The number of Americans without health insurance is 45-million and rising. The vast majority of those uninsured have been without health insurance for more than two years. The uninsured are much less likely to seek health care than the insured and more likely to go to expensive emergency rooms to unknown physicians for medical services. The Institute of Medicine concluded that the uninsured receive too little medical care and receive it too late, receive poorer care when in the hospital, are sicker and die sooner.
Eighty-five percent of the uninsured are from working families priced out of coverage. They are less likely to afford prescribed drugs. Many treatable conditions go unmanaged, such as hypertension, diabetes or heart disease. Acute conditions are often ignored, possibly triggering costly emergency services. The overall health of the uninsured is inferior to those who receive routine medical care.
Surprisingly, the fastest growing group of uninsured earns $75,000 or more per year. The largest populations of uninsured are middle-income families. The working poor (income less than 100 percent of federal poverty guidelines) represent 24 percent of the uninsured population.
The reasons Americans are uninsured include affordability, pre-existing conditions, employment without medical benefits, loss of employer-sponsored benefits, termination of employment and divorce or other family changes (i.e. children who reach adulthood may lose parents' coverage). Medicaid eligibility changes and welfare reform have also increased the ranks of the uninsured.
Minorities are more likely to be uninsured than whites and more than half of the total uninsured populations are families with children. More than one third of Hispanics are uninsured, representing the largest ethnic disparity. Government programs targeting youngsters have had some success, but 25 percent of the uninsured are children.
States such as Hawaii, Pennsylvania, Minnesota and Massachusetts, having low numbers of uninsured, consistently have strong employer coverage. In every state, the percentage of individuals who buy their own insurance is very low. It remains clear that one of the keys to keeping health care costs in check is extensive coverage.
Mandates may be necessary to protect our health care system. Hawaii has had employer health coverage mandates since 1974 _ plus a generous indigent program minimizing their uninsured population. Inversely, those states with employer coverage less than 55 percent tend to have the highest proportion of uninsured. Employers cover 51 percent of Texas workers and the state ranks first for uninsured. Florida, whose employers cover 50 percent of its workers, ranks eighth.
Employers curtailing health care benefits to their workers are swelling the ranks of the uninsured. It is a shortsighted savings that is already affecting the overall health of the population and driving health care costs up. The uninsured are a dilemma for physicians who are finding it more difficult to access specialty services when needed. Hospitalization and care of the uninsured is often hindered and addresses only the most seriously ill through unfunded government mandates. The U.S. health care system is buckling under the weight of the uninsured, lawsuits and inadequate insurance reimbursements.
There are several approaches that could resolve the burgeoning insurance crisis. Employer mandates, which are so effective in Hawaii, could be adopted in other states. Rules for insurance underwriting and physician record keeping could address escalating administrative costs taking 31 percent of the health care dollar.
Physicians for a National Health Plan advocate a one-payer system covering all Americans. Such a system would dramatically reduce administrative costs and allow consistent coverage. Detractors claim this would be socialized medicine and mention the failings of the Canadian system.
Former U.S. Rep. Sam Gibbons of Tampa wanted to expand Medicare services to all. His plan gained some favor but was never effectively promoted. Lower administrative costs and universal coverage would have been addressed in the plan.
The American Medical Association touts a plan that would allow tax credits to encourage individuals to purchase health insurance. It allows the marketplace to determine premiums and specifics of coverage without mandates.
Another approach to affordable insurance entails catastrophic coverage under which the patient pays for office visits and vaccines. Insurance would protect the patient from hospitalization and other identified expensive health needs.
The success of efforts geared to universal health coverage will require integrity of purpose, an improved public health infrastructure, corporate responsibility, public outcry and political will. Unfortunately, all seem to be in short supply.
Dr. Marc J. Yacht is director of the Pasco Health Department.