Health Care Reform: An Introduction

Congressional research reportAug 31, 2009

Ask Donna

What actually matters in this document.

Text

-name redacted-, Coordinator

Analyst in Health Care Financing

-name redactedSpecialist in Health Care Financing

-name redacted-

August 31, 2009

Congressional Research Service

7-....

www.crs.gov

R40517

CRS Report for Congress

Prepared for Members and Committees of Congress

Health Care Reform: An Introduction

Summary

Health care reform is a major issue in the 111th Congress, driven by growing concern about

millions of people without insurance coverage, continual increases in cost and spending, and

quality shortcomings. Commonly cited figures indicate that more than 45 million people have no

insurance, which can limit their access to care and ability to pay for the care they receive. Costs

are rising for nearly everyone, and the country now likely spends over $2.5 trillion, more than

17% of gross domestic product (GDP), on health care services and products, far more than other

industrialized countries. For all this spending, the country scores but average or somewhat worse

on many indicators of health care quality, and many may not get appropriate standards of care.

These concerns raise significant challenges. Each is more complex than might first appear, which

increases the difficulty of finding solutions. For example, by one statistical measure, far more

than 45 million people face the risk of being uninsured for short time periods, yet by another,

substantially fewer have no insurance for long periods. Insurance coverage and access to health

care are not the same, and it is possible to have one without the other. Having coverage does not

ensure that one can pay for care, nor does it always shield one from significant financial loss in

the case of serious illness. Similarly, high levels of spending may be partly attributable to the

country’s wealth, while rising costs, though difficult for many, may primarily mean that less

money is available for other things.

Solutions to these concerns may conflict with one another. For example, expanding coverage to

most of the uninsured would likely drive up costs (as more people seek care) and expand public

budgets (since additional public subsidies would be required). Cutting costs may threaten

initiatives to improve quality. Other challenges include addressing the interests of stakeholders

that have substantial investments in present arrangements and the unease some people have about

moving from an imperfect but known system to something that is potentially better but untried.

How much reform might cost and how to pay for it is also an issue.

Health care reform proposals rekindle debate over perennial issues in American health care

policy. These include whether insurance should be public or private; whether employment-based

insurance should be strengthened, weakened, or left alone; what role states might play; and

whether Medicaid should be folded into new insurance arrangements. Whether changes to

Medicare should occur at the same time is also being considered. Concerns about coverage, cost

and spending, and quality are likely to be addressed within the context of these issues.

The committees of jurisdiction for health care have prepared comprehensive reform proposals.

The Senate HELP Committee approved a measure on July 15 (Affordable Health Choices Act),

whereas H.R. 3200, a coordinated measure by three House committees (Education and Labor,

Ways and Means, and Energy and Commerce), was approved by the first two committees with

some variations on July 17 and by Energy and Commerce on July 31. The Senate Finance

Committee has no draft available to the public, though it has released policy option documents

and many of its debates have been publicized. More than a dozen other comprehensive bills have

also been introduced.

This report does not discuss or even try to identify all of the concerns about health care in the

United States that are prompting calls for reform. Other concerns may also be important, at least

to some, and will likely contribute to the complexity of the reform debate. The report may be

updated to include other health care reform issues as the debate in Congress unfolds.

Congressional Research Service

Health Care Reform: An Introduction

Contents

Introduction ................................................................................................................................1

Three Predominant Concerns ......................................................................................................2

Coverage ..............................................................................................................................2

Cost and Spending ................................................................................................................4

Quality..................................................................................................................................5

Some Likely Legislative Issues ...................................................................................................7

The Scope of Reform ............................................................................................................8

Public or Private Insurance....................................................................................................9

Employment-Based Insurance............................................................................................. 10

The Role of States............................................................................................................... 11

The Cost of Reform .................................................................................................................. 11

Congressional Proposals ........................................................................................................... 12

Tables

Table A-1. Health Insurance Coverage, by Type of Insurance and Age, 2007 ............................. 14

Table C-1. Distribution of National Health Care Expenditures by Service, Product, and

Activity, 2007 ........................................................................................................................ 16

Table C-2. Distribution of National Health Care Expenditures by Source of Funds, 2007........... 17

Appendixes

Appendix A. Overview of Health Insurance Coverage............................................................... 14

Appendix B. Characteristics of the Uninsured ........................................................................... 15

Appendix C. Distribution of National Health Care Expenditures................................................ 16

Contacts

Author Contact Information ...................................................................................................... 17

Additional Author Information .................................................................................................. 17

Key Policy Staff........................................................................................................................ 18

Congressional Research Service

Health Care Reform: An Introduction

Introduction

Health care reform is again an issue. For the first time since 1994, when sweeping changes

proposed by President Clinton and others failed to be enacted, there is demonstrable interest in

reforming health care in the United States. Surveys and studies show persistent problems,

political leaders are debating issues and solutions, and interest groups of all persuasions are

holding conferences and staking out positions. Some states have enacted their own reforms, and

others are considering doing so. President Obama says that it is his top priority, and bills have

been prepared, and in some cases approved, by the congressional committees with principal

jurisdiction.

Interest in reform is being driven by three predominant concerns. One is coverage. By a

commonly cited estimate, more than 45 million people were uninsured at some point in 2007—

more than one-seventh of the population. The recession may have increased this number. Without

private insurance or coverage under government health programs, people can have difficulty

obtaining needed care and problems paying for the care they receive.

A second concern is cost and spending. Health care costs are rising for nearly everyone—

employers, workers, retirees, providers, and taxpayers—sometimes in unexpected, erratic jumps.

Costs are a particular source of anxiety for families that are planning for retirement or where

someone is seriously ill. National health care spending now likely exceeds $2.5 trillion, more than

17% of the gross domestic product (GDP). Spending has climbed from over 12% of GDP in 1990

and 7% in 1970.

Third, there is concern about quality. Although the United States spends substantially more on

health care per person than other industrialized countries, it scores only average or somewhat

worse on many quality of care indicators. Medical and medication errors harm many people

annually, sometimes resulting in death.

The three concerns raise significant challenges. For one thing, each is more complex than might

first appear, which makes it difficult to find solutions, or at least simple or uniform solutions.

Second, solutions to the three concerns may conflict with one another. Under many scenarios, for

example, providing coverage to the 45 million uninsured would likely drive up costs (as more

people seek care) and expand public budgets (since public subsidies would be required to help

them get insurance). Attempts to restrict costs may impede efforts to increase quality, since new

initiatives often require additional, not fewer, resources. It is possible, however, that cost savings

might allow those initiatives to be funded. Other challenges involve significant stakeholder

interests that reform might threaten, including those of insurers, hospitals and other health care

facilities, and doctors and other providers, many of whom have substantial investments in present

arrangements. In 2007, for example, nearly one-third of total health care expenditures occurred in

hospitals (see Table C-1 in Appendix C), which cannot be quickly built, easily shut, or

transformed simply by their own choice into different kinds of health care providers. In addition,

if debates over the Clinton plan are still a guide, some people may be uneasy about moving from

an imperfect but known system to something that is potentially better but untried.

This report provides an introduction to health care reform. It focuses on the three predominant

concerns just mentioned—coverage, cost and spending, and quality—and some of the legislative

issues within which they likely will be debated, including the scope of reform (particularly

whether Medicare and Medicaid should be included); the choice between public and private

Congressional Research Service

Health Care Reform: An Introduction

coverage; whether employment-based insurance should be strengthened, weakened, or left alone;

and what role states might play. The report does not attempt to identify, let alone discuss, all the

relevant concerns about health care in the United States, even though others may also be

important and will likely contribute to the complexity of the reform debate. The report may be

updated to include other health care reform issues as the debate in Congress unfolds.

Three Predominant Concerns

The three concerns discussed below—coverage, cost and spending, and quality—loom large in

the emerging debate over health care reform. Some Members might not consider every one

important, but all have been included in recent congressional debate and proposals.

Other concerns about health care in the United States that are not discussed in this report include

the following:

•

problems in the private insurance market, particularly for individual and smallgroup insurance,

•

problems with shortages of health care providers,

•

problems with public health programs, funding, and administrative oversight,

•

problems of economic concentration among insurers and providers,

•

problems of equity in access to care and the type of care received, and

•

problems of equity in public subsidies.

Coverage

In August 2008, the U.S. Census Bureau estimated that 45.7 million people had no health

insurance at a point in time in 2007. The number had declined from 47 million the previous year,

largely due to increases in Medicaid and CHIP (the State Children’s Health Insurance Program)

enrollment.1 The number may now be going back up due to the recession.

There are both higher and lower numbers that give different perspectives. Families USA, an

advocacy group, recently estimated that 86.7 million people—one in three of those under age

65—were uninsured for some or all or the two-year period 2007-2008.2 The number indicates that

more than 45 million people are likely to be uninsured over a short time period, even if many

have coverage at some point. On the other hand, the Agency for Healthcare Research and Quality

(AHRQ) has estimated that 26.1 million people were uninsured for the entire two-year period

2004-2005, and that 17.4 million were uninsured for the preceding two years as well—four

straight years.3

U.S. Census Bureau, Health Insurance Coverage: 2007, http://www.census.gov/hhes/www/hlthins/hlthin07/

hlth07asc.html.

Families USA, Americans at Risk: One in Three Uninsured, March 2009, http://www.familiesusa.org/resources/

publications/reports/americans-at-risk.html.

Jeffrey A. Rhoades and Steven B. Cohen, The Long-Term Uninsured in America, 2002-2005: Estimates for the U.S.

Population under Age 65, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey Statistical

(continued...)

Congressional Research Service

Health Care Reform: An Introduction

Coverage is not the same as access, and it is possible to have one without the other. Some

uninsured people can get care in community health clinics or from doctors providing pro bono

work, even if they have no money. If people need emergency care, hospitals that participate in

Medicare are required to stabilize them or provide an appropriate transfer to another facility. On

the other hand, having coverage does not guarantee that one can easily find a doctor, as both

Medicare and Medicaid participants sometime report. Having coverage also does not ensure that

one can pay for care. People with high deductible insurance, perhaps chosen when they were

healthy or because premiums were lower, may have to pay several thousand dollars out of pocket

before their plan begins reimbursements. 4 For some people, including those who lose their jobs,

paying for health care is a major problem. 5 Even people with comprehensive plans with low

deductibles may have difficulty paying the ongoing costs of chronic conditions or the major costs

of serious illnesses.

Being uninsured can cause problems. According to some studies, uninsured people are more

likely to postpone or do without care, including screening and preventive tests that health care

practitioners commonly use. They are less likely to have regular sources of care and more likely

to use emergency rooms.6 At the same time, it is sometimes difficult to attribute differences in

health status or outcomes to whether one has insurance because other unobservable factors may

be important.7

The uninsured have diverse characteristics, which suggests they may lack coverage for different

reasons. As shown in Appendix B, most are employed full time or are family members of those

who are, but some are in families where no one is in the labor force. Most are not poor, but many

are low income. About one in eight uninsured in 2007 were in household insurance units with

incomes over $50,000.8

As Congress considers what to do about the uninsured, a number of issues have arisen, including

the following:

•

whether it is important for everyone to have coverage,

•

whether people should be required to have coverage (an individual mandate),

•

what people at various income levels should be required to pay for coverage, and

(...continued)

Brief #183, August 2007, http://www.meps.ahrq.gov/mepsweb/data_files/publications/st183/stat183.pdf.

The minimum deductible for a family plan that qualifies for a health savings account (HSA) is $2,300, though

insurance reimbursements for preventive care are allowed without any deductible. Families could use funds in their

HSAs to pay for some of the deductible, but some accounts may not be large enough. For additional information see

CRS Report RL33257, Health Savings Accounts: Overview of Rules for 2009, by (name redacted).

Peter Cunningham, Carolyn Miller, and Alwyn Cassel, Living on the Edge: Health Care Expenses Strain Family

Budgets, Center for Studying Health System Change, Research Brief No. 10, December 2008,

http://www.hschange.com/CONTENT/1034/1034.pdf.

See Families USA, op. cit., pp. 12-13 and the numerous studies referenced there. Also see Randall R. Bovbjerg and

Jack Hadley, Why Health Insurance is Important, The Urban Institute, Health Policy Briefs DC-SPG no. 1, November

2007, http://www.urban.org/UploadedPDF/411569_importance_of_insurance.pdf.

Helen Levy and David Meltzer, “The Impact of Health Insurance on Health,” Annual Review of Public Health, vol. 29

(2008), pp. 399-409.

For another recent study, see June E. O’Neill and Dave M. O’Neill, Who Are the Uninsured? Employment Policies

Institute. June, 2009, http://www.epionline.org/studies/oneill_06-2009.pdf.

Congressional Research Service

Health Care Reform: An Introduction

•

whether coverage provided with public subsidies should meet minimum benefit

and cost-sharing standards.

Cost and Spending

According to the U.S. Department of Health and Human Services, spending on health care in the

United States increased from 7.2% of GDP in 1970 to 12.3% in 1990 and 16.2% in 2007.9 It

likely is more than 17% in 2009.10 Barring changes in law, the Congressional Budget Office

(CBO) projected in 2008 that it would rise to 25% of GDP by 2025 and much higher levels

beyond.11 CBO has cautioned that “as health care spending consumes a greater and greater share

of the nation’s economic output in the future, Americans will be faced with increasingly difficult

choices between health care and other priorities.”12

The United States spends considerably more on health care than other industrialized countries: on

a per capita basis, its spending is more than two times greater than the spending of the median

Organization for Economic Cooperation and Development (OECD) country. 13 It has been argued

that some of the higher health care spending has added real value through medical advances. 14

Some of it may be attributable to the higher per capita GDP in the United States, which simply

allows Americans to spend more. 15 However, its value has been questioned in light of the mixed

performance of the United States on many indicators of health care quality, as described in the

next section.

“Cost” and “spending” are often used interchangeably, particularly with the issues discussed in

this report. Use of one term instead of the other may reflect differences in context or perspective,

not substance, though this is not always the case (for example, prices are usually described as

costs, while purchases are usually described as spending). It is apparent that what are called rising

costs can cause serious problems for people and entities that cannot easily absorb them. Concern

about costs arises from a number of trends. The average annual rate of growth in medical care

prices between 1980 and 2007 was 4.7%, in contrast to 2.5% for the entire consumer price index

(CPI). Health insurance premiums on average increased by 114% from 1999 to 2007, far more

Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. National Health Care

Expenditures, 2007. Table 1. http://www.cms.hhs.gov/NationalHealthExpendData/downloads/tables.pdf.

Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. National Health

Expenditure Projections 2008 – 2018, Table 1, http://www.cms.hhs.gov/NationalHealthExpendData/downloads/

proj2008.pdf.

Congressional Budget Office, Growth in Health Care Costs, CBO Testimony before the Committee on the Budget

United States Senate, January 31, 2008, http://www.cbo.gov/ftpdocs/89xx/doc8948/01-31-HealthTestimony.pdf

Congressional Budget Office, The Long-Term Outlook for Health Care Spending, November, 2007,

http://www.cbo.gov/ftpdocs/87xx/doc8758/11-13-LT-Health.pdf.

Gerald F. Anderson and Bianca K. Frogner, “Health Spending in OECD Countries: Obtaining Value Per Dollar,”

Health Affairs, vol. 26, no. 6 (2008), pp. 1718-1727. Also see CRS Report RL34175, U.S. Health Care Spending:

Comparison with Other OECD Countries, by (name redacted) and Rachel Burton.

David M. Cutler, Your Money or Your Life: Strong Medicine for America’s Health Care System (Oxford University

Press, 2005).

Uwe E. Reinhardt, Peter S. Hussey, and Gerard F. Anderson, “U.S. Health Care Spending in an International

Context,” Health Affairs, vol. 23, no. 3 (2004), pp. 10-25. Citing their previous work, the authors argue that higher

prices for health care in the United States can partly be attributed to the compensation needed to attract talented

professionals and the relatively greater power of the supply side versus the demand side in health care markets.

Congressional Research Service

Health Care Reform: An Introduction

than increases in workers’ earnings (27%).16 The rising cost of health insurance likely is one

reason there are increasing numbers of uninsured.

Controlling cost and spending is unlikely to be easy. Many economists argue that the principal

factor driving increases in health care spending is technology, both new pharmaceuticals and

other products and services and wider use of existing ones. 17 It is not obvious whether some

developments can be limited or their application blocked (for example, by limiting diffusion on

the basis of clinical evidence) and some would question whether they should. One challenge in

controlling costs is that payers may shift burdens to others, sometimes in ways that are not clearly

understood or measurable. For example, most economists argue that employer payments for

health insurance are actually borne by workers through reduced wages and other forms of

compensation. Attempts to limit employer-paid insurance may lead to increases in wages in ways

that are difficult to predict.

One particular congressional concern is the cost of federal health insurance programs. In 2007,

Medicare and Medicaid, the two largest programs, accounted for about 20% of the federal budget

and over 27% of total national health care expenditures (for the latter, see Table C-2 in Appendix

C). They also constituted about 5% of GDP. If past cost trends continue, it has been estimated the

two programs would grow to about 20% of GDP by 2050, approximately the same share of GDP

as all federal spending recently. 18 Increases of that magnitude would likely cause serious

problems.

As Congress considers what to do about health care costs and spending, a number of issues have

arisen, including the following:

•

whether markets in health care, if they were less regulated, would result in price

reductions and quality improvements that have occurred in other markets,

•

whether efforts to reduce costs for some would increase costs for others,

•

whether efforts to reduce costs would adversely affect the health of consumers,

and

•

whether efforts to reduce spending or slow its growth would impede efforts to

provide coverage to more people or to improve quality.

Quality

Despite spending more on health care than other industrialized countries, the United States scores

only average or somewhat worse on many quality of care indicators. It is near the top for some

measures, such as survival rates for breast and colorectal cancer, but near the bottom for others,

Paul B. Ginsburg, High and Rising Health Care Costs: Demystifying U.S. Health Care Spending, Robert Wood

Johnson Foundation. The Synthesis Project, October 2008, p. 1, http://www.rwjf.org/files/research/

101508.policysynthesis.costdrivers.rpt.pdf.

Ginsburg, op. cit., p. 1. Technology is often treated as a residual variable in studies of health care costs, so it could be

overstated.

Testimony of Peter R. Orszag before the Committee on Budget, United States Senate, January 13, 2009,

http://budget.senate.gov/democratic/testimony/2009/OrszagFINAL011309.pdf. Due to the recession and federal

spending in response to it, some of these percentages may be changing.

Congressional Research Service

Health Care Reform: An Introduction

such as mortality and hospitalization rates for asthma.19 A recent Centers for Disease Control and

Prevention (CDC) report found that the United States ranked 29th in the world in infant mortality

in 2004. The U.S. position in rankings on this measure has been declining.20 Notwithstanding

difficulties of cross-national comparisons, these indicators show that Americans do not receive

the best value for their health care spending and that there is room for improvement.

Concerns about health care quality in the United States go beyond international comparisons, and

they cannot be reduced simply to returns on the dollar. Medical errors appear to be one systemic

shortcoming. An influential 1999 Institute of Medicine study found that at least 44,000 people,

and perhaps as many as 98,000, die from in-patient hospital care every year. The study found that

most medical errors do not result from individual recklessness or actions of a particular group;

rather, they are attributable to “faulty systems, processes, and conditions that lead people to make

mistakes or fail to prevent them.”21 A more recent study estimated that if all hospitals performed

as well as the best group of hospitals for patient safety, more than 44,000 deaths among Medicare

beneficiaries could have been avoided during the years 2002 through 2004.22 Another Institute of

Medicine study reported in 2006 that there were more than 400,000 preventable drug-related

injuries each year in hospitals alone, and that altogether medication errors harmed at least 1.5

million people.23

Not adhering to evidence-based practice or clinical practice guidelines is also a problem. One

2003 study found that Americans receive recommended evidence-based care only about 55% of

the time. Recommended care was provided more often for conditions such as breast cancer

(75.7%) and hypertension (64.7%) than it was for others such as atrial fibrillation (24.7%) or hip

fracture (22.8%).24 A later study using the same data found that while differences among

sociodemographic subgroups were relatively small, quality problems were profound and

systemic. 25 Most studies of disparities have found significant differences by sociodemographic

subgroups, with whites receiving better care on many core measures than racial and ethnic

minorities.26

Anderson and Frogner, op. cit.

Marian F. MacDorman and T.J. Mathews, Recent Trends in Infant Mortality in the United States, National Center for

Health Statistics, Centers for Disease Control and Prevention, October 2008, http://www.cdc.gov/nchs/data/databriefs/

db09.htm. The report notes that “international comparisons of infant mortality can be affected by differences in

reporting of fetal and infant deaths. However, it appears unlikely that differences in reporting are the primary

explanation for the United States’ relatively low international ranking.”

Institute of Medicine, To Err is Human: Building A Safer Health System, November 1999.

Health Grades, Third Annual Patient Safety in American Hospitals Study, April 2006, p. 4,

http://www.healthgrades.com/media/dms/pdf/patientsafetyinamericanhospitalsstudy2006.pdf.

Institute of Medicine, National Academies, “Medication Errors Injure 1.5 Million People,” press release, July 20,

2006, http://www8.nationalacademies.org/onpinews/newsitem.aspx?RecordID=11623.

Elizabeth A. McGlynn et al., “The Quality of Health Care Delivered to Adults in the United States,” The New

England Journal of Medicine, vol. 348, no. 26 (June 26, 2003), pp. 2635-2646. The study was based on a random

sample of adults in 12 metropolitan areas in the United States. Over 12,000 adults who received care participated in the

survey.

Steven M. Asch et al., “Who Is at Greatest Risk for Receiving Poor-Quality Health Care?,” New England Journal of

Medicine, vol. 354, no. 11 (March 16, 2006), pp. 1147-1156.

For example, see Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services,

National Healthcare Disparities Report, 2008 (May 2009), http://www.ahrq.gov/qual/nhdr08/nhdr08.pdf.

Congressional Research Service

Health Care Reform: An Introduction

Over the past decade, there have been numerous efforts to improve quality of care in the United

States.27 Among other things, there have been attempts to improve and refine the metrics used for

measuring quality, to publicly report comparative information, and, in some cases, to use quality

standards as one basis for payment policies. Despite observable progress, the most recent

National Healthcare Quality Report (2008) indicated that health care quality is suboptimal and

continues to improve at a slow pace.28 Among the challenges to making further improvements are

disagreements about the utility or appropriateness of some measures (including concerns about

how the public might interpret them), the fragmented nature of the American health care system,

and barriers to access for some groups that complicate the work of providers.

As Congress considers what to do about health care quality, a number of issues have arisen,

including the following:

•

whether quality improvements should be pursued for their own sake, regardless

of whether they promise to save money,

•

whether it is possible to improve the quality of care without reorganizing and

restructuring health care delivery systems,

•

whether preventive care should have a significant role in improving quality,

relative to acute or chronic care services,

•

whether the evidence-base is adequate for guiding quality improvement efforts,

or whether the way research is organized, financed, and carried out needs to be

changed, and

•

whether employers and other entities that are not health care providers can play a

role in improving health outcomes.

Some Likely Legislative Issues

The reform debate in the 111th Congress has raised some perennial issues about national health

care policy. These include deep-seated disagreements about whether insurance should be public

or private; whether employment-based insurance should be strengthened, weakened, or left alone;

and what role states should play. The scope of reform is itself an issue.

The legislative issues discussed below will affect attempts to deal with the three predominant

concerns raised at the beginning of the report. For example, even if there were a consensus that

everyone should have coverage—something some Members actually might not consider a

priority—that would not resolve questions of whether the coverage should be public or private,

whether employer-provided coverage should in some way be favored, or whether states should

According to one observer, efforts to improve patient safety stemmed from the Institute of Medicine report cited

above (To Err is Human) and reflected growing skepticism about the health care system after a decade of managed

care. Robert M. Wachter, “The End of the Beginning: Patient Safety Five Years After ‘To Err is Human’,” Health

Affairs Web Exclusive, November 30, 2004, pp. W4-534-W4-545, http://content.healthaffairs.org/cgi/reprint/

hlthaff.w4.534v1?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=wachter&andorexactfulltext=

and&searchid=1&FIRSTINDEX=0&resourcetype=HWCIT.

Agency for Healthcare Quality and Research, U.S. Department of Health and Human Services, Key Themes and

Highlights From the National Healthcare Quality Report, 2008. (May, 2009), http://www.ahrq.gov/qual/nhqr08/

nhqr08.pdf.

Congressional Research Service

Health Care Reform: An Introduction

have the principal responsibility for enrolling people in plans and subsidizing those who need

assistance. Disputes over any of these issues could derail attempts to meet coverage goals.

The discussion below does not cover all issues currently being debated. Other controversies

include the following:

•

how much health care reform might cost, and how it should be financed,

•

whether there should be individual or employer mandates, or possibly both,

•

how much individuals and families might be expected to pay for coverage from

their own resources, and

•

how insurance benefit standards might be set and updated.

The Scope of Reform

The scope of reform is one of the first issues to confront proponents of change. Changing private

insurance for people under age 65 through a combination of market restructuring, benefit

standards, and financing reforms was the core and most controversial aspect of President

Clinton’s 1993 proposal, but it was only one part of a comprehensive package. His Health

Security Act also would have brought about important changes in Medicare, Medicaid, long-term

care, and the tax code, and it included initiatives for administrative simplification, health

information privacy and security, health care quality, malpractice reform, prevention and public

health, and healthcare workforce expansion.

Perhaps as a consequence of the failure of that legislation, most subsequent health care reform

bills have been smaller in scope. Many proposals for insuring people under age 65 have been less

sweeping, focusing on creating better options for small businesses, for example, or allowing a

Medicare buy-in (i.e., allowing early retirees and others to pay premiums for coverage before age

65.) Other parts of the Clinton proposal that got less attention at the time were addressed in

legislation that followed, such as the privacy rules included in the Health Insurance Portability

and Accountability Act of 1996 (HIPAA, P.L. 104-191), as were other parts of some Republican

proposals of the time, such as the Health Savings Accounts included in the Medicare Prescription

Drug, Improvement, and Modernization Act of 2003 (P.L. 108-173). Congress proceeded in

incremental steps.

Changing the private insurance market for people under age 65 is once again the center of health

care reform. Nearly all uninsured people are under that age (see Table A-1 in Appendix A), and

many advocates for reform call for giving them access to coverage (and sometimes choice of

coverage) that meets specified benefit and cost-sharing standards. If this could be accomplished,

many advocates would consider reform initiatives to be successful.

Others argue that reform needs to address additional problems as well. Medicare might be

included because older people consume a share of health care disproportionate to the number and

Medicare policies and payments significantly affect health care delivery systems. Considering the

projected growth in Medicare spending, said to be unsustainable, some argue that it should be

reformed sooner rather than later. (H.R. 3200, the House Committees’ bill, includes extensive

Medicare changes. The Senate HELP Committee measure does not because Medicare is not

within its jurisdiction.) Medicaid might also be included because new public subsidies could

allow lower-income families to have the same private insurance options as other Americans.

Congressional Research Service

Health Care Reform: An Introduction

However, Medicaid provides some benefits that historically private coverage has not, so some

part of it might have to remain in a system that otherwise has private options. Moreover, some

think it preferable to expand Medicaid programs, as discussed in the next section. Arguments are

being advanced that improvements in quality, public health, and other matters are needed so that

people of all ages, regardless of their insured status, can receive adequate health care.

Public or Private Insurance

Private insurance is the largest source of funding for national health expenditures, providing

34.6% of the total (see Table C-2 in Appendix C). It is somewhat larger than the combined

contributions of Medicare and Medicaid (33.9%), the two largest public programs. Private

insurance has always been larger than these two programs, though in the past the difference has

been greater.

The distinction between public and private insurance sometimes is hard to draw. Medicare has

private plan options (Medicare Advantage plans) that now enroll 20% of Medicare beneficiaries,

and Medicaid has commercial managed care plans. In both cases, the private plans are publicly

financed and closely regulated, but participants often have choices that are characteristic of

private coverage. In turn, private insurance is regulated more than other consumer products,

including requirements and restrictions on benefits, pricing, and marketing when sold as

commercial insurance and tax code and ERISA rules when employers self-insure (for the latter,

see “The Role of States,” below). Nonetheless, important differences remain with respect to

financing (public programs usually are financed largely with tax dollars, not premiums),

eligibility (public programs do not use underwriting), and flexibility (private plans usually can

innovate and make other changes quickly). Some people consider these differences important

both for health care and for the role of government in general.

Whether public programs should be expanded has become an issue in the current debate. H.R.

3200 would expand Medicaid to all individuals and families with incomes under 133% of the

federal poverty level. Proponents of expansion argue that Medicaid would be a simpler way to

extend comprehensive coverage to these populations, whereas opponents are concerned about

denying them access to private insurance. Even though H.R. 3200 would provide 100% federal

financing for the newly added populations, states remain concerned about their ability to finance

other parts of the program over the long term.

H.R. 3200 and the Senate HELP Committee legislation would establish health insurance

purchasing exchanges like Massachusetts adopted for its comprehensive reform.29 Currently there

is contentious debate over whether a public insurance option should be included within their

exchanges. Depending on what the public option is—there are a number of possible models—it

could provide coverage for people that private insurers normally do not seek, and it could use the

government’s purchasing power to control costs. With its potential access to public financing,

however, some think that a public plan might compete unfairly against private plans, eventually

driving them out of the market.

The exchange in Massachusetts is called the Connector. For more information, see its website,

http://www.mahealthconnector.org/portal/site/connector/.

Congressional Research Service

Health Care Reform: An Introduction

Employment-Based Insurance

Employment-based insurance is the principal form of coverage for people under age 65. As

shown in Table A-1 in Appendix A, more than three-fifths of that population is insured either as

a worker or the spouse or dependent of a worker. Employment-based insurance has several

strengths, including risk pools that are not formed on the basis of health status, ease of acquisition

by workers, and tax subsidies that exceed those for individual market insurance. On the other

hand, plans chosen by employers may not meet individual workers’ needs, and changing jobs may

require obtaining both new insurance and new doctors.

Whether employment-based insurance should be strengthened, weakened, or left alone has arisen

in several ways. Some Members have proposed that the tax exclusion for employer-paid coverage

be eliminated or capped, both to help finance reform and to discourage what some consider

overly generous health benefits. Completely eliminating the exclusion could increase federal

receipts by more than $225 billion a year, more than enough to pay for the reform proposals

currently under consideration.30 Because this change might result in tax increases for many

households and weaken the attractiveness of employment-based insurance, currently more

attention is being given to capping the exclusion. (H.R. 3200, so far the only committee bill to

deal with tax issues, would not cap or limit the exclusion.) In assessing the impact of these

possible changes, one must take account of how the budget savings they generate are used in a

reformed system. 31

Debate over employment-based insurance is also occurring regarding small employers. Small

employers are less likely to offer insurance than large employers: according to one survey, 62%

of firms with 3 to 199 workers offered coverage in 2008 whereas 99% of firms with 200 or more

workers did. Very small employers (3 to 9 workers) were least likely to offer coverage. 32 Both

H.R. 3200 and the Senate HELP legislation would allow assistance to small firms to help them

offer or maintain coverage. The House bill would establish a 50% tax credit for small businesses

that pay at least certain portions of the cost; it would be phased out for firms with 10 to 25

employees or with average wages of $20,000 to $40,000 a year. The HELP legislation assumes

there would be a tax credit for employers with 50 or fewer employees that pay at least certain

amounts. However, both measures would also require employers with more than 25 workers to

either offer insurance or pay a penalty. Some argue that the last provision would reduce the

number of jobs that all but the smallest employers would create.

The Joint Tax Committee estimates that the exclusion reduced individuals’ federal income taxes in 2008 by about

$132.7 billion, and individuals’ and employers’ Social Security and Medicare taxes by about $93.5 billion. Background

Materials for Senate Committee on Finance Roundtable on Health Care Financing, (JCX-27-09), May 8, 2009,

http://www.jct.gov/publications.html?func=startdown&id=3557.

For additional information on eliminating or capping the exclusion, see CRS Report RL34767, The Tax Exclusion for

Employer-Provided Health Insurance: Policy Issues Regarding the Repeal Debate, by (name redacted), and CRS Report

R40673, Limiting the Exclusion for Employer-Provided Health Insurance: Background and Issues, by (name redacted) and

(name redacted).

Employer Health Benefits: 2008 Summary of Findings. The Kaiser Family Foundation and Health Research and

Educational Trust., p. 4, http://ehbs.kff.org/images/abstract/7791.pdf.

Congressional Research Service

Health Care Reform: An Introduction

The Role of States

States have long played a significant role in health care. They are the principal regulators for

insurance sold in the private market, particularly the individual and small group markets. While

their authority to regulate self-insured employer plans has been preempted by the Employee

Retirement Income Security Act (ERISA), they remain largely responsible for regulating business

practices associated with the insurance that employers purchase.33 (Employers that self-insure

assume the risk of paying for covered services, though some limit their exposure to large losses

through stop-loss insurance. A majority of people covered under employer plans are under selfinsured plans.) States are also responsible for licensing of health care providers and investigating

certain complaints about them, approval of health care facilities, and much of the law governing

contracts, employment, and other matters. As shown in Table C-2 in Appendix C, states and

their local subdivisions were also the source of $281.4 billion in health care expenditures in 2007,

over 12% of the total.

An important issue for health care reform is what role states would continue to play. Conceivably

one might envision a reformed system that is governed entirely by national policies and national

administration, whether part of the federal government or not. However, reform proposals that

would do this typically assign some responsibilities to the states or, by their silence, allow much

existing state law and regulation to continue. With respect to the health insurance purchasing

exchanges, H.R. 3200 would create a national exchange (though states could establish their own

instead) whereas the HELP legislation would have only state-based exchanges. Both measures

would establish national rules for matters now largely governed by state law, including benefit

design, requirements for guaranteed issue and disregard of pre-existing conditions, marketing

standards, and pooling mechanisms.

If federal legislation is not enacted, some states will likely attempt to bring about substantial

change on their own. Reforms adopted in Massachusetts in 2006 might serve as a model, at least

for the possibility of action, as might smaller changes adopted in other states.34 States that act on

their own may be able to tailor plans to their particular needs and preferences. However, the

problems states face vary greatly, as do their fiscal capacities to pay for reforms. Massachusetts

had one of the lowest uninsured rates in the country and one of the highest per capita incomes,

though its health care costs are also among the highest. States might be slow to act unless they

receive federal assistance. ERISA preemption might block some initiatives. State reforms could

leave the country with a patchwork quilt of health care systems, though some might find this

better than current arrangements or a national system not to their liking.

The Cost of Reform

The cost of reform and how to pay for it have become important issues in the current debate.

Reform is likely to be expensive. The principal proposals under consideration could cost the

federal government more than $1 trillion over the next 10 years, depending on their scope and

details. The largest part would be for subsidies to help people under age 65 pay for health

CRS Report RS20315, ERISA Regulation of Health Plans: Fact Sheet, by (name redacted).

The Massachusetts plan requires everyone to have insurance, with some exceptions, and established an insurance

marketplace called the Connector to help some find coverage. Premium subsidies are available depending on income

and family size, and employers that do not offer coverage must pay a penalty.

Congressional Research Service

Health Care Reform: An Introduction

insurance or be covered by public programs. Not only is reducing the number of uninsured a

major goal for many, but individual mandates for coverage (i.e., requirements that one must have

coverage) are practical only if people with little money are given assistance. Health care reform

may increase costs for others as well, including the states, employers, employees, consumers,

health care providers, and taxpayers. If their expenditures do not increase, their income may go

down, leaving them in a worse position financially. At the same time, reform would likely have

the opposite effect for some of these parties, making them better off.

Under current congressional budget enforcement rules, health care reform legislation must not

increase the federal deficit. Projected spending increases and revenue reductions are to be offset

by reductions in spending or increases in revenue. Conceptually there are a number of ways this

could be accomplished, including increasing general tax rates, reducing various tax subsidies,

reducing spending for federal health programs, reducing other federal program spending, and

increasing borrowing. Currently, the principal offsets under consideration are Medicare

reductions and tax increases. The Medicare changes at issue include reducing the annual updates

of Medicare’s many fee-for-service payment rates, reducing spending in Medicare Advantage by

basing payments on spending in fee-for-service Medicare, and requiring drug manufacturers to

provide rebates and discounts in specific circumstances under the Part D prescription drug

program. The largest tax increases being considered include limiting the tax rate that high-income

taxpayers can use to reduce their tax liability by itemized deductions, an income tax surcharge on

high-income taxpayers, and caps or other limits on the exclusion for employer-provided health

care. For analyses of some of the proposals, see CRS Report R40648, Tax Options for Financing

Health Care Reform, by (name redacted), and CRS Report R40673, Limiting the Exclusion for

Employer-Provided Health Insurance: Background and Issues, by (name redacted) and (name red

acted). Other options were outlined last year by the Congressional Budget Office. 35

Congressional Proposals

The committees of jurisdiction for health care have prepared comprehensive reform proposals.

The Senate HELP Committee approved a measure on July 15 (Affordable Health Choices Act),36

whereas the Senate Finance Committee has not yet released a proposal, though earlier it provided

a range of policy options and many of its debates have been publicized.37 H.R. 3200, a

coordinated measure by three House committees (Education and Labor, Ways and Means, and

Energy and Commerce), was approved by the first two committees with some variations on July

17 and by Energy and Commerce on July 31.38

Congressional Budget Office, Budget Options Volume 1: Health Care (December, 2008), http://www.cbo.gov/

ftpdocs/99xx/doc9925/12-18-HealthOptions.pdf.

For a detailed summary prepared by the HELP Committee, see In Historic Vote, HELP Committee Approves the

Affordable Health Choices Act, http://help.senate.gov/Maj_press/2009_07_15_b.pdf.

The policy options are discussed in three separate documents: (1) Transforming the Health Care Delivery System:

Proposals to Improve Patient Care and Reduce Health Care Costs, http://finance.senate.gov/sitepages/leg/LEG

2009/042809 Health Care Description of Policy Option.pdf; (2) Expanding Health Care Coverage: Proposals to

Provide Affordable Coverage to All Americans, http://finance.senate.gov/sitepages/leg/LEG 2009/051109 Health Care

Description of Policy Options.pdf; and (3) Financing Comprehensive Health Care Reform: Proposed Health System

Savings and Revenue Options, http://www.finance.senate.gov/sitepages/leg/LEG 2009/051809 Health Care Description

of Policy Options.pdf.

The bill as introduced and the amendments adopted by the Education and Labor Committee are available through this

link: http://edlabor.house.gov/markups/2009/07/hr-3200-americas-affordable-he.shtml. The bill as introduced and the

(continued...)

Congressional Research Service

Health Care Reform: An Introduction

Other comprehensive reform bills introduced in the 111th Congress include H.R. 15 (Dingell),

H.R. 193 (Stark), H.R. 676 (Conyers), H.R. 1200 (McDermott), H.R. 1321 (Eshoo), H.R. 2399

(Langevin), H.R. 2520 (Ryan of Wisconsin), H.R. 3000 (Lee), S. 391 (Wyden), S. 703 (Sanders),

S. 1099 (Coburn), S. 1240 (DeMint), S. 1278 (Rockefeller), and S. 1324 (DeMint). In general,

these bills would provide coverage for nearly all people in the United States, sometimes for

everyone under new insurance plans and sometimes only for people not covered by Medicare or

some other current plans and arrangements. Many would have an individual mandate (i.e., a

requirement that everyone have coverage). Some would address quality, administrative simplicity,

and other issues as well.

The Administration has not proposed a health reform bill of its own. However, it has been

working continually with the House and Senate committees that have prepared (or are still

preparing) the legislation mentioned above, and it has been negotiating with some of the principal

stakeholders. The FY2010 budget that it released in February included broad principles for

reform;39it also proposed a number of tax changes that would raise $300 billion over the next 10

years, mostly from limiting the tax rate that high-income taxpayers can use to reduce their tax

liability by itemized deductions. 40 The budget also proposed more than $280 billion in Medicare

savings and $22 billion in Medicaid savings.41 On June 13, the President announced more than

$300 billion additional possible savings from Medicare.42 Additionally, the Administration

transmitted legislation to Congress called the Independent Medicare Advisory Council (IMAC)

Act of 2009 on July 17.43 The IMAC would consist of five members who are either physicians or

possess specialized expertise in medicine or health care policy. The council’s primary function,

beginning in fiscal year 2015, would be providing annual recommendations to the President for

changing federal payments for various services covered by Medicare. These recommendation

packages would have to be created so that implementation would not exceed aggregate Medicare

spending over the subsequent 10 year period, compared with expected spending without any

changes. Upon the President’s approval, recommendations would become active no sooner than

30 days thereafter, unless Congress enacts a joint resolution to disapprove. On July 25, CBO had

scored the savings of such proposal to be $2 billion over the 2016-2019 period. 44 CBO notes there

is a possibility of considerably more savings beyond 2019 contingent on the scope of IMAC

recommendations.45

(...continued)

amendments adopted by the Ways and Means Committee are available through this link:

http://waysandmeans.house.gov/MoreInfo.asp?section=52. The bill as introduced and the amendments adopted by the

Energy and Commerce Committee are available through this link:

http://energycommerce.house.gov/index.php?option=com_content&view=article&id=1687&catid=156&Itemid=55

Office of Management and Budget, A New Era of Responsibility: Renewing America’s Promise, February 26, 2009,

http://www.whitehouse.gov/omb/assets/fy2010_new_era/A_New_Era_of_Responsibility2.pdf.

U.S. Department of the Treasury, General Explanations of the Administration’s Fiscal Year 2010 Revenue Proposals

(May 2010), p. 130.

CRS Report R40587, Medicare: FY2010 Budget Issues, coordinated by (name redacted).

See http://www.whitehouse.gov/MedicareFactSheetFinal/.

See http://www.whitehouse.gov/omb/assets/legislative_letters/Pelosi_071709.pdf.

See http://www.cbo.gov/ftpdocs/104xx/doc10480/07-25-IMAC.pdf; pg. 2.

See http://www.cbo.gov/ftpdocs/104xx/doc10480/07-25-IMAC.pdf; pg. 6.

Congressional Research Service

Health Care Reform: An Introduction

Appendix A. Overview of Health Insurance

Coverage

The following table provides an overview of the sources of health insurance that people have as

well as estimates on the number of uninsured. Estimates for 2009 likely have changed somewhat

because of additional population growth and the recession.

Table A-1. Health Insurance Coverage, by Type of Insurance and Age, 2007

Type of Insurance

Population

(millions)

Employmentbased

Private

Nongroup

Medicare

Medicaid

Other

Public

Under 19

78.7

60.7%

5.3%

0.7%

27.6%

2.8%

11.3%

8.9

Under 65

262.3

64.4%

6.5%

2.7%

13.8%

3.2%

17.1%

45.0

65+

36.8

35.0%

25.9%

93.2%

8.9%

7.1%

1.9%

0.7

All ages

299.1

60.8%

8.9%

13.8%

13.2%

3.7%

15.3%

45.7

Age

Military

Veterans’

Coverage

(percent)

(millions)

Uninsured

Source: CRS analysis of data from the March 2008 Current Population Survey (CPS). The table is a truncated

version of Table 1 in CRS Report 96-891, Health Insurance Coverage: Characteristics of the Insured and Uninsured

Populations in 2007, by (name redacted) and (name redacted).

Note: People may have more than one source of coverage; percentages may total to more than 100.

Congressional Research Service

Health Care Reform: An Introduction

Appendix B. Characteristics of the Uninsured

People under age 65 who were uninsured in 2007 had the following diverse characteristics:46

•

Age: Young adults ages 19 to 24 represented 9.2% of this population but 16.2%

of the uninsured,

•

Race and ethnicity: Hispanics represented 16.6% of this population but 32.4% of

the uninsured,

•

Citizenship: More than one-quarter were not native-born U.S. citizens,

•

Employment: More than half were full-time, full-year workers or their spouses

and children. About a quarter were part-time or partial-year workers or their

spouses or children. Less than one-fifth of the uninsured were in households with

no attachment to the labor force.

•

Income: About 57% of household insurance units had incomes below $25,000,

27% between $25,000 and $49,999, 9% between $50,000 and $74,999, and 3%

between $75,000 and $99,999. About 4% had incomes of $100,000 or more.

•

Poverty status: Three-quarters had family incomes above poverty thresholds.

Uninsurance rates for people under age 65 vary widely among the states. Based upon Current

Population Survey data for 2006 and 2007, states with the highest rates were Texas (27.4%), New

Mexico (25.6%), Florida (24.3%), Louisiana (23%), Arizona (21.8%), and California (20.4%).

States with the lowest rates were Massachusetts (8.9%), Hawaii (9.2%), Wisconsin (9.6%), and

Minnesota (9.9%).47

Estimates are from CRS Report 96-891, Health Insurance Coverage: Characteristics of the Insured and Uninsured

Populations in 2007, by (name redacted) and (name redacted). The estimates are based on data from the Current

Population Survey.

Robert Wood Johnson Foundation and the State Health Access Data Assistance Center, At the Brink: Trends in

America’s Uninsured, A State-by-State Analysis, March 2009, http://www.rwjf.org/files/research/20090324ctuw.pdf.

Congressional Research Service

Health Care Reform: An Introduction

Appendix C. Distribution of National Health Care

Expenditures

The following table provides an overview of how the nation’s $2.2 trillion in spending for health

care was distributed among various services, products, and activities in 2007. The estimates were

prepared by the Centers for Medicare and Medicaid Services (CMS) of the Department of Health

and Human Services. CMS estimates that aggregate growth between 2007 and 2008 was 6.1%,

which would bring total expenditures for the latter year to over $2.3 trillion.48

Table C-1. Distribution of National Health Care Expenditures by Service, Product,

and Activity, 2007

Expenditures

(in billions of dollars)

Percentage

of Total

Expenditures

696.5

31.0

Physician and clinical services

478.8

21.4

Other professional services

62.0

2.8

Dental services

95.2

4.2

Other personal health care

66.2

3.0

Nursing home and home health

190.4

8.5

Prescription drugs

227.5

10.2

Other medical products

61.8

2.8

Government administration and net cost of private health insurance

155.7

6.9

Government public health activities

64.1

2.9

INVESTMENT (research, structures, and equipment)

143.1

6.4

TOTAL

2,241.2

100.0

Type of Service, Product, or Activity

HEALTH SERVICES AND SUPPLIES

Personal health care

Hospital care

Professional services

Retail outlet sales of medical products

Source: Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. National

Health Care Expenditures, 2007, Table2, at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/

tables.pdf.

Note: Data might not sum to total due to rounding.

The following table provides an overview of how the nation’s $2.2 trillion in health care spending

in 2007 were distributed by source of funds.

Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. NHE Fact Sheet,

http://www.cms.hhs.gov/NationalHealthExpendData/25_NHE_Fact_Sheet.asp.

Congressional Research Service

Health Care Reform: An Introduction

Table C-2. Distribution of National Health Care Expenditures by

Source of Funds, 2007

Expenditures

(in billions of

dollars)

Percentage

of Total

Expenditures

Out-of-pocket payments

268.6

12.0

Private health insurance

775.0

34.6

162.0

7.2

Medicare

431.2

19.2

Medicaid

186.1

8.3

Other federal

137.0

6.1

Medicaid

143.3

6.4

Other state and local

138.1

6.2

2,241.2

100.0

Source of Funds

PRIVATE

Consumer payments

Other private funds

PUBLIC

Federal

State and local

TOTAL

Source: Centers for Medicare and Medicaid Services, U.S. Department of Health and Human Services. National

Health Care Expenditures, 2007, Table 3, at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/

tables.pdf.

Notes: Data might not sum to total due to rounding.

Author Contact Information

(name redacted), Coordinator

Analyst in Health Care Financing

#redacted#@crs.loc.gov, 7-....

(name redacted)

Specialist in Health Care Financing

#redacted#@crs.loc.gov, 7-....

(name redacted)

Specialist in Health Care Financing

#redacted#@crs.loc.gov, 7-....

(name redacted)

Additional Author Information

This report is largely based on the previous work of (name redacted). Other CRS analysts who contributed to the

report include (name redacted), (name redacted), Tom Gabe, (name redacted), Chris Peterson, Amanda

Sarata, Erin Williams, and Carl Mueller (providing the most recent update to this report).

Congressional Research Service

Health Care Reform: An Introduction

Key Policy Staff

Area of Expertise

Name

Phone

E-mail

Health Insurance Coverage

Chris Peterson

7-....

/redacted/@crs.loc.gov

The Uninsured

Chris Peterson

7-....

/redacted/@crs.loc.gov

Health Information Technology and

Patient Safety

(name redacted)

Health Care Quality

Amanda Sarata

7-....

Private Health Insurance

(name redacted) and

7-....

/redacted/@crs.loc.gov

(name redacted)

7-....

/redacted/@crs.loc.gov

Medicare

(name redacted)

Medicaid

Lisa Herz

Congressional Research Service

7-....

/redacted/@crs.loc.gov

7-....

/redacted/@crs.loc.gov

EveryCRSReport.com

The Congressional Research Service (CRS) is a federal legislative branch agency, housed inside the

Library of Congress, charged with providing the United States Congress non-partisan advice on

issues that may come before Congress.

EveryCRSReport.com republishes CRS reports that are available to all Congressional staff. The

reports are not classified, and Members of Congress routinely make individual reports available to

the public.

Prior to our republication, we redacted names, phone numbers and email addresses of analysts

who produced the reports. We also added this page to the report. We have not intentionally made

any other changes to any report published on EveryCRSReport.com.

CRS reports, as a work of the United States government, are not subject to copyright protection in

the United States. Any CRS report may be reproduced and distributed in its entirety without

permission from CRS. However, as a CRS report may include copyrighted images or material from a

third party, you may need to obtain permission of the copyright holder if you wish to copy or

otherwise use copyrighted material.

Information in a CRS report should not be relied upon for purposes other than public

understanding of information that has been provided by CRS to members of Congress in

connection with CRS' institutional role.

EveryCRSReport.com is not a government website and is not affiliated with CRS. We do not claim

This is a copy of a public record, reproduced as it was published. It is not legal advice, and it may not be the version a court would rely on. Check the official source before you cite it.