The Commonwealth Fund Connection A roundup of recent Fund publications, charts, multimedia, and other timely content.

December 19, 2018

What’s New
Americans Are Paying More for Employer Health Coverage
U.S. workers and their families, especially those living in the South, are spending a bigger share of their income on health care. According to a Commonwealth Fund study, average employee premium contributions for single and family plans consumed nearly 7 percent of U.S. median income in 2017, up from 5 percent in 2008. In Louisiana, premium contributions represented 10.2 percent of median income. For Americans whose incomes fall in the midrange of the income distribution, total spending on employer plan premiums and potential out-of-pocket costs to meet deductibles amounted to 11.7 percent of income last year, up from 7.8 percent a decade earlier.


Policymakers must address rising #healthcare costs. Doing so will be critical for keeping down the rising employer premiums and deductibles that are a growing burden for middle-income families.
Health Insurance Coverage and Access
Jost: Court Decision to Invalidate the Affordable Care Act Would Affect Every American
On Friday, Texas federal court Judge Reed O’Connor delivered a judgment purporting to accomplish what Republicans in Congress had failed to do and what the Supreme Court had twice refused to do: invalidate the Affordable Care Act. Legal expert Timothy S. Jost explains in a new To the Point post why “the logic of Judge O’Connor’s decision is simple and straightforward, but clearly wrong.”


Waivers Would Radically Restructure Coverage
The Centers for Medicare and Medicaid Services recently outlined how states could use Section 1332 of the Affordable Care Act in ways that could undermine the law. On To the Point, legal expert Timothy S. Jost discusses the four waiver concepts the administration put forward to restructure health coverage, including allowing states to use federal funds for subsidies to pay for health plans that aren’t compliant with the health care law.


Medicaid Work Requirements: States’ Actions, and Inaction, Are Putting People’s Coverage at Risk
“With thousands in Arkansas losing their Medicaid benefits under the state’s work-requirement demonstration, the importance of evaluating such experiments could not be clearer,” say George Washington University’s Sara Rosenbaum and colleagues. But as the authors report in a Commonwealth Fund issue brief, the nation’s first-ever Medicaid work demonstration is proceeding despite the absence of any federally approved evaluation to test the requirements’ impact on people, as called for under Section 1115 of the Social Security Act.


Few Differences in Market Participation Before and After Affordable Care Act
When the Affordable Care Act and its consumer protections became law, insurers feared that people enrolling in marketplace plans would generally be less healthy than people who chose not to enroll. But an analysis by Sherry Glied and Adlan Jackson of New York University finds few differences in individual-insurance market participation before and after the law took hold.


Association Health Plans Could Harm Small-Group Market
A recent federal rule has paved the way for many more small firms and self-employed individuals to purchase insurance through association health plans, which are not subject to preexisting-condition protections and other Affordable Care Act regulations. To estimate the potential impact of these health plans, Wake Forest University’s Mark A. Hall and Virginia Commonwealth University’s Michael J. McCue analyzed how “market segmentation” has functioned in the small-group market to date.


Delivery System Reform
Listen to The Dose: What It Means to Be Sick
On the latest episode of The Dose podcast, host Shanoor Seervai talks about a recent “Health Care in America” survey on the experiences of 1,500 patients who have had two or more hospital stays and visits with three or more doctors in the past three years. Survey codirectors Robert Blendon, a professor of health policy at the Harvard T.H. Chan School of Public Health, and Eric Schneider, M.D., senior vice president for policy and research at the Commonwealth Fund, discuss the findings.


Physicians Are Unhappy with Electronic Health Records: How Can We Fix Them?
It’s no secret that many physicians are unhappy with their electronic health records (EHRs), says Commonwealth Fund President David Blumenthal, M.D. As Blumenthal points out on To the Point, EHRs really have one critical performance requirement in our current fee-for-service health system: generating clinical revenues. What they don’t do so well is support the things that physicians, patients, and policymakers value, including better care experiences, reduced costs, and population health management.


Why Do Primary Care Physicians for Low-Income Patients Love Their Jobs?
The stories of primary care doctors who care for low-income people — about the pride and joy they derive from their work, despite obstacles in meeting patients’ needs — is the focus of a new Commonwealth Fund feature article. The doctors say that the opportunity to provide emotional support enables them to make a difference in their patients’ lives.


New on the “Better Care Playbook”
In honor of the second anniversary of the Better Care Playbook‘s launch, Jay Want, M.D., executive director of the Peterson Center on Healthcare, reflects on the philosophy behind the Playbook and his vision of how organizations can use its information and innovative models to improve care for patients with complex needs.


Affordable, quality health care. For everyone.
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What Is the Status of Women’s Health and Health Care in the U.S. Compared to Ten Other Countries? December 19, 2018 Munira Z. Gunja,

December 19, 2018

Women in the United States have long lagged behind their counterparts in other high-income countries in terms of access to health care and health status. This brief compares U.S. women’s health status, affordability of health plans, and ability to access and utilize care with women in 10 other high-income countries by using international data.


  • U.S. women report the least positive experiences among the 11 countries studied. They have the greatest burden of chronic illness, highest rates of skipping needed health care because of cost, difficulty affording their health care, and are least satisfied with their care.
  • Women in the U.S. have the highest rate of maternal mortality because of complications from pregnancy or childbirth, as well as among the highest rates of caesarean sections. Women in Sweden and Norway have among the lowest rates of both.
  • Women in Sweden and the U.S. report the highest rates of breast cancer screening among countries surveyed; women in Norway, Sweden, Australia, and the U.S. have the lowest rates of breast cancer–related deaths.
  • More than one-quarter of women in the U.S. and Switzerland report spending $2,000 or more out of pocket on medical costs for themselves or their family in the past year compared to 5 percent or fewer in most of the other study countries.
  • More than one-third of women in the U.S. report skipping needed medical care because of costs, a far higher rate than the other countries included in the study.
  • U.S. women are less likely to rate their quality of care as excellent or very good compared to women in all other countries studied.

Women's Maternal Mortality Infographic


Compared to women in other high-income countries — like, for instance, Germany or Australia — American women have long struggled to access the health care they need. The United States spends more on health care than other countries do, but Americans report high rates of not seeking care because of costs, as well as high instances of chronic disease. Prior research has found that poor access to primary care in the United States had led to inadequate management and prevention of diagnoses and diseases.

With the Affordable Care Act (ACA) now in place, most women in the U.S. have guaranteed access to health coverage (Appendix 2); more than 7 million working-age women have gained insurance since the implementation of the law. Millions of others who had been insured now receive additional benefits and cost protections through the law’s reforms. But recent changes by the Trump administration and Congress may jeopardize this progress. These changes include repeal of the law’s individual mandate penalty; expansion of plans that do not have to comply with the law’s consumer protections and benefit requirements, including the requirement to provide maternity care; threats to remove guaranteed coverage of preexisting conditions; and proposed changes to Title X funding. In the future, these changes may raise costs and limit access to health insurance and services for people who do not qualify for subsidized care, especially those with health problems. They could reduce the recent gains U.S. women have made and widen differences between women in the U.S. and those in other countries.

Using data from the Commonwealth Fund International Health Policy Survey (2016) and measures from the Organisation for Economic Co-operation and Development (OECD) and the United Nations Children’s Fund (UNICEF), this brief compares U.S. women’s health status, affordability of health plans, and ability to access and utilize care with women in 10 other industrialized countries.

For an overview of each country’s health care system, see Appendix 1, and for further detailed information on each country’s health system, see the Commonwealth Fund International Health Care System Profiles here.

Has single-payer health care’s time finally come?

December 11, 2018
Democrats are coming out of the woodwork to back the New York Health Act.
DECEMBER 9, 2018

With their new majority in the state Senate, Democrats are finally preparing to pass long-stalled progressive legislation. Perhaps the most expansive and expensive item on the agenda – and among the most controversial – is the New York Health Act, which would establish a single-payer health care system in the state, and one study estimated it would cost $139 billion in 2022. Many incoming lawmakers campaigned on the promise that they would get it done, but even if it does pass, it likely won’t be implemented right away.

The Democratic-controlled Assembly has passed the legislation every year since 2015, but in that time it never came up for a vote in the state Senate thanks to the Republican majority. Now that the chamber will be in Democratic hands, the legislation seems far more likely to pass.

A single-payer health care system means that a single entity covers the cost of all health care, which is still delivered by private or nonprofit providers. Everyone pays into a single plan run by the government, which in turn is the only provider of coverage paying claims. Assemblyman Richard Gottfried’s single-payer bill has proposed one public option and a ban on the sale of private insurance unless it offers additional coverage not included in the state plan.

One major obstacle the New York Health Act must overcome is a less than enthusiastic governor. Although Gov. Andrew Cuomo has expressed support for single-payer health care as a concept, he has repeatedly said that it would be better implemented at the national level. In a recent interview on WCNY, he expressed doubt that the state would be able to finance the $150 billion program, since that would nearly double the state’s budget. “There will be rhetorical desire to do things,” Cuomo said. “Governmentally there will have to be a reality test to get all things to fit in the budget.”

Although this sounds like it could put a serious damper on the future of the legislation, Gottfried called the governor’s stance “a perfectly reasonable position for a governor,” noting that Cuomo is already far more progressive than other governors by simply supporting the concept of single-payer health care. Gottfried said he has been in talks with the administration and expects those conversations to accelerate now that passage is more realistic.

Gottfried said that stakeholders who have remained quiet in the past are coming forward to voice their concerns. Most recently, Gottfried and state Sen. Gustavo Rivera, the bill’s Senate sponsor, have been negotiating with New York City public unions over concerns that union members would pay more or have fewer benefits. “What we’re talking about is modifications just to accommodate concerns that people are raising now that it looks like it can easily pass both chambers this session,” Gottfried told City & State. “People who we haven’t heard from are starting to come forward and say, ‘Gee, could you add this nuts and bolts?’ or ‘Tighten it up here.’’”

Gottfried said making tweaks to the bill will continue at least a couple weeks into the session, which begins in early January. However, Gottfried said that he and Rivera will not make any major structural changes to the bill and said the Assembly is “well positioned” to pass the bill this upcoming session.

People who we haven’t heard from are starting to come forward and say, ‘Gee, could you add this nuts and bolts?’ or ‘Tighten it up here.’ – Assemblyman Richard Gottfried

Rivera expressed more caution, telling City & State that he feels confident that the chamber will engage in meaningful conversations about the bill, which it has never done before, but did not want to make any promises about a timeline for passage. “This is not a simple thing that we’re trying to do,” Rivera said. “We want to make sure that we don’t put anything up for a vote, to be signed by the governor, unless it’s ready to go.”

Bill Hammond, a health policy expert at the right-leaning Empire Center for Public Policy, argued that no amount of change to the New York Health Act would actually make the legislation viable. “I think (Gottfried and Rivera’s) posture right now is not to acknowledge the sacrifice, it’s to make it even more attractive to whatever interest group thinks they’re going to lose,” Hammond told City & State. He added that any changes would likely add to the already astronomical cost of the bill.

But Gottfried maintained that a single-payer system will lead to lower overall health care spending despite the introduction of a new payroll tax because the average New Yorker would no longer pay insurance premiums and copays. He cited the Rand Corp. study, commissioned by the New York State Health Foundation, which found total health care spending could be lower under the New York Health Act than under the status quo. “To me, the issue is not about where your check goes,” Gottfried said. “What people really care about is how much are they going to have to spend, and how much they will be able to keep under the New York Health Act.”

However, Hammond pointed out that since there is no precedent for the system in the country, the details of the new tax plan have not been worked out yet and it is hard to accurately predict the cost of the program, so the Rand study could be wrong. He added that it also hinges on the federal government providing waivers to in order to divert Affordable Care Act, Medicare and Medicaid funding into the single-payer system, an unlikely prospect with the current administration. “There’s all kind of doubt and uncertainty about who’s going to pay more and who’s going to pay less,” Hammond said.

Rivera dismissed the idea that the New York Health Act depends on receiving those federal waivers, saying they would be helpful, but not necessary. “We believe, both my colleague and myself, believe that there are ways within the system that we could actually extend the New York Health Act as a wraparound service that would ultimately not require waivers,” Rivera said. He added that since the single-payer system would take years to put into place, he remained hopeful that a different, more sympathetic administration would be in the White House by then.

Another sticking point in evaluating and passing the New York Health Act is the fact that the previous legislation contained no specific language on tax rates for the proposed payroll tax, forcing Rand to use a hypothetical tax schedule. Gottfried said no language about tax brackets will be added to the legislation that he and Rivera will introduce and that it will be worked out after the bill’s passage since the program will take years to implement. He added the absence of this information will not pose an impediment to passage and that it could be easily added in if it becomes necessary.

Despite the many obstacles the legislation appears to face, Gottfried said that he and Rivera have learned from their previous mistakes, such as not including a revenue stream, and they remain confident New York will lead the country in single-payer health care. “Anything has to start with somebody,” Gottfried said. “And New York is ideally suited to be the state that begins single-payer coverage.”

RELATED: Albany’s checklist of health care bills

Rebecca C. Lewis
is an editorial assistant at City & State.

This American Life Stories-When health care premiums went up in New York State…

December 10, 2018

Know That You Are Unprecedentedly Negative

When health care premiums went up in New York State, a bunch of people got mad and wrote letters to the state. Producer David Kestenbaum takes us into the raw world of these letters. (15 minutes)

How 2 New York Women Erased $1.5 Million In Medical Debt For Hundreds Of Strangers

December 9, 2018

Judith Jones and Carolyn Kenyon discuss their fundraising efforts that resulted in $1.5 million medical bill debt forgiveness for New York strangers.

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