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Health Insurance/Access to Care

Access to comprehensive, quality health care services is important for promoting and maintaining health, preventing and managing disease, reducing unnecessary disability and premature death, and achieving health equity for all Americans. Three components of access to consider are: insurance coverage, availability of services (both geographically and timewise), and finding a health care provider that the patient trusts (personal relationship).

Health insurance is a contract between an individual and an insurance company. The insurance plan specified in the contract provides part or complete payment of specified health care costs for the enrollee(s). Coverage of health care costs depends on the plan. Some plans are provided by employers, some by government programs such as Medicare, and others are purchased directly by individuals from insurance companies. The Hawai'i Prepaid Health Care Act specifies that employees who work at least 20 hours per week for four consecutive weeks are entitled to health care coverage where the employer pays at least half of the premium.

Most people need health care at some time in their lives. Health care includes medical care, oral health care and mental health care and is becoming more expensive. Health insurance covers all or some costs of care and protects people from very high expenses. People without health coverage have to cover all costs. This can sometimes lead people into debt or even bankruptcy. Rising health care costs make insurance less affordable for individuals, families, and businesses.

People without health insurance are more likely to lack a usual source of medical care, such as a primary care provider. More often than not they skip routine and preventive medical care, thus increasing their risk for developing serious and disabling health conditions that cost more to treat and can result in premature death.

Concerns about rising health care costs and affordability of health care insurance led to the enactment of the Affordable Care Act, or ACA. The key challenge moving forward will be finding the best mix of policies that promote health and prevent illness, while also ensuring that government, corporate, and private health spending is as efficient as possible and best meets the health care needs of the nation.

Health care costs per capita in the U.S. grew an average 2.4 percentage points faster than the GDP from 1970 to 2012. Although this rapid increase has leveled off in recent years, the share of economic activity (gross domestic product or GDP) devoted to health care was 17.9% in 2017 compared to 7.2% in 1970. In 2017, the U.S. spent $3.5 trillion on health care, an average of $10,739 per person. Many experts believe that new technologies and the spread of existing ones account for a large portion of medical spending and its growth. The U.S. spends substantially more on health care than other developed countries. Though the rapid growth in spending for prescription drugs has received considerable attention recently, as of 2017, it accounted for 10% of total costs. The largest shares of total health spending in 2017 were paid for by the federal government and households (28% each) followed by private business (20%), state and local governments (17%) and other private revenues (7%).

Health care expenditures in Hawai'i have historically been lower and have grown more slowly than expenditures nationally. Favorable demographics (younger population) and healthier lifestyles contribute to these relatively low per capita health care expenditures. However, an aging and expanding population, medical technology advancements, and the limits of managed care to contain costs may cause per capita expenditures to rise. As a percentage of per capita income, per capita expenditures for medical care slowly increased from 1993 to 2014.

Health care insurance costs more today than ever. Health insurance premium increases have consistently outpaced inflation and the growth in workers' earnings. Families are also paying more out-of-pocket for health care. Concurrently, employer shares of payroll going toward health insurance costs continue to rise. In addition, eligibility standards for public programs such as Medicaid and CHIP do not keep pace with rapid increases in the cost of health coverage.

All people are at risk of needing costly health care services during their lives. People without the financial means and/or adequate health insurance coverage are at risk for not receiving the kinds of health care that can optimize their health, especially as costs continue to increase and options for care expand.

Health status is strongly associated with age. In general, health status declines with age. As health status declines, there is more need for medical services. Those with worse health use medical services more often. Women have higher medical services utilization than men.

Data from the Healthy People Midcourse Review demonstrate that there are significant disparities in access to care by sex, age, race, ethnicity, education, and family income. These disparities exist with all levels of access to care, including health and dental insurance, having an ongoing source of care, and access to primary care. Disparities also exist by geography, as millions of Americans living in rural areas lack access to primary care services due to workforce shortages.

Healthy People 2020 states that future efforts will need to focus on the deployment of a primary care workforce that is better geographically distributed and trained to provide culturally competent care to diverse populations.

Specific issues that should be monitored over the next decade include:
  • Increasing and measuring insurance coverage and access to the entire care continuum (from clinical preventive services to oral health care to long-term and palliative care)
  • Addressing disparities that affect access to health care (e.g., race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, gender identity, and residential location)
  • Assessing the capacity of the health care system to provide services for newly insured individuals
  • Determining changes in health care workforce needs as new models for the delivery of primary care become more prevalent, such as the patient-centered medical home and team-based care
  • Monitoring the increasing use of telehealth as an emerging method of delivering health care

Health Care Coverage -
Estimates of the number of people who are uninsured are available from several different sources, including a number of federal surveys. Four federal surveys provide this information.
  1. The U.S. Census Bureau Current Population Survey (CPS) - state-level estimates
  2. The American Community Survey (ACS) - state and sub-state level estimates
  3. The National Health Interview Survey (NHIS) - state level estimates for 43 states
  4. The Medical Expenditure Panel Survey - Household Component (MEPS-HC)

In Hawai'i we track health insurance coverage using the Hawai'i Behavioral Risk Factor Surveillance System (BRFSS) and the Pregnancy Risk Assessment and Monitoring System (PRAMS).