The Uninsured

QUESTION:   Is the uninsured problem that serious?    

In early 2001 43 million Americans now (early 2001) lacked any health insurance, up some six million since the Clinton plan debacle.  By early 2002 among the civilian non-institutionalized population alone, 46.2 million were uninsured (more than one in six for that population ^{*REF 1} ). This is the official US census data which underestimates the number of uninsured Americans in any given month by about 50%, counting only those uninsured for an entire fiscal year (jan 1 - dec 31). Young adults ages 19-24, 34.9 % of whom were uninsured, were the age group at the greatest risk of being uninsured in early 2002.    Localized uninsurance rates in some areas of California, for example, are up to for times the national average. The number of uninsured in middle-income hard-working (often two worker) families has risen dramatically during the GW Bush administration. 

Additional studies have shown that for a longer period (like 2 years) the official figure for the uninsured underestimates the number of Americans who lacked uninsurance for some significant period during those two-years by about 60% (yes, the real number who suffered uninsurance was about 2.5 times greater).   And during the GW Bush years the problem has been escalating with an additional 6 million Americans entering the ranks of the "officially uninsured" from 2000 to 2004 and further escalation of the uninsurance plague imminent. For more details CLICK HERE. Or for the official Census figures (800,000 additional uninsured added by official census count) in 2004 CLICK HERE.

QUESTION:   Haven't the uninsured always been able to get treated at most public clinics and hospitals, which have the ability to cover a few extra patients?

Prior to the era of managed care, providing this care was achieved largely through cost-sharing (some of the surplus charge to insured and more wealthy patients) was cycled into care for some who could not afford needed treatments.  This was usually arranged informally at the level of individual practice, clinic or hospital.  But as businesses those institutions remained viable even while sharing some of their surplus.

Because managed care companies have extracted deep discounts, it has become impossible for hospitals and doctors to provide uncompensated care, since the surplus revenues are no longer there to subsidize the care of those who could not pay. According to one study when, uncompensated care was reduced by as much as 36 % in markets with high managed care penetration.  Increasingly, public and teaching hospitals are running into the red and threatened with closings because of this problem, which is all the worse since increased competition is forcing the uninsured away from the private clinics which used to provide for them through cost-sharing (search our news archives for articles about the financial crisis for public hospitals around the nation). Think that the ER's are the safety net? See details on how our Emergency Care system has deteriorated since 1993.

Also it's just not true that the uninsured get the care they need, or that they can always find a way. ^{* REF-2}, ^*REF-3, ^*REF-4 Nor is it true that charity care, even when highly publicized by our "Commander in Chief" has reached significantly into our nation's poorer communities. New data in 2006 demonstrated that the level of charity care in the country declined by more than 10% even while the number of uninsured Americans grew enormously.

QUESTION:   Aren't the uninsured adequately cared for already at charity clinics and at public ER's?

Research has clearly demonstrated that the uninsured – even those who are sick, chronically ill, or who have special health care needs – get less health care than those who have insurance. They are more likely to delay getting the care they need and less likely to use preventive services.  Many studies have shown that increasing coverage improves access to care.  So, in fact, the community clinic/ER safety net of earlier years DID NOT provide for the uninsured the medical attention they needed.  Now the uninsured simply don't get the care they need, and if they get it, it's delayed.

In late 2002 the Bush Administration was pushing CHC's and charity care as the solution for the uninsured problem.  But by late 2005 it became clear that they had not penetrated into the most needy areas of our nation. Certainly CEOs and corporate heads have always been in favor of people working without reimbursement, so this solution of erecting facilities where medical and house staff (already overburdened and in short supply) will work without wages and benefits is indeed brilliant.  Maybe its important, though, that care will necessarily be rushed, follow-up poor, patient/doctor trust low with little opportunity for specialist referrals? 

Maybe it is important that uninsured numbers are rapidly increasing due to increasing poverty in our wealthy nation and due to employers backing away from covering their workforce.

QUESTION:   Who are these uninsured people anyway?

The largest number of uninsured are Caucasian, although higher percentages of minorities are uninsured. African-American children are twice as likely as white children to be uninsured. Hispanics in often have the most limited access to health care.  Most uninsured adults work. Most uninsured persons live in families headed by a worker. Increasingly middle-income families cannot afford to insure their families (2000-7)

So most of the people without health insurance are "the working poor", still the number of uninsured middle income workers is growing. People without health insurance, then are doing the best they can to play by the rules. They do not have health insurance because they cannot afford it, not because they don't need health insurance.

About 30% of the poor (likely not working) also never qualify for Medicaid.  Medicaid has many restrictions in order to qualify.  Most Medicaid payments are for chronically ill people in long term care facilities.  The elderly in nursing homes utilize Medicaid once their insurance and assets are gone. Only a third of Medicaid is spent on the families with dependent children program.

QUESTION:  Can't everyone with a job get insurance now? 

Increasingly fewer employees can afford to insure themselves or their families. In particular, small businesses are commonly charged a higher premium by health insurance companies, and so are increasingly shifting these costs to their employees and unable to offer their employees very favorable plans.  Even many medical practices (small businesses) cannot afford to offer good health plans to their staff.  Furthermore, certain communities in are country are disproportionately suffering uninsurance even though well-employed.

And how many of us are certain we will never be laid off and temporarily at least find ourselves out of work?  If we are threatened with one day being without insurance, then we are underinsured now (see underinsurance).  Those with chronic medical conditions now or who develop such before they are forced to switch plans may be discriminated against legally, as for-profit companies practice cherry-picking to increase profits.

QUESTION:   Doesn't Medicare already pick up the slack for the people who are truly unfortunate and needy?

Even for the elderly, people who have given most of a lifetime productively for our society, Medicare covers less than half the medical expenses.  For some of the disabled and impovershed Medicaid does fill in - IF YOU QUALIFY. Medicare does NOT cover long-term nursing-home care or prescription medications (now in 2006 you must buy an additional private coverage plan for prescriptions). Co-pays and deductibles are required for hospital and doctor visits.  In NC, for example,  in 1994, the average out-of-pocket spending for health care for a typical elderly person was 23% of family income.

QUESTION:   Why should we insure all "residents"?  At least let's restrict our concern to the hard-working citizens of the country.

Consider farm workers, likely the hardest working group of people within our borders.  Most live on annual wages between $7500 and $10000 on which the pay state and federal tax, yet in California 70% are uninsured and over one third of the males have never in their life been to a doctor.  Their occupation and lifestyle increase the likelihood of high blood pressure, anemia and obesity.  (see article in SF Chronicle of 12/15/00).  Also, workers from certain ethnic backgrounds are disproportionately left out from health insurance.  Furthermore even for the insured in many districts of high ethnic diversity resources are so overburdened by the uninsured that the insured too have reduced access.

QUESTION:   I've heard that illegal aliens are a major factor in driving up all our health care costs, anyway. Aren't they just clogging up all our Emergency Rooms, as that's their only access to care?

Actually although such myths are being promulgated with increasing vigor, especially with all the election year posturing of 2006, the research on this issue shows astonishingly just the opposite. A study published in July of 2006 in the journal Health Affairs determined that inappropriate use of Emergency Departments (visits that could have easily been made in a primary care clinic) were actually lower in locations with high illegal alien populations.  

QUESTION:   Even if they are uninsured, they can still buy whatever is really necessary medically can't they?  They don't necessarily go without care.

Actually we know that the uninsured frequently do go without needed medical care.  And that when things are critical they will be treated at ERs at a much higher cost to everyone (than earlier treatment).  And we know that there are many who are forced to go without ANY ONE of the basic necessities even during relatively prosperous years for the country.