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Davis Web Exclusive: October 9, 2002
D A T A W A T C H : M E D I C A R E
W E B E X C L U S I V E
9 October 2002
Medicare Versus Private Insurance:
Rhetoric And Reality
Medicare provides a level
of security that is not typically
found in employer or individual coverage markets.
by Karen Davis, Cathy Schoen, Michelle
Doty, and Katie Tenney
ABSTRACT:
Many policymakers have called for the remodeling of Medicare to more closely
resemble private insurance, which is often assumed to work better than public
programs do. However, evidence from this 2001 survey demonstrates that Medicare
beneficiaries are generally more satisfied with their health care than are persons
under age sixty-five who are covered by private insurance. Medicare beneficiaries
report fewer problems getting access to care, greater confidence about their
access, and fewer instances of financial hardship as a result of medical bills.
Making the program more like private insurance runs the risk of undermining
a program that is working well from the perspective of beneficiaries.
Medicare reform has been the focus of federal health policy since 1997.1
The National Bipartisan Commission on the Future of Medicare was established
by the Balanced Budget Act (BBA) of 1997, primarily because Medicare has been
consuming an increasing share of the federal budget and the nation’s economic
resources, and those shares will rise markedly as the baby-boom generation reaches
retirement.2 Converting Medicare to a defined-contribution
program, through Medicare+Choice (M+C), premium support, or vouchers, is viewed
by some policymakers as a mechanism for controlling federal budget outlays and
potentially achieving savings through financial incentives for beneficiaries
and competition among private plans.3
However, Medicare beneficiaries’ out-of-pocket health expenses will also
rise markedly between 2000 and 2025.4 For those
concerned with beneficiaries’ financial burdens and their access to needed
care, Medicare reform is primarily about modernizing its benefit package, most
notably adding a prescription drug benefit.5 The
discussion over a Medicare prescription drug benefit has been stalled, in part,
by a debate over the role of private insurance.
A common theme running through the debate is that Medicare ought to be more
like private insurance, which is depicted as being effective in controlling
costs and providing beneficiaries with the kinds of health care choices they
might desire. In the mid-1990s, when private health insurance spending was increasing
at a slower rate than that of Medicare spending, the short-term trends were
cited as evidence that Medicare could achieve savings by adopting private managed
care techniques. In the late 1990s, however, Medicare spending grew at a slower
rate than did private insurance spending. Long-term trend analysis reveals that
Medicare and private outlays tend to grow at similar rates over time.6
In the debate over Medicare costs and reform, few have considered how well Medicare
works for its beneficiaries compared with persons under age sixty-five who are
covered by private health insurance. Surveys have found a higher degree of satisfaction
with coverage among Medicare beneficiaries compared with privately insured working
families, better care experiences for persons newly covered by Medicare (ages
65–70) than for persons not yet covered (ages 50–64), and better ratings
of managed care plans by Medicare enrollees than by those covered under employer-sponsored
managed care plans.7
In this paper we present new evidence on how well Medicare works for beneficiaries
compared with how private insurance works for persons under age sixty-five.
Based on a 2001 survey of adults age nineteen and older, the analysis explores
how the experiences of Medicare beneficiaries compare with the experiences of
persons under age sixty-five who are insured through private employer-sponsored
insurance in achieving two key goals of insurance: assuring that those covered
are able to obtain health care services when needed, and assuring that they
are protected against financial hardship from medical bills. We also compare
how Medicare beneficiaries and those with private employer-sponsored coverage
rate their coverage and their confidence about being able to obtain care in
the future.
Data And Methods
The analysis is based on data from the Commonwealth Fund’s 2001 Survey
of Health Insurance, which was conducted by Princeton Survey Research Associates
from 27 April through 29 July 2001. The survey consisted of twenty-five-minute
telephone interviews with a random national sample of 3,508 adults, age nineteen
and older, living in households with telephones in the continental United States.
The interviews included 2,829 adults ages 19–64 and 628 adults age 65 and
older. The analysis drops from the sample fifty-one respondents who did not
provide an age, yielding a study sample of 3,457 persons age nineteen and older.
The study oversampled adults from low-income communities to yield a final sample
with disproportionately large numbers of low-and moderate-income and minority
households. The final sample is weighted to the adult population by sex, age,
race/ethnicity, education, region, telephone service interruption, and household
size, using the U.S. Census Bureau’s March 2000 Current Population Survey
(CPS). The resulting sample is representative of the 196 million adults living
in the continental United States. Of those contacted for interviews, 69 percent
agreed to participate. Counting eligible adults who were not reached by phone,
despite numerous attempts, the overall survey response rate was 54 percent.
The response rate is typical of most recent random-digit-dialed telephone surveys.
Our exhibits compare experiences among Medicare beneficiaries age sixty-five
and older; disabled Medicare beneficiaries; Medicaid beneficiaries; and adults
under age sixty-five who are covered by private insurance (91 percent are employer-based
plans, 9 percent individual), with subanalysis in logit regression results that
differentiate between employer-based coverage, individual coverage, and the
uninsured. In the analyses, persons with more than one source of coverage were
assigned hierarchically to the Medicare, Medicaid, employer, and individual
insurance categories, so that Medicare beneficiaries with supplemental coverage
such as Medicaid, retiree coverage, or Medigap coverage are categorized as being
Medicare enrollees.
The discussion focuses primarily on comparisons between Medicare elderly and
nonelderly adults who are insured through employer-group plans.8
Logit regression results for the Medicare disabled and individually insured
are also presented but represent small samples for these groups (n =157 and
167, respectively); caution must be exercised in interpreting these results,
given the small sample sizes. Results for Medicaid beneficiaries and the uninsured
are presented as well, where applicable.
We initially present responses to questions about access, cost, and care experiences
by insurance group, regardless of differences in income or health status. However,
since different health care experiences are likely to be a function of varying
needs for health care and ability to pay for care, we also present summary results
of regression analyses (odds ratios from logit analyses) that take into consideration
the effects of health and income. These exhibits compare the relative odds of
reporting a problem or experience by insurance group (with adults under age
sixty-five who are insured through employer plans as the reference group), taking
into account the effects of health status, poverty, and other factors, including
presence or absence of a prescription drug benefit. Exhibits indicate where
findings and odds ratios are significant at the p < .05, p
< .01, or p <.001 levels.
Study Results
Demographics.
Medicare beneficiaries are more likely than the privately insured are to be
in poor health and have low incomes. In the survey, two-thirds of persons under
age sixty-five with private health insurance rated their health status as excellent
or very good, compared with two-fifths of elderly Medicare beneficiaries (Exhibit
1). The proportion of elderly Medicare beneficiaries rating their health
as fair or poor was three times higher than that of privately insured adults.
Four of five Medicare beneficiaries had a chronic condition, compared with just
over one-third of the privately insured. Medicare beneficiaries were four times
as likely as the privately insured were to report having two or more chronic
conditions.
Medicare beneficiaries were more than twice as likely as the privately insured
were to have incomes below 200 percent of the federal poverty level. Four-fifths
of privately insured persons were employed either full or part time, compared
with only one in ten Medicare beneficiaries.
Satisfaction, access, and
cost experiences.
Levels of satisfaction with and access to health care also vary by source of
coverage, as do experiences with health care costs. Elderly Medicare beneficiaries
were more likely to rate their health insurance as “excellent” and
less likely to have negative experiences with their insurance than were the
privately insured (Exhibit
2). Sixty-two percent of elderly Medicare beneficiaries reported being very
satisfied with their care, compared with 51 percent of those covered by private
insurance. Elderly Medicare beneficiaries were also more confident in their
future ability to get care than were the privately insured.
In spite of having poorer health and lower incomes than the privately insured
had, elderly Medicare beneficiaries were somewhat less likely to report access
problems resulting from costs, such as not getting needed specialist care or
having a medical problem but not visiting a doctor or clinic. They were also
less likely to report having problems paying their medical bills, such as not
being able to pay, being contacted by a collection agency, or having to change
their way of life to pay medical bills. However, they were more likely than
the privately insured were to pay more than $500 a year out of pocket for health
care and to devote more than 5 percent of their income to medical expenses.
Interestingly, 45 percent of Medicaid beneficiaries reported a medical bill
problem. This might reflect the fact that 32 percent of Medicaid beneficiaries
were covered for less than a year (not shown), so that bills might have been
incurred while they were uninsured, or Medicaid beneficiaries might have paid
out of pocket when seeing nonparticipating providers or after reaching limits
on covered services.
The observed differences between the health care experiences of Medicare beneficiaries
and the privately insured are likely to reflect underlying differences in health
status and income as well as the presence or absence of insurance benefits such
as prescription drug coverage. Exhibits 3,
4,
and 5
present the odds of reporting problems with insurance, experiences with quality
of care, access to care, or financial burdens by Medicare beneficiaries relative
to those with employer coverage, when income, health status, and drug coverage
are taken into account.
Satisfaction with insurance.
After differences in income, health status, and drug coverage were accounted
for, respondents insured through the two main public insurance programs—elderly
Medicare and Medicaid beneficiaries—were found to be more satisfied with
their insurance than were those with employer coverage (Exhibit
3). Elderly Medicare beneficiaries were 2.7 times more likely than those
with employer coverage were to rate their health insurance plan as “excellent,”
and Medicaid beneficiaries were 2.1 times more likely than those with employer
coverage to do so.
Elderly Medicare beneficiaries were only one-third as likely as those with employer
coverage were to report negative experiences with their coverage. Negative experiences
included finding out that the plan did not pay for a given medical service,
that it paid for only part of a medical bill, or that the limit of what the
plan would pay for a specific illness or injury had been reached. Forty-three
percent of elderly Medicare beneficiaries reported any of these negative experiences,
compared with 61 percent of privately insured adults (Exhibit
2).
Elderly Medicare beneficiaries were found to be less than half as likely as
those with employer coverage were to report that they paid a lot out of pocket
for prescriptions or dental services. Medicaid, which typically includes drug
and dental coverage with little or no patient cost sharing, was also more effective
than employer coverage was in protecting beneficiaries from out-of-pocket costs.
The analysis indicates that having a prescription drug benefit, across all age
groups, is associated with more positive overall ratings of coverage as well
as cost experiences. As illustrated in Exhibit
3, having insurance with drug benefits increases the likelihood of rating
coverage as excellent and reduces the risk of large out-of-pocket expenses.
These results may be a direct reflection of drug benefits or may reflect the
fact that plans with such benefits tend to provide more comprehensive benefits
in general.
As reported in other studies, the survey finds that respondents’ income
and health status affect their levels of satisfaction with coverage.9
Across all insurance sources, the poor and near-poor were less likely than adults
with incomes at or above 200 percent of poverty were to rate their coverage
as excellent (in 2002 the federal poverty level for a single person in the contiguous
United States was $8,860). Respondents with self-rated health status that was
less than excellent were also significantly
(p < .05, p < .001) less likely to give their insurance
an excellent rating. Those with two or more chronic conditions were about twice
as likely as others were to report negative experiences with their health insurance
plan and to report paying a lot out of pocket for prescription drugs and dental
services.
Quality of care.
Elderly Medicare beneficiaries were more likely than those with employer coverage
were to report being very satisfied with their care, more likely to rate their
doctor as excellent, and more likely to be very confident in their ability to
get care in the future (Exhibit
4). Having any source of insurance was better than being uninsured on all
quality-of-care measures. The uninsured were systematically less likely to be
very satisfied with the overall quality of care, to rate their physician as
excellent, or to be very confident of their ability to get care in the future.
Employer coverage clearly improves patient ratings of care, compared with having
no coverage at all. On five of the six measures of insurance rating and quality
of care, the ratings by adults with individual (nongroup) insurance coverage
were similar (no significant differences) to those by adults with employer coverage.
However, given the small number of individually insured adults in the survey
sample, caution should be exercised in interpreting this result.
Medicare beneficiaries generally have very stable coverage. Ninety-nine percent
of them had been insured the entire year when surveyed, compared with 92 percent
of persons with employer coverage (not shown). However, even for continuously
insured employed persons, employers change the plans that are available during
annual enrollment periods. Changing plans often means changing physicians, especially
for the privately insured under age sixty-five, who are much more likely than
Medicare beneficiaries are to be enrolled in managed care plans.10
This instability can lead to disruptions in continuity of care.
Access to care and financial
problems. Based
on reports of access and bill problems, after health status and income are controlled
for, Medicare successfully fulfills the two main purposes of health insurance:
assuring access to needed health care services and preventing financial burdens
from medical bills. Elderly Medicare beneficiaries were one-third as likely
as those with employer coverage were to experience access problems because of
cost, after income, health status, and drug coverage were adjusted for (Exhibit
5). Access problems include avoiding filling a prescription, not getting
needed specialist care, skipping recommended tests or follow-up care, or having
medical problems but not visiting a doctor or clinic because of cost.
Among the insurance groups, the uninsured were generally most at risk for access
problems: They were 3.6 times as likely as those with employer coverage were
to experience one or more access problem as a result of cost. These findings
underscore how well employer coverage performs in improving access to care relative
to having no coverage at all. Persons with low incomes, in poor health, or without
prescription drug coverage reported more problems getting access to health care
than others reported.
Medicare provides better coverage against financial hardship than employer coverage
provides, after income and health status are controlled for. Elderly Medicare
beneficiaries were one-fourth as likely as those with employer coverage were
to report problems with medical bills, including not being able to pay, being
contacted by a collection agency, or having to change their way of life to pay
medical bills. The uninsured, by contrast, were 2.6 times as likely as those
with employer coverage were to report a medical bill problem. Lower income and
poorer health status also significantly (p <.01, p < .001)
increased the likelihood of experiencing medical bill problems.
Medicare beneficiaries and those with employer coverage reported similar experiences
of high medical costs, defined in this analysis as out-of-pocket expenses greater
than $500 a year or totaling 5 percent or more of income. Medicaid beneficiaries,
by contrast, were much less likely than those with employer coverage were to
incur substantial out-of-pocket costs.
Those without prescription drug coverage were more likely to experience high
out-of-pocket costs than were those with such coverage. Lower income levels
and chronic conditions were also associated with higher out-of-pocket costs.
Income, health status, and
insurance ratings.
Medicare was systematically more likely than employer coverage was to be rated
as excellent across all income and health status categories (Exhibit
6). For example, 43 percent of healthy elderly Medicare beneficiaries with
incomes greater than twice the poverty level rated their insurance as excellent,
compared with 22 percent of persons with employer coverage at comparable income
and health-status levels. While only 26 percent of elderly Medicare beneficiaries
with low incomes and poor health rated their insurance as excellent, those with
employer coverage at similar income and health-status levels were even less
likely to rate their insurance as excellent (12 percent).11
Discussion
And Policy Implications
This survey’s findings that Medicare beneficiaries are generally more satisfied
with their health care than the privately insured are, are more confident about
their access to care, and for key services experience fewer access problems
challenge the accepted notion that Medicare is “out of date” and should
“catch up” with the private insurance model. Medicare beneficiaries
have less comprehensive benefits and often pay higher out-of-pocket premiums
than those covered by employer plans pay, and their Part B premiums exceed premiums
paid directly by employees for employer coverage.12
Nevertheless, elderly Medicare beneficiaries are less likely than persons with
employer coverage are to report negative insurance experiences or problems paying
medical bills. This may reflect greater denial of claims under employer coverage
or the lower continuity of coverage under employer plans that periodically leaves
some persons without insurance.
Medicare beneficiaries’ more positive access experiences and ratings of
their care indicate that their coverage is working relatively well in providing
choice of services and access to needed care. This may be due to the fact that
most Medicare beneficiaries are covered under the traditional fee-for-service
program, while adults with employer coverage are more likely to be enrolled
in managed care plans. As a result, Medicare beneficiaries have a wider choice
of physicians and fewer restrictions on care, such as the prior approval for
specialist services required by many managed care plans.
In markets with M+C options, Medicare beneficiaries might also have more plan
choices than persons with employer coverage have. Only about 41 percent of employees
have a choice of employer-sponsored insurance plans, and fee-for-service options
are not common.13 A number of studies have found
that consumer choice leads to higher satisfaction with coverage.14
The more positive access and insurance satisfaction findings from Medicare beneficiaries
might also reflect the stability and relative simplicity of coverage under Medicare.
Except for the minority in M+C plans, the core set of benefits and insurance
rules as well as coverage have remained constant over time.
Private coverage varies widely. It was not possible to contrast the experiences
of persons covered under large employer plans with those in the small-business
market. The financial burdens of those with individual insurance point to the
limited benefits available in that market, which may also be true of some employer
plans. It was also not possible, given the sample size, to contrast the experiences
of those with Medicare managed care coverage with those in Medicare’s traditional
fee-for-service plan. Proposals to “privatize” Medicare might be able
to avoid some of the disadvantages of private coverage by keeping central features
of social insurance—guaranteed coverage regardless of health status, defined
benefits, and multiple choice of plans—and by retaining Medicare’s
fee-for-service option.
In spite of these positive findings for Medicare for seniors, the need for a
Medicare prescription drug benefit remains clear.15
For those without such a benefit, ratings of insurance are lower, access problems
are greater, and out-of-pocket costs for all medical and dental care and for
prescription drugs are higher.
There are too few disabled (nonelderly) Medicare beneficiaries in this survey
to draw conclusions about this group, although findings indicate that this group
is at risk. A recent study of the Medicare disabled also finds that this group
is vulnerable because of the combined effects of low income, poor health, and
coverage gaps, with consequent needs for comprehensive benefits.16
Further investigation of this group’s experiences is warranted.
In the policy debates over
the future of Medicare, it is important to listen to the experiences of individuals,
whether covered by Medicare or by private insurance. Apart from the lack of
a prescription drug benefit, Medicare is reportedly working better for its beneficiaries
than is the employer-group coverage available to most persons under age sixty-five.
The greater confidence in getting care when needed and lower incidence of access
problems reported by Medicare beneficiaries are notable, given that Medicare
beneficiaries are disproportionately sicker and poorer than the privately insured
are.
The survey also raises questions about how well private coverage is protecting
persons at greater risk because of lower incomes or poor health or both. Current
trends to increase cost sharing or shift responsibility for health coverage
to individuals in the form of defined-contribution plans or personal health
accounts may make low-income and chronically ill adults more vulnerable. Increased
cost sharing as part of Medicare reform may also be particularly problematic
for chronically ill Medicare beneficiaries.
Medicare provides a level of security not typically found in employer or individual
coverage. Its beneficiaries are assured that they will not lose their coverage,
while coverage for persons under age sixty-five can vary with employment status,
employers’ decisions to change plans, or even the onset of a serious illness.
Medicare beneficiaries also live in a world with more stable benefits and, for
most, fewer complex insurance arrangements than the privately insured have.
Thus, attempts to reform Medicare that would pattern coverage on private employer
coverage run the risk of undermining the confidence of the people it is designed
to serve.
The authors thank the three anonymous reviewers for their helpful comments.
The views expressed are those of the authors and should not be attributed to
the Commonwealth Fund, its directors, or its officers.
NOTES
1. Reform proposals include converting Medicare to a program
like the Federal Employees Health Benefits Program (FEHBP); converting Medicare
to a premium-support program; encouraging enrollment in managed care plans;
and moving to competitive pricing or value-based purchasing under Medicare+Choice.
Incremental changes to the fee-for-service program include improving benefits,
tightening provider payments, and setting budget caps on Medicare. See S.M.
Butler, “The FEHBP as a Model for a New Medicare Program,” Health
Affairs (Winter 1995): 47–61; H.P. Cain II, “Moving Medicare to
the FEHBP Model, or How to Make an Elephant Fly,” Health Affairs
(July/Aug 1999): 25–39; H.J. Aaron and R.D. Reischauer, “The Medicare
Reform Debate: What Is the Next Step?” Health Affairs (Winter 1995):
8–30; R.A. Berenson, “Medicare+Choice: Doubling or Disappearing?”
28 November 2001, www.healthaffairs.org/WebExclusives/Berenson_Web_Excl_112801.htm
(6 September 2002); M. Moon and K. Davis, “Preserving and Strengthening
Medicare,” Health Affairs (Winter 1995): 31–46; J. Oberlander,
“Is Premium Support the Right Medicine for Medicare?” Health Affairs
(Sep/Oct 2000): 84–99; and K. Thorpe and A. Atherly, “Reforming Medicare:
Impacts on Federal Spending and Choice of Health Plans,” 10 October 2001,
www.healthaffairs.org/WebExclusives/Thorpe_Web_Excl_101001.htm
(6 September 2002).
2. C. Kahn and H. Kuttner, “Budget Bills and Medicare Policy:
The Politics of the BBA,” Health Affairs (Jan/Feb 1999): 37–47.
3. National Bipartisan Commission on the Future of Medicare,
Final Proposal: Breaux-Thomas Premium Support Model for Medicare (Washington:
Bipartisan Commission, March 1999).
4. M. Moon, Growth in Medicare Spending: What Will Beneficiaries
Pay? (New York: Commonwealth Fund, May 1999); M. Moon, Restructuring
Medicare: Impacts on Beneficiaries (New York: Commonwealth Fund, May 1999);
and S. Maxwell, M. Moon, and M. Segal, Growth in Medicare and Out-of-Pocket
Spending: Impact on Vulnerable Beneficiaries (New York: Commonwealth Fund,
January 2001).
5. P. Neuman et al., “Understanding the Diverse Needs of
the Medicare Population: Implications for Medicare Reform,” Journal
of Aging and Social Policy 10, no. 4 (1999): 25–50; M. Davis et al.,
“Prescription Drug Coverage, Utilization, and Spending among Medicare Beneficiaries,”
Health Affairs (Jan/Feb 1999): 231–243; J. Poisal and L. Murray,
“Growing Differences between Medicare Beneficiaries With and Without Drug
Coverage,” Health Affairs (Mar/Apr 2001): 74–85; J. Blustein,
“Drug Coverage and Drug Purchases by Medicare Beneficiaries with Hypertension,”
Health Affairs (Mar/APR 2000): 219–230; M. Moon, “Will the
Care Be There? Vulnerable Beneficiaries and Medicare Reform,” Health
Affairs (Jan/Feb 1999): 107–117; and C. Cassel, R. Besdine, and L.
Siegel, “Restructuring Medicare for the Next Century: What Will Beneficiaries
Really Need?” Health Affairs (Jan/Feb 1999): 118–131.
6. C. Boccuti and M. Moon, “Comparing Medicare and Private
Insurance: Growth Rates in Spending for Health Care over Thirty Years,”
Draft Report (New York: Commonwealth Fund, 16 May 2002); and M. Moon, Beneath
the Averages: An Analysis of Medicare and Private Expenditures (Washington:
Henry J. Kaiser Family Foundation, September 1999).
7. C. Hoffman et al., “Gaps in Health Coverage among Working-Age
Americans and the Consequences,” Journal of Health Care for the Poor
and Underserved 12, no. 3 (2001): 46–58; C. Schoen et al., Counting
on Medicare: Perspectives and Concerns of Americans Ages Fifty to Seventy
(New York: Commonwealth Fund, July 2000); and H. Taylor, “Most People Continue
to Think Well of Their Health Plans,” Harris Interactive Health Care
News 2, no. 3 (2002): 1–4.
8. Reflecting coverage patterns for the under-sixty-five population,
all but 9 percent of persons with private coverage in the survey were covered
through the employer-group market.
9. B. Druss et al., “Chronic Illness and Plan Satisfaction
under Managed Care,” Health Affairs (Jan/Feb 2000): 203–209;
and K. Davis et al., “Choice Matters: Enrollees’ Views of Their Health
Plans,” Health Affairs (Summer 1995): 99–112.
10. Only 16 percent of Medicare beneficiaries were enrolled
in managed care plans in 2000. Among persons with employer-based coverage, 26
percent were enrolled in HMO plans and 52 percent in PPO plans in 2002. J. Gabel
et al., “Job-Based Health Benefits in 2002: Some Important Trends,”
Health Affairs (Sep/Oct 2002): 143–151; and M. Gold and L. Achman,
Trends in Premiums, Cost-Sharing, and Benefits in Medicare+Choice Health
Plans, 1999–2001 (New York: Commonwealth Fund, April 2001).
11. Healthy is defined as being in excellent or very
good health status, while higher income is defined as having income of
200 percent of the federal poverty level or greater. Predicted probabilities
in each category are based on appropriate values for chronic conditions for
each income and self-assessed health status group, while holding prescription
drug coverage constant.
12. L. Levitt, E. Holve, and J. Wang, Employer Health Benefits,
2001 Annual Survey (Washington: Henry J. Kaiser Family Foundation and Health
Research and Educational Trust, 2001); and K. Davis, “Medicare’s Cost
Sharing: Implications for Beneficiaries,” Testimony before the House Ways
and Means Committee, 9 May 2001.
13. B.S. Schone and P.F. Cooper, “Assessing the Impact
of Health Plan Choice,” Health Affairs (Jan/Feb 2001): 267–275.
14. See, for example, R. Miller and H. Luft, “HMO Plan
Performance Update: An Analysis of the Literature, 1997–2001,” Health
Affairs (July/Aug 2002): 63–86; T. Rice et al., “Workers and Their
Health Plans: Free to Choose?” Health Affairs (Jan/Feb 2002): 182–187;
A. Gawande et al., “Does Dissatisfaction with Health Plans Stem from Having
No Choices?” Health Affairs (Sept/Oct 1998): 184–194; and Davis
et al., “Choice Matters.”
15. Neuman et al., “Understanding the Diverse Needs of
the Medicare Population”; Davis et al., “Prescription Drug Coverage,
Utilization, and Spending”; and Poisal and Murray, “Growing Differences
between Medicare Beneficiaries With and Without Drug Coverage.”
16. B. Briesacher et al., Medicare’s Disabled Beneficiaries:
The Forgotten Population in the Debate over Drug Benefits (New York: Commonwealth
Fund, September 2002).
Karen Davis is president
of the Commonwealth Fund in New York City. Cathy
Schoen is its vice-president for health policy, research, and evaluation; Michelle
Doty, a senior analyst; and Katie Tenney, special assistant to the president.
©2002 Project HOPE–The
People-to-People Health Foundation, Inc.
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