Universal care is nowhere to be found
Jeff Stryker
Sunday, April 27, 2003
©2003 San Francisco Chronicle
One in seven citizens in the world's richest country is without health insurance.
The uninsured are not some wretched underclass, some marginalized group with whom policymakers and opinion leaders somehow find it impossible to identify.
They are, for the most part, middle class. More than 80 percent of the uninsured live in households with either a full-time or part-time worker. A third live in families with household incomes of $50,000 or more.
After a couple of years of improvement in the late 1990s, the number of the uninsured has begun to rise again, with a vengeance. Spurred by the sour economy, the ranks of the uninsured swelled to more than 41 million last year. They are neither old or disabled enough for Medicare nor poor enough to qualify for Medicaid.
The lack of universal insurance coverage is only the most evident flaw in a vastly complex, wildly inefficient health care system that would make Rube Goldberg proud.
"If we had set out to design the worst system we could imagine, we couldn't have imagined one as bad as we have," says Marcia Angell, former editor of the New England Journal of Medicine.
Perhaps the system's most fundamental flaw involves the uneven structure of health insurance. Since World War II, when health insurance costs, designed to be routed through large employers, were exempted from wage controls, most private health insurance comes through a job.
Those who receive health insurance through the workplace enjoy a tax break to the tune of $141 billion a year. The unemployed and those who work for smaller employers who don't provide coverage must pay for coverage out of their own after-tax income.
Even those with health coverage through the workplace are increasingly burdened by high copayments and coverage restrictions. Princeton health economist Uwe Reinhardt calls the coverage many workers now have "unsurance" because they are unsure what it covers today and unsure what it will cover next month.
With so many lacking insurance, and those lucky enough to have coverage worried they may be a mere pink slip away from losing it, why so little public agitation for universal access?
According to a survey conducted by National Public Radio, the Kaiser Family Foundation and the Kennedy School of Government at Harvard, when asked to name the two most important problems facing the nation, only 10 percent mentioned health care, ranking it behind problems such as the economy, terrorism, war and crime. Yet only 1 in 5 of those surveyed thinks the health care system works pretty well.
"However, it does not appear that people's worries and experiences are causing them to push for sweeping change in the health care system," the survey's authors concluded.
The researchers asked respondents about a variety of measures to expand access. The survey results showed, "A majority of the public favors no single option. This fact, combined with the cost and winners and losers involved in any proposal, helps explain why consensus is often hard to reach dealing with issues of expanding health coverage."
The reluctance to embrace proposals for wholesale change comes in part because the picture is so complicated. Lacking health insurance does not necessarily mean going without care entirely. Federal law prohibits hospital emergency rooms from turning away sick people, until they are stabilized. A variety of free and subsidized clinics helps fill in the gaps, along with heaps of uncompensated care. (A recent study by the Urban Institute, a Washington, D.C., think tank, put the price tag for uncompensated care in 2001 at $35 billion, 85 percent of which came from public sources.)
Well, if people are getting care anyway, why make a big fuss about who is insured or not and who pays? As it turns out, health insurance makes a huge difference in who gets care and the type of care they get.
The title of a report issued last year by the Institute of Medicine summed up the situation -- "Care Without Coverage: Too Little, Too Late." The summary of 130 research studies found that the uninsured are likely to be sicker and die sooner than their insured counterparts.
Even when admitted to the hospital, say after an auto accident or a heart attack, the uninsured receive fewer diagnostic and treatment services. The uninsured receive less frequent cancer screenings, resulting in delayed diagnoses and premature mortality. Professionally recommended standards for managing chronic diseases are often forgone with tragic consequences, such as the timely eye and foot exams that can help avert blindness and amputations in persons with diabetes.
The inefficiencies of the system reverberate in ways that have consequences,
not just for uninsured folks, but for the community at large. As Diane Rowland, executive director of the Kaiser Commission on Medicaid and the Uninsured, said in releasing the study on uncompensated care, "Uncompensated care is not a substitute for insurance. We are paying for a substantial amount of care for a large uninsured population without a guarantee of coverage. The implication is that we pay for care in the least efficient way possible -- after people get sick and need emergency or hospital care."
Emergency departments in many American cities are becoming so crowded that diversion -- rerouting patients because an ER is full -- is a perennial problem. As an article in the Annals of Emergency Medicine put it, "Unless the problem is solved in the near future, the general public may no longer be able to rely on emergency departments for quality and timely emergency care, placing the people of the country at risk."
The Bush administration proposes implementing tax credits to help more people pay for health insurance, tinkering with Medicaid and offering seniors prescription drug benefits in exchange for enrolling in private Medicare plans.
Ron Pollack, executive director of Families USA, said the president's health care proposal is "like throwing a 10-foot rope to a person in a 40-foot hole."
Well, then, who has a 40-foot rope?
Quixotic advocates of single-payer, universal coverage schemes are still proposing wholesale reforms. More calls have been heard recently for employer coverage mandates.
Perhaps, for the first time since then-first lady Hillary Rodham Clinton took on the health care system (and met her match), universal coverage and access may truly be up for debate.
Jeff Stryker is a San Francisco writer specializing in medical ethics. He is working on a book about sperm banking.
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