The Impact Of Uninsurance On Texas Economy - Wrgh

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THE IMPACT OFUNINSURANCEON TEXAS’ECONOMYTexas Alliancefor Health Care

If Texas does not address the issue ofuninsurance in a proactive way, it isestimated that by 2040, over 6.1 millionTexans will be uninsured. By then, Texascould see the loss of 178.5 billiondollars due to both lost earnings and thevalue of poor health attributable to thelack of insurance.

TEXAS ALLIANCEFOR HEALTHCAREDelegates: (partial)Center for Health CareServicesCommunity HealthChoiceCook’s Children’sHealth PlanCenter for PublicPolicy PrioritiesDriscoll Children’sHealth PlanEpiscopal HealthFoundationFirst Care Health PlansHarris Health SystemHealth Policy Institute,Texas Medical CenterHouston EndowmentTexas ImpactTexas Association ofCommunity HealthPlansTexas Association ofCommunity HealthCentersTexas Association ofBusinessTexas HospitalAssociationTexas MedicalAssociationTexas Organization ofRural and CommunityHospitalsYoung InvinciblesTEXAS ALLIANCE FOR HEALTH CARE(Report on the Economic Impact of the Uninsured on the Texas Economy)January 2019The Alliance was created as a broad-based resource to policy makers for issuespertaining to health policy and coverage. We are a diverse group of stakeholders fromprivate and public sectors representing hospitals, health plans, community clinics,philanthropy, other providers, business, and public health. Our goal is to provide wellthought out research and policy recommendations that will inform and offer guidance onthe impact of proposed changes in the finance and delivery of health care in Texas.We are currently managing three work streams: role of the Texas Department ofInsurance (TDI), the marketplace and coverage, and Medicaid. In February of 2017,the Alliance commissioned Manatt to research Capped Federal Medicaid funding;implications for Texas. The timely analysis explored the anticipated impact of blockfunding and was cited broadly during the national debate.Today the Alliance has commissioned Applied Policy Group, with oversight by Dr.Mark McClellan, to perform an analysis of the financial impact on Texas’ economymaintaining a high level of uninsured today, five, ten and twenty years out. (See findingsbelow.) This report has been published to inform public policy makers on the uninsuredeconomic impact on the Texas economy.The Alliance is well positioned as an honest broker bringing disparate intereststogether to advance common ground in Texas and D.C. An adjunct activity to the TexasAlliance is the D.C. Dinner group. Led by WRG, this group meets several times a yearin D.C. to exchange insights. At the national level we are working with a broad crosssection of interests representing Catholic Health Association, American Medical GroupAssociation, Health Care Leadership Council, Tivity, Council for Affordable HealthCoverage, US Chamber of Commerce and National Retail Federation, Health Care ValueHub, Families USA, Third Way, American Public Health Association, etc. This work isintended to help inform our state efforts.For more information contact Jon Comola jrcomola@wrgh.org.

Highlights:The rising number of uninsured in Texas undermines our economy. Texas has thegreatest number of uninsured of any state in the nation and we pay dearly for it. Today Texas has 4.8 million Texans under the age of 65 without health insurance—17% of the population, a rate almost double the national average. If we continuedown this road, by 2040 there will be 6.1 million Texans under the age of 65without health insurance. Lack of health insurance affects people in two ways: it leads to worse health, andas a result of that it reduces their earning ability. In 2016, the cost of lower lifetimeearnings and worse health for uninsured Texans was a whopping 57 billion – andon the present path that cost will be 178.5 billion in 2040! Uninsurance also affects Texas employers. We know that lack of insuranceincreases absenteeism and presenteeism among the employed. Poor healthis also a significant reason why people drop out of the labor force, potentiallyrobbing employers of skilled workers. Our communities are also hit hard. Unsubsidized uncompensated care providedby hospitals and physicians was 3.5 billion in 2016 and if we do nothing tochange this trend it will be 12.4 billion by 2040.o In addition to this uncompensated care, state and local governments helpfinance care of uninsured Texans. The Institute of Medicine reminds us that thisresults in a higher tax burden at the local level or the diversion of resourcesfrom other public purposes.o What’s worse, the IOM notes, is that state and local governments’ capacityto finance health care for uninsured persons tends to be weakest at timeswhen the demand for such care is likely to be highest (i.e., during periods ofeconomic recession). It may surprise you to learn that that the lack of coverage also undermines familywealth.o Nationwide, 20% of insured families and 53% of uninsured families hadproblems paying medical bills, according to data from KFF/NYT. This meansthat 1.2 million uninsured Texans in 2016 lived in families facing medical billsthey had trouble paying.o The problem is not limited to low-income families, either: 14% of familieswith income above 100,000–13% of insured families and 29% of uninsuredfamilies–reported problems paying medical bills. More than half of uninsuredfamilies facing trouble with those bills reported that they had used up mostor all of their savings to pay for medical care, and almost two-thirds reportedcutting back on spending for food, clothing, or basic household items.o Not only does lack of insurance impoverish families: it reduces what they spendin the economy as well, as personal wealth is being directed toward health carecosts.

ContentsHigh Rates of Uninsurance Hurt Texas Workers,Businesses, and Health Care Providers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Uninsurance Negatively Impacts Texans’Health and Household Wealth Spending Allocation . . . . . . . . . . . . . . . . . . . . . . 6Uninsurance Costs Employers ThroughReduced Employee Productivity and Household Discretionary Income . . . . . . . . . . . . 10Uncompensated Care Impacts State, Regional, and Local Government Spending . . . . . . . . 13Uninsurance Negatively Impacts the Texas Economyand Workforce and Should be Addressed as a Business Issue . . . . . . . . . . . . . . . . . 17Technical Appendix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Endnotes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22

High Rates of Uninsurance Hurt Texas Workers, Businesses,and Health Care ProvidersIn 2016, almost 5 million Texans under theage of 65 (approximately 16% of the state’spopulation) were without health insurance,almost double the national average.1 Withoutintervention, by 2040, there will be anestimated six million Texans under the ageof 65 without health insurance. Uninsuranceimpacts Texas households, businesses, healthcare providers, and the Texas economy as awhole.We estimate that without action to correctthe situation, Texans who were uninsuredin 2016 will lose an estimated 57 billionin lifetime earnings; by 2040, the value of“health loss” — or the value of lost earningsand poor health due to uninsurance in Texas— is estimated to be 178.5 billion ( 74billion in 2016 dollars). The high uninsuredrate impacts the Texas economy by negativelyaffecting labor productivity, businessprofitability, household financial stability,and future earnings and requires health careproviders to absorb the costs of unsubsidized,uncompensated care. In short: By 2030, more than 16% ofTexans are estimated to beuninsured, a rate that wouldexceed the predicted nationaluninsurance rate by 45%.Texas 178 BillionOur analysis found the following: In 2016, there were approximately4.8 million Texans (about 16% of thepopulation) without health insurance.Assuming stability of demographictrends and rate of insurance:oBy 2030, there will be more than5.5 million Texans without healthinsurance. This would be morethan 16% of the state’s populationand would exceed the estimatednational rate of uninsurance by 45%,as the Congressional Budget Office(CBO) estimates that by 2027, thenational uninsurance rate will be11%.oBy 2040, there will be more than6.1 million Texans without healthinsurance.Workers without health insurance missmore days of work than workers withhealth insurance.2 Presenteeism andabsenteeism affect labor productivity,which affects business profitability.oThis, in turn, affects the rate ofeconomic growth for Texas. Lack of insurance increases poor healthoutcomes and rates of premature deathfor Texans; this affects future earningsand the Texas economy. Lack of insurance affects the creation offamily wealth, as well as the immediatefinancial stability of families in Texas. Lack of insurance affects Texascommunities, doctors, and hospitals tothe extent that they must absorb thecost of care for uninsured patients.4By 2040, Uninsurance Could Cost The continued lack of insuranceis anticipated to have a negativeimpact on Texas hospitals and healthThe Impact of Uninsurance on Texas’ Economy

Uninsured Texans6.1M4.8M20165.5M2030 178.5 BillionValue of “Health Loss”by 20402040 12.4 BillionEstimated Unsubsidized,Uncompensated Care by 2040households reporting problemspaying medical bills would drop byhalf.care providers due to unsubsidized,uncompensated care. By 2040: oIt is estimated that Texas healthcare providers will have to provide 12.4 billion in unsubsidizeduncompensated care if currentuninsurance rates continue.oThe value of “health loss” — orthe value of lost earnings and poorhealth — is estimated to be 178.5billion ( 74 billion in 2016 dollars).The data shows that there is a strongcorrelation between insurance statusand the likelihood that a household willface problems with medical payments.oIf Texans who are currentlyuninsured were offered coverageequivalent to the average insuranceplan available in the state, it isestimated that the number of theirTexas Alliance for Health Care The pressure of medical bills can causehouseholds to reduce spending in otherareas, which can have a downstreamimpact on other sectors of the economy.In a national survey, almost threequarters of people who reportedproblems paying medical bills saidthat they reduced spending on food,clothing, and basic household items topay medical bills.oSimilarly, 72% of respondents(including those who were insuredand uninsured) reported that theyhad delayed major householdpurchases because of medical bills;almost 60% had used all or most oftheir savings paying medical bills.5

Uninsurance Negatively Impacts Texans’ Health andHousehold Wealth Spending AllocationThe state of Texas is falling behind otherstates on measures of insurance status.The average Texan is more than twice aslikely to be uninsured than the averageAmerican. Texans also have lower rates ofaccess to all types of insurance: employersponsored, direct-purchased private plans,and government programs.3 Our initialanalysis estimates insurance coverage trendsfor Texans assuming no changes to existingpolicies.Over the next 20 years, Texas can expecta slight decrease in employer-sponsoredinsurance (ESI) coverage, coupled with aslight increase in other commercial insurance(which would include health plans purchasedon or off the Exchange) and a larger increasein Medicare coverage, which reflects generaldemographic trends of an aging population.Medicaid enrollment is projected to staystable, and the uninsurance rate is expectedto decrease modestly to 16%. While theCongressional Budget Office (CBO) onlyissues projections 10 years into the future,the CBO predicts that in 2027, approximately11% of Americans nationwide under the ageof 65 will be uninsured,4 indicating that Texaswould continue to have an uninsurance ratehigher than the national uninsurance rate.Studies demonstrate that alack of insurance commonlyresults in poorer health status,and that once an individualgains insurance, he or sheexperiences improvements inhealth outcomes, resulting incost-savings for the state.Impact of Uninsurance on HealthOutcomesStudies demonstrate that a lack of insurancecommonly results in poorer health status, andthat once an individual gains insurance, heor she experiences improvements in healthoutcomes, resulting in cost-savings for thestate.Insurance Type*Actual2016Projected 2030Employer-Sponsored Insurance (ESI)Other Commercial 4%5.5%16%*Numbers exceed 100% because individuals may have more than one form of insurance at thesame time; for example, an individual may be dually eligible for both Medicare and Medicaid.6The Impact of Uninsurance on Texas’ Economy

For example: Uninsured adults are less likely toreceive wellness checks, blood pressureand cholesterol tests, blood sugarscreenings, colon cancer screenings,and pap smears or mammogramscreenings;5 all of these are essential forpreventative care.Uninsured individuals are also morelikely to delay or go without neededmedical care, resulting in poorer healthoutcomes, including cancer diagnosesat more advanced stages, poorlymanaged diabetes and hypertension,and worse health outcomes aftera stroke, respiratory failure, orcardiovascular disease;6,7 For adults in their 50s and 60s, beingcontinuously uninsured results in arelative risk of a major decline in overallhealth of 1.63 and being intermittentlyuninsured results in a relative riskof major decline in overall health of1.41 compared to adults who werecontinuously insured;8 and There is an association between lackof insurance and mortality, with studiesshowing that uninsured adults have a25% greater chance of dying comparedto privately insured adults,9 and agreater risk of dying after an acutemyocardial infarction;10 hospitalizedadults who lack insurance have a higherrisk of hospital mortality than do insuredhospitalized adults (1.16 odds ratio).11Individual health outcomes improve oncepeople obtain health insurance: Uninsured adults aged 55 to 64 yearsold report statistically significantimprovements in health once theyreached age 65 and became eligible forMedicare;12 Young adults aged 19 to 25 who wereuninsured and then gained healthinsurance report an increase in selfreported physical and mental healthstatus, despite not increasing theirutilization of health care services;13Texas Alliance for Health Care There are significant improvements inaccess, utilization, and self-reportedphysical and mental health afterone year of coverage for previouslyuninsured adults.14 One recent study estimated that itcost between 327,000 and 867,000(in 2007 dollars) in lifetime medicalexpenses to save one life. The mostrecent estimate of the value of astatistical life calculated by the federalgovernment ( 7.4 million in 2006dollars) is close to 10 times higherthan that, meaning that on a statisticallevel, investing in insurance results in asurplus.15A meta-analysis of studies performed inthe past 10 years shows strong evidencethat access to health insurance is associatedwith increased rates of having a usual sourceof care and being able to afford care whenneeded. The Centers for Disease Controland Prevention’s 2016 National HealthInterview Survey (NHIS) found that 78%or more of those with Medicaid or privatehealth insurance reported having a usualplace of care, compared with 46% or lesswho were uninsured.16 Increased access topreventive care services is also associatedwith statistically significant increases in testingfor diabetes, hypercholesterolemia, HIV, andcervical, prostate and breast cancer. Lowincome adults with insurance are more likelyto receive selected health care services,such as mammograms, colon cancer tests,and cholesterol, blood pressure, and bloodsugar checks, compared to those withoutinsurance.17 Studies have been mixed on theimpact of emergency department use andhospitalizations; some studies have shownthat expanded access to health insuranceleads to reduced utilization, while others haveshown increased utilization, though it is notalways clear if the care provided was critical orlow-value.18While improved access to care doesnot always equate with improved healthoutcomes, studies indicate clear correlationbetween access to care and better outcomeswith certain health conditions. For example,studies indicate that depression, which isone of the leading causes of disability in theUnited States for adults in their prime working7

years,19 is one chronic condition that hasbeen found to improve with access to care.20Studies have also found that earlier-stagediagnosis and treatment of cervical cancerin young women increases with increasedaccess to care.21 In Massachusetts, there wasan increase in low-income patient accessto potentially curative surgery for earlystage colon cancer after gaining access tocoverage.22In 2016, less than 34% of low-incomeadults with either Medicaid or private healthinsurance reported having unmet medicalneeds, compared with 50% or more ofthose without insurance.23 When comparingreported health status of uninsured, lowincome adults in Medicaid expansion andnon-expansion states, the NHIS found that alarger percentage of people reported beingin “good” health and a smaller percentagereported “fair or poor” in expansionstates. However, studies have not shown arelationship between gaining access to healthinsurance coverage and better blood sugarcontrol, hypertension, or cholesterol levels.24“Being uninsured can be devastating.People without health coverage have muchless access to preventive, acute, and ongoingmedical care than those with insurance, whichcan lead to delayed care, later diagnosis ofeasily detectable or preventable diseases,worsening of chronic conditions, higher costs,and potentially serious financial hardship,”said Dr. Eduardo Sanchez, Chief MedicalOfficer for Prevention at the American HeartAssociation.There is a discrepancy in the estimates ofdeaths each year that can be attributed tothe lack of insurance coverage. However,modeling of population-level data estimatesthat expanded coverage does lead to lowerthan-expected mortality rates, particularlyamong previously uninsured individualsdiagnosed with HIV. A recent study estimateda reduction in mortality of up to 6% could beattributable to the gain of health insurancecoverage.25 Not only is reduced mortality anet positive for individuals and families, butreduced mortality also benefits employersand the government as individuals are able tocontinue to work.The maternal mortality rate for Texasmothers has been the subject of severalscholarly reports in recent years, so much8“Being uninsured can be devastating.People without health coverage havemuch less access to preventive, acute,and ongoing medical care than thosewith insurance, which can lead todelayed care, later diagnosis of easilydetectable or preventable diseases,worsening of chronic conditions, highercosts, and potentially serious financialhardship,” said Dr. Eduardo Sanchez,Chief Medical Officer for Prevention atthe American Heart Association.so that the state legislature has conveneda task force to study the issue.26 “Womenwith Medicaid insurance lose their coverage60 days after delivery, yet the manycomplications of pregnancy haven’t beenresolved, like high blood pressure anddiabetes,” said Mary Dale Peterson, ExecutiveVice President and Chief Executive Officer ofDriscoll Health System. “Too many of thesewomen are dying, leaving their newbornswithout a mother.”Household Wealth AccumulationAs mentioned previously, the expected lossof income for Texans who were uninsuredin 2016 over their lifetimes (assuming theyremain uninsured until age 65) is 57 billion.Looking forward, the value of “health loss,”or the value of lost earnings plus the loss ofvalue attributable to poor health for Texans,could reach as high as 178.5 billion ( 74billion in 2016 dollars) if no changes are madeto current policy.Americans spend more money on healthcare services per year than any other nation inthe world, both in terms of absolute spendingand as a percentage of gross domesticproduct. In 2016, health care spendingincreased to 3.3 trillion, a 4.3% increase over2015 spending levels. This represents almost18% of gross domestic product (GDP).27Comparatively, Switzerland spends 12% ofGDP; France, Germany and Japan spend 11%The Impact of Uninsurance on Texas’ Economy

of GDP; and Canada and the United Kingdomspend approximately 10% of GDP on healthcare each year.28Hospital care makes up the largest portionof U.S. health care expenditures (32%), whilephysician and clinical services comprise 20%,and prescription drugs account for 10% ofspending.29 Private health insurance accountsfor 34% of health care expenditures; however,the combined spending of Medicare andMedicaid accounts for 37% of expenditures.While year-over-year expenditures continueto rise, the rate of the annual increase slowedbetween 2014 and 2016.Like other expenditures, health careexpenditures require households to maketrade-offs; a dollar spent on health care isa dollar that cannot go towards somethingelse, such as savings or assets. “In the caseof trauma or a catastrophic event such asheart attack, stroke, or cancer, an uninsuredpatient’s recovery will come with significantfinancial hardship,” added Dr. Sanchez ofthe American Heart Association. “Patientsmay have to miss work, lose their jobs, andcontinue to accrue debt, while public andprivate healthcare systems take on the burdenof the cost of care that cannot be paid for.This ruinous spiral could be reversed byfinding a way to increase the percentage ofTexans with health insurance.”According to a recent survey, 37% of verysick people used most or all of their savingspaying hospital bills, and 23% reported being“Patients may have to miss work,lose their jobs, and continue toaccrue debt, while public andprivate healthcare systems take onthe burden of the cost of care thatcannot be paid for. This ruinous spiralcould be reversed by finding a wayto increase the percentage of Texanswith health insurance.”– Dr. Sanchez of theAmerican Heart AssociationTexas Alliance for Health Careunable to pay for basic necessities such asfood, heat, or housing as a result.30 Anotherrecent survey found that approximately 40%of American adults said that they did nothave 400 to cover an unexpected expense;25% reported having no retirement savingsor pension. A larger 56% of very sick peoplereported having difficulty paying one or moreof their health care bills, and 27% reportedthat their illness was a major source offinancial strain on their household.31More than 25% of adults reported avoidingnecessary medical care due to affordabilityconcerns.32 Avoidance of necessary medicalcare for affordability concerns could manifestin skipping prescription doses, delaying fillinga prescription, taking less medication, orrequesting a lower cost drug. Comparatively,the CDC’s 2016 NHIS found that 12% or lessof low-income adults with Medicaid or privatehealth insurance reported financial barriersto needed medical care, such as eyeglasses,prescription medication, mental healthevaluation and counseling, or attention from aspecialist or dental professional.Uninsured individuals with savings aremore likely to devote those savings topaying health care bills than individuals thathave insurance;33 this dynamic can lead tobankruptcy. A survey of 1,000 Americanswho filed for bankruptcy in 2007 foundthat medical debt was cited as the reasonfor declaring bankruptcy in 62% of cases.Comparing those results to a 2001 study, theauthors concluded that between 2001 and2007, the incidence of medical debt-relatedbankruptcies would increase almost 50%during that time-period.34 As recently as 2014,half of debt collections are related to medicaldebts.35When uninsured households gain insurancecoverage, there is evidence that the newlyinsured individuals are 40% less likely toborrow money to pay medical bills or toskip medical payments. The individuals inthe study were also 25% less likely to havemedical debt sent to a collections agency.36This infers that a lack of health insurance,especially among low-income populations,can lead to increased debt and that accessto health insurance may reduce — but noteliminate — the need to accumulate medicaldebt.9

Uninsurance Costs Employers Through Reduced EmployeeProductivity and Household Discretionary IncomeOur analysis estimates that by 2040, thevalue of “health loss” — or the value of lostearnings and poor health due to uninsurancein Texas — is estimated to be 178.5 billion( 74 billion in 2016 dollars). Health insurancecoverage results in a more consistentstream of care for individuals, which leads toincreased preventive care visits and greaterclinician attention for chronic conditions andin the event of an illness or injury. Sufficientaccess to primary and specialty care andcoordinated patient services improve theindividual’s overall health.Healthier individuals, and thus healthieremployees, miss less work as a result ofreduced number of sick days, doctors’appointments, or the travel time neededto receive care. The U.S. Bureau of LaborStatistics (BLS) defines an absence from workas missed work due to own illness, injury, ormedical problems; child care problems; otherfamily or personal obligations; civic or militaryduty; and maternity or paternity leave. Illnessand injury are the most common reasonsfor absence, and the BLS collects data onabsence due to those separately from theother reasons. In 2017, the average full-timeworker missed almost 2 days of work due toillness or injury.37Annually, 407 million days of work aremissed by 69 million workers in the UnitedStates because of illness.38 An additional478 million days were negatively affectedbecause of an estimated 55 million workers’inability to concentrate while at work due tosickness. This results in 260 billion dollarslost in economic productivity.39 According tothe Institute of Medicine’s Committee on theConsequences of Uninsurance, there is aneconomic loss of 65 to 130 billion per yearfor Americans who are uninsured becauseof decreased health status and prematuremortality.4010“Without access to preventative healthcare, our workforce is compromised byabsenteeism that limits Texas employers’access to a reliable and consistentworkforce. Texas employers shouldnot struggle to find the skilled workersthey need, nor lose employees fallingout of the workforce altogether due tounmanaged illness,”— Jeff MosleyChief Executive OfficerTexas Association of Business (TAB).Healthier employees also have lowerrates of “presenteeism,” which is whenan employee is present at work but is lessproductive due to poor health, and are moreproductive contributors to the workforce forthe time they are in the office, resulting inbetter employer outcomes. In short, a lack ofhealth insurance reduces labor productivityand increases presenteeism and absenteeism,subsequently impacting the success of theeconomy.Productivity, Presenteeism, andAbsenteeismCertain conditions have a greater impacton job productivity and absenteeism. Onaverage, hypertension, heart disease, mentalillnesses, and arthritis cost between 330The Impact of Uninsurance on Texas’ Economy

Case Study OneIn 2002, a group of researchers randomly selected over 12,000 full-time Dow Chemical Company(Dow) employees in Michigan and Texas to participate in a health survey online that identifiedtheir chronic conditions. Participants also completed the Stanford Presenteeism Scale and aWork Limitation Questionnaire. Based on survey responses, the researchers calculated totalannual health costs based on their medical treatment costs (such as appointments and pharmacyexpenses), absenteeism costs, and presenteeism costs. They found that chronic conditionsalone are estimated to cost Dow more than 100 million annually in lost productivity for its U.S.workforce.43Case Study TwoAn illustrative example of the relationship between uninsurance and workplace productivity liesin mental health care. About 7.5% of the U.S. workforce has depression according to analyzeddata from the National Comorbidity Survey Replication.44 In turn, depression costs employers anestimated 187.8 billion per year in healthcare costs, absenteeism, and lost productivity. Thesecosts may fluctuate, however, when employees receive the treatment needed to manage theircondition.Case Study ThreeA March 2018 report from the Texas House of Representatives Select Committee on EconomicCompetitiveness stated there are approximately 300,000 people in Texas with severe mentalhealth needs who are not receiving the appropriate care.45 In 2016, the U.S. Department of Healthand Human Services (HHS) released data showing that only 9.4% of the uninsured populationin Texas received treatment for mental illness46 and that Texans with health insurance wereapproximately 50% more likely to receive mental health treatment than those without insurance.47Relatedly, Texas ranks 43rd in mental health outcomes in state comparisons.48 The assumed impacton Texans’ productivity, therefore, is significant.Case Study FourResearch shows that uninsurance also impacts productivity and absenteeism of family membersand caregivers in addition to the uninsured individual. In 2006, a Metlife study estimated that thetotal cost to employers for full-time employees with significant caregiving responsibilities is 17.1billion per year. These costs are associated with absenteeism, workday interruptions, crisis in care,replacing employees, and reducing hours from full- to part-time.49Case Study FiveTo thoroughly examine the

without health insurance. Lack of health insurance affects people in two ways: it leads to worse health, and as a result of that it reduces their earning ability. In 2016, the cost of lower lifetime earnings and worse health for uninsured Texans was a whopping 57 billion - and on the present path that cost will be 178.5 billion in 2040!