Over the last several years, the number of uninsured in the United States has continued to rise steadily, underscoring the need to enact policies designed to achieve health insurance coverage for all Americans. Health care continues to be one of the most pressing issues affecting Americans and there is a growing expectation that the next president and Congress will address health care reform in 2009.

To guide reform efforts in 2009 and beyond, it is important to look both to the past and to recent successes for lessons to be learned. In preparation, I have reviewed our work on this issue from the past year. Below are some of the important findings from RWJF-supported projects in the following areas:

• Defining the extent of the problem and possible solutions
• Examining how the policy environment has changed since the last attempt at national health care reform in 1993–94
• Assessing state efforts at coverage expansions.

Solving our nation's health care problems will take more than research and evaluation, but looking back at the highlights below, I hope you will agree that we're making the most of the tools at our disposal to help elected officials and policy-makers who will ultimately need to act on health care reform.

For more information on RWJF's publications and research, visit RWJF's Publications and Research section at www.rwjf.org/pr.

David C. Colby, Ph.D.
Vice President, Research and Evaluation

Defining the Problem and Potential Solutions

Falling Behind: Americans' Access to Medical Care Deteriorates, 2003–2007
Between 2003 and 2007, the number and proportion of Americans reporting going without or delaying needed medical care increased sharply, according to findings from the Center for Studying Health System Change's nationally representative 2007 Health Tracking Household Survey. People reporting access problems increasingly cited cost as an obstacle to needed care, along with rising rates of health plan and health system barriers.

• Read the article  

Are the Uninsured Responsible for the Increase in Emergency Department Visits in the United States?
The authors analyzed emergency department (ED) visits in the United States to learn whether the rise in ED use could be attributed to uninsured individuals. They conclude that the documented rise in ED visits between 1996 and 2004 cannot be primarily attributed to the uninsured. Instead, major contributors to the rise in number of visits are increased visits by non-poor people and people with other regular sources of care.

• Read the article

Health Insurance Coverage of Young Adults
This Urban Institute analysis looks at why young adults are disproportionately uninsured and what policies could address their coverage gaps. While conventional wisdom suggests that these largely healthy young adults reject coverage because of their youth and vitality, the facts tell a more complicated tale. Large numbers of young adults do not work full time and are not full-time students, leaving them without their own employer-sponsored insurance—or their parents'—and without the income to afford private market coverage.

• Read the issue brief

Employment-Based Health Benefits Under Universal Coverage
In the context of proposals for universal coverage, a key emerging issue is the role of employer-sponsored coverage. Such coverage has been slowly eroding and has been criticized for providing little meaningful plan choice. But real-world experience with such a reform is needed before considering the substitution of individual coverage for employer-based coverage.

• Read the article

Knowing What Works in Health Care
This report provides a blueprint for a national clinical effective assessment program. One of the key recommendations is for the U.S. Department of Health and Human Services to create a single entity with the authority, resources and capacity to set priorities for evidence assessment; assess evidence (systematic review); and develop or endorse standards for evidence-based clinical practice guidelines.

• Read the report

Igniting Health Care Payment Reform
Health care costs, which are driven by payments to hospitals, physicians and other health care providers, have been steadily increasing across time. The PROMETHEUS Payment® approach is an attempt to address the rise in health care costs while maintaining high quality patient-centered care by developing a new approach to pay for health care services.

• Read the report

What's Changed Since the Previous Health Care Reform Efforts in 1993 and 1994?

ERIU Interactive Webinar Examines How the Health Reform Landscape Has Changed Since 1994
With the presidential campaign in full swing, health care reform is once again in the national spotlight. Not since the debates of 1994 has the prospect of comprehensive health reform received this level of attention. That year, the Robert Wood Johnson Foundation sponsored a conference at Princeton University where academics from across the country presented papers on health reform and coverage mandates. These papers were later compiled for the Spring 1994 issue of Health Affairs. Fourteen years later, the Economic Research Initiative on the Uninsured (ERIU) assembled four of the original authors for an interactive Webinar to discuss the current landscape for health reform and what has changed since 1994.

• Read the transcript from the webinar

Lessons Learned: The Health Reform Debate of 1993–1994
No matter who wins the White House and control of Congress in November, health reform legislation will likely be a front-burner issue for both House and Senate in 2009. The Alliance for Health Reform organized a briefing in which the speakers examined the debates about reform and the behind-the-scenes activity of 1993 and 1994, and drew lessons on what should be done differently the next time Congress takes up this issue.

• Read the issue brief

State Efforts to Cover The Uninsured

On the Road to Universal Coverage: Impacts Of Reform In Massachusetts At One Year
This paper provides an early look at the impact of health reform in Massachusetts on working-age adults—the primary target population for the initiative. The study finds that, in roughly the first year under reform, uninsurance among working-age adults was reduced by almost half among those surveyed, and despite higher-than-anticipated costs, most residents of the state continued to support reform.

• Read the article

How Far Can States Take Health Reform?
Expectations for state leadership in health reform have never been higher. States are thought to function as "laboratories of democracy," but they do not fulfill this role. This paper offers a description of a more robust state-federal partnership that would be more likely to yield substantial health reform.

• Read the article

State Health Access Profile: A Chartbook of Health Care Access Indicators for States
Who is insured? What percentage of employers in a state offer health insurance? Who could get medical care if they needed it? The State Health Access Profile answers those questions, and many more, on a state-by-state basis. The chartbook is published annually by the University of Minnesota's State Health Access Data Assistance Center (SHADAC), with support from RWJF.

• View the interactive chartbook