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Front and Center: Ensuring that Health Reform Puts People First

The stakes are high for U.S. families as the nation considers health system reforms. The major beneficiaries of reform would be people who do not fare well in our current systems for financing and delivering health care services, including those at risk for losing their health insurance or affordable access to care when they get sick.

In a nation replete with modern medical centers, there are countless stories of Americans whose lives could have been saved or disabilities averted if they had been able to afford medical care or had timely access to high-quality, safe care. In today’s health system both the insured and the uninsured are at risk. Even families whose incomes place them solidly in the middle class worry that they will not be able to afford to get sick, that they will see their children lose the protection of family coverage, or that they will exhaust a lifetime of savings paying off medical debt.

This report examines the multiple ways in which the current health insurance and care delivery systems fail people when they need it. And it describes the people who would benefit from health reforms aimed at providing secure, comprehensive coverage and enabling the delivery of accessible, safe, patient-centered health care.

A Health System in Crisis
Health reform in many nations has been triggered by tragic incidents caused by dysfunctional health care systems. In the United States, 18,000 people die every year as a result of being uninsured—and these preventable deaths are only the tip of the iceberg of missed opportunities to improve health. The U.S. remains the only wealthy country where a serious illness could bankrupt an otherwise well-off family. We may have reached the point where Americans can no longer tolerate the human toll of delayed or inadequate care for those who are sick and unable to pay for care, or the fear of knowing that none of us is truly secure.

The current economic crisis only intensifies the crisis in our health care system, as millions more lose their jobs and enter the ranks of the uninsured. The two purposes of insurance are to ensure access to essential health care and protect against financial hardship of medical bills, yet we have increasingly designed insurance that does neither. With the comprehensiveness and adequacy of insurance eroding, medical bills are often beyond families' ability to pay. Health insurance premiums now exceed a year's pay for minimum wage workers—making them unaffordable for employees and employers alike.

In this report, we focus on the people who would benefit most from health care reform: the uninsured; the underinsured; those with unstable coverage who lose and gain insurance; those who lose their coverage when their life circumstances change; those entering the labor market who cannot find a job with coverage; those who must wait to qualify for coverage until they have worked long enough or been disabled long enough; those who cannot afford their out-of-pocket costs or health insurance premiums; those who are discriminated against because they are sick, older, or female; those who spend hours with hassles over medical bills; and those who cannot find a doctor who provides easy access and helps coordinate their care.

Most people in the U.S. fall into one of these categories and have personally experienced the shortcomings of our current system. Even before the severe recession, an estimated 116 million working-age adults—two-thirds of all adults—reported they were uninsured or underinsured, had medical bill or debt problems, or experienced difficulties obtaining needed care. The beneficiaries of reforms that ensure affordable health insurance and access to high-quality care would include: 

  •  46 million who were uninsured at the start of the recession, and 55 million who were uninsured at some point during the past year;
  • 25 million working-age adults who are underinsured;
  • 72 million working-age adults who have difficulty paying medical bills;
  • 49 million small business employees who now pay higher premiums than employees in larger businesses;
  • 4 million adults under age 65 with individual coverage whose premiums go toward high overhead costs, leaving less room for benefits;
  • one-third of insured people who change plans frequently, often not by choice;
  • 46 percent of workers with employer coverage who do not have a choice of plans;
  • Medicaid beneficiaries, who would have expanded choices and better access to care if Medicaid provider payments were increased;
  • women, who as a group carry greater financial burdens from health care expenses;
  • 13 million young adults without coverage;
  • older adults and early retirees, who have few affordable insurance options;
  • 2 million disabled individuals in the waiting period for Medicare coverage;
  • any Medicare beneficiary who now pays high hospital deductibles or high premiums for supplemental coverage; and
  • 37 million adults and 10 million children who lack easy access to a regular source of care.

The Benefits of Comprehensive Reform
This report examines how a comprehensive, integrated strategy for health care reform could improve the health and health care experiences for these diverse groups. It is based a framework previously set forth in The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, a report of the Commonwealth Fund Commission on a High Performance Health System that outlined ways to ensure health insurance coverage for all and eliminate the financial burdens that now undermine personal economic security (referred to here as the "Path report" or "Path framework").

Building on current job-based health insurance while expanding the coverage choices available, the reforms would ensure affordable coverage to everyone—covering the uninsured and improving coverage for those who are underinsured. A national health insurance exchange would offer an array of competing private plans and a new public health insurance plan, helping to improve coverage for 138 million currently insured individuals through more choices, better benefits, and/or more affordable premiums, which would be 20 to 30 percent lower than those now charged in the individual and small-business markets for comparable benefits and enrollees. Savings would be realized by employers and households at every income level.

If coupled with broad health system reforms, the average family would save $2,314 a year by 2020, as the annual increase in health care costs slowed from 6.7 percent to 5.5 percent. Cumulative national savings to the health system over the period 2010 to 2020 would be $3 trillion, compared with projected trends. While the federal government would need to make upfront investments, the benefits would accrue over time to all of those who finance the health system.

The most important outcome of health system reform that puts people first would be the health benefits to the American people. If the achievable targets included in the Path framework are reached, by the year 2020 an estimated 100,000 lives per year would be saved, 68 million more adults would receive recommended preventive care, and 37 million more adults and 10 million more children would receive care from physician practices that ensure easy access to care and are accountable for providing patients all essential health services. Avoidable hospitalizations would decline each year as well: 640,000 fewer Medicare beneficiaries would be hospitalized for ambulatory care–sensitive conditions, and 180,000 fewer Medicare beneficiaries would be readmitted within 30 days following their initial hospital discharge. In addition, there would be 70,000 fewer children hospitalized for asthma-related complications each year, and 250,000 fewer adults hospitalized for diabetes-related complications.

Payment and system reforms would make the organization and delivery of health care services responsive to peoples’ needs and preferences. In a 2008 survey, three-quarters of all adults reported difficulty accessing care, half reported problems with care coordination, and one-quarter reported serious problems related to time spent on paperwork or disputes about medical bills or health insurance in the previous two years. Reforms that promote accessible, coordinated, patient-centered primary care would be of particular benefit to families and individuals with chronic illnesses. To ensure that people get the right care, at the right time, and in the right way—and to avoid waste and duplication—it will be necessary to invest in health information technologies. By 2020, 98 percent of physicians should have electronic information systems that meet national standards, up from only about one-fourth of primary care physicians today. Payment systems that enable providers to spend time with their patients and reward excellent results would raise the standards of care. There also should be incentives for providers to innovate and improve.

As the political deliberations over health reform increasingly center on how those who provide care or insurance would be affected by various reform options, it is important to focus on the core purpose of reform: ensuring affordable health coverage and health care for all. Putting people first is a shared goal of health professionals, and it is one that needs to guide health reform deliberations. This strategy enjoys widespread support among the public across income groups, geographic regions, and political affiliation. Nine of 10 people believe that health reform should improve the quality of care, ensure that care and insurance are affordable to all, and reduce the numbers of uninsured.

The political challenges to doing so are formidable, but the expectations for our political leaders are also high. Too often, the voices heard in the halls of Congress speak for those who have a strong financial stake in the $2.5 trillion now spent on the health care system. At a time of severe economic crisis, now is the time to listen to the concerns of individuals and families. Designing health reforms that put peoples’ interests first should go a long way to forging consensus and enacting legislation during this historic window of opportunity.

Publication Details



K. Davis, K. Stremikis, C. Schoen, S. R. Collins, M. M. Doty, S. D. Rustgi, and J. L. Nicholson, Front and Center: Ensuring that Health Reform Puts People First, The Commonwealth Fund, June 2009.