Endnotes Despite not having health insurance, millions of uninsured Americans use health care services every year. Since health care is costly and the vast majority of uninsured have limited financial means, many uninsured often cannot pay their medical bills. With the enactment of the Affordable Care Act ACAmillions of previously uninsured individuals will gain insurance coverage through either Medicaid or private plans purchased through the health care marketplaces. These estimates provide an important baseline against which to measure major changes that are occurring under the ACA.
Department of Veterans Affairs VAand local health departments. The authors note that these separate program appropriation and expenditure figures may double count some expenditures for the uninsured because many clinics and health centers are grantees of multiple federal and state programs.
For local health departments, for which client health insurance status is not available, the authors assumed that the same proportion of local public health clinic expenditures were attributable to uninsured users as for Bureau of Primary Health Care programs, 32 percent.
As shown in Table 3. Physicians By waiving or reducing their fees to uninsured patients and volunteering their time in free clinics and similar settings, physicians provide a significant amount of charity care.
One American Medical Association AMA survey reports that physicians provided about equal amounts of reduced-price and free care Emmons, Unlike the case with hospitals and publicly supported clinics, physicians and others in individual and small-group practices usually do not receive explicit subsidies for uncompensated care nor do they have the organizational superstructure and capacity of larger providers to absorb and balance the financial burdens of uncompensated care.
These two sources provide similar estimates of the proportion of practicing physicians who provide any charity care and quite different estimates of the average amount of charity care provided by those physicians who provide any.
Hadley and Holahan based their estimate of the value of uncompensated care physicians provide to uninsured persons on the midpoint of the range of average weekly hours of charity care reported for the AMA survey 7.
They assumed that all of the free care and one-third of the reduced-price care were provided to uninsured patients. Overall, public support from the federal, state, and local governments accounts for between 75 and 85 percent of the total value of uncompensated care estimated to be provided to uninsured people each year.
Sixty percent of governmental support for uncompensated care in hospitals is federal, through Medicare and Medicaid disproportionate share hospital DSH payments to general hospitals, a portion of Medicare payments for indirect medical education that supports services to medically indigent patients, and other supplemental Medicaid financing such as upper-payment limit UPL mechanisms.
As just discussed, federal, state, and local subsidies of various kinds appear to equal the estimate of hospital uncompensated care costs. Philanthropic support for hospitals in general accounts for between 1 and 3 percent of hospital revenues Davison, and, because much of this support is dedicated to other purposes e.
These surplus payments, however, tend to be inversely related to the amount of free care that hospitals provide. Thus, those hospitals with private payer surplus revenues and revenues from sources other than patient care, such as parking fees are not the hospitals that bear most of the load of uncompensated care.
Based on this reasoning, Hadley and Holahan assume that between 10 and 20 percent of these surplus revenues subsidize care to the uninsured. The issue of cross-subsidies of uncompensated care from private payers and the impact of uninsurance on the prices of health care services and insurance are discussed in the following section.
There is mixed evidence that uncompensated care is subsidized by private payers. The impact of any such shifting of costs to privately insured patients and insurers is unlikely to be so large as to affect the prices of health care services and insurance premiums.
Have the 41 million uninsured Americans contributed materially to the rate of increase in medical care prices and insurance premiums through cost shifting?
Health care prices and health insurance premiums have increased more rapidly than other prices in the economy for many years. Inmedical care prices rose by 4.
Since the last bench-marking of the series between andoverall prices have risen by about 80 percent, while medical care prices have risen by percent BLS, Health insurance premiums rose by These high rates of increases in medical care prices and health insurance premiums have been attributed to a number of factors, including medical technology advances e.
If people without health insurance paid the full bill when they were hospitalized or used physician services, there would seem to be no reason to believe that they contributed any more to the large increases in medical care prices and insurance premiums than insured persons.
Although uninsured patients are not the only people who account for uncompensated care, the estimates presented assume that they are responsible for much of it. It is certainly an overestimate to attribute all hospital bad debt and charity care to uninsured patients, as Hadley and Holahan acknowledge, because patients who have some insurance but cannot or do not pay deductible and coinsurance amounts account for some of this uncompensated care.
Of those physicians reporting that they provided charity care, about half of the total was reported as reduced fees, rather than as free care Emmons, To reach their final estimate, Hadley and Holahan assumed that all of the free care by physicians and one-third of the reduced price care were provided to uninsured patients.
Although 60 to 80 percent of the users of publicly funded clinic services, such as provided by federally qualified community health centers, the VA, and local public health departments are publicly or privately insured, these providers are not likely to be able to shift costs to private payers.
Little information is available for investigating the extent to which private employers and their employees subsidize the care given to uninsured persons through the insurance premiums they pay or the size of this subsidy.
Because uninsured patients are disproportionately served by safety-net facilities, which serve relatively low proportions of privately insured patients Gaskin and Hadley, a,b; Lewin and Altman, ; IOM, athe opportunity for cross-subsidy is limited. Using the example of South Carolina, about seven-eighths of the private subsidies for uninsured care from nongovernmental sources came from philanthropies and other hospital nonoperating revenue, while the remaining one-eighth came from surpluses generated from private-pay patients Conover, It is difficult to interpret the changes in hospital pricing because published studies have examined individual hospitals rather than the overall relationships among uncompensated care, high uninsured rates, and pricing trends in the hospital services market overall.
If for-profit hospitals are presumed to be profit maximizers as standard economic theory predictsthey would have little or no opportunity to raise prices to private payers to compensate for providing services to the uninsured Needleman, ; Zwanziger et al, Finally, the total burden of utilization and expenses by uninsured people has remained quite stable over the past decade or so Taylor et al.
For uncompensated care utilization by the uninsured to affect the rate of increase in service prices and premiums, the proportion of care that was uncompensated would have to be increasing as well. There is somewhat more evidence for cost shifting among nonprofit hospitals than among for-profit hospitals because of their service mission and their location Hadley and Feder, ; Dranove, ; Frank and Salkever, ; Morrisey, ; Gruber, ; Morrisey, ; Needleman, ; Hadley et al.
Private hospitals have become less able to shift costs as health services markets have become more competitive Morrisey, ; Bamezai et al. Some studies have demonstrated that the provision of uncompensated care has declined in response to increased market pressures Gruber, ; Mann et al.* Between and , healthcare spending in the United States increased.
The reduction in uncompensated care costs could have a significant impact on hospitals’ financial sustainability; roughly 40 percent of the hospitals studied had operating margins of less than percent of operating costs in A review of the health care systems of five different countries suggests that the United States system is not necessarily the best health delivery system in terms of access —especially when compared to that of England and Canada (Weiss & Lonnquist, ).
THE US HEALTH CARE SYSTEM. America does not have a purposeful "system" of health care as much as a tradition of laissez-faire practices that have developed over time.
The central element is a financial arrangement that pays for health care services through employer-purchased insurance. For uncompensated care utilization by the uninsured to affect the rate of increase in service prices and premiums, the proportion of care that was uncompensated would have to be increasing as well.
Over the decade, S&P has seen the growth by multihospital systems, vertically integrated healthcare providers, HMOs, specialty hospitals, rehabilitation institutions, long-term care providers, and physician group practices in the rated tax-exempt market.