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VIEWS: 98 PAGES: 22 CATEGORY: Personal Finance POSTED ON: 4/16/2010
Health Insurance
Order Code RL32237 CRS Report for Congress Received through the CRS Web Health Insurance: A Primer Updated February 3, 2005 Bernadette Fernandez Analyst in Social Legislation Domestic Social Policy Division Congressional Research Service ˜ The Library of Congress Health Insurance: A Primer Summary People buy insurance to protect themselves against possible financial loss in the future. Such losses may be due to a motor vehicle collision, natural disaster, or other circumstance. For patients, financial losses may result from the use of medical services. Health insurance then provides protection against the possibility of financial loss due to health care use. In addition, since people do not know ahead of time exactly what their health care expenses will be, paying for health insurance on a regular basis helps smooth out their spending. While health insurance continues to be mainly a private enterprise in this country, government plays an increasingly significant role. Especially during the latter half of the 20th century, the government both initiated and responded to dynamics in medicine, the economy, and the workplace through legislation and public policies. For example, the Internal Revenue Service clarified that employer contributions to employee health benefits are exempt from taxation, which encouraged the growth of employment-based health coverage. Given the frequent introduction of legislation aimed at modifying or building on the current health insurance system, understanding the potential impact of such proposals requires a working knowledge of how health insurance is designed, provided, purchased, and regulated. This report, which will be updated, provides basic information about those topics. Persons and families without health coverage are more likely than those with coverage to forgo needed health care, which often leads to worse health outcomes and the need for expensive medical treatment. Since uninsured persons are more likely to be poor than insured persons, the uninsured are less able to afford the health care they need. Uninsurance can lead to health care access problems for communities, such as overcrowding in emergency rooms. Furthermore, individual states and the nation as a whole are affected through increased taxes and health care prices to cover uncompensated care expenses. Americans obtain health insurance in different settings and through a variety of methods. People may get health coverage through the private sector, or from a publicly funded program. Consumers may purchase health insurance on their own, as part of an employee group, or through a trade or professional association. A small minority of employees get health insurance at no up-front cost because their employer pays the total insurance premium. However, 45 million Americans did not have health coverage for the entire year of 2003. Health insurance benefits are delivered and financed under different systems. The factors that distinguish one delivery system from another are many, including how health care is financed, how much access to providers and services is controlled, and how much authority the enrollee has to design her/his health plan. To illustrate, managed care is characterized by predetermined restrictions on accessing services, whereas individual decision-making regarding use of health benefits is a hallmark of consumer-driven health care. And as economic conditions change, a specific delivery system may gain or lose the interest of affected parties. Contents Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1 What Is Health Insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Basic Definitions and Principles . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Uneven Distribution of Health Care Expenses . . . . . . . . . . . . . . . . . . . 2 Risk Pool and Rate Setting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Risk Pool Composition and Adverse Selection . . . . . . . . . . . . . . . . . . . 3 Group Market, Nongroup Market, and Medical Underwriting . . . . . . . 4 Fully Insured vs. Self-Insured Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Self-only vs. Family Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Administrative Expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Tax Preference . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Health Insurance Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Responsibility of the States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6 Key Federal Statutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Why Is Health Insurance Considered Important? . . . . . . . . . . . . . . . . . . . . . . . . . 8 Where Do People Get Health Insurance? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Employer-Sponsored Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10 Advantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Disadvantages . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Large vs. Small Groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Public Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medicare . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Medicaid and the State Children's Health Insurance Program (SCHIP) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13 Individual Health Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 State High-Risk Pools . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 The Uninsured . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 How Are Health Benefits Delivered and Financed? . . . . . . . . . . . . . . . . . . . . . . 16 Indemnity (Traditional) Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16 Managed Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Consumer-Driven Health Plans . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18 List of Tables Table 1. Health Insurance Coverage by Type of Insurance, 2003 . . . . . . . . . . . 10 Health Insurance: A Primer Introduction Health insurance coverage dominates many state and federal health care discussions. As health coverage evolved from an uncommon benefit to a routine one, government's role in subsidizing and regulating that coverage also changed for workers, employers, and insurers. Although health insurance continues to be mainly a private enterprise in this country, public entities play an increasingly significant role. Government's involvement in health coverage expanded dramatically in the latter half of the 20th century. Public policies and legislation initiated or responded to dynamics in medicine, employment, and other areas. ! A long-standing rule issued by the Internal Revenue Service (IRS) stated that an employer's contributions to employment-based health insurance could not be included in an employee's gross income for tax purposes (Internal Revenue Code, Section 106). This ruling helped spur the growth of employer-sponsored health benefits. The IRS also stated separately that employers could deduct such contributions as part of business expenses. ! Advances in medicine led to escalating consumer demand for newer, better treatments. At the same time the cost of health care increased, which was especially problematic for certain groups of care consumers who lacked health coverage. This led to government efforts to assist consumers in paying for health care through social insurance programs.1 ! More and more employees began to work for more than one employer over their lifetimes. Government was called on to address a problem many workers faced: keeping health coverage as they moved from job to job. Given the frequent introduction of legislation aimed at modifying or building on the current health insurance system, understanding the potential impact of such proposals requires a working knowledge of how health insurance is designed, provided, purchased, and regulated. This report provides basic information about those topics. 1 Publicly funded health programs generally either provide funding for direct medical services or assist consumers in paying for health care. The latter are included in a broad category of programs based on "social insurance" principles. Social insurance refers to publicly funded insurance programs that are statutorily mandated for certain groups of people, such as low-income individuals. CRS-2 What Is Health Insurance? Basic Definitions and Principles People buy insurance to protect themselves against possible financial loss in the future. Such losses may be due to a motor vehicle collision, natural disaster, or other circumstance. For patients, financial losses may result from the use of medical services. Health insurance then provides protection against the possibility of financial loss due to health care use. In addition, since people do not know ahead of time exactly what their health care expenses will be, paying for health insurance on a regular basis helps smooth out their spending. The concept underlying insurance is "risk;" i.e., the likelihood and magnitude of financial loss. In any type of insurance arrangement, all parties seek to minimize their own risk. In health insurance, consumers and insurers approach the management of insurance risk differently. From the consumer's point of view, a person (or family) buys health insurance for protection against financial losses resulting from the future use of medical care. From the insurer's point of view, it employs a variety of methods to minimize the risk it takes on when providing health coverage to consumers, so as to assure that it operates a profitable business. One method is to cover only those expenses arising from a pre-defined set of services (generally called "covered" services). Another method for limiting risk is to encourage healthier people to obtain health coverage, presumably because healthier people would not need as many medical services as sicker people. While the methods employed by an insurer differ from those of a consumer, each person or entity has the same goal: to minimize risk in an uncertain future. It is this uncertainty of the future and risk of loss which form the context for insurance, and the strategies to make financial loss more predictable and manageable which drive insurance arrangements. Uneven Distribution of Health Care Expenses. In health care, a minority of consumers are responsible for a majority of expenses. According to a study that looked at the distribution of health care spending, 5% of the population accounted for over half of all health expenditures, and 10% of the population accounted for around two-thirds of those expenditures.2 Such findings were consistent for selected years spanning three decades. Given the unevenness of health care spending and the impossibility of identifying all of the highest spenders before they use medical services, insurers employ various strategies in order to minimize the risk they take on. 2 Marc L. Berk and Alan C. Monheit, "The Concentration of Health Care Expenditures, Revisited," Health Affairs, vol. 20, no. 2 (Mar./Apr. 2001), pp. 9-18. CRS-3 Risk Pool and Rate Setting. The main objective of insurance is to spread risk across a group of people. This objective is achieved in health insurance when people contribute to a common pool ("risk pool") an amount at least equal to the average expected cost resulting from use of covered services by the group as a whole. In this way, the actual costs of health services used by a few people are spread over the entire group. This is the reason why insuring larger groups is considered less risky — the more persons participating in a risk pool, the less likely that the serious medical experiences of one or a few persons will result in catastrophic financial loss for the entire pool. An insurer calculates and charges a rate (i.e., a "premium") in order to finance the health coverage it provides. The premium generally reflects several factors, including the expected cost of claims for using services in a year, administrative expenses associated with running the plan, and a risk or "profit" charge. The premium also will vary depending on if it buys self-only coverage or family coverage (see later discussion). If the insurer accurately estimates future costs and sets appropriate premium levels, then claims for that risk pool should be reasonably predictable over time. In other words, the premiums paid by healthy persons in the risk pool help subsidize the costs of less healthy persons. Risk Pool Composition and Adverse Selection. As noted above, one of the ways insurers attempt to make future costs more predictable is by spreading the risk of high costs for a few people across many people. But the number of people is not the only significant factor. Equally as important, if not more so, is the composition of the group. A consumer's decision to obtain health coverage is based on a variety of factors, such as health status, estimated need for future medical care, and disposable income. Consumers with different health conditions, as well as varying degrees of comfort towards risk-taking, will differ on whether they consider health insurance necessary. This is a circumstance that insurers will consider when estimating the cost to cover future health care use. With this in mind, insurers generally will vary the premiums they charge and the health services they cover (subject to state and federal statues) in order to attract various segments of the population. This flexibility in rate setting and benefit determination is particularly important in a competitive insurance market where insurers try to provide the most attractive rates to increase their market share. However, some risk pools do attract a disproportionate share of unhealthy individuals. In part, this is because people generally know more about their own health conditions than any other person or entity, such as an insurer. Health care consumers typically are the best informed about when they will need medical care and what kind of services they will need. The "information asymmetry" between what consumers know compared to what insurers know gives consumers an advantage when looking for health coverage that will meet their future demand for health care. This asymmetry is another source of uncertainty which insurers take into account when developing and pricing insurance products (or health plans). CRS-4 When a disproportionate share of unhealthy people make up a risk pool, a phenomenon known as "adverse selection," the average cost for each person in the pool rises. The higher costs may encourage the departure of healthier members from the group, and discourage the entrance of other healthy people, since healthier people may be able to find cheaper coverage elsewhere, or decide that coverage is too costly and become uninsured. In either situation, it leaves an even less healthy group of people in the risk pool, which again causes the average cost to rise for the remaining participants. If there is no change in this dynamic, the group may experience a "death spiral" as it suffers substantial adverse selection leading to an increasingly expensive risk pool and possibly dissolution of the pool altogether. Therefore, despite the consumer's information advantage, it does not guarantee access to affordable and adequate health coverage. Group Market, Nongroup Market, and Medical Underwriting. Health insurance can be provided to groups of people that are drawn together by an employer or other organization, such as a professional association or trade union. Such groups are generally formed for some purpose other than obtaining insurance, like employment. When insurance is provided to a group, it is referred to as "group coverage" or "group insurance." In the group insurance market, the entity that purchases health insurance on behalf of a risk pool is referred to as the "sponsor." Consumers who are not associated with a group can obtain health coverage by purchasing it directly from an insurer in the individual (or nongroup) insurance market. Insurance carriers in the nongroup market conduct an exhaustive analysis of each applicant's insurability. An applicant usually must provide the insurer with an extensive medical history and often undergo a physical exam. This information is used by carriers to assess the potential medical claims for each person by comparing characteristics of the applicant to the loss experience of others with similar characteristics. Once such an evaluation has been conducted, the carrier decides whether or not to provide health coverage and determines the conditions for coverage. This evaluation and determination process is called "underwriting." Medical underwriting is standard practice in the individual insurance market, though a carrier's ability to reject applicants or vary the terms of coverage are restricted to some degree by federal and state requirements. In the group insurance market, insurers forgo underwriting in the traditional sense; i.e., reviewing each person's demographics and medical history. Instead, an insurer looks at the characteristics of the collective group — such as its claims history, demographics (e.g., industry of firm and age distribution of enrollees), and geographic location — to conduct the insurance risk and loss analysis. The insurer then charges a premium based on the analysis of the group's characteristics. There are exceptions to this for very small groups. For example, when a firm with only a handful of employees applies for health coverage, the insurer may choose to review the health conditions of each person in order to establish a premium for the entire group. Or, the insurer CRS-5 may charge a larger premium due to the larger risk attributed to smaller groups, if permitted under law.3 Fully Insured vs. Self-Insured Plans. A common distinction made between types of health insurance products is whether they are fully insured or self- insured. A fully insured health plan is one in which the sponsor purchases health coverage from a state-licensed insurer (also referred to as an insurance carrier). The carrier assumes the risk of providing covered services to the sponsor's enrolled members. In contrast, organizations who self-insure (or self-fund) do not purchase health coverage from state-licensed insurers. Self-insured plans refer to health coverage that is provided directly by the organization (e.g., employing firm) seeking coverage for its members (e.g., employees). Such organizations directly take on the risk for covering medical expenses, and such plans are not subject to state insurance regulations. Thus, a large employer that self-funds employee health benefits acts as both sponsor and insurer for that coverage. Firms that self-fund typically contract with third-party administrators (TPAs) to handle administrative duties such as member services, premium collection, and utilization review. TPAs do not underwrite insurance risk. Self-only vs. Family Coverage. Another common distinction made in health insurance is whether the policy covers one person or a family. Under self-only coverage, the holder of the insurance policy is the only person insured. (Self-only coverage sometimes is referred to as individual coverage. Individual coverage in this sense should not be confused with health coverage from the individual insurance market — see discussion below.) Family coverage applies to the policyholder, her/his spouse, and children.4 Self-only and family policies may differ from each other in terms of the services they cover and the cost-sharing they impose. Administrative Expenses. Costs for administrative functions encompass a wide range of operational activities. Administrative expenses include costs associated with contracting with providers, sales and marketing, enrollment and billing, customer service, utilization review, case management, and other functions. The estimate of administrative expenses as a percent of claims often is used as a measure of operational efficiency. For large firms that self-insure, administrative costs make up 5-11% of claims, compared with 33-37% for insurers of small firms.5 In the nongroup market, administrative expenses are often higher on a per-person basis compared to the group market. 3 G. Claxton, "How Private Insurance Works: A Primer," Kaiser Family Foundation (KFF) website, Apr. 2002, at [http://www.kff.org/insurance/loader.cfm?url=/commonspot/ security/getfile.cfm&PageID=14053]. 4 Policies vary on the requirements children must meet (e.g., age, martial status, etc.) in order to become eligible for or stay on a family policy. 5 Rose C. Chu and Gordon R. Trapnell, "Study of the Administrative Costs and Actuarial Values of Small Health Plans," Small Business Research Summary no. 224, at [http://www.sba.gov/advo/research/rs224.pdf], Jan. 2003 CRS-6 Tax Preference Unlike most industrialized countries, the United States does not guarantee health coverage to all of its citizens. Instead, it relies on a patchwork approach that combines private and public means for providing and accessing health insurance and health care. One of the key pieces of this approach encouraged the growth of employment-based health coverage via the tax code. Section 106 of the Internal Revenue Code states that employer contributions to employment-based health insurance are not included in employees' gross incomes for tax purposes. This tax preference encourages workers to sign up for ("take-up") health coverage within the work setting. A separate ruling by the Internal Revenue Service clarified that such employer contributions are business expenses and, therefore, deductible from employers' taxable income. Both parties benefit: employers use health insurance coverage as a means to recruit and retain workers, while employees typically get access to more services at better rates (see discussion below). However, employees generally receive reduced wages to compensate for richer fringe benefits. The tax exclusion of fringe benefits is one of the primary reason why health coverage is provided mainly through the workplace in this country. Approximately two out of three nonelderly (under 65) Americans have employment-sponsored insurance (ESI). Moreover, of nonelderly persons with private health insurance coverage, approximately nine out of 10 obtain it through the workplace. Health Insurance Regulation Regulation occurs at multiple points in the process of providing health coverage. Health insurance regulation addresses a wide variety of issues: the benefits that must be offered, the individuals to whom the insurance is made available, and the responsibilities insurers have to their health plan enrollees are a few of those issues. The most common distinction (and one of the most contentious areas) in the regulation of health insurance is whether it is the responsibility of individual states or the federal government. This distinction is important because federal and state laws governing health plans differ on issues such as compensation in courts, access to care, and mandated coverage for certain benefits. Responsibility of the States. The regulation of insurance traditionally has been a state responsibility, as clarified by the 1945 McCarran-Ferguson Act. However, overlapping federal requirements complicate the matter with respect to health insurance. Individual states have established standards and regulations overseeing the "business of insurance," including requirements related to the finances, management, and business practices of an insurer. For example, all states have laws that require state-licensed insurance carriers to offer coverage for specified health care services (known as "mandated benefits"). Because fully insured plans are subject to state-established requirements, those plans must offer those mandated benefits. On the other hand, self-insured plans are not subject to state insurance regulations so they are exempt from such requirements. CRS-7 Key Federal Statutes. Regardless of whether health plans are fully insured or self-funded, they all are subject to a number of federal laws (e.g., the Americans with Disabilities Act). Two of these federal laws, the Employee Retirement Income Security Act of 1974 (ERISA, P.L. 93-406) and the Health Insurance Portability and Accountability Act of 1996 (HIPAA, P.L. 104-191), have significant impact on how health insurance is provided. ERISA outlines minimum federal standards for private-sector employer- sponsored benefits. (Public employee benefits and plans sponsored by churches generally are exempt from ERISA). Passed in response to pension abuses, the Act was developed with a focus on pensions, but the law applies to a long list of "welfare benefits" including health insurance. The Act requires that funds be handled prudently and in the best interest of beneficiaries, participants be informed of their rights, and there be adequate disclosure of a plan's financial activities. ERISA preempts state laws for issues that "relate to" employee benefit plans. (In other words, the federal law overrides state laws affecting private-sector employee benefits). This portion of ERISA was designed to ensure that plans would be subject to the same benefit laws across all states, partly in consideration of firms that operate in multiple states. However, state laws still apply for issues which involve the "business of insurance." Given the ambiguity of the phrases "relate to" and "business of insurance," the ERISA preemption is an area of heated debate and active litigation.6 The core motivation behind the Health Insurance Portability and Accountability Act of 1996 (HIPAA) is to address the concern that insured persons have about losing their coverage if they switch jobs or change health plans ("portability" of health coverage). The Act's health insurance provisions established federal requirements on private and public employer-sponsored health plans and insurers. It ensures the availability and renewability of coverage for certain employees and other persons under specified circumstances. HIPAA limits the amount of time that coverage for pre-existing medical conditions can be denied, and prohibits discrimination on the basis of health status-related factors. The Act also includes tax provisions designed to encourage the expansion of health coverage through several mechanisms, such as a demonstration project for tax-advantaged medical savings accounts and a graduated increase of the portion of premiums self-employed persons could deduct from their federal income tax calculations. Another set of HIPAA provisions addresses the electronic transmission of health information and the privacy of personally identifiable medical information (administrative simplification and privacy provisions, respectively).7 6 For more information about ERISA, see CRS Report RS20315, ERISA Regulation of Health Plans: Fact Sheet, by Hinda Chaikind. 7 For more information about HIPAA, see CRS Report RL31634, The Health Insurance Portability and Accountability Act (HIPAA) of 1996: Overview and Guidance on Frequently Asked Questions, by Hinda Chaikind, Jean Hearne, Bob Lyke, Stephen Redhead and Julie Stone. CRS-8 Why Is Health Insurance Considered Important? While health insurance coverage is not necessary to obtain health care, it is a vital mechanism for accessing services in an environment of increasingly expensive health care. As health care costs rise — at times outstripping the rise in wages — more people need greater assistance with covering medical expenses. Health insurance provides some measure of protection for consumers, especially those who have limited means or greater-than-average need for medical care. Health insurance is considered important also because of the well-documented, far-reaching consequences of uninsurance. For instance, uninsured persons are more likely to forgo needed health care than people with health coverage. This includes forgoing services for preventable or chronic conditions which often leads to worse health outcomes.8 Uninsured persons also are less likely to have a "usual source of care;" i.e., a person or place identified as the source to which the patient usually goes for health services or medical advice (not including emergency rooms). In 2002, while only one-tenth of all adults with private health insurance identified no usual source of care, almost half of all uninsured adults had no usual source.9 Having a usual source is important because people who establish ongoing relationships with health care providers or facilities are more likely than persons without a usual source to access preventive health services and have regular visits with a physician.10 Therefore, to the extent that health insurance coverage facilitates access to medical services, people without coverage face substantial barriers in the pursuit of the health care they need. The negative consequences of uninsurance extends beyond the persons directly involved. The Institute of Medicine found that the insurance status of parents affects the amount of health care their children receive.11 In places with crowded emergency rooms, increasing uninsurance rates can add to that problem, since uninsured persons have fewer places from which they can get general health services outside of emergency departments (EDs), compared to people with health coverage. Overcrowding in EDs, in turn, leads to longer waits for all patients seeking emergency care. Moreover, many uninsured persons forgo preventive health care and end up developing more serious conditions requiring complex, expensive medical services. Since health coverage is positively related to income, uninsured persons are less likely to be able to afford this level of care. In cases where patients are unable to cover the costs associated with receiving health services, the facilities that provided those services must take it as a financial loss (i.e., uncompensated care). These losses can be staggering. For example, one study estimated that health care 8 Kaiser Commission on Medicaid and the Uninsured, "The Uninsured and Their Access to Health Care," KFF website at [http://www.kff.org/uninsured/loader.cfm?url=/commonspot/ security/getfile.cfm&PageID=29284], Dec. 2003. 9 National Center for Health Statistics, Health, United States, 2004. 10 J. E. DeVoe et al., "Receipt of Preventive Care Among Adults: Insurance Status and Usual Source of Care," American Journal of Public Health, May 2003. 11 Institute of Medicine, Committee on the Consequences of Uninsurance, Coverage Matters: Insurance and Health Care, 2001. CRS-9 providers gave approximately $35 billion of uncompensated care to the uninsured in 2001.12 Ultimately, though, the costs for caring for the uninsured are "passed down to all taxpayers and consumers of health care in the form of higher taxes and higher prices for services and insurance."13 Taxpayers are affected because the federal government makes payments to hospitals — for patients enrolled in certain programs — which take into account the share of poor people treated. The assumption is that facilities that treat a larger proportion of poor people have a greater problem with uninsurance and uncompensated care. The federal government also provides grants to many health centers and other facilities that serve poor communities. In addition, states and localities fund local health programs, public hospitals, and clinics — facilities that generally serve an uninsured (or medically underserved) population. Health care consumers are affected by uninsurance because in order for physician practices and hospitals to survive financially they have to make-up the losses they sustain. Hospitals and physicians may raise rates for certain services or discontinue unprofitable programs in order to recoup those losses, thereby affecting consumers' pocketbooks and access to services. Uninsurance, then, has negative health and financial consequences for uninsured persons, their families, communities, states, and the nation as a whole. Where Do People Get Health Insurance? Americans obtain health insurance in different settings and through a variety of methods (see Table 1). People may get it through the private sector, or from a publicly funded social insurance program. Consumers may purchase health coverage on their own, as part of an employee group, or through a trade or professional association. A small minority of employees get health insurance at no up-front cost because their employer pays the total insurance premium (both the employee and employer shares of the premium). However, 45 million Americans did not have health coverage for the entire year of 2003.14 12 J. Hadley and J. Holahan, "How Much Medical Care Do the Uninsured Use, and Who Pays for It?," Health Affairs Web Exclusive, Feb. 12, 2003. The cost of uncompensated care for 2001 is the most-recent estimate on a national level. 13 Institute of Medicine, Committee on the Consequences of Uninsurance, A Shared Destiny, 2003, p 122. 14 U.S. Census Bureau, Current Population Survey, 2004. CRS-10 Table 1. Health Insurance Coverage by Type of Insurance, 2003 Coverage distribution Millions of persons Total population 100.0% 288.3 Employment Based 61.8 178.2 Nongroup 9.2 26.5 Medicare 13.7 39.5 Medicaid/SCHIP/State programs 12.4 35.7 Military/Veterans Coverage 3.5 10.1 No health insurance 15.6 45.0 Source: CRS Report 96-891 EPW, Health Insurance Coverage: Characteristics of the Insured and Uninsured Populations in 2003, by Chris Peterson. Note: The most-current data on health insurance coverage for a full year is for the year 2003. Columns do not add to totals because persons may receive insurance coverage from more than one source. Employer-Sponsored Insurance Even though examples of health insurance in this country stretch back almost 200 years, most Americans did not have health coverage until the latter half of the 20th century.15 The demand for more workers during World War II and a wage freeze imposed by the National War Labor Board generated great interest in employer- sponsored insurance (ESI) as a worker recruitment and retention tool.16 Buoyed by legislation and court rulings declaring the tax exemption of fringe benefits, and support from unions for work-based coverage, health insurance became a pervasive employment benefit. In employer-sponsored insurance, risk pools may be comprised of active workers, dependents, and retirees. Insurers use a number of strategies to increase the likelihood that each risk pool includes a good proportion of healthy individuals, thus avoiding adverse selection. For instance, insurers may restrict employees' opportunities to take-up health coverage or switch health plans by designating a specific time frame each year for such activities ("open enrollment period"). Such a strategy decreases the likelihood that people will "game" the system by taking up coverage only when they plan on using health services (e.g., for pregnancy and birth), and dropping coverage when they no longer plan to access care. Insurers also may require the employer to enroll a certain proportion of the firm's eligible population. Assuming that the eligible population consists of a good percentage of healthy 15 See timeline from Employee Benefit Research Institute's (EBRI) "History of Health Insurance Benefits," EBRI website, Mar. 2002, at [http://www.ebri.org/facts/0302fact.htm]. 16 Health Insurance Association of America, Fundamentals of Health Insurance, 1997. CRS-11 people, requiring a certain proportion of all eligibles to enroll leads to an enrollee population which contains at least some healthy people. Employers also use strategies to encourage insurance take-up by healthy people. For example, employers usually pay part (or, in very few instances, all) of the total premium. This practice makes health coverage a more attractive benefit, even to those who do not plan to use medical services on a regular basis. Overall, insurers may assume that not all people in ESI risk pools take-up health coverage for reasons primarily related to personal health status or immediate demand for medical care. Advantages. ESI plans retain enrollees better than the individual health insurance market. As previously mentioned, health benefits provided at the workplace are exempt from income and employment taxes, encouraging the growth and continuity of employer-sponsored health insurance. Large risk pools with a good proportion of healthy enrollees tend to be more stable than small pools or those with a higher proportion of unhealthy enrollees. Given the strategies discussed above to discourage adverse selection, insurers assume that ESI pools — particularly large, diverse ones — are more stable. Generally, this translates into less volatile costs and better overall rates in the group market compared to the nongroup market. Also, large ESI groups can use their size to negotiate for better benefits and cost-sharing, in contrast to individual applicants in the nongroup market. Plan sponsors negotiate and interact with insurers on behalf of all of their insured members, unlike in the individual market where each consumer must deal with the insurance carrier directly in order to apply for and purchase coverage. In addition, there are economies of scale for enrollees in the group market compared to the nongroup market for such administrative activities such as sales, billing, and customer service. For these reasons, workers and their families benefit from receiving coverage through the workplace. For plan sponsors, the main advantage is to use health coverage to recruit and retain workers. This is particularly appealing in a growing economy — such as during most of the 1990s — when there may be high demand for workers. Disadvantages. While there are many advantages to obtaining ESI coverage, there are challenges as well. From the vantage point of the enrollee, one of the biggest disadvantages is the general lack of portability. Because ESI coverage is tied to the job and not the person, any change in employment (such as going from full- time to part-time status, or changing jobs) may alter the health care providers or services to which the worker has access, or disrupt health coverage altogether. Also, in firms that offer health coverage, there is a trade off made between wages and benefits. For workers who do not take up health insurance from those firms, they end up accepting lower wages for a set of benefits they do not access. From the perspective of the sponsor, an underlying challenge is the lack of enrollee awareness of the true costs of health care. Because the sponsor contributes to the cost of the premium, enrollees do not bear the full cost of obtaining health coverage. More importantly, enrollees generally do not have to cover the entire cost of the services they use, since sponsors negotiate for lower rates and better cost-sharing arrangements from insurers. Consumers enrolled in managed care plans in particular are shielded from health care's true costs. Some observers contend that this lack of cost awareness gives little incentive to consumers to utilize medical services prudently, which leads to greater use of services and greater overall health care expenditures. In addition, sponsors' efforts to constrain their health care spending CRS-12 — by increasing the employee share of the premium or employee cost-sharing — are made even more difficult to justify or implement. Finally, from the perspective of the federal budget, the tax exclusion of employer-sponsored health insurance represents a lost source for Treasury funds. Large vs. Small Groups. The group insurance market often is thought of as consisting of large and small groups. The underlying reason for this distinction is rooted in the inverse relationship between insurance risk and group size; i.e., the risk associated with a group grows as the size of the group shrinks. This concept affects employers' offers of health benefits. For instance, a very large employer often is able to offer multiple health plan options to its members (e.g., the Federal Employee Health Benefit Program (FEHBP)). A large business can leverage its size to get a more comprehensive set of benefits. On the other hand, small employers are less able to provide health coverage at all because of the greater risk associated with small groups. Even when small employers do offer coverage, the benefits are often limited. Small employers also are much less likely to self-fund health coverage, since there is a smaller pool for spreading risk and protecting against catastrophic loss. Furthermore, such entities generally do not have the necessary administrative capacity to negotiate with multiple provider groups and handle all the day-to-day operational functions conducted by insurers. It is conditions such as these which prompt legislators to develop proposals for expanding small group participation in health insurance; for example, targeting association health plans and health marts, and opening up FEHBP to the small group market. Association health plans and health marts are examples of the spectrum of entities which bring groups of people together for the purpose of buying health insurance. These entities include trade and professional associations that offer health coverage to their members ("association-sponsored plans"), and small firms that band together to purchase coverage as a group ("health insurance purchasing cooperatives"). The premise behind pooling arrangements is to decrease the administrative burden on and increase the negotiating capacity of participants who cannot afford to offer or purchase coverage on their own. Around one-third of small firms buy health coverage through some type of purchasing pool.17 Public Programs While most Americans with health insurance obtain it through the private- sector, tens of millions of people get their medical care paid for through public programs. Below are descriptions of selected federal and state programs which provide payments on behalf of many persons who, due to low incomes or high health care expenses, could not afford health care otherwise. Medicare. The Medicare program was established in 1965, and is a federal program for seniors (65 years and older), certain nonelderly persons with disabilities, and persons with end-stage renal (kidney) disease. Medicare currently consists of three parts: Part A, Hospital Insurance; Part B, Supplementary Medical Insurance; 17 For additional information, see CRS Report RL31963, Association Health Plans, Health Marts, and the Small Group Market for Health Insurance, by Jean Hearne. CRS-13 and Part C, Medicare Advantage, formerly referred to as the Medicare+Choice program. Together, Parts A and B cover many medical services, such as care provided in hospitals and skilled nursing facilities, hospice care, home health care, physician services, physical and occupational therapy, and other services. The then Medicare+Choice program, added three decades after Medicare was established, was created to expand the availability and diversity of managed care plans that cover all Part A and B services. P.L. 108-173 added a new Part D to the Medicare program. Effective in 2006, Medicare beneficiaries may access outpatient prescription drug benefits through Part D. A large majority of Americans age 65 and older are automatically entitled to coverage under Part A and do not have to pay a premium because either they or their spouse paid Medicare payroll taxes on their past earnings. (Even if an elderly person did not pay Medicare taxes, she/he may be able to purchase Part A coverage.) Part A also provides coverage for certain nonelderly persons who receive Social Security cash benefits. Enrollment in Medicare Part B is voluntary for eligible individuals. For most persons who are entitled to benefits under Part A, they are enrolled automatically in Part B, but they are given the option to decline coverage. The small minority of people who do not have automatic enrollment may request enrollment in writing. All Part B enrollees pay a monthly premium for coverage. Since its creation in the mid-1960s, Medicare has provided health coverage to tens of millions of Americans, and in 2003 had 40 million enrollees. The program has been so successful in covering the elderly that the problem of uninsurance usually is described in terms of the under-65 population. Medicaid and the State Children's Health Insurance Program (SCHIP). Medicaid is the main health insurance program for very low-income Americans. It provides coverage for health care and long-term-care services to certain adults (generally parents and pregnant women), children, the elderly, and persons with disabilities. Medicaid is jointly funded by federal and state governments, and is administered by the states within federally set guidelines. State Medicaid programs provide a comprehensive set of services, reflecting its diverse enrollee population. These programs must provide a set of federally specified benefits, such as hospital services (both inpatient and outpatient), physician services, nursing home care, home health care for those entitled to services from nursing facilities, and certain services for children. States also have the authority to cover additional services. Some states have used their waiver authority under Medicaid to extend coverage to uninsured persons who could not meet the program's financial tests. Medicaid is a means-tested program and applicants must meet financial and other criteria in order to be eligible for program services. Everyone who meets the eligibility criteria is entitled to Medicaid benefits. The State Children's Health Insurance Program was established in 1997 to allow states to cover certain low-income children. In designing their programs, states can choose among three options: expand Medicaid, create a new "separate state" insurance program, or devise a combination of both approaches. States that choose to expand Medicaid to SCHIP eligibles must provide the full range of Medicaid benefits, as well as all optional services specified in their state Medicaid plans. States that establish SCHIP programs that are separate from Medicaid choose one of CRS-14 three benefit options. All 50 states, the District of Columbia, and five territories have established some type of SCHIP program. SCHIP's eligibility rules target uninsured children under 19 years of age whose families' incomes are above Medicaid eligibility levels. States may raise the upper income level for low-income children up to 200% of the federal poverty level, or higher under certain circumstances.18 Individual Health Insurance The individual insurance ("nongroup") market is often referred to as a "residual" market. The reason being that this market provides coverage to persons who cannot obtain health insurance through the workplace and do not qualify for public programs such as Medicare, Medicaid, or SCHIP. Consequently, the enrollee population for this private health insurance market is small. The residual nature of the nongroup market is evident in the demographic make- up of those who purchase coverage from it. The market is over-represented by the near elderly (55-64 years old); a group that has relatively weak attachments to the workplace. The individual market disproportionately consists of part-time workers, part-year workers, and the self-employed, groups unlikely to have access to ESI coverage.19 Also, some people use the nongroup market as a temporary source of coverage, such as those in-between jobs or early retirees who are not yet eligible for Medicare. Applicants to the individual insurance market must go through robust underwriting. Insurance carriers in most states conduct an exhaustive analysis of each applicant's insurability. An applicant usually must provide her/his medical history, and often undergo a physical exam. This information is used by carriers to assess the potential medical claims for each person. Federal and state requirements restrict somewhat insurers' ability to reject applications or design coverage based on health factors (such as benefit exclusions for certain pre-existing health conditions). Nonetheless, some applicants are rejected from the nongroup market altogether, and others who are approved may receive limited benefits or are charged premiums that are higher than those in the group market for similar coverage.20 Rigorous underwriting results in an enrollee population that is fairly healthy (three out of four enrollees report that their health is excellent or very good),21 thereby excluding persons with moderate to severe health problems from the private nongroup insurance market. 18 For additional information about SCHIP, see CRS Report RL30473, State Children's Health Insurance Program (SCHIP): A Brief Overview, by Elicia J. Herz and Peter Kraut. 19 D. J. Chollet, "Consumers, Insurers, and Market Behavior," Journal of Health Politics, Policy and Law, Feb. 2000. 20 M. V. Pauly and A.M. Percy, "Cost and Performance: A Comparison of the Individual and Group Health Insurance Markets," Journal of Health Politics, Policy and Law, Feb. 2000. 21 General Accounting Office, Private Health Insurance: Millions Relying on Individual Market Face Cost and Coverage Trade-Offs, Nov. 1996. CRS-15 State High-Risk Pools Many states have high-risk pools, which are nonprofit entities that provide health coverage to persons with high health care expenses. Generally, such persons are denied coverage in the individual insurance market because of their health conditions and/or predicted use of costly medical services. If they are not eligible for public programs (e.g., their incomes may exceed the financial eligibility criteria), they have very few options for obtaining care. As of December 2003, 32 states run high-risk health insurance pools.22 These programs tend to be small and eligibility varies by state. While some state high-risk pools have successfully provided health coverage to high-risk people, many programs are beset by accessibility, adequacy, and affordability problems.23 The Uninsured Despite the various private and public sources of health insurance, millions of Americans are without health coverage. In 2003, 45 million people were without health insurance coverage for the entire year.24 For the vast majority of the uninsured, they lack coverage because they cannot access coverage (e.g., their employer does not offer health insurance as an employment benefit) or they cannot afford it. Uninsurance is characterized as a problem of the under-65 population, given the near-universal coverage of seniors through Medicare. The nonelderly uninsured population differs from the insured population on a number of key demographic factors. One of the most striking characteristic of persons who lack coverage is that a significant proportion are in low-income families. For instance, among all uninsured persons under age 65, two-thirds were in poor or near poor families in 2003.25 Moreover, among nonelderly persons who are poor, a full one-third lacked health insurance coverage, compared to less than one-fifth of the poor who received coverage through the workplace.26 A defining characteristic of the nonelderly uninsured population is that over 80% are persons with ties to the paid labor force, or dependents of such persons. Even more surprising is that over half of the nonelderly uninsured were workers with full-time, full-year status, or the dependents of those workers. While such findings may be counter-intuitive, there are multiple reasons why employed persons and their 22 States with high-risk pools: AL, AK, AR, CA, CO, CT, FL, ID, IL, IN, IA, KS, KY, LA, MD, MN, MS, MO, MT, NE, NH, NM, ND, OK, OR, SC, SD, TX, UT, WA, WI, and WY. A map of state high-risk pools is available at [http://www.statehealthfacts.org]. 23 For additional information about state high-risk pools, see CRS Report RL31745, Health Insurance: State High-Risk Pools, by Julie Stone. 24 U.S. Census Bureau, Current Population Survey, 2004. 25 According to the Census Bureau, the poverty level for a family of four was an annual income of $18,810 in 2003. 26 For additional information, see CRS Report 96-891, Health Insurance Coverage: Characteristics of the Insured and Uninsured Populations in 2003, by Chris Peterson. CRS-16 families may lack health coverage. For example, a worker may be offered health insurance by his/her employer, but declines it because he/she thinks it is too expensive. An employee may work for a small firm which is less likely than a large firm to offer health insurance as a benefit. A low-wage employee, even working full time, is less likely to be offered health insurance at work and less likely to be able to afford it than higher-wage workers in the same firm. Finally, a healthy worker may be willing to take on the risk of being uninsured and choose not to purchase insurance. Despite the dominance of employer-sponsored health insurance, the dynamics of work, insurance risk, and financial resources intersect to impede the coverage of all workers and their families. The problem of the uninsured is a paramount health care concern to many policymakers and legislators. One of the topics of ongoing debate is the overall number of uninsured and the direction of the uninsurance rate. These issues have generated some controversy over dueling analyses which show slightly different (and sometimes, moderately different) findings. But despite the forceful discussions regarding trends in uninsurance, the year-to-year changes in the uninsurance rate actually are small. For example, from 1987 to 2003 (the last year of available data), the change in the annual uninsurance rate usually was one-half of 1% or less.27 Nonetheless, tens of millions of Americans were without coverage during that time period. Such circumstances beg the questions: why does pervasive uninsurance persist (even during the robust economy of the mid-1990s), and what are the implications for legislation and public policies to expand health coverage? How Are Health Benefits Delivered and Financed? Given the complexity of the health care system overall, it is no surprise that health benefits are delivered and financed through different arrangements. Those arrangements vary due to numerous factors such as: how health care is financed, how much access to providers and services are controlled, and how much authority the enrollee has to design her/his health plan. While delivery systems may share certain characteristics, general distinctions can be made based on payment, access, and other critical variables. Indemnity (Traditional) Insurance Under indemnity insurance, the insured person decides when and from whom to seek health services. If the services the enrollee receives are covered under his/her insurance, the enrollee or the enrollee's provider files a claim with the insurer. Thus, insurers make payments retrospectively (i.e., after the health services have been rendered), up to the maximum amounts specified for each covered service. In this model of health care delivery, the financing of health services and the obtaining of those services are kept separate. This bifurcated arrangement was unquestioned for a time. But as medical costs began to rise, sometimes faster than other sectors of the national economy, many 27 Data available at [http://www.census.gov/hhes/hlthins/historic/index.html]. CRS-17 observers criticized this delivery model as contributing to increasing expenses. Because providers were compensated on a fee-for-service basis, some argued that providers were not given incentives to provide efficient health care. In fact, some critics accused health care practitioners and institutions of providing an over- abundance of health care in order to generate greater revenue. By the early 1970s, legislators, analysts, and others expressed considerable interest in alternative models, such as managed care models, with cost control as a key feature. Managed Care While managed care means different things to different people, several key characteristics set it apart from traditional (indemnity) insurance. One of the main differences is that the service delivery and financing functions are integrated under managed care. Managed care organizations (MCOs) employ various techniques to control costs and manage health service use prospectively. Among those techniques are restricting enrollee access to certain providers ("in-network" providers); requiring primary-care-physician approval for access to specialty care ("gatekeeping"); coordinating care for persons with certain conditions ("disease management" or "case management"); and requiring prior authorization for routine hospital inpatient care ("pre-certification"). MCOs may offer different types of health plans that vary in the degree to which cost and medical decision-making is controlled. As a consequence, enrollee cost-sharing also varies. Generally, the more tightly managed a plan is, the less the premium charged. Other distinguishing features of the managed care approach include an emphasis on preventive health care and implementation of quality assurance processes. Managed care was touted as the antidote to rapidly rising health care costs. Starting with the passage of federal legislation in the 1970s which supported the growth of managed care (specifically in the form of health maintenance organizations (HMOs)), the number of MCOs grew quickly. Increased market competition among these organizations led to decreases in premiums, in order to gain market share. With high medical inflation in the 1980s and early 1990s, enrollees flocked to these less- costly managed care plans. By the mid-1990s, more insured workers were enrolled in HMOs than any other health plan type, and health insurance premiums had stabilized. But in the latter half of the 1990s, a "backlash" of sorts against managed care grew.28 Some enrollees had grown weary of provider and service restrictions. Many MCOs that had increased market share through artificially low premiums began to raise them in order to increase revenue.29 Consumers and others accused the managed care industry of caring more about controlling costs than providing health care. Some providers resented the role managed care played in medical decision- making. Many enrollees began to leave HMOs. The industry responded by developing insurance products that were less-tightly managed, but more costly. 28 Richard Kronick, "Waiting for Godot: Wishes and Worries in Managed Care, " Journal of Health Politics, Policy and Law, vol. 24, no. 5 (Oct. 1999), pp. 1099-1106. 29 Jon Gabel, et al., "Job-Based Health Insurance in 2001: Inflation Hits Double Digits, Managed Care Retreats," Health Affairs, vol. 20, no. 5 (Sept./Oct. 2001), pp. 180-186. CRS-18 Some traditional HMOs widened their provider networks and eliminated the gatekeeping function, while employers began to offer plan types that were less tightly managed, such as preferred provider organizations (PPOs). In fact, by the end of the 1990s, more people with work-based health coverage were enrolled in PPOs than in HMOs.30 As the influence of managed care waned and health care costs began to rise at an increasing pace during the late 1990s, the impact on consumers began to be felt. For example, in the employment setting, employers absorbed the extra costs at first in order to recruit and retain workers during the booming economy of the mid to late 1990s.31 But as the economy soured, employers began to pass these expenses along to enrollees in the form of greater cost-sharing.32 Consumer-Driven Health Plans By the turn of the millennium, large increases in health costs again became commonplace. With the belief by some observers that the age of managed care was over, they began to search for alternatives. Consumer-driven (or consumer-directed) health plans have been offered as one such option. Consumer-driven health care refers to a broad spectrum of approaches that give incentives to consumers to control their use of health services and/or ration their own health benefits. In the workplace, at one extreme employers may choose to provide an array of insurance products from which workers can choose, while at the other end an employer could increase wages but not offer any health coverage allowing workers to decide how to spend that extra money to meet their health care needs. Within those two endpoints, the consumer-directed approach varies in the degree to which consumers are responsible for health care decision-making.33 For example, one health benefits option that is at the heart of discussions about consumer-driven health care is the health savings account (HSA). Under this approach, the consumer is responsible for management of the account. HSAs are investment accounts in which contributions earn interest tax free. Consumers, their employers, or both may make contributions to HSAs. Consumers withdraw funds on a tax-free basis to cover medical expenses not covered by health insurance. Unused contributions roll over to the next year. HSAs must be paired with high- deductible health plans. If the HSA funds are exhausted and the deductible level has not been reached, the consumer is responsible for covering that gap. Once the 30 American Association of Health Plans, "Health Plans and Employer-Sponsored Plans," Oct. 1999. Available at [http://www.ahip.org/content/default.aspx?bc=41|331|366]. 31 Jon B. Christianson and Sally Trude, "Managing Costs, Managing Benefits: Employer Decisions in Local Health Care Markets," Health Services Research, pt. II, vol. 38, no. 1, (Feb. 2003), pp. 357-373. 32 Jon Gabel et al., "Job-Based Health Benefits in 2002: Some Important Trends," Health Affairs, vol. 21, no. 5 (Sept./Oct. 2002), pp. 143-151. 33 P. Fronstin, ed., Employee Benefit Research Institute, Consumer-Driven Health Benefits: A Continuing Evolution? (Washington: EBRI, 2002). CRS-19 consumer's spending reaches the deductible level, then coverage from the high- deductible plan takes effect. While consumer-driven health care can take on many forms, the premise common to all of the approaches is that by making enrollees more responsible for their own health care, it creates incentives for people to use services prudently. The expectation is that greater cost-consciousness on the part of consumers will result in lower overall health costs. In essence, the service and cost control functions administered by MCOs and providers under managed care shifts to enrollees under the consumer-driven plan scenario. Proponents of consumer-directed plans assert the merit in having people take increased responsibility for their own health care use and expenses. They predict that this approach will lead to better-informed consumers, more appropriate use of health services, and lower overall spending on health care. Opponents express concern that this approach does not recognize the possible range of health conditions in an enrolled population. They argue that these plans benefit the young and healthy who use relatively few services, and, therefore, would not need to expend a great deal of time and energy making these health care decisions. However, these plans impose a greater burden on individuals with moderate to severe health conditions because of their greater-than-average use of medical services.
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Clarion Collection Hotel Principessa Isabella
Via Sardegna, 149/151
Rome, 00187
Phone: (39) 06 484523
Fax: (39) 06 4885964
Arts & Museums
»Museo Boncompagni Ludovisi
This is Italy's first collection dedicated to the decorative arts. It exhibits objects from architecture, fashion and design from 1700 to the modern day. One of the most famous pieces is the silver and gilded bronze cradle given by the Comune of Rome to King Vittorio Emanuele III and Queen Elena on the birth of Princess Iolanda. There are objects of glassware, pottery, furniture and clothes, some donated by famous designers such as Galitzine, Valentino, Lancetti, Gattinoni and the Fontana sisters. Admission: Free.
»Museo e Galleria Borghese
This collection is housed in a building constructed in 1613 for Cardinal Scipione Borghese, one of Bernini's greatest patrons. In fact, this great sculptor has exhibited some of his most famous sculptures here; amongst them is the renowned Apollo and Daphne. When one thinks of the Museo Borghese, the sculpture that immediately springs to mind is Canova's Pauline Borghese, in which she poses as Venus, wearing just a drape around her midriff. There are six major pieces by Caravaggio in the Galleria, including The Boy with a Basket of Fruit and the Madonna della Serpe. Titian is also represented with Sacred and Profane Love, Raphael with The Deposition, and there are important works by Correggio. The gallery can only hold 300 visitors at a time, so it is advisable to book in advance.
»Il Museo della Zecca
This museum, situated within the Treasury, contains a collection of more than 20,000 items including coins, medallions, wax models and equipment used in the minting process. The papal medallions begin with Pope Martin V who started the first mint. Amongst the wax models the series by Benedetto Pistrucci is worth noting; he was a famous Roman engraver who worked at the London mint and he is responsible for the St. George on horseback that is found on the English pound coin. Take an identification card with you because you will need to leave it with the concierge after filling out a form. Admission: Free.
»MACRO - Museo d'arte Contemporanea Roma
The MACRO Museum in Rome is an modern art museum that offers a permanent collection of some of the most important expressions in the Italian art scene since the 1960, with works by Italian artists. The Museum was founded in 1999 by the conversion of the old plants of Peroni beer. The new museum building has a large terrace of 2,500 square meters, parking for 161 cars and various museum services.
»Galleria Tartaglia Art
Such vibrant and expressive are the works of art at Galleria Tartaglia Art that you could almost reach forward and hold on to them. The exhibits at the gallery are an extension of one's wild and carefree nature with a riot of colors and a contrast of expressiveness. Artist Piero Tartaglia's brainchild is one of the best galleries in all of Rome and you can always view the work of the artist and his students as a part of the permanent collection too. The gallery has the works of quite a few artists who have dedicated themselves to promoting contemporary art.
»Istituto Svizzero di Roma
Located in the neighborhood of Monti, Istituto Svizzero di Roma promotes artistic and cultural influences between Switzerland and Italy. This institution, inaugurated in 1947, was founded by the Swiss Confederation. Villa Maraini is where the main office is, to manage the operations. The library that was functional by 1948 consists of books exhibiting great historical and modern knowledge about the cultures of the Swiss land. Being a venue for a lot of exhibitions, seminars and lectures, this is a must visit! For event schedules and more information, visit the website or call ahead.
Part of the Museum of Modern Art of Rome, MACRO is dedicated to contemporary art. It acts as an exhibition space, hosting some of the most important events in Rome; it also seems to host a fair share of controversial artists. Do visit with your entire family as children under six go in for free.
»Cripta dei cappuccini
Creepy, bizarre and completely captivating, the crypt of the Capuchin Friars is worth the venture off the well beaten tourist path in Rome. The crypt, or cemetery of sorts, lies under the church of Santa Maria della Concezione dei Cappuccini. Since 1764 the bones of over 4000 deceased Capuchin Franciscans were arranged in elaborate, decorative floor to ceiling designs spread throughout five rooms. Each room highlights certain bones, and the designs even extend onto the light fixtures. Skulls flanked by shoulder blades create angelic figures looming above on the ceiling and the final room contains the skeleton of a child grim reaper and the inscription "what you are, we once were too and what we are now, you will be". Morbid, but like nothing you have ever seen before or could even imagine.
»National Museum of Rome- Baths of Diocletian
The Baths of Diocletian are a group of public baths that were built in 298 CE and 306 CE. The huge structures could allow 3000 people to bathe at one time, making it one of the largest baths in the city. There are a series of cold baths and hot baths along with gyms and libraries for the people. The water for the baths were sourced via aqueducts. It is one of the four sites of the Museo Nazionale Romano.There are various exhibitions held here are worth seeing. The price is inclusive of the other sites of the Museo Nazionale Romano.
»Museo Canonica
When the Commune of Rome allowed one of its no longer used administrative buildings in Villa Borghese to be used by a sculptor, it did not contemplate it being turned into a museum. The sculptor Pietro Canonica renovated the building at his own expense by promising to donate his works to the city. The museum was opened about 40 years ago and exhibits studies, models, sketches and original works of the artist. After the death of his wife, Canonica's house was also opened to the public where a collection of 19th-century Piedmontese paintings, objects and furnishings can be admired. Admission: EUR 2.
»Museo Carlo Bilotti
The Carlo Bilotti Museum is housed in a restored 16th-century marble palazzo that was once the Villa Borghese's aranceria, a store-house for oranges. Bilotti, an Italian-American, donated pieces of art by Andy Warhol, Gino Severini, Giacomo Manzù, and Larry Rivers, along with 18 works by Greek-Italian surrealist Giorgio de Chirico, that comprise the museum's permanent collection. De Chirico's sculpture, Hector and Andromache, stands outside the museum entrance.
»The National Gallery of Ancient Art (Galleria Nazionale d'Arte Antica)
The National Gallery of Ancient Art (Galleria Nazionale d'Arte Antica) houses works by Caravaggio, Raffaello, Tintoretto, and Holbein, among many others. These paintings belong to the Barberini family's massive collection, most of which is scattered all over the world. Baroque architects Maderno, Bernini, and Borromini designed the palace. Two grand staircases lead to the main floor: the larger one was designed by Bernini and the smaller, oval construction by Borromini. On the first floor, the large ceiling of the Salone (main hall) was covered in frescoed by Piertro da Cortona and depicts the triumph of Pope Urban VIII. You'll notice the Bernini family symbol, a bee, painted or sculpted almost everywhere in the building.

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OP Junior Member
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I just flashed CM10.2.1 on my Nexus 4. I'm unable to get the Wifi & Bluetooth working ?
I have CWM Touch recovery. Let me know if you need more info. Even Flashed it twice. Still not working
Hoping y'all can help.
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We're proud of our planetarium shows and know how important it is to deliver high quality productions that speak directly to our local audiences.
But did you know that it's not just Melburnians that get to enjoy our planetarium shows?
Melbourne Planetarium shows screening around the world. The eight shows are distinguished by colour.Image: Warik LawranceSource: Museum Victoria
Since 2007, we have been licensing our shows to play in planetariums around the world. From countries as different as India, South Korea and Turkey, to cities across Europe and the USA, people are enjoying our unique brand of planetarium shows. We've even had one show Black Holes: Journey into the Unknown translated into Spanish, Swedish, Finnish and Russian.
Have you seen any Melbourne Planetarium shows on your travels?
We love receiving comments, but can't always respond.
Updates on what's happening at Melbourne Museum, the Immigration Museum, Scienceworks, the Royal Exhibition Building, and beyond.
the last time i spotted the emperor moth was about ten years ago it was in marlborough-blenheim nz
To read the latest tweets from @museumvictoria
Follow Museum Victoria on
Hi Lorraine,
Dates and prices for Discover the Night Sky are still being finalised. Please keep an eye on our website or subcribe to E-News for further informa...


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Ooooh I was just informed by our translation department that I cannot present phone numbers any other way than 514 123-4567.
I had spiced things a bit with 514.123.4567 in a new design, but Noooooo I am not allowed to present phone numbers that way in the French version of the booklet because we follow the rules of the Office de la langue française, and *they* say phone numbers must not be presented any other way.
I'm so annoyed with this. It's stupid, it's silly, but where is the boundary between language and design? I understand language-specific punctuation and hyphenation etc... it's necessary. But phone numbers?
/off to do some find and replace.
Personally I wouldn't like to view a phone number as you prefer, given its similarity to how IP addresses are formatted.
I'm sure it looked cool though. Don't lose heart.
I'm with you Kristina -- the way they want it for Francais is not even internally consistent. :-)
It reminds me of a job I had once...
I had a really fabulous assignment to design one of those educational "wall charts" for a national laboratory -- you know, those dense things that are hanging on the wall of your science class in high school? The design process unfortunately included regular meetings with a large group of government bureaucrats and scientists. One day, well into the project, the panel ganged up on me to insist I change the typeface used throughout (Myriad MM) to some kind of font with serifs, because "fonts with serifs are more readable." Despite the fact that the overall design required a wide range of weights and widths, and consisted mostly of short text passages, I could not dissuade them from the idea that "serifs are always better."
(Somewhat fortunately, soon after, I was forced out of my job through a spectacular political showdown that gave me the rare opportunity to tell a particularly odious bureaucrat, to their face, "Well then I will just have to quit!" Ah, the memories. Someone else finished the wall chart.)
I am not, actuslly, invested in the one presentation or the other. In other, less trendy, publications we've used (514) 123-4567. This would not be acceptable to them, either.
My beef is that I just don't see how this is a language issue. To me it's a style preference. You don't like it? I'm cool with that. Tell me you just plain don't like it or give me reasons. But don't tell me that the government says that there is only one correct way to present phone numbers in French.
I went through the dots-for-phone-numbers phase in college. I'm back to the 555 555-5555
Design is just as much about not reinventing the wheel as it is being creative and new. A phone number is a basic bit of data and sticking with the tried-and-true format isn't all bad.
Don't forget to use GREP to find and replace it will make it all a piece of cake. (This presumes that you are using CS3)
Ah, your gummint strikes again.
(Not that I should talk: Alberta is the only province where 'Murrican spelling is actually encouraged!)
As a protest find the official rules and do something that's within them but totally stupid - maybe use Hindi numerals, or pick a font that's impossible to read, or maybe set the dash subscript at a smaller type size - stay within their silly rule while subverting it.
I'm not sure if I agree with sticking to tried-and-true. Most of times, tried-and-true are just people staying in their comfort zone. But you can still communicate outside your comfort zone. When people complain to me about something like that, I say "can you read it?" or "Did you understand it?", or even "Would you be able to make a call to that number?"
That usually gets the true reason out on why they want things this or that way, and most of the time is about personal taste.
I prefer the way you designed, with the dots. More elegant and super clear, not mentioning consistent.
"I'm not sure if I agree with sticking to tried-and-true. Most of times, tried-and-true are just people staying in their comfort zone."
I'm fine with pushing comfort zones, but I'm also a fan of pragmatic design that helps with usability. In this particular case, does it matter? Maybe not.
My not-very-expert opinion is that in design very little boils down to "rules". Most of it is personal preference and consensus.
Tried and true reigns at this institution -- or I should say unquestioned tradition. And I can deal with it. Most of the time. I nod and smile and bite my tongue, but lately I've been wanting better answers for why we do things a certain way. "Because we've always done it that way" is just not very convincing.
We now have one style for phone numbers in English text and one style for phone numbers in French text. This confuses me (why??????) and makes more work for me.
I changed all the French to what the translation department wanted. The English have already gone off to print, and so they won't get changed from the (514) 123-4567 format to the 514-123-4567 that our marketing communications department wants. Too bad, but I'm not sure I really care that much.
No, I don't have CS3. I have CS2. :(
I was having a very frustrating day, and I don't know any better place to come for understanding and venting than here. You guys get me through the day sometimes!
I have had a very frustrating couple of months. I've often wondered if I'm becoming a monkey who knows the software instead of a designer and editor who just might possibly know a little bit more about the job than administrative secretaries and assistants. The phone numbers are not important. They were just the proverbial cherry.
Some days I want to clean houses for rich families in Westmount. The salary would be about the same. I'd be following orders. I'm detail-oriented--I can polish silverware. The main difference is I wouldn't feel that my skills and knowledge were being crushed, or worse, ignored. And I'd have dry hands and broken nails instead of bad eyes and back pain.
Whaddyall think? Time for a career change?
/off to drink my troubles away. ;)
Never let them win - ever. And if you don't want to do this anymore I certainly don't blame you. There are WAY too many marketers (or marketing experts). After all - my wife hates yellow.
Have a drink for me.


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Robotic salvage retropubic prostatectomy after radiation/brachytherapy: initial results
Article first published online: 11 APR 2008
DOI: 10.1111/j.1464-410X.2008.07570.x
BJU International
Volume 102, Issue 1, pages 93–96, July 2008
Additional Information
How to Cite
Kaouk, J. H., Hafron, J., Goel, R., Haber, G.-P. and Jones, J. S. (2008), Robotic salvage retropubic prostatectomy after radiation/brachytherapy: initial results. BJU International, 102: 93–96. doi: 10.1111/j.1464-410X.2008.07570.x
Publication History
- Issue published online: 11 APR 2008
- Article first published online: 11 APR 2008
- Accepted for publication 5 December 2007
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"Dude, cameras are on the way out."
Heard this from a multi-tattooed teenageer yesterday, talking to his friend.
"Dude," he said, "cameras are on the way out. Everyone's got a phone."
Yeah, they do. I see people--including some in my own family--snapping pictures with their phones all the time. In fact, I've noticed some people seem much more comfortable having their pictures taken with phones. They don't even notice it. But when my camera appears, they start objecting.
I don't think cameras are on the way out, though. Maybe it's because I hang out on photography forums, but I'm certain cameras are here to stay. If they're not, I guess I'll have to learn how to take a picture with my phone. So far I haven't been tempted to try.
How about you? Got a camera?
Got a camera, got a phone... I use both.
But if you are not "in to photography"... - I am seeing a lot more people go to their phones for cameras. The quality has improved so much. Why carry a separate camera, if your phone will take a decent picture.
I do see a HUGE contingent of the Mammarazzi with the big DSLR and zoom lenses (guilty!) at all school events though.
In the same vein, someone recently made me feel very unhip by exclaiming "I don't know anyone who wears a watch anymore!"
Were they looking down at and interacting with their phone when they said that? I think there must be some people that have their phone in their hand almost all their waking hours...you know the sort...Walking blindly through a crowd staring at their phone, and not watching where they are going at all.
Yesterday a jaywalker blindly crossed 4 lanes of traffic on a rather busy street, never seeming to look up to see that there was oncoming traffic. grrrrr......
Why carry a separate camera, if your phone will take a decent picture.
It depends on your definition of decent, I guess. I'm with Nycefarm on this one.
But I realize not everyone has the same goal in mind when taking a picture. Not everyone is going to look at it with a critical eye . . . not everyone is interested in post-processing . . . not everyone wants to have the option of blowing it up to 16x20 . . . and on and on.
"And why wear a watch when you can check the phone just as easily?"
Because if you're in a meeting or stuck talking to someone from whom you wish to get away, it's much, much easier to sneak a peak at your watch on your wrist than it is to pull out your cell phone and take a look at it.
Unless, of course, you're one of those folks who can't take a breath without having your phone in your hand in front of you.
Unless you can't use the online editors....:0) A phone would be enough.
No I don't own a cell phone(they cost the smae as a land line). Yes I own a camera or 3, but 2 were free gifts....ie: opening a bank account,; using points on my credit card.
I agree with "The dude". :0)
"Dude," he said, "cameras are on the way out. Everyone's got a phone."
Am I the other one that envision this guy wearing droopy jeans with the crotch hanging about to his knees and several inches of his underwear showing?
Sue...who would rather twist my arm over to view my watch than look for and pick-up and glance at a phone for the time.
I was surprised at the photo quality from today's cell phones. My Canon camera is 4 years old and it's certainly not a high tech model. But when I went on vacation last year and stopped to buy a new photo card the salesman commented that my cell phone would take better photos than my camera. I thought he was just trying to sell me a new camera but then I had other knowledgeable people tell me the same thing.
I think the big difference is if you merely want to 'point and shoot' then the camera on a newer phone is probably sufficient - and at the very least you'll probably always have it with you. However I still like using my camera, I just need to replace it and the newer ones are better and smaller.
Over and Out, Dude.
"Why carry a separate camera, if your phone will take a decent picture."
my philosophy has always been:
"Why bother taking a picture at all, if it just going to be a crappy one."
Yes the cameras in phones are getting better. And the picture the phones take now may well be better than the crappy digital camera they used in the past, and much better then the fixed-focus, point-and-shoot, film camera they might have used even further in the past.
But if the best they can do with a phone is a poorly composed, poorly exposed, poorly focused, grainy, blurry snapshot -- why even bother?
I think Instagram is responsible for so many sub-par photos on FB. I hope Instagram is on the way out.
But I agree....so many people seem to resist deleting. One guy on a DPReview forum proudly directed people to his 3,500 pictures taken with his new camera. Many were so similar they looked like duplicates. How many straight-on images of a flower shot in bright sunlight should anyone keep?? The unfortunate thing is if you do a Flickr search on this camera you come up with his pictures and those from a couple of others who way overdid it.
Yes, edit and delete!
I took some pictures for my DD's friend a couple weeks ago with her new iPhone and was amazed at how good the pictures looked. It felt awkward though and I felt like I didn't have a good grip on the phone while taking the photos. Doesn't make me want a fancy phone though... I'll keep my old basic phone and have a separate camera for now.
I have just joined the digital camera age. Up until a month ago I used a film camera so cameras had better not be on the way out. Oh, and I don't own a cell phone. (I don;t own one for self-preservation as I don;t want DH or DS's calling me when I'm out and about - when are you coming home, I need the car, what's for dinner, can you pick up this....blah,blah,blah....)
I'm taking a photography course to learn how to download and edit pics on the computer, learning how to use the camera is easy but the computer part leaves me a little baffled. Anyway, our teacher said that iphone5's take surprisingly good pictures. He also said that the best camera is the one you have with you and the one that most people always have with them is their cellphone. My kids take alot of pics of their friends, their hikes, funny little moments and all because they have their cell phones with them.
I love random pics! Although I've been known to carry around my big camera at many events, there are times I just want to go somewhere with out the bag and just pleasantly watch without a care in the world. So if I find myself wanting to document a moment in time, say at school after a sporting event and I don't have my 18 mp camera, the 8mp I-phone comes to my rescue! It takes some awesome pictures that are easy to download and just as easy to erase. So depending on whats happening, they both do a nice job for what I want. Eventually the big cameras will get smaller IMO.
There are members of my family that never leave the house without their camera in hand and I am not talking about the ones on their cell phones. I don't have a real camera so I am thankful for the one I do have use of on my iPod but the pictures are never to my liking.
Digital cameras are good but somehow I miss the days of using film. I still have my first camera sitting in the box it came in that I got for Christmas one year when I was a kid. It used those square flash bulbs. I even have the Kodak disc camera I bought my Mom but I don't think you can even get the film for that anymore LOL
I look at your Dad's pictures Susan and I bet you wouldn't get the same effects using a digital camera. I still think you should publish a book of your Dad's pictures and sell them. I love to see how people lived back then and the furniture and home goods they used in their homes, the clothes and shoes that were worn. Sometimes I think there is no warmth in a digital image


text:
TUCSON -- Police say four people have been shot after gunfire erupted in the parking lot of a Tucson strip club.
Tucson police Sgt. Chris Widmer says an officer who was near Ten's Showclub on Speedway Boulevard heard gunfire just before 1 a.m. Saturday and rushed to the scene. The officer found lots of people in the parking lot and vehicles rushing to leave.
After the lot cleared out four men were found with gunshot wounds. Widmer says one man was hit in the head and has life-threatening injuries but the other men have non-serious wounds. All were taken to local hospitals for treatment.
Widmer says there apparently was an exchange of gunfire between at least two people.
Detectives interviewed about a dozen people but have not made any arrests.
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Arsenal Training Session
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Bacary Sagna and Emmanuel Frimpong of Arsenal before a training... News PhotoArsenal F.C.,Bacary Sagna,Club Soccer,Emmanuel Frimpong,England,Event,London Colney,Soccer,Sport,Sports Training,St. Albans,UK,VerticalPhotographer Stuart MacFarlaneCollection: Arsenal FC 2013 The Arsenal Football Club PlcST ALBANS, ENGLAND - JANUARY 15: (L-R) Bacary Sagna and Emmanuel Frimpong of Arsenal before a training session at London Colney on January 15, 2013 in St Albans, England. (Photo by Stuart MacFarlane/Arsenal FC via Getty Images)


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Indonesia has one of the fastest-growing aviation industries in the world. To combat an expected pilot shortage, the Indonesian transportation ministry launched a free, 14-month accelerated program to train civil servants as pilots. In exchange for their training, pilots will serve five years as government flight instructors.
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Al Schmitt & Bernie Grundman Nominated for Grammys "The Absence" & "Slingshot" Get Nods for Best Engineered Album, Non-Classical
Recording artist Melody Gardot's "The Absence" was recorded/mixed by Moogie Canazio, mixed by Al Schmitt, and mastered by Bernie Grundman, all three of whom share the nomination. Grundman is also nominated with recording engineer Helik Hadar for mastering Rebecca Pidgeon's "Slingshot."
Over the course of more than three decades, Al Schmitt and Bernie Grundman have collaborated on numerous hit albums.
|Pictured (L-R) at Capitol Recording Studios are mix engineer Al Schmitt and mastering engineer Bernie Grundman. Photo by David Goggin.
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Rayburn Royal OF22 (1970s)
Fancy owning an old Rayburn? This OF22 from 1974 could be yours. Everything takes ages to cook in it. It doesn't have a grill so cooking options are limited. Do you need to cook a few things at once? You never will with this cooker as it can only cop
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