Running Head: THE UNINSURED AND NDERINSURED IN...
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Running Head: THE UNINSURED AND UNDERINSURED IN HEALTHCARE 1
Brenda Rivas
Workshop 5
The Uninsured and Underinsured in Healthcare
Critical Issues in Healthcare
Professor Chris Tokonitz
December 2, 1013
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Uninsured and Underinsured
Working for a Healthcare organization we are constantly changing and evolving we have
gone through changes in structure, laws, the rise of the uninsured patients and we are starting to
see a rise of underinsured patients. Today in healthcare we are experiencing many changes and
challenges when it comes to the Affordable Care Act, the health exchange, and how we are going
to be reimbursed. With all the changes that are taking place we can no longer choose if we want
to move forward with the changes if we want to be successful and continue being a leader in
patient care. We have to look at ways that we can evolve with the changes and how it is going to
affect us a health care organization and our patients.
We have always dealt with uninsured patients but when the recession happened in 2007-
2008 we saw an increase to individuals that lost their jobs, lost their insurance, some of these
individuals did not qualify for Medicaid they were receiving unemployment benefits and did not
meet the income guidelines or Medicaid had cut their funds and only insured children or mothers
that are expecting qualified, government programs were being cut such as behavior health,
employers could no longer afford to offer health insurance because of the cost, or the cost of
employee’s premiums went up and employees are no longer able to afford it. These are some of
issues that we are dealing with the rise of the uninsured and it affects individuals because they no
longer have access to receive care when they become ill. These individuals end up in our
emergency room or end up being admitted because they took so long to seek treatment and their
condition worsened. This is affecting not only the patients trying to figure out how they will pay
for their medical bills but it also affects us as a health care facility that provides the care but most
likely will end up writing off the balance to charity or bad debt if the patient has inability to pay.
This is does not imply that all uninsured patients do not pay their medical bills we do have
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patients that make arrangements on their balances by paying their remaining balances in full or
setting up payment arrangements.
36th
Annual report from the CDC (Center of Disease and Control) it states that 20% of
U.S. adults reported to be seen at the emergency room once in the past year it also states that in
2001-2011 children under the age of 18 and adults ages 18-64 were seen at the emergency room
that carried Medicaid coverage and also private insurance, this contradicts the reports that are
reviewed by health care organization we are seeing an increase of adjustments due to charity or
bad debt and the lack of revenue coming in the door. Even though Medicaid patients are walking
into our emergency rooms we are only getting paid pennies on the dollar and the individuals that
carry private insurance they can potentially end up with high deductibles, high out of pocket, or
high co pay. We eventually have to end up writing the balances off to charity or bad debt and for
our Medicaid patients we take a larger contractual adjustment since we are unable to bill patient
for the remaining balance based on our contracts as an organization we are still affected at the
end.
As a health care facility we are reporting a rise in the uninsured and underinsured we are
having to consistently look at how we are going to shift cost in the past to be able to continue
providing charity care and be able to continue to offer benefits to the communities we serve. In
the past based on our contractual agreement contracts we set with insurance companies we could
shift some of the cost to them but now they are also looking at ways to reduce their cost. They
can no longer afford to have higher cost and are asking health care facilities to reevaluate their
contracts for us to be able to continue to work with them or we can potentially lose them and an
Insurance carrier that considers us within in network and this affects our patients. Insurance
companies now are reimbursing services at a lower percentage and leaving patients with higher
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out of pockets. They are also denying claims and we have to end up adjusting it because based
on the patient’s insurance coverage patient is not responsible for the remaining balance.
Below is a graph that shows you the rise in the uninsured from 2007-2012 and which the
graph shows that in 2011-2012 we saw slight decrease we still have many individuals with no
health insurance that are adults and children.
The reason why we are seeing a decrease in children being covered because of the expansion of
Medicaid and the expansion of the CHIP (Children Health Insurance Act) program to cover all
children up to the age of nineteen that did not qualify for Medicaid because they did not meet the
income guidelines but could apply for CHIP but would end up with minimal out of pocket
expense. We also are seeing a decrease in adults because the Affordable Care Act (ACA) now
has a rule in place that if parents choose they can cover their adult child to the age of twenty six
and they do not have to be enrolled in school to be able qualify based on the new guidelines.
Individuals that are uninsured it does not mean that they are currently not employed there
is also a rise in uninsured employees that work for small and large companies, studies show that
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when the recession hit employers could no longer afford to insure their employees because it
affected their business they had declines in manufacturing jobs, changes in structure. In, 1987 to
2001 the proportion of uninsured workers who were employed by firms of 500 or more
employees grew from 25 to 32 percent. The growing share of uninsured workers employed by
larger firms, Sherry Glied, Jean Lambier, and Sarah Little, The Commonwealth Fund, October
2012. The workers that were affected the most are the low wage work force they do not make
enough to pay for insurance and are part of one income household.
As we see a slight decrease in the uninsured we are starting to see an increase in
individuals that are underinsured that carry insurance but they now have to pay higher premiums
and more out of pocket because the insurance that their employer offers is not the best insurance
they selected for their company because they also had to shift their cost. This leaves the
employees with having to make choice to carry insurance or opt out or only cover insurance for
themselves versus purchasing insurance for the entire family because they are not able to afford
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it or are worried about high deductibles, possible high prescription cost and they do not make
enough money to pay for balance owing after insurance has paid.
The underinsured are also affect us as a Health Care facility depending on the plan the
employees opted for we are being reimbursed at a lower rate, insurance companies deny certain
procedures that are no longer covered and depending on the plan selected patients are no longer
in net work and are not able to see our physicians or have procedures at our health care facilities.
The patient now has to make a decision to continue seeing their physician that they have seen for
years and pay a higher out of pocket or choose to be seen by a physicians that is in network or
facilities that would only leave them with a co pay. If patients choose to stay with their physician
or healthcare facility but are not able to afford to pay for their remaining balance after their
insurance has been billed after making attempts to collect as a health care organization we end up
having to make decisions to write these accounts off to bad debt or patients submit an application
to see if they qualify for charity care adjustment. The patient already have a hard time trying to
understand their insurance coverage and they do not pay attention until they get a statement
showing a balance due. Not only do the patients lose in this situation as an organization we lose
because our patients can lose faith in us or we end up affecting patient’s credit because at one
point we have to make the decision to adjust it to bad debt. Here is a graph that helps you
understand how many individuals are underinsured in health care.
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Exhibit ES-2. In 2012, Nearly Half of Adults Were Uninsured During
the Year or Were Underinsured
Note: Numbers may not sum to indicated total because of rounding.
* Combines “Uninsured now” and “Insured now, time uninsured in past year.” ^ Underinsured defined as insured all year but
experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled
5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income.
Source: The Commonwealth Fund Biennial Health Insurance Survey (2012).
Insured all
year, not
underinsured^
54%
100 million
184 million adults ages 19–64
Insured
all year,
underinsured^
16%
30 million
Uninsured during
the year*
30%
55 million
We know what is happening in our health care facilities but now the question is what do
we do about it? What are our challenges? And how do we set ourselves up for success with the
changes in the Affordable Care Act, health exchange, moving from a fee for service to global
payments and also providing the best quality of care to our patients.
I decided to a SWOT analysis on the ACA to see where they, strengths, weaknesses,
opportunities, and threats are at, below is the chart I came up with on this it shows that they have
more strengths than other areas but there is a lot of work that needs to be done.
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Strengths
Access to Healthcare
No Pre Existing Conditions
Parents with Children on Medicaid
Medicaid- Cover Oregon
Federal Grant SNAP/CHIP
Coverage Options
Tax Credit lower monthly payments
Weaknesses
Tax Penalty
Certain Coverage does not apply to
individuals
Reimbursement
Opportunities
Raise Tax Penalty
Functional Site
Threat
Bronze Coverage
Overestimated how many individuals
would sign up for coverage
Website not working
Brokers
As shown in the SWOT Analysis there are many strengths that are going to assist in the
reduction of the uninsured by having insurance available to millions of individuals, no longer
having pre existing conditions restrictions and must spend $.80 of every premium dollar on care.
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For example insurance companies in the past could deny your care if you had were previously
diagnosed with the condition you were being treated for and this caused for patient to either
discontinue there treatment or have to figure out how they were going to pay for balance owing
especially if the diagnosis they were dealing with was life or death this is a big win for
individuals. It is going to assist individuals with a tax credit to help reduce their insurance
premiums they have to meet certain guidelines to qualify. According to the IRS.gov website here
are the guidelines to qualify for a tax credit.
Buy health insurance through market place
Are ineligible for coverage through employer or government plan
Are within certain income limits
Filed a joint return if married and
Cannot be claimed as an dependant
While it has is strengths it also has weaknesses such as the tax penalty individuals can opt
not to apply for insurance and they will pay a fee 1% of their yearly income or $95 per person
whichever is higher and if parents choose not to insure they children they have to pay $47.50 per
child capped at $285 these fees will continue to increase every year and in 2016 it will increase
to 2.5% of income or $695 per person or whichever is higher. As a health care organization we
will be affected if individuals decide that they would rather pay for a one time penalty versus
having to pay a monthly premium especially those individuals that are currently struggling to
make ends meet and they have to choose if they will have money to spend on food or have pay
for their monthly premiums. We will also have the individuals that feel they do not get sick often
and opt out to receive health care benefits and rather endure the penalty cost. These individuals
end up at our health care facilities and we will continue to offer them care but we end up with
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large debt that is owed to us. The tax penalty is set to increase in 2016 to 2.5% of income or
$695 per person, whichever is higher but this does not guarantee that individuals will choose to
apply for insurance.
Another strength would be that starting January of 2014 when patients presents
themselves at our health care facilities we can potentially qualify them onsite for Medicaid
coverage with the new Medicaid Expansion Cover Oregon as long as they meet the Federal
poverty guidelines that was increased to 138% from 100% if they meet income guidelines they
will be pre approved and it will cover their initial visit and follow up care for up to 30 days
while patient submits additional information needed to process their application. Even though
Medicaid is only reimburses us cents on the dollar this will be a win for us because in the past we
would have to adjust all of it off to charity or bad debt.
Below is a graph of our current 2013 Federal Poverty Level
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Event though we can get individuals pre approved when they present themselves in the
emergency room one our biggest threats is that we overestimated how many individuals would
sign up by 2014 as an organization we are looking at being able to offset the cost by depending
on healthy young adults to obtain insurance even if they only purchase the bronze package that
covers their services at 60% this will still offset any catastrophic cost. The reality is that we are
not seeing an increase on individuals signing up for health care insurance and some of the
challenges that we are running into first and foremost is that Cover Oregon is not up and running
and the only applications that are being processed currently are paper applications and the people
that qualify for Medicaid are the ones that are getting priority over other regular insurance
coverage. This is discouraging individuals from applying and blaming the President Obama and
the Democrats that this was put in place and it is not working effectively. This is not the first
time this has happened when Medicare Part D was passed after several years of trying to get it
was enacted in 2003 things did not run smoothly an at the time this was put in place President
George Bush was in office. Rep. Steve Israel said in an interview on MSNBC, “When things go
wrong, there are two things we can do as a country. We can spend all our time figuring out who
to blame or we can spend all our time figuring out how to fix it”. He also stated, after eight years
of having Medicare Part D in place the seniors are happy and they seem to use it. The health care
exchange implementation is not running as smooth as expected and it will have an effect to our
health care organization because we planned to have millions of individuals insured by January
of 2014 and we started to budget for that but now we have to go back and revisit our strategic
plan and figure out how we are still going to meet the community’s needs while operating we
continue to service the same amount of patients with or without insurance.
Another area that I was able to look at in my SWOT analysis is that many are under the
impression that ACA is going to solve all our problems when it comes to the uninsured patients
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According to the Federation for American Immigration Reform (FAIR) there is an estimate of
11.2 million individuals that are living in the Unites States illegally the illegal immigrants will
not be able to qualify for benefits based of the ACA guidelines. This does not mean that all 11.2
individuals are not working there is an estimate that 8 million of them are currently working and
are hired by companies that know they can pay them less than the minimum wage or they can
obtained fake documentation . These individual could potentially purchase insurance from a 3rd
party broker but the premiums can be costly or they still would not qualify depending on the
state they reside in. An article from The California Report states “Undocumented immigrants are
barred from purchasing health insurance on the California marketplace even if they have the
money to pay for it” These individuals will continue to seek care in our health care facilities and
we will continue to treat them but will be a loss for us since we potentially will have to write the
balances off. Below is data showing how many individuals are currently illegal immigrants but
are working and by states that have reported 5,000 and above individuals.
State Jobs Taken
Alabama 89,550
Alaska 7,165
Arizona 279,395
Arkansas 39,400
California 1,887,695
Colorado 139,700
Connecticut 85,965
DC 25,075
Delaware 21,490
Florida 587,440
Georgia 322,375
Hawaii 21,490
Idaho 21,490
Illinois 394,015
Indiana 85,965
Iowa 46,565
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Kansas 50,145
Kentucky 35,820
Louisiana 42,985
Maryland 211,335
Massachusetts 136,115
Michigan 82,385
Minnesota 71,640
Mississippi 21,490
Missouri 42,985
Nebraska 28,655
Nevada 143,280
New Hampshire
10,745
New Jersey 293,720
New Mexico 71,640
New York 537,295
North Carolina 293,720
Ohio 78,805
Oklahoma 60,895
Oregon 121,785
Pennsylvania 128,950
Rhode Island 25,075
South Carolina 50,145
Tennessee 85,965
Texas 1,296,670
Utah 71,640
Virginia 186,260
Washington 197,010
Wisconsin 68,055
Data taken from (http://www.fairus.org/issue/illegal-aliens-taking-u-s-jobs)
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As we look as some of our challenges we have to also look at the things that are going
well and the State of Oregon was able to receive a waiver from the Federal Government for
individuals that are currently receiving SNAP benefits (Supplemental Nutrition Assistance
Program) or have children that currently enrolled in Medicaid over 260,000 individual received
letters that were mailed out on September 26 with an enrollment form and they do not have to
apply through the exchange they just need to return the form or contact Medicaid office. As of
today it is estimated that about 56,000 individuals have enrolled and will be effective as of
January 1, 2014. Also, the individuals that are currently have Medicaid coverage with will be
automatically signed up for Cover Oregon what does this mean for an individual that they will
start receiving more benefits such as preventative/wellness care, Mental and Behavioral health,
prescription drugs, laboratory services, and this is just some that they did not have with their
current Medicaid coverage. How does this help health care organization patients will have better
coverage that will provide them with the care that they need and those services will be covered
instead of health care organization having to eat the cost because most likely they were already
performing the services and will have less to adjust to contractual, charity, or bad debt.
Underinsured individuals that have insurance but their current insurance does not qualify
based on the guidelines of the Qualifying Health Plan they have 10 key things they need to be
able to offer individuals for them to be able to sell health insurance to individuals. These are the
10 key things they have to have:
1. Ambulatory patient services
2. Emergency services
3. Hospitalization
4. Maternity and newborn care
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5. Mental health and substance use disorder services, including behavioral health treatment
6. Prescription drug
7. Rehabilitative and habilitative services and device
8. Laboratory services
9. Preventive and wellness services and chronic disease management
10. Pediatric services, including oral and vision care
(http://obamacarefacts.com/obamacare-health-insurance-exchange.php)
If they do not have these employees can apply through the exchange and potentially will pay less
out of pocket but receive more benefits. One of the issues that employee are currently having to
face is that they are receiving cancellation notices from their current health insurance because
they do not meet the 10 key points that QHP requires. It has been left to individual states to
approve for people that have received cancellation notices for their insurance to be rein instated
and it will affect us because all those individuals had great coverage and we will end up with
higher out of pocket expensed and premium cost from the individuals that are sick and are going
through the exchange. The health exchange is broken down by different packages Bronze, Silver,
Gold, and Platinum packages. Graph below illustrates what percentage is covered based on the
packages that are purchased
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Graph taken from (http://obamacarefacts.com/obamacare-health-insurance-exchange.php)
The health exchange can be a great for individuals that are lacking coverage, seeking coverage
but as many benefits as it covers some individuals are not happy that they will have to pay for
services that are not needed for example; a single male does not need maternity and new born
care, or pediatric services but they new health care package includes this and some individuals
would like the option to pay less for services that they are not going to use. The exchange has it
cons but overall even if you are not using certain services it still provides a much larger coverage
for other benefits that possibly were not covered by your current insurance.
We have talked about some of the pros and cons that come with the ACA and the health
care exchange but what can we do as a company to get ahead of all these changes or evolve with
the changes. One of the areas that I wanted to touch on is “How will it affect our Charity dollars
and our community benefits” I had the pleasure to sit down and interview Lesa Ellis, Director of
Financial Assistance and Charity care at Providence Health and Services (L.Ellis, personal
communication, November 13, 2013) some of the subjects that we discussed is has she made an
changes in the way financial counselors see patients when they are admitted to the hospital and
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we know they are uninsured? She stated that we are not waiting until patients are admitted to the
hospital to find out if they are uninsured or will have high out of pocket expense. She stated that
they are currently piloting a program where they have financial counselors working in
scheduling patients and when patient expresses they are uninsured they are immediately asking
the questions to see if they would qualify for Cover Oregon and if they do they get patient pre
qualified for services. If this pilot works then they will train all of the registration team to ask
these questions and get people prequalified. She stated that way when patients come in they are
walking in the door with insurance versus them having a procedure done and then worried about
how they are going to pay for their hospital services at the end. She stated that the pilot is fairly
new but they are hoping that they will see big wins. The reality is that if they can get one patient
that could potentially end up with thousands of dollars in medical bills pre-qualified that is a big
win already. She stated that she is also looking at utilizing our new EPIC system to see if we can
use it to drive some of these uninsured patients’ visits into work queues or putting a flag on
account for financial counselors to work on this a work in progress because EPIC does had
limitations of what it can do or we are running scarce with analyst that can assist us because we
are still going through go lives with other hospitals. I asked if she is aware of anything else that
we pro actively are doing to get patients pre-qualified she stated that now when a patient presents
themselves at the emergency room that we can see if they can pre qualify for Medicaid benefits
this is for any patient that presents themselves at the ED department. In my interview with Lesa
I asked her, “I know that she has monthly meeting with our CFO’s, and I asked what main
concerns are there when it comes to the changes?” She stated they are worried about the
reimbursement, getting individuals enrolled in healthcare and also potential Medicare penalties
for re admissions since we need to prevent re admissions by working with the patients by
providing them with coordinated care.
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When it comes to healthcare everyone is worried about all the changes that are happening
but they are happening faster then what some of us where prepared for or some organizations
have had a strategic plan in place long before the changes knowing that we are moving into a
new pay schedule from fee for service to a global payments system. That we are going to be
evaluated in the care we provide the patient, how we do educate patients about preventative care,
educate patients that they can go see a primary care doctor versus them coming to the emergency
room for a diagnosis that could have been treated at their primary care facilities. We are
responsible in putting programs in place to educate patients about all the benefits in providing
preventative care and also education our doctors and ensuring that all medical staff is providing
the highest quality of care.
While interviewing Lesa she asked that I reached out to Matt Shuler a Project Manager
(M.Shuler, personal communication, November 15, 2013) working on the charity reduction
workgroup and I was able to touch base with him and he gave me a primary example why we are
moving into the right direction with preventative care and Coordinated Care model. He asked me
if I ever heard Governor Kitzhaber’s air conditioning example and I had not heard of it. Well he
went on to explain the example that the Governor gives to everyone to better understand why
moving to coordinate care makes sense. The example that he gives is that a 90 year old woman
comes into the emergency room and presents with congestive heart failure while sitting in her
apartment on a hot day that the heat alone can send her body to having congestive heart failure.
We then bill Medicare for ambulance, care provided in ICU medical debt at $48,000 versus us
purchasing a $200 air conditioner to prevent her from coming into the emergency room and
through it all it has no effects in her quality of life. Yes, of course we are not in the business of
purchasing air conditioner for patients but with the new coordinate care model it will give a
patient advocate the accessibility to evaluate patient’s needs and be able to bill for that
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preventative care that would cause less than the patients being admitted to the hospitals. This
would not be possible if we continued to bill as a fee for service versus us having global
payment. With the CCO patients will have a team of health care workers that will assist them in
getting the care that is needed for preventative care for chronic issues such as diabetes, heart
disease, respiratory this team could potentially go an evaluate their home to see if there is
anything that needs to be done at home first. They could potentially come to their household to
teach them how to shop and make meals of course with any change they will have challenges
because certain individuals are not comfortable with change. Health care individuals are going to
have to be trained in all the different cultures they will serve in their communities to understand
the difference in cultures for them to be successful. Coordinated care is going to look at the
overall well being of the individuals the picture below shows the team of individuals that a
patient might have when it comes to their care they are the center of it.
With coordinated care it involves everyone because in order of us to continue to get reimbursed
we have to able to provide high quality of care and also prevent from having re admissions to the
hospital for us not to be penalized. Unfortunately we are depending on our patients for them to
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do their part and while they cannot be forced we just have to do a better job at showing them that
we truly care about their well being and they are just not a number walking into our doors.
Overall we are moving in the right direction when it comes to healthcare we are going to
have many challenges but with healthcare this is nonstop because there is always a change that
takes place whether it be a change in process, a new law put in place, or how we being
reimbursed we always adapt to change. Unfortunately some facilities have to close down, lay off
people, and some have to merge with other health care facilities. Through it all it does not
change the main focus that we have is that is our patients and the care that we provide to them.
The changes can affect them but it is our job when they walk into the doors that the care is
seamless, we provide high quality of care, and that the patient leaves knowing that we did
everything under our control to get them back to healthy. At Providence we have a commitment
to our patients and that is “Know Me, Care for Me, Ease my Way” and for us to get to know the
patients we care for, giving the best quality of care, and have them go through our delivery
system and have a positive experience from beginning to end and that all starts from the minute
they register to them calling into the call center.
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References:
Health Well Foundation (n.d.). When Insurance Isn’t Enough; Underinsured America, Retrieved
November 23, 2013 from
http://www.healthwellfoundation.org/sites/default/files/About.the_.Underinsured.Final__0.pdf
Oregon Health Plan (n.d). Fast Track Enrollment, Retrieved November 22, 2013 from
http://www.oregon.gov/oha/healthplan/Pages/fast-track.aspx
AAOS NOW (March, 2008). Issues facing America: Underinsured Patients
http://www.aaos.org/news/aaosnow/mar08/reimbursement1.asp
S. R. Collins, R. Robertson, T. Garber, and M. M. Doty, Insuring the Future: Current Trends in
Health Coverage and the Effects of Implementing the Affordable Care Act, The Commonwealth
Fund, April 2013, Retrieved From November 22, 2013
http://www.commonwealthfund.org/Publications/Fund-Reports/2013/Apr/Insuring-the-
Future.aspx
Kaiser Family (Sept 2013). Key facts about The Uninsured Population, Retrieved November 23,
2013 from http://kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/
Obama Care Facts (n.d) Dispelling the Myths, Retrieved from November 23, 2013
http://obamacarefacts.com/obamacare-health-insurance-exchange.php
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Sherry Glied, Jeanne M. Lambrew, and Sarah Little, The growing share of uninsured workers
employed by large firms, The Commonwealth Fund, October 10, 1013, Retrieved from
November 23, 2013. http://www.commonwealthfund.org/Publications/Fund-
Reports/2003/Oct/The-Growing-Share-of-Uninsured-Workers-Employed-by-Large-Firms.aspx
Cathy Schoen, M.S., Sara R. Collins, PH.D, Jennifer L. Kriss, How many are underinsured?
Trends among the U.S. adults, The Commonwealth Fund, June 10, 2008, Retrieved from
November 23, 2013 http://www.commonwealthfund.org/Publications/In-the-
Literature/2008/Jun/How-Many-Are-Underinsured--Trends-Among-U-S--Adults--2003-and-
2007.aspx
Steve Israel, Interview on MSNBC, November 6, 2013, Things went wrong with the Medicare
prescription D plan that George Bush rolled out, Retrieved from November 22, 2013
http://www.politifact.com/truth-o-meter/statements/2013/nov/13/steve-israel/medicare-part-d-
and-obamacare-health-care-gov/
Kari Chisholom, Blue Oregon, May 21, 2013, What comes after Obama care? John Kitzhaber’s
air conditioner, Retrieved from November 23, 2013 http://www.blueoregon.com/2013/05/what-
comes-after-obamacare-john-kitzhabers-air-conditioner/