82.4, 81.7 years | ||||
| • | Total expenditure on health as a percentage of GDP in 1999 and 2007, with mean value for 1999–2007 | ||||
| • | United States: 12.9%, 16.0%, 15.0% [N/A] | ||||
| • | Germany: 10.3%, 10.4%, 10.5% [11%] | ||||
| • | Japan: 7.4%, 8.2%, 8.0% [N/A] | ||||
| • | Total healthcare insurance coverage as a percentage of population in 1997 and 2007 with a mean value for 1997 through 2007. | ||||
| • | United States: 45%, 47%, 46.3% [82%–85%] | ||||
| • | Germany: 92.2%, 92.8%, 92.6% [99%] | ||||
| • | Japan: 100%, 100%, 100% [N/A] | ||||
In comparison, the United States spends much more on healthcare (reducing the ability for competitive pricing on the global market) and offers fewer services to its citizens, yet life expectancy is appreciably less than Germany or Japan. Much of the reason for these differences is found in how the cultures promote and provide for prevention, public health, and primary care. For example, when an uninsured American is ill, and being aware that he or she cannot afford or fully afford the cost of care, the individual often waits to seek care with the concomitant result that the acuity or severity of the problem increases (in many cases). Thus, when treatment is sought, the cost of treatment is much greater than what it would have been had the person sought medical treatment at the onset of the problem. Further, it can be extrapolated to this example the further societal issues of not just infection, but also complication rates due to untreated illness and disease and the costs of widespread productivity loss.
Indeed, in dealing and caring for the uninsured, hospitals across the United States spent $19 billion (6% of total expenses) on uncompensated care (also known as charity care) in 1998 (an increase from $18.5 billion in 1997; Bellandi 1999) and $26.9 billion in 2004 (American Hospital Association [AHA] 2001). The figure of $26.9 billion dollars equals or exceeds the total net margin and profit of hospitals, which is the amount needed to be invested in new capital equipment and health service programs (AHA 2001). In 2004, hospitals spent 5.6% of total expenses on uncompensated care (AHA 2009).
The United States has struggled mightily over the last two decades to control healthcare cost. This being said, we assert that it is imperative that the nation provide basic primary care for its uninsured. These two issues at first blush seem to be at odds. After all, how does the nation control total healthcare spending and yet provide additional healthcare to millions? In the remainder of this article we build the case for developing a program for the uninsured while providing emphasis on primary care and prevention within a cost-controlled structure.
The basic value question of a nation, as related to the uninsured, is whether primary healthcare is a right or a privilege. We take the position that primary healthcare ought to be considered a right of citizenry, and a right that should be funded in a prudent fashion. It is easily demonstrated that access to primary healthcare shows the comparison of a nation and contributes to the overall productivity and safety, and thus should be considered a public good. Primary care for all citizens (universal access) is a public good when including in the calculation (1) infectious disease rates and infection transfer rates (around the world, infectious disease is the second leading cause of lost years of work and cessation of life); (2) the reality of global travel and the relative ease of worldwide transmission of disease; (3) the need for a clinical infrastructure that can deal effectively with the spectrum of care needed to deal with present and future bioterrorism threats, including immunization, general prophylaxis, detection, and rapid response; and (4) the need that a society and its citizens have to build a sense of compassion for each other.
With these issues considered, Access America, a primary care and prevention program for the uninsured in the United States, was conceptualized. Hopefully Access America will be considered by national leaders and legislatures as a viable option to address more assertively the problem of the uninsured.
Dilemma of the Uninsured in the United States
In the year 2001, an estimated 14.6% of the American population, or 41.2 million people, were uninsured. By 2004, this number grew to 48.1 million uninsured individuals. “For the first half of 2004, the most recent MEPS-HC estimates available, 19.0% (48.1 million people) of the non-elderly population was uninsured” (Rhoades 2005a, p. 2). In comparison, approximately 240.9 million Americans had health insurance coverage in that same year (Mills 2002; U.S. Census Bureau 2002). In 2009, the number of uninsured individuals ranged from 45 to 48.1 million (Cover the Uninsured 2009). Young adults (18–24 years old), American Indians, Alaska Natives, and residents of New Mexico and Texas were most likely to not have health insurance as compared to other groups (U.S. Census Bureau 2002).
It is important to emphasize that many working Americans lack health insurance coverage as well. Among Americans aged 18–64 years, more than 17% lack health insurance and nearly 20% of uninsured are children. Nearly 40% of uninsured children live in poverty. Hispanics are most likely to be uninsured. In 2007, nearly 34% of the uninsured were Hispanic. Other minority groups also suffer disproportionately. Even more surprising is that fact that over two-thirds of the uninsured hold full-time jobs (Cover the Uninsured 2009).
A study by the Center for Health System Change reported that at least 7.4 million adults with chronic conditions lacked health insurance in 1999, confounding the problem (Parker 2002, p. 3). Furthermore, lack of health insurance influences the health behaviors of the uninsured. They are less likely to obtain screenings and participate in other health promotion programs than are the insured. In 2005, nearly 7% of uninsured women had never had a Papanicolau smear, compared to 3.2% of insured American women. Similarly, 34% of uninsured women had never had a mammogram and 61% of uninsured men had never had a prostate exam (compared to 25% and 44% of the insured, respectively; Cover the Uninsured 2009).
The combination of uninsured with a chronic condition, and uninsured with acute episodic conditions, puts a Herculean burden on the healthcare system. People without insurance (chronically and acutely ill) tend to wait to seek healthcare; subsequently their episodic and noncontinuous care increases the acuity of their primary complaints, which are often comorbidities. The lack of continuity of primary care for the uninsured is a serious problem and over time this problem becomes larger and more complex. At the front lines of care for the uninsured are the local hospital emergency departments.
Overburdened Emergency Departments Threatened By the Problem of Uninsured
Emergency Departments (ED) across the nation are in crisis because of the perfect storm caused by the immense uncompensated care burden of the uninsured, lower reimbursements, and government regulation (Carpenter 2001). The Emergency Medical Treatment and Labor Act (EMTALA), an unfunded mandate passed into law in April, 1986, requires emergency departments of participating Medicare hospitals to screen and treat anyone with an emergency medical condition. The viability of hospitals is severely compromised by an emergency department function that struggles with the growing ranks of the uninsured (Carpenter 2001). Unless the project is addressed (to include dealing with the nation's uninsured), average Americans may find it increasingly difficult to access emergency care in their communities (Menninger 2002; Parker 2002).
Americans with chronic diseases and without health insurance significantly add to the overuse and abuse of hospital emergency rooms (Parker 2002). 45% of uninsured Americans with chronic diseases have incomes less than 200% of the poverty level (Cover the Uninsured 2009). Little has changed in this respect over the last decade. Emergency departments are overburdened by inappropriate use by the nation's uninsured chronically ill (Parker 2002). The uninsured utilize the emergency departments of local hospitals at twice the rate of insured persons (Parker 2002) The care provided in the emergency department is not the most effective, efficient, or efficacious for primary or acute care needs (Carpenter 2001). The results of years of emergency department misuse include over 1,100 emergency departments closed in the past decade, exhausted staff, physicians refusing to work in the ED, and inefficient primary care (Carpenter 2001). Emergency departments are in serious trouble given the state of healthcare, regulation, and the uninsured (uncompensated care). It is not unusual for many hospitals around the country to simply, and often unexpectedly, close their ERs for a short time to reduce growing financial losses (Menninger 2002). A significant number of emergency department patient visits are from the 45 million Americans without health insurance (Carpenter 2001). This trend continues with a greater number of uninsured.
The financial burden of uncompensated care is severe for hospitals and physicians across the nation. In 1999, “nationally, an estimated 150,000 people owed $50,000 or more in unpaid medical bills and an estimated 20% of the 1.4 million bankruptcies each year are due at least in part to high medical expenses” (Seifert & Sokol 1999, p. iv). In 2002 in Michigan, “hospitals reported charges of over $1.1 billion for uninsured and uncompensated care in 2000 with associated costs of $456.2 million after accounting for recoveries, offsets and private payment receipts” (Citizens Research Council 2002, p. 1). These trends have continued and worsened over the past decade.
In the 1990s through the early 2000s, hospitals across the nation contributed to the welfare system through uncompensated care. Georgia hospitals reported spending over $1.28 billion in indigent or uncompensated care each year (Rust 2000). Missouri hospitals incurred $364.6 million in uncompensated care costs in 1995 (Burda 1996). “Wisconsin hospitals recently reported a 60% increase in uncompensated care since 1996 and nearly a quarter of them (the hospitals) lost money on patient care in 2001” (Receivables Report 2002, p. 10). Over 82% of California emergency departments reported financial losses totaling $325 million in 2000, over $8 million more than in 1999, and this financial burden has created an environment that fosters ED closure; in fact, 10 emergency departments closed in 1999 and more than 60 have closed since 1990 (Health Forum 2001). Again, these trends continue to burden the healthcare system of the nation.
Physicians are also burdened by the uninsured. According to the California Medical Association, physicians in that state lost an estimated $130 million in 2001 due to the uninsured uncompensated care burden (Fujimoto 2002).
Business Feels the Consequences of the Uninsured Problem
Not only do healthcare costs reduce the nation's ability to compete in the global marketplace, but the loss of productivity due to illness or injury is of concern to any business. For the uninsured, time away from work further complicates family financial issues but also decreases overall productivity of the nation. Median time away from work in 2000 due to illness and injury was six days (median: men = 6 days; women = 5 days; U.S. Bureau of Labor Statistics 2001a). A total of 1,664,000 days away from work were reported (those that were reported) in 2000 (U.S. Bureau of Labor Statistics 2001b). In 1996, temporary illness or injury caused 1,234,000 people between the ages of 20 and 64 years to miss work (Weismantle 2001). The mean days of missed work ranged from 6 to 9 days. Using the median days of missed work per person (6 days) and the number of people missing work due to temporary illness or injury (1,234,000) by a very conservative percentage of Americans without health insurance (14.6% and removing the 24.7% of the uninsured that did not work), a crude estimate of workdays missed is calculated to be nearly 814,000 days attributed to uninsured working Americans. If those Americans had health coverage, how many days of missed work and productivity could have been avoided? If only 20% of those lost workdays of the uninsured could have been avoided, over 160,000 workdays could have been added to the nation's productivity.
In retrospect, considering the last decade, and given current discussions of health reform, what makes the most sense for the U.S.? Historical literature review coupled with practical experience served as the basis for the methods used to set the stage to develop a value—seeking solution. The solution must be fiscally responsible and yet, provide the basic access to care needed by so many Americans.
Access America: A Primary Care Program for the Uninsured
The natural question arises: Why not simply provide total healthcare insurance coverage for the nation's uninsured? The straightforward answer: money and politics. A simple estimate of cost to provide comprehensive coverage for the uninsured would range from an additional $927 to $1,854 per working family or single person in tax burden per year, at the conservative end, to an additional $2,107 to $2,776 per working family or single person in tax burden per year. We maintain that this additional tax burden would not be acceptable to average Americans, given the present economic, political, and socioeconomic environment.
There is a good middle position, however. As a step in the right direction, a primary care and prevention program for the uninsured would be far less costly and probably more palatable to the nation's taxpayers. A program that would cost less than $435 per working family or single person on the high side may be the solution as an incremental step to address the uninsured problem. This proposed program is Access America (AA). Two additional variations of the proposed program are also presented, and are called Access America Plus (AA+) and Access America Plus Plus (AA++). These two additional versions would provide somewhat more extensive benefits and therefore are higher in cost, as indicated. Each of these programs would be countrywide and would not include regional variations due to Geographic Practice Cost Indices (GPCI) in payment structure.
A is designed to be a primary care and prevention program for the uninsured in the United States. It would provide five primary care visits (and one of the visits for preventive services) a year for those among the uninsured who earn up to four times the federal poverty level. AA+ provides five visits and four ancillary authorizations attached to those visits (e.g., laboratory, radiology, physical therapy, occupational therapy). In addition to the AA+ benefits, the AA++ program would provide four pharmaceutical prescriptions per year. Primary care visits for program beneficiaries that exceed five visits, four ancillaries, and four prescriptions would be paid out of pocket by the beneficiary or patient up to the amount allowed in the program ($268.70).
The program could be run through the established CMS system for eligibility, claims processing, reimbursement, and compliance. The existing regulations regarding Medicare Part B and Medicaid would be utilized to provide the regulatory structure for this program. This model addresses many of present healthcare issues: the need for primary care for the uninsured; the uncompensated cost burden on the nation's hospitals and physicians; the needed collaboration between healthcare providers in a community (e.g., hospitals, physicians, ancillary providers); and the fee schedule set within an established cost control structure (the Relative Value Unit [RVU] conversion factor; 2009 conversion factor is $36.067; Centers for Medicare and Medicaid Services [CMS] 2009). The program costs presented are maximum costs; ancillary services, and pharmaceutical prescriptions that cost 15% or more below the allowed 2.25 RVU times conversion factor rate should be reimbursed at cost plus a reasonable margin or profit (e.g., 7–12%).
METHOD
In retrospect, considering the last two decades, and given present discussions and legislation of health reform, what makes the most sense for the United States? Historical literature review coupled with practical experience served as the basis for the methods used to set the stage to develop a value-seeking solution. The solution must be fiscally responsible and yet provide the basic access to care needed by so many Americans. In devising a national primary care coverage program (versus a universal insurance program), data elements for the uninsured, RVU costs, and productivity rates were obtained as referenced and provided the input variables for a program modeling process for the progressive program.
The model response variables of cost, tax base implications, and productivity improvements were compiled. A sensitivity analysis, based on program stages was conducted for cost, tax implications, and productivity enhancements (AA, AA+, AA++).
Table 1 Program Basics and Cost
Table 2 Access America Program Efficacy and Cost
Table 3 Access America Tax or Philanthropic Burden Per Capita
RESULTS
The tables illustrate the benefits of the AA program, costs, and burden on the working citizens of the United States.
As shown in Table 1, the progressive AA program would be available to uninsured Americans who earn under four times the poverty level. It is estimated in this structure that approximately 99.5% of the uninsured would be covered by this program. Mandatory primary care coverage for working adults who opt out of employer-based coverage (as a benefit to employment) could further reduce the overall cost of the program by reducing the number of eligible citizens for this program. The program costs include administrative (5.2% of program costs) and marketing (3% of program costs) resources that would be necessary to have a viable program (Book 2009; Healthcare Economist 2006). The AA program (with five provider visits per year) pays nearly three times (2.95) the established conversion factor, whereas AA+ and AA++ pay two and a quarter conversion factors per use (up to four times a year). The provider is paid an RVU of 2.95 (approximately $108) based on the 2009 conversion factor rate for an AA visit. This compares to a 2001 mean RVU cost of 2.9529 (CMS 2001) for the average provider (work RVU = 0.9952174; practice expense RVU = 1.004913; malpractice RVU = 0.9527826).
Table 2 illustrates the reduction in net cost to the U.S. taxpayer as the AA program benefits improve health and reduce missed workdays. Assuming program enrollment of 47,859,500 of the previously uninsured, with each person losing eight workdays per annum while uninsured, equates to 382,852,000 lost workdays per year. Each of the plans (AA, AA+, AA++) is proposed to reduce missed workdays by 30%, 40%, and 50%, respectively. The reductions in workdays lost are expressed as potential workdays gained in Table 2. The value of these workdays gained ($120/day) reduce the net program cost. Net program costs are further reduced by considering the tax impact to workdays gained. Additional workdays, using $120 as a conservative estimate for the value of a day of work, would increase the tax income between $689,176,800 and $1,148,628,000 (depending on program) using the tax burden/rate of 5% for the population covered under this program. Therefore, this program could result in improved productivity through the avoidance of loss of productive days. However, there are a number of unemployed individuals that are uninsured that could not be included in this estimation because they are not working.
The AA program, considering the three variants of the program, costs between $194.58 and $432.03 per capita for full-time employed persons, equating to a $36 per month tax burden for employed Americans and legal alien residents. Paying for the AA programs could be achieved from one or a combination of alternatives. Table 3 shows the per capita cost burden for this program.
DISCUSSION
The U.S. federal government has grappled with the dilemma of the uninsured many times over the last several decades, and most notably in 1993 when a national consensus proposed that total, universal healthcare coverage was too much and too expensive. Even the recent health reform legislation does not provide foundational health services and access to the extent necessary to benefit the nation considering the value of tax dollar expenditures attributed to healthcare. At present, the U.S. needs a fresh perspective and a practical, incremental model for delivering primary healthcare to substantially all Americans. AA is a potential solution to the issue of rising healthcare costs and access disparity in today's society.
Although a detailed discussion of funding models and alternatives could create a volume of text, the following are potential methods worth pursuing, presented in order of political possibility.
| • | Requiring mandatory primary care coverage (based on minimums of the Access America program) for all working adults who earn or gross four times or more above the poverty level; this enhancement would reduce the overall cost of the program; | ||||
| • | Developing a corporate donation-based program for tax deductions for individuals and businesses (per capita costs are shown at the bottom of Table 3); | ||||
| • | Developing a collaborative hospital–physician partnership in which the physician bills the AA program and the hospital subsidizes the physician for the care because the program would reduce the uncompensated care burden on hospitals, although it could increase the burden on physicians; it is in the hospitals’ best interest (and in the best interest of the uninsured patient, considering continuity of care) to shift acute care uninsured patients away from the emergency room; | ||||
| • | Initiating an increase in sin taxes (e.g., tobacco, alcohol, gambling); | ||||
| • | Installing a tax base and income shift from an existing set of programs, and a federal block grant to the states. The individual states would administer the program, using the same state infrastructure that presently administers the Medicaid programs; | ||||
| • | Initiating a general income tax increase. | ||||
As with all healthcare reform programs, there is a potential for negative impact due to the implementation of the AA program. The following should be considered with the Access America program.
| • | The possible disincentive for employers to reduce or eliminate employer-based health insurance, especially during periods of economic slowdown; | ||||
| • | The possible increase in fraud and abuse of the federal healthcare payment system; | ||||
| • | The possible legal challenges to a system that provides a narrowly defined set of primary care benefits (similar to the Oregon Medicaid experience); | ||||
| • | The possible negative political fallout from perceptions of a federalization of local healthcare delivery; | ||||
| • | The possible negative financial fallout from society some day expecting the federal government to provide greater than just primary care benefits (i.e., total, universal healthcare benefits); and | ||||
| • | The lack of secondary and tertiary care connected to the program. | ||||
The implementation of AA could potentially solve the problems that have created a need for healthcare reform in the United States. It would open the doors for thousands of Americans that presently do not have access to primary care providers. In doing so it should effectively improve the health outcomes of all Americans. Over a generation, this program could reduce the chronic care burden on the secondary and tertiary care system as well (consider Medicare costs). This reform solution could be the next step toward progress in healthcare.
| Variable | Access America (AA) | AA+ | AA++ |
|---|---|---|---|
| Number of individuals without health insurance (uninsured) | 48,100,000 | 48,100,000 | 48,100,000 |
| Federal poverty level | 4 times ceiling | 4 times ceiling | 4 times ceiling |
| Estimate of percentage of uninsured covered by program based on federal poverty level | 99.50% | 99.50% | 99.50% |
| Eligible individuals in program | 47,859,500 | 47,859,500 | 47,859,500 |
| Number of annual primary care visits authorized (4 visits for acute care, 1 visit for preventive medicine) | 5 | 5 | 5 |
| Annual cost of primary care visits | $25,460,409,279.83 | $25,460,409,279.83 | $25,460,409,279.83 |
| Number of annual ancillaries authorized (e.g., lab, radiology) | 0 | 4 | 4 |
| Annual cost of ancillaries | $0 | $15,535,164,984.30 | $15,535,164,984.30 |
| Number of annual prescriptions authorized | 0 | 0 | 4 |
| Annual cost of prescriptions | $0 | $0 | $15,535,164,984.30 |
| Annual subtotal cost of primary care for program | $25,460,409,279.83 | $40,995,574,264.13 | $56,530,739,248.43 |
| Estimated percentage for administration of the program | 5.20% | 5.20% | 5.20% |
| Annual cost of administration | $1,323,941,282.55 | $2,131,769,861.73 | $2,939,598,440.92 |
| Estimated percentage for marketing of the program | 3.00% | 3.00% | 3.00% |
| Annual cost of marketing | $763,812,278.39 | $1,229,867,227.92 | $1,695,922,177.45 |
| Annual subtotal cost of administration and marketing for program | $2,087,753,560.95 | $3,361,637,089.66 | $4,635,520,618.37 |
| Total annual cost of program | $27,548,162,840.77 | $44,357,211,353.78 | $61,166,259,866.80 |
| Note. The conversion factor used in the analysis was $36.067. | |||
| aCenters for Medicare and Medicaid Services 2009. | |||
| bHealthcare Economist (2006). | |||
| Variable | Access America (AA) | AA+ | AA++ |
|---|---|---|---|
| Program efficacy percentage | 30.00% | 40.00% | 50.00% |
| Potential work days gained | 114,862,800.00 | 153,150,400.00 | 191,438,000.00 |
| Value of work days gained | $13,783,536,000.00 | $18,378,048,000.00 | $22,972,560,000.00 |
| Net program cost before tax multiplier | $27,548,162,840.77 | $44,357,211,353.78 | $61,166,259,866.80 |
| Tax base gain (without multiplier effect) | $689,176,800.00 | $918,902,400.00 | $1,148,628,000.00 |
| Net cost of program | $26,858,986,040.77 | $43,438,308,953.78 | $60,017,631,866.80 |
| Note. Lost work days per uninsured = 8; eligible individuals in program = 47,859,500; estimated value of one work day = $120; tax burden percentage on uninsured = 5%. | |||
| Funding burden | Access America (AA) | AA+ | AA++ |
| Annual cost per capita | $89.60 | $144.27 | $198.94 |
| Annual cost per employed capita | $194.58 | $313.31 | $432.03 |
| Monthly tax burden per employed capita | $16.21 | $26.11 | $36.00 |
| Note. Approximate number of Americans and legal aliens = 307,455,700; number of employed Americans and legal aliens working full-time (does not include part-time workers) = 141,578,000 (U.S. Bureau of Labor Statistics n.d.); conservative absolute mean federal tax rate = 12%. | |||
REFERENCES
- American Academy of Family Physicians. 2010. Health care for all: A framework for moving to a primary care-based health care system in the United States http://www.aafp.org/online/en/home/policy/policies/h/healthcare.html (accessed June 25, 2010) [Google Scholar]
- American Hospital Association. 2001. For the record, uncompensated care costs rise. Modern Healthcare, 31(6): 22 [Google Scholar]
- American Hospital Association. 2009a. Uncompensated care fact sheet http://www.aha.org/aha/content/2005/pdf/0511UncompensatedCareFactSheet.pdf (accessed on September 22, 2009) [Google Scholar]
- Book, R. A. 2009. Medicare administrative costs are higher, not lower, for private insurance, Washington, DC: The Heritage Foundation. http://www.heritage.org/Research/Reports/2009/06/Medicare-Administrative-Costs-Are-Higher-Not-Lower-Than-for-Private-Insurance (accessed June 26, 2010) [Google Scholar]
- Bellandi, D. 1999. Hospital profits up, care for poor down. Modern Healthcare, 29(7): 14 [Google Scholar]
- Burda, D. 1996. Uncompensated care costs rose in ‘95 for Missouri hospitals. Modern Healthcare, 26(49): 14 [Google Scholar]
- Carpenter, D. 2001. Our overburdened ERs. Hospitals & Health Networks, 75(3): 44–47. [Google Scholar]
- Centers for Medicare and Medicaid Services. 2001. Vol. 66, No. 212. http://www.cms.gov (accessed November 3, 2010) [Google Scholar]
- Centers for Medicare and Medicaid Services. 2009. RMV rates. http://cms.gov/apps/ama/license.asp?file=/physicianfeesched/downloads/RVU09AR.zip (accessed on April 24, 2009) [Google Scholar]
- Citizens Research Council of Michigan. 2002. Health insurance coverage and uninsured/uncompensated care in Michigan hospitals, Livonia, MI: Citizens Research Council of Michigan. [Google Scholar]
- Collins, S., Schoen, C., Davis, K., Gauthier, A. and Schoenbaum, S. 2007. A roadmap to health insurance for all: Principles for reform, New York: The Commonwealth Fund. [Google Scholar]
- Cover the Uninsured. 2009. State children's health insurance program (SCHIP) http://covertheunisured.org/content/schip-overview (accessed September 21, 2009) [Google Scholar]
- Cudney, A. E. and Klepper, B. 2002. Healthcare reform: One coalition's efforts at effecting change. Journal of Healthcare Management, 47: 352–355. [Google Scholar]
- Freeman, J. 2010. Universal coverage and primary care: The U.S. needs both http://medicinesocialjustice.blogspot.com/2010/05/universal-coverage-and-primary-care-us.html (accessed June 26, 2010) [Google Scholar]
- Fujimoto, D. R. 2002, September 13. A shot in the arm for emergency rooms. Business Journal Serving Fresno & the Central San Joaquin Valley, : 1–2. [Google Scholar]
- Health Forum. 2001. Regulatory update. Health Facilities Management, 14(12): 36 [Google Scholar]
- Healthcare Economist. 2006. Healthcare's (true) administrative costs http://healthcare-economist.com/2006/07/27/medicares-true-administrative-costs/ (accessed June 26, 2010) [Google Scholar]
- Kaiser Family Foundation. 2009. Trends in health care costs and spending http://www.kff.org/insurance/upload/7692_02.pdf (accessed on September 21, 2009) [Google Scholar]
- Menninger, B. 2002. State of emergency. Health Leaders, 5(11): 34–38. [Google Scholar]
- Mills, R. 2002. United States Department of Commerce health insurance coverage: 2001, Washington, DC: U.S. Census Bureau. [Google Scholar]
- Oganization for Economic Cooperative and Developement. 2001/2009. http://www.ecd.org/home/0,2987,en_2649_201185_1__1_1_1_1,00.html (accessed July 27, 2010) [Google Scholar]
- Parker, C. 2002. Study: Chronic conditions, coverage gaps = health risks and ER overuse. AHA News, 38(7): 1–3. [Google Scholar]
- Petaschinick, J. (ed.). 2002. Uncompensated care on the rise. Receivables Reports, 17(10): 10 [Google Scholar]
- Rhoades, J. A. 2005a. The uninsured in America, 1996–2004: Estimates for the U.S. civilian noninstitutionalized population under age 65. Medical Expenditure Panel Survey, Statistical Brief #84, Rockville, MD: Agency for Healthcare Research and Quality. [Google Scholar]
- Rhoades, J. A. 2005b. The uninsured in America, 2004: Estimates for the U.S. civilian population under age 65. Medical expenditure panel survey, Statistical Brief #83, Rockville, MD: Agency for Healthcare Research and Quality. [Google Scholar]
- Rust, G. 2000. Georgia's health safety net: Access to primary care for Georgia's uninsured and underserved, Atlanta, GA: National Center for Primary Care at Morehouse School of Medicine. [Google Scholar]
- Seifert, R. W. and Sokol, K. 1999, October. The uninsured in Illinois and Chicago: Close to 2 million face barriers to health care, Boston: The Access Project. [Google Scholar]
- U.S. Bureau of Labor Statistics. 2001a. Percent distribution of nonfatal occupational injuries and illnesses involving days away from work by selected worker characteristics and number of days away from work—2000, Washington, DC: U.S. Department of Labor. http://www.bls.gov/news.release/osh2.t07.htm (accessed on December 3, 2002) [Google Scholar]
- U.S. Bureau of Labor Statistics. 2001b. Injuries, illnesses, and fatalities, Washington, DC: U.S. Department of Labor. http://www.bls.gov/iif/home.htm (accessed December 3, 2002) [Google Scholar]
- U.S. Bureau of Labor Statistics. 2010. The employment situation—September 2010 Press release. http://www.bls.gov/news.release/empsit.nr0.htm (accessed September 15, 2010) [Google Scholar]
- U.S. Bureau of Labor Statistics. n.d.. http://www.bls.gov (accessed July 3, 2010) [Google Scholar]
- U.S. Census Bureau. 2002. Health insurance in America: Numbers of Americans with and without health insurance rises, Washington, DC: U.S. Census Bureau. http://www.census.gov/Press-Release/www/2002/cb02–127.html (accessed December 5, 2002) [Google Scholar]
- U.S. Census Bureau. 2007. Income, poverty, and health insurance coverage in the U.S, Washington, DC: U.S. Census Bureau. [Google Scholar]
- Webster, S. 2002, December 1. Health costs rob big 3 bottom line: Some workers, retirees pay price; automakers lose competitive edge. Detroit News and Free Press, : 1A–11A. [Google Scholar]
- Weismantle, M. 2001. Reasons people do not work: Household economic studies 1996, Washington, DC: U.S. Census Bureau. [Google Scholar]