The Underinsured

QUESTION:  Who are the underinsured?

The problem of the underinsured is the sleeping giant of the US health care system.  There are several classes of underinsured, all of whom can be threatened by not being able to obtain absolutely necessary and urgent medical treatment.  It is the sleeping giant, because it includes virtually all of us, hard-working, basically healthy Americans.  Sleeping giant because it is unrecognized and virtually unmentioned in the popular press. Any worker can easily find themselves temporarily out of work and then suddenly ill (or one of their family) who then has a pre-existing non-insurable major or chronic condition, which they subsequently will find no insurer is willing to include in coverage. Charity care has never been able to fill the gap with high quality care and specialist referral. Even after the promises of GW Bush charity care has never entered the most needy counties of the US.  

Examples of underinsurance are exclusion of our most needed health care from our particular policy (pre-exisiting condition), exclusion of mental health coverage, winding up without insurance during a period of unemployment, being excluded or priced-out of coverage as we grow old (former employers and their carriers fail) among many others.  Even the public programs we all contribute towards have been eroded and cut back (to allow millionaires new tax-cuts) so that they will provide less of our needs. How can we consider ourselves well-insured now when these conditions including being elderly, or unemployed are bound to be enforced on our coverage one day? Would you consider yourself well-covered for auto insurance if you knew that next year you would be dropped by your company and no other company would pick you up either?

QUESTION:  What is and who might have a "pre-existing condition"?

A pre-existing condition is any medical condition which an individual has before they sign up with a new insurer, including switching insurers whether out of choice or requirement.  An employer for example may decide to offer different plans in one year, or an employee may switch jobs.  A young person may get their first job, or a woman may re-enter the workplace after being home with an infant.  Any of these people who has some chronic (continuing) medical condition may be excluded or limited from coverage by an insurer.  Pre-existing conditions might also be medical conditions of the such a worker's wife or children.

In the case of exclusion the individual may not be offered any contract with that insurer, perhaps the only plan offered by their employer, or the terms that are offered for that one individual can be several times the premium offered to other employees because of that condition (yes, thousands per month even).  

In the case of limitation the individual may be offered limited coverage, but only for "new conditions" unrelated to the individuals "pre-existing condition".  The most likely source of that individual's future medical problems will not be covered to any extent, even though they are paying for medical insurance. Another health crisis related to this condition and the individual and their family can become destitute and troubled in finding medical care.

QUESTION:  Why is underinsurance a problem that most of us need to be concerned about?

Few workers can be certain that they will not be forced to switch insurers, or have to switch jobs(and therefore insurers) at some time in the future.  And few can be certain that they and their families will NOT have any chronic medical conditions at that time.  Furthermore, any working person who is out of work for a period of time is exposed (together with their family) to great risk during that period.  For if any of them develop a serious chronic illness even finding a job with good health coverage, they may find themselves still excluded from coverage (an illness developed during such a period would then be pre-existing to future coverage) or priced-out of such coverage with exorbitant premiums proposed to cover the medically needy. Or they may find themselves dependent on some life-saving medication which they sadly cannot afford .

Thus any working person in this country or their family is truly underinsured.  No matter how good our present policy looks, we may be uninsured for the crisis we or our family might have in the future.  Many unfortunate families have been bankrupted and failed in finding the care they needed because of this underinsurance problem. Don't forget how few Americans are adequately covered for the possible mental health needs of their families.

QUESTION:  Isn't it pretty easy though to look over a plan and see that all the basic areas of potential health care need are covered?  Don't almost all plans cover all the needed general areas?

Maybe and No.  What if no plan offered covers one of the basic and important general areas of health care?  Even if an employee notices or plan subscriber notices, what could they do about it?  Such a general area is mental health where many plans are poor or severely limit the duration of treatments regardless of need or potential benefit. See additional FAQ on the issue of so-called "consumer-driven" health care.

QUESTION: But statistically isn't underinsurance a small problem?  Most of us have good insurance don't we?

No, most of us don't have good insurance, but most of us have not been seriously ill or injured and thus have not really tested how good our coverage is.  The hard-working middle class is no longer protected. Consider these statistics from a July 2002 report from the Kaiser Commission on the uninsured:

Though health insurance is one of the most important factors in assuring access to health care, gaps in coverage can create access problems even among the insured. Fully 38% of insured individuals report that they or their families experienced at least one problem accessing medical services in the past year. Nearly one-fifth (18%) report that they postponed seeking medical care, 15% had a problem paying medical bills, 10% did not get a prescription drug they felt they needed, 8% were contacted by a collection agency about a medical bill, and 6% didn't get care they felt they needed.

In a 2005 report analyzing 2003 data, it was found that beyond the official federally recognized uninsured for the year [uninsured for all 12 months of the calendar year] another 35% were underinsured (61 million rather than 45 million Americans) and could not cover their health care expenses. And in that report the underinsured were very conservatively defined. By the way, CHIP and other programs for children will not suffice to give all children a level playing field. Over a million children in the USA must shoulder responsibility as caregivers in their families, often where medically needed care cannot be accessed. Un- and under-insurance of adults will always put burdens and limitations on children in those families.

Many of these problems arise because some individuals' health plans do not cover all the services they need. In other cases, individuals cannot afford the cost sharing associated with covered benefits.  Either of these conditions is an example of underinsurance.

Is underinsurance a systemic problem though, or just the natural result of individuals who choose to run a risk by personal choice and who take the consequences if they choose poorly?

Wrong on both counts. First of all we all pay the price together for low-quality insurance (that's why people are underinsured because they buy insurance of low quality), and second, its not so much a matter of personal choice as it usually is low-income families trying to figure out how they can possibly meet the material needs of their family -from a pot that just doesn't stretch thin enough.

Take for example the case of depression among young adults. Antidepressant (SSRI) use in children came under intense scrutiny in early 2005 because the use had been poorly studied and inadequately monitored resulting in many teen deaths. Depression is a major risk factor for suicide, but depression also carries with it an increased likelihood of substance abuse disorders, early pregnancy, poor academic performance, and impaired psychosocial function. Despite the prevalence of these symptoms in young persons, fewer than 1% of children and adolescents receive mental health treatment for depression. Even that treatment, usually psychotherapy, is very short-term, with a mean number of 7.8 visits per year, and many persons are seen only 1 or 2 times.

The costs of this lack of care for our young people, with disorders stretching out into their compromised lives is incalculable, but must exceed many billions of dollars yearly - a cost to them, their communities and to the nation. Not just the loss due to suicide but all the poor performance and psychosocial dysfunction, including addictions and crime mentioned above. [Find article from Reuters Health News "Controversy Over Suicide Risk in Children and Adolescents Taking Antidepressants: Lessons Learned" from 12/21/2004 by Jay M. Pomerantz, MD]