Order Code RL32237
CRS Report for Congress
Received through the CRS Web
Health Insurance: A Primer
Updated February 3, 2005
Bernadette Fernandez
Analyst in Social Legislation
Domestic Social Policy Division
Congressional Research Service ˜ The Library of Congress

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Health Insurance: A Primer
Summary
People buy insurance to protect themselves against possible financial loss in the
future. Such losses may be due to a motor vehicle collision, natural disaster, or other
circumstance. For patients, financial losses may result from the use of medical
services. Health insurance then provides protection against the possibility of
financial loss due to health care use. In addition, since people do not know ahead of
time exactly what their health care expenses will be, paying for health insurance on
a regular basis helps smooth out their spending.
While health insurance continues to be mainly a private enterprise in this
country, government plays an increasingly significant role. Especially during the
latter half of the 20th century, the government both initiated and responded to
dynamics in medicine, the economy, and the workplace through legislation and
public policies. For example, the Internal Revenue Service clarified that employer
contributions to employee health benefits are exempt from taxation, which
encouraged the growth of employment-based health coverage. Given the frequent
introduction of legislation aimed at modifying or building on the current health
insurance system, understanding the potential impact of such proposals requires a
working knowledge of how health insurance is designed, provided, purchased, and
regulated. This report, which will be updated, provides basic information about those
topics.
Persons and families without health coverage are more likely than those with
coverage to forgo needed health care, which often leads to worse health outcomes
and the need for expensive medical treatment. Since uninsured persons are more
likely to be poor than insured persons, the uninsured are less able to afford the health
care they need. Uninsurance can lead to health care access problems for
communities, such as overcrowding in emergency rooms. Furthermore, individual
states and the nation as a whole are affected through increased taxes and health care
prices to cover uncompensated care expenses.
Americans obtain health insurance in different settings and through a variety of
methods. People may get health coverage through the private sector, or from a
publicly funded program. Consumers may purchase health insurance on their own,
as part of an employee group, or through a trade or professional association. A small
minority of employees get health insurance at no up-front cost because their employer
pays the total insurance premium. However, 45 million Americans did not have
health coverage for the entire year of 2003.
Health insurance benefits are delivered and financed under different systems.
The factors that distinguish one delivery system from another are many, including
how health care is financed, how much access to providers and services is controlled,
and how much authority the enrollee has to design her/his health plan. To illustrate,
managed care is characterized by predetermined restrictions on accessing services,
whereas individual decision-making regarding use of health benefits is a hallmark of
consumer-driven health care. And as economic conditions change, a specific
delivery system may gain or lose the interest of affected parties.

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Contents
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
What Is Health Insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Basic Definitions and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2
Uneven Distribution of Health Care Expenses . . . . . . . . . . . . . . . . . . . 2
Risk Pool and Rate Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
Risk Pool Composition and Adverse Selection . . . . . . . . . . . . . . . . . . . 3
Group Market, Nongroup Market, and Medical Underwriting . . . . . . . 4
Fully Insured vs. Self-Insured Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Self-only vs. Family Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Administrative Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5
Tax Preference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Health Insurance Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Responsibility of the States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
Key Federal Statutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7
Why Is Health Insurance Considered Important? . . . . . . . . . . . . . . . . . . . . . . . . . 8
Where Do People Get Health Insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
Employer-Sponsored Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10
Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Large vs. Small Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Public Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Medicaid and the State Children’s Health Insurance Program
(SCHIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
Individual Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14
State High-Risk Pools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
The Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
How Are Health Benefits Delivered and Financed? . . . . . . . . . . . . . . . . . . . . . . 16
Indemnity (Traditional) Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Consumer-Driven Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18
List of Tables
Table 1. Health Insurance Coverage by Type of Insurance, 2003 . . . . . . . . . . . 10

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Health Insurance: A Primer
Introduction
Health insurance coverage dominates many state and federal health care
discussions. As health coverage evolved from an uncommon benefit to a routine one,
government’s role in subsidizing and regulating that coverage also changed for
workers, employers, and insurers. Although health insurance continues to be mainly
a private enterprise in this country, public entities play an increasingly significant role.
Government’s involvement in health coverage expanded dramatically in the
latter half of the 20th century. Public policies and legislation initiated or responded
to dynamics in medicine, employment, and other areas.
! A long-standing rule issued by the Internal Revenue Service (IRS)
stated that an employer’s contributions to employment-based health
insurance could not be included in an employee’s gross income for
tax purposes (Internal Revenue Code, Section 106). This ruling
helped spur the growth of employer-sponsored health benefits. The
IRS also stated separately that employers could deduct such
contributions as part of business expenses.
! Advances in medicine led to escalating consumer demand for newer,
better treatments. At the same time the cost of health care increased,
which was especially problematic for certain groups of care
consumers who lacked health coverage. This led to government
efforts to assist consumers in paying for health care through social
insurance programs.1
! More and more employees began to work for more than one
employer over their lifetimes. Government was called on to address
a problem many workers faced: keeping health coverage as they
moved from job to job.
Given the frequent introduction of legislation aimed at modifying or building
on the current health insurance system, understanding the potential impact of such
proposals requires a working knowledge of how health insurance is designed,
provided, purchased, and regulated. This report provides basic information about
those topics.
1 Publicly funded health programs generally either provide funding for direct medical
services or assist consumers in paying for health care. The latter are included in a broad
category of programs based on “social insurance” principles. Social insurance refers to
publicly funded insurance programs that are statutorily mandated for certain groups of
people, such as low-income individuals.

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What Is Health Insurance?
Basic Definitions and Principles
People buy insurance to protect themselves against possible financial loss in the
future. Such losses may be due to a motor vehicle collision, natural disaster, or other
circumstance. For patients, financial losses may result from the use of medical
services. Health insurance then provides protection against the possibility of
financial loss due to health care use. In addition, since people do not know ahead of
time exactly what their health care expenses will be, paying for health insurance on
a regular basis helps smooth out their spending.
The concept underlying insurance is “risk;” i.e., the likelihood and magnitude
of financial loss. In any type of insurance arrangement, all parties seek to minimize
their own risk. In health insurance, consumers and insurers approach the
management of insurance risk differently. From the consumer’s point of view, a
person (or family) buys health insurance for protection against financial losses
resulting from the future use of medical care. From the insurer’s point of view, it
employs a variety of methods to minimize the risk it takes on when providing health
coverage to consumers, so as to assure that it operates a profitable business. One
method is to cover only those expenses arising from a pre-defined set of services
(generally called “covered” services). Another method for limiting risk is to
encourage healthier people to obtain health coverage, presumably because healthier
people would not need as many medical services as sicker people.
While the methods employed by an insurer differ from those of a consumer,
each person or entity has the same goal: to minimize risk in an uncertain future. It
is this uncertainty of the future and risk of loss which form the context for insurance,
and the strategies to make financial loss more predictable and manageable which
drive insurance arrangements.
Uneven Distribution of Health Care Expenses. In health care, a
minority of consumers are responsible for a majority of expenses. According to a
study that looked at the distribution of health care spending, 5% of the population
accounted for over half of all health expenditures, and 10% of the population
accounted for around two-thirds of those expenditures.2 Such findings were
consistent for selected years spanning three decades. Given the unevenness of health
care spending and the impossibility of identifying all of the highest spenders before
they use medical services, insurers employ various strategies in order to minimize the
risk they take on.
2 Marc L. Berk and Alan C. Monheit, “The Concentration of Health Care Expenditures,
Revisited,” Health Affairs, vol. 20, no. 2 (Mar./Apr. 2001), pp. 9-18.

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Risk Pool and Rate Setting. The main objective of insurance is to spread
risk across a group of people. This objective is achieved in health insurance when
people contribute to a common pool (“risk pool”) an amount at least equal to the
average expected cost resulting from use of covered services by the group as a whole.
In this way, the actual costs of health services used by a few people are spread over
the entire group. This is the reason why insuring larger groups is considered less
risky — the more persons participating in a risk pool, the less likely that the serious
medical experiences of one or a few persons will result in catastrophic financial loss
for the entire pool.
An insurer calculates and charges a rate (i.e., a “premium”) in order to finance
the health coverage it provides. The premium generally reflects several factors,
including the expected cost of claims for using services in a year, administrative
expenses associated with running the plan, and a risk or “profit” charge. The
premium also will vary depending on if it buys self-only coverage or family coverage
(see later discussion). If the insurer accurately estimates future costs and sets
appropriate premium levels, then claims for that risk pool should be reasonably
predictable over time. In other words, the premiums paid by healthy persons in the
risk pool help subsidize the costs of less healthy persons.
Risk Pool Composition and Adverse Selection. As noted above, one
of the ways insurers attempt to make future costs more predictable is by spreading
the risk of high costs for a few people across many people. But the number of people
is not the only significant factor. Equally as important, if not more so, is the
composition of the group.
A consumer’s decision to obtain health coverage is based on a variety of factors,
such as health status, estimated need for future medical care, and disposable income.
Consumers with different health conditions, as well as varying degrees of comfort
towards risk-taking, will differ on whether they consider health insurance necessary.
This is a circumstance that insurers will consider when estimating the cost to cover
future health care use. With this in mind, insurers generally will vary the premiums
they charge and the health services they cover (subject to state and federal statues)
in order to attract various segments of the population. This flexibility in rate setting
and benefit determination is particularly important in a competitive insurance market
where insurers try to provide the most attractive rates to increase their market share.
However, some risk pools do attract a disproportionate share of unhealthy
individuals. In part, this is because people generally know more about their own
health conditions than any other person or entity, such as an insurer. Health care
consumers typically are the best informed about when they will need medical care
and what kind of services they will need. The “information asymmetry” between
what consumers know compared to what insurers know gives consumers an
advantage when looking for health coverage that will meet their future demand for
health care. This asymmetry is another source of uncertainty which insurers take into
account when developing and pricing insurance products (or health plans).

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When a disproportionate share of unhealthy people make up a risk pool, a
phenomenon known as “adverse selection,” the average cost for each person in the
pool rises. The higher costs may encourage the departure of healthier members from
the group, and discourage the entrance of other healthy people, since healthier people
may be able to find cheaper coverage elsewhere, or decide that coverage is too costly
and become uninsured. In either situation, it leaves an even less healthy group of
people in the risk pool, which again causes the average cost to rise for the remaining
participants. If there is no change in this dynamic, the group may experience a “death
spiral” as it suffers substantial adverse selection leading to an increasingly expensive
risk pool and possibly dissolution of the pool altogether. Therefore, despite the
consumer’s information advantage, it does not guarantee access to affordable and
adequate health coverage.
Group Market, Nongroup Market, and Medical Underwriting. Health
insurance can be provided to groups of people that are drawn together by an employer
or other organization, such as a professional association or trade union. Such groups
are generally formed for some purpose other than obtaining insurance, like
employment. When insurance is provided to a group, it is referred to as “group
coverage” or “group insurance.” In the group insurance market, the entity that
purchases health insurance on behalf of a risk pool is referred to as the “sponsor.”
Consumers who are not associated with a group can obtain health coverage by
purchasing it directly from an insurer in the individual (or nongroup) insurance
market. Insurance carriers in the nongroup market conduct an exhaustive analysis
of each applicant’s insurability. An applicant usually must provide the insurer with
an extensive medical history and often undergo a physical exam. This information
is used by carriers to assess the potential medical claims for each person by
comparing characteristics of the applicant to the loss experience of others with
similar characteristics. Once such an evaluation has been conducted, the carrier
decides whether or not to provide health coverage and determines the conditions for
coverage. This evaluation and determination process is called “underwriting.”
Medical underwriting is standard practice in the individual insurance market,
though a carrier’s ability to reject applicants or vary the terms of coverage are
restricted to some degree by federal and state requirements. In the group insurance
market, insurers forgo underwriting in the traditional sense; i.e., reviewing each
person’s demographics and medical history. Instead, an insurer looks at the
characteristics of the collective group — such as its claims history, demographics
(e.g., industry of firm and age distribution of enrollees), and geographic location —
to conduct the insurance risk and loss analysis. The insurer then charges a premium
based on the analysis of the group’s characteristics. There are exceptions to this for
very small groups. For example, when a firm with only a handful of employees
applies for health coverage, the insurer may choose to review the health conditions
of each person in order to establish a premium for the entire group. Or, the insurer

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CRS-5
may charge a larger premium due to the larger risk attributed to smaller groups, if
permitted under law.3
Fully Insured vs. Self-Insured Plans. A common distinction made
between types of health insurance products is whether they are fully insured or self-
insured. A fully insured health plan is one in which the sponsor purchases health
coverage from a state-licensed insurer (also referred to as an insurance carrier). The
carrier assumes the risk of providing covered services to the sponsor’s enrolled
members. In contrast, organizations who self-insure (or self-fund) do not purchase
health coverage from state-licensed insurers. Self-insured plans refer to health
coverage that is provided directly by the organization (e.g., employing firm) seeking
coverage for its members (e.g., employees). Such organizations directly take on the
risk for covering medical expenses, and such plans are not subject to state insurance
regulations. Thus, a large employer that self-funds employee health benefits acts as
both sponsor and insurer for that coverage. Firms that self-fund typically contract
with third-party administrators (TPAs) to handle administrative duties such as
member services, premium collection, and utilization review. TPAs do not
underwrite insurance risk.
Self-only vs. Family Coverage. Another common distinction made in
health insurance is whether the policy covers one person or a family. Under self-only
coverage, the holder of the insurance policy is the only person insured. (Self-only
coverage sometimes is referred to as individual coverage. Individual coverage in this
sense should not be confused with health coverage from the individual insurance
market — see discussion below.) Family coverage applies to the policyholder,
her/his spouse, and children.4 Self-only and family policies may differ from each
other in terms of the services they cover and the cost-sharing they impose.
Administrative Expenses. Costs for administrative functions encompass
a wide range of operational activities. Administrative expenses include costs
associated with contracting with providers, sales and marketing, enrollment and
billing, customer service, utilization review, case management, and other functions.
The estimate of administrative expenses as a percent of claims often is used as a
measure of operational efficiency. For large firms that self-insure, administrative
costs make up 5-11% of claims, compared with 33-37% for insurers of small firms.5
In the nongroup market, administrative expenses are often higher on a per-person
basis compared to the group market.
3 G. Claxton, “How Private Insurance Works: A Primer,” Kaiser Family Foundation (KFF)
website, Apr. 2002, at [http://www.kff.org/insurance/loader.cfm?url=/commonspot/
security/getfile.cfm&PageID=14053].
4 Policies vary on the requirements children must meet (e.g., age, martial status, etc.) in
order to become eligible for or stay on a family policy.
5 Rose C. Chu and Gordon R. Trapnell, “Study of the Administrative Costs and Actuarial
Values of Small Health Plans,” Small Business Research Summary no. 224, at
[http://www.sba.gov/advo/research/rs224.pdf], Jan. 2003

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Tax Preference
Unlike most industrialized countries, the United States does not guarantee health
coverage to all of its citizens. Instead, it relies on a patchwork approach that
combines private and public means for providing and accessing health insurance and
health care. One of the key pieces of this approach encouraged the growth of
employment-based health coverage via the tax code.
Section 106 of the Internal Revenue Code states that employer contributions to
employment-based health insurance are not included in employees’ gross incomes
for tax purposes. This tax preference encourages workers to sign up for (“take-up”)
health coverage within the work setting. A separate ruling by the Internal Revenue
Service clarified that such employer contributions are business expenses and,
therefore, deductible from employers’ taxable income. Both parties benefit:
employers use health insurance coverage as a means to recruit and retain workers,
while employees typically get access to more services at better rates (see discussion
below). However, employees generally receive reduced wages to compensate for
richer fringe benefits.
The tax exclusion of fringe benefits is one of the primary reason why health
coverage is provided mainly through the workplace in this country. Approximately
two out of three nonelderly (under 65) Americans have employment-sponsored
insurance (ESI). Moreover, of nonelderly persons with private health insurance
coverage, approximately nine out of 10 obtain it through the workplace.
Health Insurance Regulation
Regulation occurs at multiple points in the process of providing health coverage.
Health insurance regulation addresses a wide variety of issues: the benefits that must
be offered, the individuals to whom the insurance is made available, and the
responsibilities insurers have to their health plan enrollees are a few of those issues.
The most common distinction (and one of the most contentious areas) in the
regulation of health insurance is whether it is the responsibility of individual states
or the federal government. This distinction is important because federal and state
laws governing health plans differ on issues such as compensation in courts, access
to care, and mandated coverage for certain benefits.
Responsibility of the States. The regulation of insurance traditionally has
been a state responsibility, as clarified by the 1945 McCarran-Ferguson Act.
However, overlapping federal requirements complicate the matter with respect to
health insurance. Individual states have established standards and regulations
overseeing the “business of insurance,” including requirements related to the
finances, management, and business practices of an insurer. For example, all states
have laws that require state-licensed insurance carriers to offer coverage for specified
health care services (known as “mandated benefits”). Because fully insured plans are
subject to state-established requirements, those plans must offer those mandated
benefits. On the other hand, self-insured plans are not subject to state insurance
regulations so they are exempt from such requirements.

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Key Federal Statutes. Regardless of whether health plans are fully insured
or self-funded, they all are subject to a number of federal laws (e.g., the Americans
with Disabilities Act). Two of these federal laws, the Employee Retirement Income
Security Act of 1974 (ERISA, P.L. 93-406) and the Health Insurance Portability and
Accountability Act of 1996 (HIPAA, P.L. 104-191), have significant impact on how
health insurance is provided.
ERISA outlines minimum federal standards for private-sector employer-
sponsored benefits. (Public employee benefits and plans sponsored by churches
generally are exempt from ERISA). Passed in response to pension abuses, the Act
was developed with a focus on pensions, but the law applies to a long list of “welfare
benefits” including health insurance. The Act requires that funds be handled
prudently and in the best interest of beneficiaries, participants be informed of their
rights, and there be adequate disclosure of a plan’s financial activities. ERISA
preempts state laws for issues that “relate to” employee benefit plans. (In other
words, the federal law overrides state laws affecting private-sector employee
benefits). This portion of ERISA was designed to ensure that plans would be subject
to the same benefit laws across all states, partly in consideration of firms that operate
in multiple states. However, state laws still apply for issues which involve the
“business of insurance.” Given the ambiguity of the phrases “relate to” and “business
of insurance,” the ERISA preemption is an area of heated debate and active
litigation.6
The core motivation behind the Health Insurance Portability and Accountability
Act of 1996 (HIPAA) is to address the concern that insured persons have about
losing their coverage if they switch jobs or change health plans (“portability” of
health coverage). The Act’s health insurance provisions established federal
requirements on private and public employer-sponsored health plans and insurers.
It ensures the availability and renewability of coverage for certain employees and
other persons under specified circumstances. HIPAA limits the amount of time that
coverage for pre-existing medical conditions can be denied, and prohibits
discrimination on the basis of health status-related factors. The Act also includes tax
provisions designed to encourage the expansion of health coverage through several
mechanisms, such as a demonstration project for tax-advantaged medical savings
accounts and a graduated increase of the portion of premiums self-employed persons
could deduct from their federal income tax calculations. Another set of HIPAA
provisions addresses the electronic transmission of health information and the
privacy of personally identifiable medical information (administrative simplification
and privacy provisions, respectively).7
6 For more information about ERISA, see CRS Report RS20315, ERISA Regulation of
Health Plans: Fact Sheet, by Hinda Chaikind.
7 For more information about HIPAA, see CRS Report RL31634, The Health Insurance
Portability and Accountability Act (HIPAA) of 1996: Overview and Guidance on Frequently
Asked Questions, by Hinda Chaikind, Jean Hearne, Bob Lyke, Stephen Redhead and Julie
Stone.

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Why Is Health Insurance Considered Important?
While health insurance coverage is not necessary to obtain health care, it is a
vital mechanism for accessing services in an environment of increasingly expensive
health care. As health care costs rise — at times outstripping the rise in wages —
more people need greater assistance with covering medical expenses. Health
insurance provides some measure of protection for consumers, especially those who
have limited means or greater-than-average need for medical care.
Health insurance is considered important also because of the well-documented,
far-reaching consequences of uninsurance. For instance, uninsured persons are more
likely to forgo needed health care than people with health coverage. This includes
forgoing services for preventable or chronic conditions which often leads to worse
health outcomes.8 Uninsured persons also are less likely to have a “usual source of
care;” i.e., a person or place identified as the source to which the patient usually goes
for health services or medical advice (not including emergency rooms). In 2002,
while only one-tenth of all adults with private health insurance identified no usual
source of care, almost half of all uninsured adults had no usual source.9 Having a
usual source is important because people who establish ongoing relationships with
health care providers or facilities are more likely than persons without a usual source
to access preventive health services and have regular visits with a physician.10
Therefore, to the extent that health insurance coverage facilitates access to medical
services, people without coverage face substantial barriers in the pursuit of the health
care they need.
The negative consequences of uninsurance extends beyond the persons directly
involved. The Institute of Medicine found that the insurance status of parents affects
the amount of health care their children receive.11 In places with crowded emergency
rooms, increasing uninsurance rates can add to that problem, since uninsured persons
have fewer places from which they can get general health services outside of
emergency departments (EDs), compared to people with health coverage.
Overcrowding in EDs, in turn, leads to longer waits for all patients seeking
emergency care. Moreover, many uninsured persons forgo preventive health care and
end up developing more serious conditions requiring complex, expensive medical
services. Since health coverage is positively related to income, uninsured persons are
less likely to be able to afford this level of care. In cases where patients are unable
to cover the costs associated with receiving health services, the facilities that
provided those services must take it as a financial loss (i.e., uncompensated care).
These losses can be staggering. For example, one study estimated that health care
8 Kaiser Commission on Medicaid and the Uninsured, “The Uninsured and Their Access to
Health Care,” KFF website at [http://www.kff.org/uninsured/loader.cfm?url=/commonspot/
security/getfile.cfm&PageID=29284], Dec. 2003.
9 National Center for Health Statistics, Health, United States, 2004.
10 J. E. DeVoe et al., “Receipt of Preventive Care Among Adults: Insurance Status and
Usual Source of Care,” American Journal of Public Health, May 2003.
11 Institute of Medicine, Committee on the Consequences of Uninsurance, Coverage
Matters: Insurance and Health Care, 2001.

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providers gave approximately $35 billion of uncompensated care to the uninsured in
2001.12
Ultimately, though, the costs for caring for the uninsured are “passed down to
all taxpayers and consumers of health care in the form of higher taxes and higher
prices for services and insurance.”13 Taxpayers are affected because the federal
government makes payments to hospitals — for patients enrolled in certain programs
— which take into account the share of poor people treated. The assumption is that
facilities that treat a larger proportion of poor people have a greater problem with
uninsurance and uncompensated care. The federal government also provides grants
to many health centers and other facilities that serve poor communities. In addition,
states and localities fund local health programs, public hospitals, and clinics —
facilities that generally serve an uninsured (or medically underserved) population.
Health care consumers are affected by uninsurance because in order for physician
practices and hospitals to survive financially they have to make-up the losses they
sustain. Hospitals and physicians may raise rates for certain services or discontinue
unprofitable programs in order to recoup those losses, thereby affecting consumers’
pocketbooks and access to services. Uninsurance, then, has negative health and
financial consequences for uninsured persons, their families, communities, states, and
the nation as a whole.
Where Do People Get Health Insurance?
Americans obtain health insurance in different settings and through a variety of
methods (see Table 1). People may get it through the private sector, or from a
publicly funded social insurance program. Consumers may purchase health coverage
on their own, as part of an employee group, or through a trade or professional
association. A small minority of employees get health insurance at no up-front cost
because their employer pays the total insurance premium (both the employee and
employer shares of the premium). However, 45 million Americans did not have
health coverage for the entire year of 2003.14
12 J. Hadley and J. Holahan, “How Much Medical Care Do the Uninsured Use, and Who
Pays for It?,” Health Affairs Web Exclusive, Feb. 12, 2003. The cost of uncompensated
care for 2001 is the most-recent estimate on a national level.
13 Institute of Medicine, Committee on the Consequences of Uninsurance, A Shared Destiny,
2003, p 122.
14 U.S. Census Bureau, Current Population Survey, 2004.

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Table 1. Health Insurance Coverage by Type of Insurance, 2003
Coverage distribution
Millions of persons
Total population
100.0%
288.3
Employment Based
61.8
178.2
Nongroup
9.2
26.5
Medicare
13.7
39.5
Medicaid/SCHIP/State programs
12.4
35.7
Military/Veterans Coverage
3.5
10.1
No health insurance
15.6
45.0
Source: CRS Report 96-891 EPW, Health Insurance Coverage: Characteristics of the Insured and
Uninsured Populations in 2003, by Chris Peterson.
Note: The most-current data on health insurance coverage for a full year is for the year 2003. Columns
do not add to totals because persons may receive insurance coverage from more than one source.
Employer-Sponsored Insurance
Even though examples of health insurance in this country stretch back almost
200 years, most Americans did not have health coverage until the latter half of the
20th century.15 The demand for more workers during World War II and a wage freeze
imposed by the National War Labor Board generated great interest in employer-
sponsored insurance (ESI) as a worker recruitment and retention tool.16 Buoyed by
legislation and court rulings declaring the tax exemption of fringe benefits, and
support from unions for work-based coverage, health insurance became a pervasive
employment benefit.
In employer-sponsored insurance, risk pools may be comprised of active
workers, dependents, and retirees. Insurers use a number of strategies to increase the
likelihood that each risk pool includes a good proportion of healthy individuals, thus
avoiding adverse selection. For instance, insurers may restrict employees’
opportunities to take-up health coverage or switch health plans by designating a
specific time frame each year for such activities (“open enrollment period”). Such
a strategy decreases the likelihood that people will “game” the system by taking up
coverage only when they plan on using health services (e.g., for pregnancy and birth),
and dropping coverage when they no longer plan to access care. Insurers also may
require the employer to enroll a certain proportion of the firm’s eligible population.
Assuming that the eligible population consists of a good percentage of healthy
15 See timeline from Employee Benefit Research Institute’s (EBRI) “History of Health
Insurance Benefits,” EBRI website, Mar. 2002, at [http://www.ebri.org/facts/0302fact.htm].
16 Health Insurance Association of America, Fundamentals of Health Insurance, 1997.

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CRS-11
people, requiring a certain proportion of all eligibles to enroll leads to an enrollee
population which contains at least some healthy people.
Employers also use strategies to encourage insurance take-up by healthy people.
For example, employers usually pay part (or, in very few instances, all) of the total
premium. This practice makes health coverage a more attractive benefit, even to
those who do not plan to use medical services on a regular basis. Overall, insurers
may assume that not all people in ESI risk pools take-up health coverage for reasons
primarily related to personal health status or immediate demand for medical care.
Advantages. ESI plans retain enrollees better than the individual health
insurance market. As previously mentioned, health benefits provided at the
workplace are exempt from income and employment taxes, encouraging the growth
and continuity of employer-sponsored health insurance. Large risk pools with a good
proportion of healthy enrollees tend to be more stable than small pools or those with
a higher proportion of unhealthy enrollees. Given the strategies discussed above to
discourage adverse selection, insurers assume that ESI pools — particularly large,
diverse ones — are more stable. Generally, this translates into less volatile costs and
better overall rates in the group market compared to the nongroup market. Also,
large ESI groups can use their size to negotiate for better benefits and cost-sharing,
in contrast to individual applicants in the nongroup market. Plan sponsors negotiate
and interact with insurers on behalf of all of their insured members, unlike in the
individual market where each consumer must deal with the insurance carrier directly
in order to apply for and purchase coverage. In addition, there are economies of scale
for enrollees in the group market compared to the nongroup market for such
administrative activities such as sales, billing, and customer service. For these
reasons, workers and their families benefit from receiving coverage through the
workplace. For plan sponsors, the main advantage is to use health coverage to recruit
and retain workers. This is particularly appealing in a growing economy — such as
during most of the 1990s — when there may be high demand for workers.
Disadvantages. While there are many advantages to obtaining ESI coverage,
there are challenges as well. From the vantage point of the enrollee, one of the
biggest disadvantages is the general lack of portability. Because ESI coverage is tied
to the job and not the person, any change in employment (such as going from full-
time to part-time status, or changing jobs) may alter the health care providers or
services to which the worker has access, or disrupt health coverage altogether. Also,
in firms that offer health coverage, there is a trade off made between wages and
benefits. For workers who do not take up health insurance from those firms, they end
up accepting lower wages for a set of benefits they do not access. From the
perspective of the sponsor, an underlying challenge is the lack of enrollee awareness
of the true costs of health care. Because the sponsor contributes to the cost of the
premium, enrollees do not bear the full cost of obtaining health coverage. More
importantly, enrollees generally do not have to cover the entire cost of the services
they use, since sponsors negotiate for lower rates and better cost-sharing
arrangements from insurers. Consumers enrolled in managed care plans in particular
are shielded from health care’s true costs. Some observers contend that this lack of
cost awareness gives little incentive to consumers to utilize medical services
prudently, which leads to greater use of services and greater overall health care
expenditures. In addition, sponsors’ efforts to constrain their health care spending

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CRS-12
— by increasing the employee share of the premium or employee cost-sharing — are
made even more difficult to justify or implement. Finally, from the perspective of
the federal budget, the tax exclusion of employer-sponsored health insurance
represents a lost source for Treasury funds.
Large vs. Small Groups. The group insurance market often is thought of
as consisting of large and small groups. The underlying reason for this distinction
is rooted in the inverse relationship between insurance risk and group size; i.e., the
risk associated with a group grows as the size of the group shrinks. This concept
affects employers’ offers of health benefits. For instance, a very large employer often
is able to offer multiple health plan options to its members (e.g., the Federal
Employee Health Benefit Program (FEHBP)). A large business can leverage its size
to get a more comprehensive set of benefits. On the other hand, small employers are
less able to provide health coverage at all because of the greater risk associated with
small groups. Even when small employers do offer coverage, the benefits are often
limited. Small employers also are much less likely to self-fund health coverage,
since there is a smaller pool for spreading risk and protecting against catastrophic
loss. Furthermore, such entities generally do not have the necessary administrative
capacity to negotiate with multiple provider groups and handle all the day-to-day
operational functions conducted by insurers. It is conditions such as these which
prompt legislators to develop proposals for expanding small group participation in
health insurance; for example, targeting association health plans and health marts,
and opening up FEHBP to the small group market.
Association health plans and health marts are examples of the spectrum of
entities which bring groups of people together for the purpose of buying health
insurance. These entities include trade and professional associations that offer health
coverage to their members (“association-sponsored plans”), and small firms that band
together to purchase coverage as a group (“health insurance purchasing
cooperatives”). The premise behind pooling arrangements is to decrease the
administrative burden on and increase the negotiating capacity of participants who
cannot afford to offer or purchase coverage on their own. Around one-third of small
firms buy health coverage through some type of purchasing pool.17
Public Programs
While most Americans with health insurance obtain it through the private-
sector, tens of millions of people get their medical care paid for through public
programs. Below are descriptions of selected federal and state programs which
provide payments on behalf of many persons who, due to low incomes or high health
care expenses, could not afford health care otherwise.
Medicare. The Medicare program was established in 1965, and is a federal
program for seniors (65 years and older), certain nonelderly persons with disabilities,
and persons with end-stage renal (kidney) disease. Medicare currently consists of
three parts: Part A, Hospital Insurance; Part B, Supplementary Medical Insurance;
17 For additional information, see CRS Report RL31963, Association Health Plans, Health
Marts, and the Small Group Market for Health Insurance, by Jean Hearne.

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CRS-13
and Part C, Medicare Advantage, formerly referred to as the Medicare+Choice
program. Together, Parts A and B cover many medical services, such as care
provided in hospitals and skilled nursing facilities, hospice care, home health care,
physician services, physical and occupational therapy, and other services. The then
Medicare+Choice program, added three decades after Medicare was established, was
created to expand the availability and diversity of managed care plans that cover all
Part A and B services. P.L. 108-173 added a new Part D to the Medicare program.
Effective in 2006, Medicare beneficiaries may access outpatient prescription drug
benefits through Part D.
A large majority of Americans age 65 and older are automatically entitled to
coverage under Part A and do not have to pay a premium because either they or their
spouse paid Medicare payroll taxes on their past earnings. (Even if an elderly person
did not pay Medicare taxes, she/he may be able to purchase Part A coverage.) Part
A also provides coverage for certain nonelderly persons who receive Social Security
cash benefits. Enrollment in Medicare Part B is voluntary for eligible individuals.
For most persons who are entitled to benefits under Part A, they are enrolled
automatically in Part B, but they are given the option to decline coverage. The small
minority of people who do not have automatic enrollment may request enrollment in
writing. All Part B enrollees pay a monthly premium for coverage.
Since its creation in the mid-1960s, Medicare has provided health coverage to
tens of millions of Americans, and in 2003 had 40 million enrollees. The program
has been so successful in covering the elderly that the problem of uninsurance usually
is described in terms of the under-65 population.
Medicaid and the State Children’s Health Insurance Program
(SCHIP). Medicaid is the main health insurance program for very low-income
Americans. It provides coverage for health care and long-term-care services to
certain adults (generally parents and pregnant women), children, the elderly, and
persons with disabilities. Medicaid is jointly funded by federal and state
governments, and is administered by the states within federally set guidelines. State
Medicaid programs provide a comprehensive set of services, reflecting its diverse
enrollee population. These programs must provide a set of federally specified
benefits, such as hospital services (both inpatient and outpatient), physician services,
nursing home care, home health care for those entitled to services from nursing
facilities, and certain services for children. States also have the authority to cover
additional services. Some states have used their waiver authority under Medicaid to
extend coverage to uninsured persons who could not meet the program’s financial
tests. Medicaid is a means-tested program and applicants must meet financial and
other criteria in order to be eligible for program services. Everyone who meets the
eligibility criteria is entitled to Medicaid benefits.
The State Children’s Health Insurance Program was established in 1997 to allow
states to cover certain low-income children. In designing their programs, states can
choose among three options: expand Medicaid, create a new “separate state”
insurance program, or devise a combination of both approaches. States that choose
to expand Medicaid to SCHIP eligibles must provide the full range of Medicaid
benefits, as well as all optional services specified in their state Medicaid plans.
States that establish SCHIP programs that are separate from Medicaid choose one of

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CRS-14
three benefit options. All 50 states, the District of Columbia, and five territories have
established some type of SCHIP program. SCHIP’s eligibility rules target uninsured
children under 19 years of age whose families’ incomes are above Medicaid
eligibility levels. States may raise the upper income level for low-income children
up to 200% of the federal poverty level, or higher under certain circumstances.18
Individual Health Insurance
The individual insurance (“nongroup”) market is often referred to as a “residual”
market. The reason being that this market provides coverage to persons who cannot
obtain health insurance through the workplace and do not qualify for public programs
such as Medicare, Medicaid, or SCHIP. Consequently, the enrollee population for
this private health insurance market is small.
The residual nature of the nongroup market is evident in the demographic make-
up of those who purchase coverage from it. The market is over-represented by the
near elderly (55-64 years old); a group that has relatively weak attachments to the
workplace. The individual market disproportionately consists of part-time workers,
part-year workers, and the self-employed, groups unlikely to have access to ESI
coverage.19 Also, some people use the nongroup market as a temporary source of
coverage, such as those in-between jobs or early retirees who are not yet eligible for
Medicare.
Applicants to the individual insurance market must go through robust
underwriting. Insurance carriers in most states conduct an exhaustive analysis of
each applicant’s insurability. An applicant usually must provide her/his medical
history, and often undergo a physical exam. This information is used by carriers to
assess the potential medical claims for each person. Federal and state requirements
restrict somewhat insurers’ ability to reject applications or design coverage based on
health factors (such as benefit exclusions for certain pre-existing health conditions).
Nonetheless, some applicants are rejected from the nongroup market altogether, and
others who are approved may receive limited benefits or are charged premiums that
are higher than those in the group market for similar coverage.20 Rigorous
underwriting results in an enrollee population that is fairly healthy (three out of four
enrollees report that their health is excellent or very good),21 thereby excluding
persons with moderate to severe health problems from the private nongroup
insurance market.
18 For additional information about SCHIP, see CRS Report RL30473, State Children’s
Health Insurance Program (SCHIP): A Brief Overview, by Elicia J. Herz and Peter Kraut.
19 D. J. Chollet, “Consumers, Insurers, and Market Behavior,” Journal of Health Politics,
Policy and Law, Feb. 2000.
20 M. V. Pauly and A.M. Percy, “Cost and Performance: A Comparison of the Individual and
Group Health Insurance Markets,” Journal of Health Politics, Policy and Law, Feb. 2000.
21 General Accounting Office, Private Health Insurance: Millions Relying on Individual
Market Face Cost and Coverage Trade-Offs, Nov. 1996.

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CRS-15
State High-Risk Pools
Many states have high-risk pools, which are nonprofit entities that provide
health coverage to persons with high health care expenses. Generally, such persons
are denied coverage in the individual insurance market because of their health
conditions and/or predicted use of costly medical services. If they are not eligible for
public programs (e.g., their incomes may exceed the financial eligibility criteria),
they have very few options for obtaining care. As of December 2003, 32 states run
high-risk health insurance pools.22 These programs tend to be small and eligibility
varies by state. While some state high-risk pools have successfully provided health
coverage to high-risk people, many programs are beset by accessibility, adequacy,
and affordability problems.23
The Uninsured
Despite the various private and public sources of health insurance, millions of
Americans are without health coverage. In 2003, 45 million people were without
health insurance coverage for the entire year.24 For the vast majority of the
uninsured, they lack coverage because they cannot access coverage (e.g., their
employer does not offer health insurance as an employment benefit) or they cannot
afford it.
Uninsurance is characterized as a problem of the under-65 population, given the
near-universal coverage of seniors through Medicare. The nonelderly uninsured
population differs from the insured population on a number of key demographic
factors. One of the most striking characteristic of persons who lack coverage is that
a significant proportion are in low-income families. For instance, among all
uninsured persons under age 65, two-thirds were in poor or near poor families in
2003.25 Moreover, among nonelderly persons who are poor, a full one-third lacked
health insurance coverage, compared to less than one-fifth of the poor who received
coverage through the workplace.26
A defining characteristic of the nonelderly uninsured population is that over
80% are persons with ties to the paid labor force, or dependents of such persons.
Even more surprising is that over half of the nonelderly uninsured were workers with
full-time, full-year status, or the dependents of those workers. While such findings
may be counter-intuitive, there are multiple reasons why employed persons and their
22 States with high-risk pools: AL, AK, AR, CA, CO, CT, FL, ID, IL, IN, IA, KS, KY, LA,
MD, MN, MS, MO, MT, NE, NH, NM, ND, OK, OR, SC, SD, TX, UT, WA, WI, and WY.
A map of state high-risk pools is available at [http://www.statehealthfacts.org].
23 For additional information about state high-risk pools, see CRS Report RL31745, Health
Insurance: State High-Risk Pools, by Julie Stone.
24 U.S. Census Bureau, Current Population Survey, 2004.
25 According to the Census Bureau, the poverty level for a family of four was an annual
income of $18,810 in 2003.
26 For additional information, see CRS Report 96-891, Health Insurance Coverage:
Characteristics of the Insured and Uninsured Populations in 2003, by Chris Peterson.

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CRS-16
families may lack health coverage. For example, a worker may be offered health
insurance by his/her employer, but declines it because he/she thinks it is too
expensive. An employee may work for a small firm which is less likely than a large
firm to offer health insurance as a benefit. A low-wage employee, even working full
time, is less likely to be offered health insurance at work and less likely to be able to
afford it than higher-wage workers in the same firm. Finally, a healthy worker may
be willing to take on the risk of being uninsured and choose not to purchase
insurance. Despite the dominance of employer-sponsored health insurance, the
dynamics of work, insurance risk, and financial resources intersect to impede the
coverage of all workers and their families.
The problem of the uninsured is a paramount health care concern to many
policymakers and legislators. One of the topics of ongoing debate is the overall
number of uninsured and the direction of the uninsurance rate. These issues have
generated some controversy over dueling analyses which show slightly different (and
sometimes, moderately different) findings. But despite the forceful discussions
regarding trends in uninsurance, the year-to-year changes in the uninsurance rate
actually are small. For example, from 1987 to 2003 (the last year of available data),
the change in the annual uninsurance rate usually was one-half of 1% or less.27
Nonetheless, tens of millions of Americans were without coverage during that time
period. Such circumstances beg the questions: why does pervasive uninsurance
persist (even during the robust economy of the mid-1990s), and what are the
implications for legislation and public policies to expand health coverage?
How Are Health Benefits Delivered and Financed?
Given the complexity of the health care system overall, it is no surprise that
health benefits are delivered and financed through different arrangements. Those
arrangements vary due to numerous factors such as: how health care is financed,
how much access to providers and services are controlled, and how much authority
the enrollee has to design her/his health plan. While delivery systems may share
certain characteristics, general distinctions can be made based on payment, access,
and other critical variables.
Indemnity (Traditional) Insurance
Under indemnity insurance, the insured person decides when and from whom
to seek health services. If the services the enrollee receives are covered under his/her
insurance, the enrollee or the enrollee’s provider files a claim with the insurer. Thus,
insurers make payments retrospectively (i.e., after the health services have been
rendered), up to the maximum amounts specified for each covered service. In this
model of health care delivery, the financing of health services and the obtaining of
those services are kept separate.
This bifurcated arrangement was unquestioned for a time. But as medical costs
began to rise, sometimes faster than other sectors of the national economy, many
27 Data available at [http://www.census.gov/hhes/hlthins/historic/index.html].

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CRS-17
observers criticized this delivery model as contributing to increasing expenses.
Because providers were compensated on a fee-for-service basis, some argued that
providers were not given incentives to provide efficient health care. In fact, some
critics accused health care practitioners and institutions of providing an over-
abundance of health care in order to generate greater revenue. By the early 1970s,
legislators, analysts, and others expressed considerable interest in alternative models,
such as managed care models, with cost control as a key feature.
Managed Care
While managed care means different things to different people, several key
characteristics set it apart from traditional (indemnity) insurance. One of the main
differences is that the service delivery and financing functions are integrated under
managed care. Managed care organizations (MCOs) employ various techniques to
control costs and manage health service use prospectively. Among those techniques
are restricting enrollee access to certain providers (“in-network” providers); requiring
primary-care-physician approval for access to specialty care (“gatekeeping”);
coordinating care for persons with certain conditions (“disease management” or “case
management”); and requiring prior authorization for routine hospital inpatient care
(“pre-certification”). MCOs may offer different types of health plans that vary in the
degree to which cost and medical decision-making is controlled. As a consequence,
enrollee cost-sharing also varies. Generally, the more tightly managed a plan is, the
less the premium charged. Other distinguishing features of the managed care
approach include an emphasis on preventive health care and implementation of
quality assurance processes.
Managed care was touted as the antidote to rapidly rising health care costs.
Starting with the passage of federal legislation in the 1970s which supported the
growth of managed care (specifically in the form of health maintenance organizations
(HMOs)), the number of MCOs grew quickly. Increased market competition among
these organizations led to decreases in premiums, in order to gain market share. With
high medical inflation in the 1980s and early 1990s, enrollees flocked to these less-
costly managed care plans. By the mid-1990s, more insured workers were enrolled
in HMOs than any other health plan type, and health insurance premiums had
stabilized.
But in the latter half of the 1990s, a “backlash” of sorts against managed care
grew.28 Some enrollees had grown weary of provider and service restrictions. Many
MCOs that had increased market share through artificially low premiums began to
raise them in order to increase revenue.29 Consumers and others accused the
managed care industry of caring more about controlling costs than providing health
care. Some providers resented the role managed care played in medical decision-
making. Many enrollees began to leave HMOs. The industry responded by
developing insurance products that were less-tightly managed, but more costly.
28 Richard Kronick, “Waiting for Godot: Wishes and Worries in Managed Care, “ Journal
of Health Politics, Policy and Law, vol. 24, no. 5 (Oct. 1999), pp. 1099-1106.
29 Jon Gabel, et al., “Job-Based Health Insurance in 2001: Inflation Hits Double Digits,
Managed Care Retreats,” Health Affairs, vol. 20, no. 5 (Sept./Oct. 2001), pp. 180-186.

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CRS-18
Some traditional HMOs widened their provider networks and eliminated the
gatekeeping function, while employers began to offer plan types that were less tightly
managed, such as preferred provider organizations (PPOs). In fact, by the end of the
1990s, more people with work-based health coverage were enrolled in PPOs than in
HMOs.30
As the influence of managed care waned and health care costs began to rise at
an increasing pace during the late 1990s, the impact on consumers began to be felt.
For example, in the employment setting, employers absorbed the extra costs at first
in order to recruit and retain workers during the booming economy of the mid to late
1990s.31 But as the economy soured, employers began to pass these expenses along
to enrollees in the form of greater cost-sharing.32
Consumer-Driven Health Plans
By the turn of the millennium, large increases in health costs again became
commonplace. With the belief by some observers that the age of managed care was
over, they began to search for alternatives. Consumer-driven (or consumer-directed)
health plans have been offered as one such option.
Consumer-driven health care refers to a broad spectrum of approaches that give
incentives to consumers to control their use of health services and/or ration their own
health benefits. In the workplace, at one extreme employers may choose to provide
an array of insurance products from which workers can choose, while at the other end
an employer could increase wages but not offer any health coverage allowing workers
to decide how to spend that extra money to meet their health care needs. Within
those two endpoints, the consumer-directed approach varies in the degree to which
consumers are responsible for health care decision-making.33
For example, one health benefits option that is at the heart of discussions about
consumer-driven health care is the health savings account (HSA). Under this
approach, the consumer is responsible for management of the account. HSAs are
investment accounts in which contributions earn interest tax free. Consumers, their
employers, or both may make contributions to HSAs. Consumers withdraw funds
on a tax-free basis to cover medical expenses not covered by health insurance.
Unused contributions roll over to the next year. HSAs must be paired with high-
deductible health plans. If the HSA funds are exhausted and the deductible level has
not been reached, the consumer is responsible for covering that gap. Once the
30 American Association of Health Plans, “Health Plans and Employer-Sponsored Plans,”
Oct. 1999. Available at [http://www.ahip.org/content/default.aspx?bc=41|331|366].
31 Jon B. Christianson and Sally Trude, “Managing Costs, Managing Benefits: Employer
Decisions in Local Health Care Markets,” Health Services Research, pt. II, vol. 38, no. 1,
(Feb. 2003), pp. 357-373.
32 Jon Gabel et al., “Job-Based Health Benefits in 2002: Some Important Trends,” Health
Affairs, vol. 21, no. 5 (Sept./Oct. 2002), pp. 143-151.
33 P. Fronstin, ed., Employee Benefit Research Institute, Consumer-Driven Health Benefits:
A Continuing Evolution? (Washington: EBRI, 2002).

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CRS-19
consumer’s spending reaches the deductible level, then coverage from the high-
deductible plan takes effect.
While consumer-driven health care can take on many forms, the premise
common to all of the approaches is that by making enrollees more responsible for
their own health care, it creates incentives for people to use services prudently. The
expectation is that greater cost-consciousness on the part of consumers will result in
lower overall health costs. In essence, the service and cost control functions
administered by MCOs and providers under managed care shifts to enrollees under
the consumer-driven plan scenario.
Proponents of consumer-directed plans assert the merit in having people take
increased responsibility for their own health care use and expenses. They predict that
this approach will lead to better-informed consumers, more appropriate use of health
services, and lower overall spending on health care. Opponents express concern that
this approach does not recognize the possible range of health conditions in an
enrolled population. They argue that these plans benefit the young and healthy who
use relatively few services, and, therefore, would not need to expend a great deal of
time and energy making these health care decisions. However, these plans impose
a greater burden on individuals with moderate to severe health conditions because of
their greater-than-average use of medical services.

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