DR. JILL YEGIAN: Discusses Factors Affecting the Uninsured
A California HealthCare Foundation study published in the current issue of Health Affairs examined the factors behind why the non-poor -- those with family incomes of at least 200% of the federal poverty level -- lack health insurance. Dr. Jill Yegian, senior program officer at the California HealthCare Foundation and co-author of the study, talked to California Healthline about the policy implications of the study and potential ways to increase the number of non-poor Californians who have health insurance. The study separated this uninsured population into three subgroups: a higher income group not worried about health insurance, called "the tough sells," that are unlikely to enter the market voluntarily; a "cost-constrained" group that is "quite concerned" about health coverage and close to the income floor of 200% of poverty; and a group that the study found was willing to purchase health insurance after they were better educated about the cost of health care. Referring to the entire non-poor uninsured population, Yegian said, "What we hoped would happen [as a result of the study] is that insurance companies would begin to think of this group as a market," since the group's "level of income doesn't eliminate them from purchasing health insurance." But Yegian said that a unique solution is needed for each of the subgroups.
The "Tough Sells"
Yegian indicated that the "tough sells" -- the group that elects not to purchase insurance because they are "unworried" about health care -- are somewhat of an enigma, because there has not been a lot of research or discussion about this group. "There is a tremendous amount of variation of how these people are treated" when they are suddenly rendered bankrupt by high health care costs, Yegian said. Though hospitals have reportedly subsidized the cost of care when higher-income individuals find themselves in these situations, Yegian stated that little research has been done to determine whether this group drains resources away from lower income groups. She suggested that this group may be convinced to enter the market by becoming educated about the financial risks associated with unpredictable health care calamities. Whether policymakers should be concerned about this higher income group, Yegian said, "is a societal question ... This group will need to be taken into account for universal health care."
Yegian believes two solutions exist for helping "cost-constrained" individuals who are near 200% poverty line enter the market: create new types of insurance products designed for this income group or "help them buy it." She noted that California has started some efforts to subsidize health care for these individuals, who barely miss the income cutoff for Medicaid, but she is "not aware of any serious proposals in the immediate future," because it is unclear what level the cutoff should be. Yegian cited other states' efforts to help this group by subsidizing coverage for parents of children enrolled in CHIP or Medicaid and Sen. Paul Wellstone's (D-Minn) recent proposal to offer states financial incentives to cover individuals at 300% of the poverty level. Yegian emphasized that such proposals have been fraught with controversy over what the income cutoff should be, and whether parents should be eligible for programs that single individuals at the same income levels cannot join.
Whose Responsibility Is It?
The California HealthCare Foundation study found that a significant percent of the non-poor uninsured may be persuaded to buy health insurance once they are educated about the options and actual costs. This finding raises the question -- who is responsible for education and outreach? Because the government is mainly concerned with efforts to ensure that lower income groups obtain health insurance, the responsibility often falls on the shoulders of other organizations. California HealthCare Foundation is trying to encourage the insurance industry to examine the results of the study and target this group as a market through education and outreach efforts, Yegian said. She added that the study was well-received by industry representatives and, that as a result, "there has been an effort on part of the industry ... to recapture this population and to get them more interested" in insurance options. Yegian concluded that the "real takeaway" from the study is that on one hand the study shows "promising potential to reduce the number of non-poor uninsured by developing educational campaigns." But on the other hand, California still has a significant group that will most likely not purchase insurance, which is "inevitable in a voluntary market" (Meredith Weiner, California Healthline, 7/28).